Decolonization of orthopedic surgical team S. aureus carriers: impact on surgical-site infections.

BACKGROUND: Orthopedic surgical-site infection (SSI), mostly due to S. aureus, is recognized as a major adverse event. This research aims to verify the usefulness of surgical team decolonization in order to reduce the risk of surgical-site infection. MATERIALS AND METHODS: We performed swabs of both nares and oropharynx to identify S. aureus carriers among orthopedic team members who consented to cooperate with the study. Carriers were treated with local application of mupirocin ointment. RESULTS: Retrospective study of 1,000 consecutive patients operated before surgical team decolonization showed 6 per thousand SSIs. Of the 300 cases considered after decolonization, none developed SSI. CONCLUSIONS: Though we are aware that more data need to be collected, this work might be relevant for the introduction of a new preventive protocol.

Recurrent secondary hyperparathyroidism due to parathyroid carcinoma: usefulness of Ki-67 immunostaining in the diagnosis of a malignant parathyroid tumor.

Parathyroid carcinoma is a very rare disease occurring in less than 2-3% of all the cases showing clinical features of primary hyperparathyroidism. Several histological markers have been used for distinguishing between benign and malignant tumors of the parathyroid glands. However, most of these markers are not easily applicable and clinical prognosis cannot be predicted by histopathological criteria alone. A recent study has drawn attention to the role of the cell cycle associated antigen Ki-67 detected by MIB-1 monoclonal immunocytochemistry in parathyroid tumors: in fact, Ki-67 seems to be a valuable marker of malignancy in such tumors since it permits an easy detection of proliferating and dividing cells. Here we report in detail a case of severe recurrent hyperparathyroidism in a 51-year-old female patient undergoing regular hemodialysis treatment. In the surgical specimens of the parathyroid glands, the tumor proliferative fraction of 56, expressed as the number of Ki-67-positive nuclei per thousand cells, and the mean mitosis count of 0.5, expressed as the percentage of the total amount of Ki-67 positive nuclei, support the diagnosis of parathyroid carcinoma despite the scanty amount of microscopical signs considered characteristic of malignancy, i.e. extensive thick fibrous bands or prominent nucleoli. To our knowledge this paper is the first clinical report that supports the diagnostic role of the cell cycle associated antigen Ki-67 in parathyroid carcinoma in a case of secondary hyperparathyroidism in a patient undergoing hemodialysis.

Middle and long-term results of flexion osteotomy for avascular necrosis of the femoral head.

The authors present the results of 19 flexion osteotomies performed in cases of avascular necrosis of the femoral head and followed up after an average of 8 1/2 years. Significant clinical improvement was achieved in 85% of the patients. The radiographic picture is not quite as positive, but only 26% of the patients developed severe degenerative arthritis. The authors therefore consider this technique to be a valid alternative to immediate prosthetic replacement in selected patients.

Clinical, histological, and chemical characterization of ectopic calcification in dialyzed and non-dialyzed patients.

In a review of 11 cases of ectopic calcification (5 of which in dialyzed patients and one in a paraplegic), the authors attempt to characterize this disorder in all its various forms using histological, clinical, and chemical methods. In dialyzed patients, two contributing factors were identified: hyperphosphatemia (plus hypercalcemia) and secondary hyperparathyroidism. In hyperphosphatemic patients the calcifications are multiple, paraarticular, labile, and have a fluid-viscous consistency. In secondary hyperparathyroidism, in addition to the above metastatic calcification there is dystrophic calcification typically localized in the anterior muscles of the hip and thigh. The ectopic calcification of the non-dialyzed patients is true ossification. The precise moment of the onset of the lesion is not always discernable, but its evolution points to primary or secondary local irritation as the trigger. Ossification is the predominant phenomenon in the paraplegic as well, while the triggering mechanism is still unknown.

Macroscopic shape of, and lamellar distribution within, the upper limb shafts, allowing inferences about mechanical properties.

Collagen orientation maps were determined for the long bones of the upper forelimb (humerus, ulna, radius) using previously described techniques. All three bones had characteristic, non-random patterns of collagen fibre orientation. In the humerus, transverse collagen predominated in the medial and posterior cortices proximally and in the anterior and posterior cortices at the mid diaphysis. In the distal radius, the medial and anterior cortices contained mostly transverse collagen. In the proximal ulna, transverse collagen was found in the anterior and anterolateral cortices. These findings may be correlated to the distribution of bending forces that may be operative in these bones.

Reaction of bone to methacrylate: interface remodelling.

