Macrodactyly, syndactyly, and localized gigantism of the forefoot. A case report.

On the basis of the observation of a rare case of lipomatous macrodactyly of the foot associated with syndactyly in a young child, the authors analyze the anatomopathologic and therapeutic aspects of the pathology and report the data found in the literature. This disease initially requires careful surveillance of its progression, and use of correct footwear. Surgery is indicated when deformity achieves unacceptable values, both functional and cosmetic, in early childhood.

Pro-inflammatory interleukins in the synovial fluid of rheumatoid arthritis associated with joint hypermobility.

BACKGROUND: Joint hypermobility (JH) is frequently seen in rheumatology; in some cases, such as rheumatoid arthritis (RA), it may represent a worsening of disease evolution. The aim of our study was to evaluate the influence of joint hypermobility on RA synovial fluid (SF) inflammation. Patients and methods. One hundred consecutive adult patients with RA and joint effusion of the knee were examined for the presence of JH. In the SF we evaluated volume, the number of white blood cells (WBC) and the levels of interleukin (IL)-1beta, IL-6 and IL-8 and prostaglandin E2 (PGE2). RESULTS: JH was associated with RA (JH-RA) in 18 patients, all of whom were female. Compared with non-JH RA, all the SF indices found in JH-RA were higher, although significant differences were observed only for volume, IL-8 and PGE2. CONCLUSION: In JH-RA, increased joint mobility seems to be associated with a more severe local inflammatory response, which may contribute to the more erosive evolution observed in our patients.

Vascular leiomyoma of the limbs.

After reporting the most significant data in the literature, the authors present 5 cases of vascular leiomyoma of the limbs (1 in the upper limb, 4 in the lower limb) in subjects of both sexes. In all of the patients, diagnosis was only possible thanks to histological examination, confirmed by an immunohistochemical examination. In none of the cases was there recurrence of neoplasm after surgical exeresis.

Antireflux mechanisms in veins draining the upper territory of the vertebral column and spinal cord in man.

The terminal segments of vertebral, right supreme intercostal and accessory hemiazygos veins from 28 cadavers of various ages were histologically examined to assess the possible presence of intrinsic mechanisms facilitating the delivery of venous blood from the upper vertebral and spinal cord territories. In these veins, blood flow is assisted by gravity (veins of receptive type); however, the tunica adventitia showed a significant amount of longitudinally oriented bundles of smooth muscle fibers together with elastic fibers, i.e., an intrinsic structure similar to that of propulsive type veins. Both the muscular and elastic components increased with age. One or two complete valves were found at the opening of these veins into their major receptors. It can be assumed that the structural changes of the venous wall and the ostial valves play a role in avoiding or limiting undue reversion of the blood flow in many physiologic and pathologic conditions, and in protecting the delicate nervous structures of the vertebral canal from possible damages due to temporary or chronic venous stasis.

Hyaluronan-based biopolymers as delivery vehicles for bone-marrow-derived mesenchymal progenitors.

The tolerability and safety of hyaluronan-based three-dimensional scaffolds as a culture vehicle for mesenchymal progenitor cells was investigated in this pilot study. The proliferation patterns and extracellular matrix production of rabbit and human mesenchymal, bone-marrow-derived progenitors first were characterized in vitro. Subsequently rabbit autologous cells were cultured in this hyaluronan-based scaffold and implanted in a full-thickness osteochondral lesion. In vitro histologic findings showed that mesenchymal progenitor cells adhered and proliferated onto the hyaluronan-derived scaffold. Human stem cells were shown to produce the main extracellular matrix molecules, accompanied by an occasional synthesis of mature type II collagen. In vivo data demonstrated that the biomaterial, with or without mesenchymal progenitors, did not elicit any inflammatory response and was completely degraded within 4 months after implantation. With regard to the efficacy of this cell therapy, even among the small number of animals tested there was histologic evidence that lesions filled with the biomaterial, either seeded or unseeded with cells, achieved a faster and better healing compared to empty controls. The present data suggest that the hyaluronan-based scaffolds are well tolerated and safe and may be a valuable delivery vehicle for tissue engineering in the repair of articular cartilage defects.

Subcutaneous rupture of the tendon of the long head of the biceps brachii in subacromial impingement syndrome.

Ruptures of the long head of the biceps brachii are mostly of degenerative nature, secondary to subacromial impingement and morphological changes in the bicipital groove. Clinical findings are typical. Treatment is controversial, as it may either be surgical or non-surgical. The authors considered only those cases in which tendinous rupture was the first manifestation of pathology caused by wearing, with typical deformity of the profile of the arm. The favorable results of surgical treatment in 14 patients aged from 38 to 70 years, followed-up after an average of 10.9 years, are reported. Among surgical methods used, tenodesis at the bicipital groove currently constitutes the method of choice.

