Orthopedic resident's learning curve for arthroscopic subscapularis tendon repair: short-term clinical and radiographic outcomes.

BACKGROUND: Arthroscopic subscapularis (SSC) repair is a technically demanding procedure with a long learning curve. As effective completion of resident's practical experience remains controversial, a prospective clinical study was performed to assess the functional and anatomical outcomes of subscapularis (SSC) arthroscopic repair by orthopedic residents. The pathological anatomy of the tears, the surgical approach and the difficulties encountered at the beginning of the learning curve were reported. MATERIALS AND METHODS: Between June 2009 and June 2010, 30 patients with rotator cuff tear were preoperatively evaluated with clinical exam, Constant and UCLA scores. Surgery was performed under arthroscopy by a team of three orthopedic surgeons in training. A SSC tear, if present, was recorded and treated. The same clinical exam and functional scores were repeated at minimum 6 months of follow-up. Subscapularis strength recovery and tendon healing were investigated with arthromagnetic resonance imaging. RESULTS: A SSC tear was observed in 11 cases out of 30 and treated arthroscopically. The clinical scores improved in all patients: the average Constant score increased from 34 ± 14 to 77 ± 11 and the UCLA score from 11 ± 5 to 29 ± 3. The SSC tests were negative in all patients with the exception of one. Tendon healing was observed in 10 out of 11 cases. CONCLUSIONS: Arthroscopic SSC repair performed by educated residents is possible and leads to good clinical and anatomical results. Surgery duration progressively improved as the learning curve advanced. LEVEL OF EVIDENCE: Level 2.

No relationship between critical shoulder angle and glenoid erosion after shoulder hemiarthroplasty: a comparative radiographic study.

INTRODUCTION: Symptomatic glenoid erosion is one of the most common causes of functional impairment after shoulder hemiarthroplasty. A decrease in the critical shoulder angle (CSA) has been associated with the development of shoulder arthritis. The inter-observer reliability of the CSA and the relationship between CSA and symptomatic glenoid erosion after shoulder hemiarthroplasty were investigated. MATERIALS AND METHODS: Twenty-eight patients with symptomatic glenoid erosion after anatomic hemiarthroplasty were compared to a control group of 30 patients with no signs of symptomatic glenoid erosion. The CSA was measured by two blinded shoulder surgeons at a mean follow-up of 105.2 and 54.7 months, respectively. The inter-observer reliability was calculated. RESULTS: The mean CSA in the control group in neutral, internal, and external rotations was 34°, 33°, and 33°, respectively. The corresponding values in the study group were 33°, 33°, and 33° (<0.01). The interclass correlation coefficient between the two examiners was 0.917 (P < 0.01), 0.924 (P < 0.01), and 0.948 (P < 0.01), respectively. The Mann-Whitney test between the control group and the study group were, respectively, 0.907, 0.932, and 0.602. CONCLUSION: There were no significant differences of CSA values between the two groups. Good inter-observer reliability was found for the CSA method.

Strength recovery after arthroscopic anterosuperior cuff repair: analysis of a consecutive series.

PURPOSE: The purpose of this study was to look at the functional outcomes of arthroscopic repair of anterosuperior rotator cuff tears. METHODS: Sixty-one patients who underwent arthroscopic repair of anterosuperior cuff tears were retrospectively reviewed. At a minimum 6 months of follow-up, shoulder functional outcome scores including the Constant score (CS), simple shoulder test (SST) and visual analogic scale (VAS) were collected. Strength recovery for supraspinatus and subscapularis was investigated. RESULTS: All patients (mean age 59 ± 7) were available at a mean follow-up of 18 ± 7 months. The average CS improved from 30.8 ± 10.2 preoperatively to 76.5 ± 12.0 postoperatively, average SST from 2.6 ± 2.0 to 8.8 ± 2.9 and average VAS pain scale from 3.8 ± 1 to 0.5 ± 0.5 (p < 0.0001). Strength at belly-press and Jobe tests significantly improved (p < 0.0001). All patients with the exception of one were satisfied with the intervention. CONCLUSIONS: Arthroscopic repair of anterosuperior rotator cuff tears provides a significant improvement in pain relief and shoulder function. Strength recovery is demonstrated in medium correlation with tendon healing.