Histologic findings of the bone-cement junction are presented for 10 implants in rabbits and 12 human specimens. Nondecalcified sections were made, employing embedding techniques that conserve the cement. Different time periods from operation were considered. The histological approach considers mainly the distribution of the osseous elements, with a description of the sites of new and old bone, of resorptive lacunae and of fibrous tissue. Fluorescent sequential labelling of bone tissue allowed a dynamic evaluation of the viability of bone after insertion of the cement. Histologic features may be summarized as follows: In the initial phase after PMMA implantation a zone of necrosis is present around the cement. In a second phase there is very active bone formation and remodelling in the tissue adjacent to the cement, with fibrous tissue formation. Long-term adaptive bone remodelling leads to extensive resorption of cortical bone and new bone formation producing a shell around the cement with new trabeculae radiating towards the cortex.

Mineralometry of the lumbar spine and histomorphometry of the iliac crest: preliminary results of a comparison of several parameters in the same individual.

Twelve patients affected with various bone pathologies (osteoporosis, renal osteodystrophy, osteogenesis imperfecta, hyperparathyroidism) were submitted to mineralometry of the lumbar spine with double photonic ray and transiliac biopsy for histomorphometry. A comparison of the values obtained for the mineralometric and histomorphometric parameters--despite the small number of cases--revealed a correlation between bone mineral content of the lumbar spine and trabecular and cortical bone volume of the iliac crest. The correlation is even more significant for the sum of these last two parameters. It may be concluded that: 1) both the methods have predictive values for an evaluation of osteopenia; 2) the measurement of cortical and subcortical bone volume increases the significance of the histomorphometric finding (which is usually limited to the trabecular bone volume); 3) there is a correlation between histomorphometry (iliac crest bone volume) and mineralometry (lumbar spine with double photonic ray) in the same individual.

Primary oxalosis mimicking hyperparathyroidism diagnosed after long-term hemodialysis.

Primary oxalosis is a rare inborn error of oxalate metabolism. Most cases are discovered in children, but occasionally symptoms begin later in life. Since early deaths in the past were from renal failure, prolonged survival obtained with chronic dialysis allows oxalosis to develop. This paper presents a 38-year-old man with an atypical history of type-I primary hyperoxaluria, not diagnosed until after 5 years of dialysis. Bone biopsy was performed because the biochemical and radiologic features did not seem consistent with a putative diagnosis of secondary hyperparathyroidism. This case emphasizes the clinical heterogeneity of this disorder, and the need for its considerations in the spectrum of dialysis-related bone diseases. It also stresses that bone oxalosis may mimic hyperparathyroidism, especially radiologically. Differential diagnosis is therefore mandatory.

Orientation of collagen in human tibial and fibular shaft and possible correlation with mechanical properties.

The pattern of collagen orientation in two human tibiae and fibulae was studied. Serial 100 microns plane parallel cross-sections at 1 cm intervals at the same level in tibia and fibula were cut using an annular blade saw. Distribution of transversely oriented collagen was mapped using circularly polarized light and an image analyzing computer. In both the tibia and fibula the pattern of collagen orientation is characteristic, which may be related to the distribution of the bending forces normally operative in these bones.

The use of scintigraphy with Tc 99 pyrophosphate for the evaluation of meniscal lesions.

The preliminary results obtained in a study of the use of scintigraphy with Tc 99 PYP for the evaluation of meniscal lesions of the knee are presented. Three different captation curves are described. Those with an elevated peak and a restricted base are characteristic of meniscal lesions. The use of this method in a series of 50 patients in whom meniscal lesions were suspected demonstrated a high diagnostic sensitivity and specificity with regard to the presence of the lesion, but not to its type.

On the structural symmetry of human femurs.

The distribution of transverse and longitudinal lamellae from osteons and interstitial bone of the two femurs from a woman aged between 25 and 30 was investigated. Exactly plane parallel cross-sections (100 micron) were prepared from the upper, middle and lower thirds of the two bones. The distributions of transverse and longitudinal lamellae was determined for both osteonic and interstitial bone, using circularly polarised light. The results show that (a) as in the male femur, the transverse and longitudinal lamellae in these female femurs have a characteristic rotational distribution along the shaft consistent with the distribution of the bending strains normally operative in bone; and (b) the rotational distribution of the two types of lamellae is slightly asymmetrical in the two female bones, probably because of imperfectly symmetrical use of the lower limbs.

Micro-biomechanics vs macro-biomechanics in cortical bone. A micromechanical investigation of femurs deformed by bending.