Compression of the inferior vena cava due to diffuse idiopathic skeletal hyperostosis.

Compression of the inferior vena cava by bony excrescences on the lumbar spine has not been previously reported as a complication of diffuse idiopathic skeletal hyperostosis. We report a phlebography-proven case in a 67-year-old man.

Vascular anatomy of the human cruciate ligaments and surrounding structures.

A detailed description of the arterial supply of the human cruciate ligaments and surrounding structures is reported as a result of autopsy dissection, contrast medium vascular injections (fine-grain x-rays, and Spalteholz clearing of the specimens), and histologic studies in cadavers of various ages. It has been confirmed that the major supplying vessel is the middle genicular artery, which may show variations in its origin and is frequently double. The fetal and neonatal connections between the branches of this artery and the vascular network of the infrapatellar fat pad, mainly nourished by the terminal branches of the inferior genicular arteries, are usually lost in the adult. A small amount of blood comes to the lower portion of the anterior cruciate ligament from the synovial network supplying the fat pad and the anterior horns of the menisci. Both the femoral and tibial attachments are deprived of vascular penetration from the underlying bone. In spite of the relatively more abundant density of blood vessels around the posterior cruciate ligament, no microangiographic and histological evidence shows that the amount of intrinsic vascularity differs in the two ligaments. Finally, the clinical relevance of the gross and fine vascular anatomy of these articular structures in trauma surgery is considered.

Reflex decalcifying algodystrophy of the hip in pregnancy (so-called transient osteoporosis). Review of the literature and four case reports.

Transient algodystrophy of the hip in pregnancy is a relatively rare condition, still unknown to many and easily overlooked. Diagnosis is important because of the related difficulties in natural delivery and the risk of fracture. Four unilateral cases are presented (two right and two left), characterised by pain, limping, limitation of the hip motion and demineralisation of the head and neck of the femur. Treatment was by rest and protected weight-bearing. Three were delivered by caesarean section. In one patient a fracture of the neck of the femur occurred a few weeks before delivery, requiring surgery. In all four cases the outcome was benign. Like algodystrophy occurring in adults of either sex the aetiology is unknown. In pregnant women the association with the right occiput anterior position of the fetus (documented in one patient where the affected hip was the right) suggests the possible involvement of one of the autonomic pelvic plexuses (right or left) in the unilateral cases.

Spontaneous remodeling of the spinal canal after burst fractures of the low thoracic and lumbar region.

A retrospective study was done on five adult patients in whom burst fractures of the low thoracic and lumbar spine were associated with intracanalar displacement of a large bony fragment. In one case two vertebrae were involved. Three of these patients presented with neurologic damage of different degrees. All but one underwent operative posterior stabilization by Harrington rods and bone autografts. Although no surgical decompression was performed, they showed gradual neurologic recovery at the follow-up, which is still incomplete in only one, initially paraplegic patient. In comparing the initial computed tomography scans of the five patients with those taken 1 1/2-5 years later at the same level, it was found that a process of total or subtotal resorption of the retropulsed fragment had occurred in all patients, with spontaneous remodeling of the spinal canal. These findings agree with the recent reports of other authors and provide the orthopedic surgeon with a new argument in favor of the possible conservative treatment of these severe, potentially unstable fractures. In most of the cases, and especially in those without neurological compromise, surgical reduction or surgical removal of the intraspinal fragment is not necessary. We believe that loss of mechanical loading and rhythmic respiratory oscillations in cerebrospinal fluid pressure are both important factors in the mechanism of bone resorption.

[Changes in the paravertebral musculature following a traditional herniated lumbar diskectomy. A computed tomographic and magnetic resonance study]. / Alterazioni della muscolatura paravertebrale dopo erniectomia discale lombare per via tradizionale. Studio con tomografia computerizzata e con risonanza magnetica.

On the basis of previous EMG data, a retrospective study was carried out on the CT and MR features of the paravertebral musculature after lumbar spine surgery through the posterior approach. The authors reviewed the CT scans and some MR images of 35 symptomatic patients hospitalized 7 months to 42 years after operation for disc herniation. Changes in the paraspinal musculature were apparent in all of them on the surgical side. The changes were minimal or very slight in 14 patients, moderate in 13 and severe in 8. A close correlation was observed between the above changes and the surgical procedure used in every single case. Histology showed atrophy and degeneration of the muscle fibres and fibrofatty substitution. The possible responsible causes of damage to the postvertebral muscles during spinal surgery are briefly mentioned and practical implications discussed.