Patella osteochondritis dissecans end stage: The osteochondral mosaicplasty option.

INTRODUCTION: Patellar damage during osteochondritis dissecans of the knee is rare. There were two objectives to this study: evaluate the functional results of surgical treatment by mosaicplasty in this disease as well as evaluate articular surface reconstruction and cylindrical bone plugs incorporation. MATERIALS AND METHODS: Six consecutive cases of patella osteochondritis dissecans in young athletes were treated using mosaicplasty by the same senior surgeon between 2002 and 2007. All these cases presented ICRS stage IV osteochondritis dissecans with an empty defect lesion. The average age at diagnosis was 20.5 ± 9.2 years old. The pre- and post-operative clinical evaluation was based on the IKDC subjective knee evaluation, the Lysholm and Tegner scores, CT arthrography and MRI. RESULTS: Evaluation of the functional results of surgical treatment at a mean follow-up of 26 months showed an average IKDC subjective evaluation score of 66.3, a Lysholm score of 85 and a Tegner score of 5.7 (37.2, 58.3 and 3.5 respectively before surgery). The radiological evaluation showed articular surface reconstruction with satisfying congruency and good incorporation of the graft into the bone at the receptor site, except in one patient in whom a 5mm diameter cartilage defect and a loose body were identified. DISCUSSION: Osteochondral grafting with the mosaicplasty technique has been shown to be effective and give satisfying functional results. The problem of the per-operative cylindrical bone plugs choice requires to be addressed during the procedure course itself, according to the patella lesion location.

Identification of severe potential drug-drug interactions using an Italian general-practitioner database.

OBJECTIVE: To analyze prescriptions in a general-practitioner database over 1 year to determine the frequency, the characteristics, and the monitoring of the severe potential drug-drug interactions (DDIs). METHODS: We retrospectively analyzed the clinical records from 16 general practitioners in the Veneto region, an area in northern Italy. The study covered the period from January 1 to December 31, 2004. We selected all severe and well-documented interactions according to the book Drug Interaction Facts by David S. Tatro (Facts and Comparisons, St. Louis, MO, 2006). We grouped severe potential DDIs according to their specific potential risk, and for the most frequently interacting drug pairs, we investigated whether some specific tests had been prescribed by physicians for safety monitoring. RESULTS: During the study period, 16,037 patients (55% female) with at least one drug prescription were recorded, and a total of 185,704 prescriptions relating to 1,020 different drugs were analyzed. Ramipril was the most frequently prescribed drug followed by acetylsalicylic acid and atorvastatin. The final number of different types of severe potential DDIs was 119, which occurred 1,037 times in 758 patients (4.7% of the total number of patients). More than 80% of drugs involved in severe potential DDIs were cardiovascular drugs. Digoxin was the most frequently involved drug. Electrolyte disturbances, increase in serum digoxin levels, risk of hemorrhage, severe myopathy or rhabdomyolysis, and cardiac arrhythmias were the most commonly implicated potential risks. When considering patients using digoxin with loop or thiazide diuretics for more than 5 months, 72% had at least one test to monitor potential digoxin toxicity, whereas 28% had no tests. Sixty-four percent of patients using digoxin with amiodarone, verapamil, or propafenone had an ECG and/or digoxin monitoring, and 36% of them did not have any tests. CONCLUSIONS: The present study revealed that, in a group of Italian general practitioners, the risks of severe potential drug interactions are relatively low and the drugs concerned are few. Analyses of specific tests showed that physicians are generally aware of the potential risks caused by digoxin drug associations. However not all patients were closely monitored and this should be improved.

A Randomized Study of Epithelial Ovarian Cancer: Is Chemotherapy Useful after Complete Remission?