Previous studies have shown that longitudinal and transverse lamellae in compact bone signal the presence of tensile and compressive forces, respectively. On this basis an investigation has been carried out to ascertain the distribution of lamellae in femoral shafts that have been deformed by bending. To do this, a series of undecalcified plane-parallel sections 100 microns thick were prepared, and the proportion of transversely oriented collagen and crystallites in the lamellae was measured, using circularly polarized light as an illuminating source and a Quantimet 720 image-analyzing computer. It has been concluded that the distribution of the two types of lamellae is in accordance with the need to compensate for the deformity produced by the bending of the bones, and that an obvious relationship exists between the macroscopic features of the femurs and their modified microscopic structures.

Distribution of lamellae in human femoral shafts deformed by bending with inferences on mechanical properties.

On the basis of previous investigations indicating that the distribution of osteonic and interstitial lamellae in a normal femur depends on its mechanical properties, a procedure has been devised to provide information on the distribution of lamellae in human femora diaphyses deformed by bending. To achieve this, exactly plane parallel cross sections, 100 micron thick, were prepared from the portion of maximum bending, using an annular blade microtome. An index of the distribution of longitudinal lamellae (whose fiber bundles and crystallites have a longitudinal course and withstand loading by tension) and transverse lamellae (whose fiber bundles and crystallites have a transverse course and withstand loading by compression) was determined using circularly polarized light as illuminating source and a Quantimet 720 image analyzing computer. The results show that, even in a pathologically deformed bone, both the microscopic structure of sections at the level of osteonic and interstitial lamellae, and their macroscopic shape may be governed by the distribution of the forces active in bone.

Bone-cement interface: a histological study of aseptic loosening in twelve prosthetic implants.

The histology of bone-cement interfaces was studied by using new fixation techniques that preserve the cement, as well as sectioning the samples without decalcification. This permits histological study of the unaltered morphology, and the precise topographical distribution of fibrous tissue, bone necrosis and cellular anomalies in relation to the cement. Twelve cases of implant loosening over an average 7 year follow-up period were examined. By dynamic studies with sequential fluorescent bone labelling it was possible to evaluate precisely the extent of bone damage after the application of cement. The characteristic findings were: fibrous tissue at the bone-cement interface; bone necrosis or reduced remodelling in proximity to the cement; away from the cement, normal bone remodelling is clearly demonstrated by fluorescent labelling.

Observations on the replacement of loose prostheses.

Revision surgery for loosening of the components in total hip prostheses is still a problem and not only from the purely technical aspects. According to our experience, the use of cement is contraindicated, at least in Schneider grades 2 and 3 of aseptic loosening, because of the biological damage it can cause to the bone grafts used in such cases. The stability of non-cemented reimplants is dependant on good biological anchorage through endosteal osteogenesis. The cardinal points of technique are: complete removal of all cement, necrotic bone, and interposed fibrous membrane; the use of autoplastic bone grafts in the form of chips to replace the lost "bone stock"; the use of prostheses designed for optimum load distribution (long stem, large acetabulum). In the case of ruptured stems, diaphyseal osteotomy is necessary for complete removal of the cement and prosthesis; this can be stabilised by using a Lord prosthesis with a long stem.

Control of post-operative infection in orthopaedic surgery. Clinical and bacteriological findings in 2555 elective operations.

Post-operative infection is still a serious problem in orthopaedic surgery. Technological advances aimed at achieving aseptic conditions in the operating theatre, and the prophylactic use of antibiotics during operation have considerably reduced this complication during the last decade. Two indispensable factors in monitoring the effectiveness of these preventive measures are the determination of the incidence of post-operative infection and monitoring of the microbacterial population of the hospital.

The lymphocytic transformation test (L.T.T.) in the evaluation of intolerance in prosthetic implants.

A state of hypersensitivity to the metallic constituents of prosthetic implants can be determined by culturing the patients lymphocytes in vitro in a medium containing the appropriate concentration of salts of the metal. If in these circumstances the lymphocytes proliferate, the patient is hypersensitive. Chromium, cobalt and nickel salts can produce such mitosis only in the lymphocytes of hypersensitive patients; the same test produces no such reaction in control subjects. This hypersensitivity can cause delayed loosening of the prosthesis. The lymphocyte transformation test (L.T.T.) is therefore a very useful preoperative measure in detecting patients who are allergic to these metals and so enables the surgeon to choose the right implant.

Osteochondritis dissecans of the femoral condyles. A histological study with pre-operative fluorescent bone labelling and microradiography.

A review of the literature in osteochondritis dissecans of the femoral condyles reveals that the aetiopathology is still unclear and that relatively few histopathological studies have been carried out. The authors describe a method of study based on microradiography and on preoperative fluorescent labelling of the osteogenetic area followed by examination of the bone remodelling under ultraviolet light microscopy. The results in 12 adult cases are reported in relation to a topographical scheme which divides the lesions into four separate zones.