Three-dimensional computed tomography in infantile atlantoaxial rotatory fixation.

Three-dimensional CT was used to examine the atlantoaxial joint of a nine-year-old girl who presented with fixed rotation of the head 3.5 months after an apparently spontaneous acute torticollis. The method provided clear, anatomical images to show the site, extent and direction of the type-I rotatory fixation (Fielding and Hawkins 1977). The 3-D reconstructions helped to guide manipulation which was successful in this late case.

Lumbar disc herniation in eight siblings with a positive family history for disc disease.

Lumbar disc herniation has been observed by the author in many members of a large family, with the maximum incidence in males of the third generation, where 8 siblings were similarly affected and 6 underwent operation, mostly in their third decade of life. A number of patients in the same family suffered from chronic low back pain. In the majority of cases environmental factors apparently do not seem to play a significant role in the development of the disease. The author believes that a genetic predisposition to early disc degeneration can be invoked to explain so large an aggregation of patients suffering from lumbar disc disorders.

The meningovertebral ligaments as a barrier to the side-to-side migration of extruded lumbar disc herniations.

The hypothesis that side-to-side migration of an extruded lumbar disc herniation can be blocked or restrained by the presence of the ventral meningovertebral ligaments has been verified by the author by using the presently available methods of imaging of the spinal canal in vivo. The images obtained at levels L4-L5 and L5-S1 from nine patients showing this type of pathology and preoperatively assessed by transverse CT (eight patients) or MRI (one patient) seem to support the above assumption. These ligaments should not be confused with pathologic adhesions.

Plaster casts for the correction of idiopathic scoliosis.

The authors report their experience in conservative management of idiopathic scoliosis treated in the last 10 years with the Risser localizer cast method. The conclusion is that this method, alone or in combination with braces, is still a particularly effective therapeutic means in the correction of both angular deviation and rotation, provided that a rigid protocol is followed.

Anatomical and radiologic studies on the lumbosacral meningo-vertebral ligaments of humans.

Among the minor soft structures of the lumbosacral spinal canal that computed tomography can visualize, the meningovertebral ligaments have been neglected. There are no specific reports on this subject, and the only knowledge we have comes from very ancient and nearly forgotten anatomical works. From our studies on cadaveric specimens, it has been confirmed that the ligaments consist segmentally of ventral and lateral fibrous bands, connecting the outer surface of the dura to the endostium of the spinal canal. The most characteristic component is the ventral one, running from the anterior wall of the dural sac to the posterior longitudinal ligament and vertebral endostium. Due to their anchoring function, the ligaments are significantly developed at the level of the dural conus (sacrodural ligaments of Trolard and Hofmann). On in vivo computed tomography studies, the ligament image appears most commonly on transverse scanograms of the lumbosacral segments as a median sagittal septum, easily identifiable when the extradural fat that it crosses is abundant. The meningovertebral ligaments may be implicated in pathological conditions of the spinal canal. They can calcify singly, though very rarely, and this process must be differentiated from degenerative marginal spurs, calcific disc herniation, circumscribed calcification of the posterior longitudinal ligament, or partial diplomyelia.

Treatment of fractures of the humeral capitulum using fibrin sealant.

Three patients with fresh displaced fractures of the capitulum humeri were treated by the fibrin sealant method, without additional internal fixation. At follow-up, between 1 1/2 and 4 1/2 years after surgery, clinical results were very good. Fibrin sealant has many advantages over traditional osteosynthesis techniques and is therefore recommended as an effective method for treating such serious but uncommon fractures of the elbow joint.

A 20-year follow-up study of a case of surgically treated massive osteolysis.

Massive osteolysis of the humerus occurred in a 19-year-old male. The lesion was successfully treated with an autogenous fibular shaft transplant. During the 20-year follow-up period, humerus function was restored. Roentgenograms showed incorporation of the graft without any recurrence of the disease. This experience and reports in the literature show that only predominantly cortical autogeneic bone grafting has been successful. This could be due to the intrinsic characteristic of cortical bone. In fact, it seems that cortical bone shows greater resistance to erosion than cancellous bone to the lymphangiomatous osteolytic tissue. Therefore, autogenous bone grafting could be considered as a reasonable alternative to radiotherapy, particularly in young people with monostotic disease localized in bones that are easily operable and have no soft-tissue involvement.