Objective. The aim of this study is to verify whether consolidation chemotherapy with Cisplatin improves disease-free survival and/or overall survival in patients affected by epithelial ovarian cancer.Methods. A multicenter study examined 122 randomized patients in complete remission as judged by laparoscopy or laparotomy following first-line chemotherapy consisting of ACy (Adriamycin + Cyclophosphamide), PCy (Cisplatin + Cyclophosphamide), or Mitoxantrone + Carboplatin. Sixty-one of these patients were treated with 3 cycles of 5-Fluorouracil (FU) 500 mg/m2 for 5 days followed by Cisplatin at 100 mg/m2 on the 6th or 7th day every 28 days; the other 61 received no further treatment (nihil group).Results. Sixty patients in the Cisplatin arm were evaluable. There were 36 relapses in the FU+Cisplatin arm and 30 in the nihil arm. Peritoneal relapses were 25% for Cisplatin treatment vs. 16.4 % for nihil. There were 29 deaths in the Cisplatin arm vs. 27 for nihil. Median overall survival time (95 months with Cisplatin vs. 96 months in the nihil group) and median disease-free survival (66 months with Cisplatin vs. 73 in the nihil group) were similar in both arms (p=0.66 and p=0.41, respectively). There were no significant differences in tumor stage and grade between the two arms. Seven patients presented a second neoplasm during follow-up: six in the nihil arm, but only one patient in the Cisplatin arm. Death in these patients was due to the second neoplasm and not to progression of ovarian cancer.Conclusion. Three courses of additional platinum+FU treatment after five cycles of first-line chemotherapy without FU produced no increase in overall survival or disease-free survival.

Bone alterations in patients with idiopathic hypercalciuria and calcium nephrolithiasis.

OBJECTIVES: To verify whether alterations in bone density and turnover in patients with calcium nephrolithiasis and hypercalciuria are observable in various subgroups of patients divided according to the pathogenesis of the hypercalciuria. METHODS: Seventy patients with calcium nephrolithiasis and idiopathic hypercalciuria, 19 to 64 years old, were assessed for spine and femur mineral metabolism and bone density using a Dexa evaluation system. After a low calcium diet, the subjects were classified into two groups: fasting hypercalciuria (FH, 39 patients) and absorptive hypercalciuria (AH, 31 patients). RESULTS: Only in the patients with FH was the lumbar spine bone density lower than in the controls (P <0.001). Also, only the patients with FH had higher bone alkaline phosphatase and urinary hydroxyproline levels than the control group (P <0.005 and <0.015, respectively). The blood pH levels were lower, even though within the normal range, in the hypercalciuric patients than in the controls (P <0.01). There was a negative correlation between the urinary hydroxyproline level and lumbar spine and femoral neck density in patients with FH (P <0.001 and <0.005, respectively), and the blood pH correlated positively with the lumbar spine bone density. CONCLUSIONS: Altered bone metabolism and overall bone loss were found only in the patients with FH. Overloading of acid valences, perhaps of dietary origin, could be the pathogenic factor responsible.

Elderly ovarian cancer: treatment with mitoxantrone-carboplatin.

OBJECTIVE: Data concerning optimal treatment of elderly patients with ovarian cancer are scanty. The management of ovarian cancer in the aged patient is many-sided: the diagnosis can be difficult and delayed, and aggressive surgery is often not attempted because of concomitant morbidity. We tested a combination of carboplatin and mitoxantrone potentially associated with low toxicity in elderly patients with ovarian cancer. METHODS: Eighty-two patients older than 70 years (median age, 75; range, 70-88) with epithelial ovarian cancer were referred to our multicenter group and enrolled into this pilot study. Carboplatin (JM8) was given at the dose of 230 mg/m2 and mitoxantrone at the dose of 9 mg/m2 every 28 days. RESULTS: Dose-limiting toxicity was represented by 4 cases of thrombocytopenia and 1 case of gastrointestinal toxicity. These 5 episodes occurred in 328 assessable cycles, representing a low toxicity profile (3%). Of the 68 assessable patients, 36 (53%) did not respond to chemotherapy (no change + progressive disease), complete response was observed in 15 (22%), and partial remission was observed in 16 (23.5%), accounting for an overall response rate of 45%. CONCLUSION: The carboplatin-mitoxantrone combination, at the dosage tested in this study, appears to be well tolerated by elderly patients with advanced ovarian cancer and is associated with an acceptable response rate. Optimally debulked patients also showed improved survival when compared with patients with more extensive tumor.

Surgical second look in ovarian cancer: a randomized study in patients with laparoscopic complete remission--a Northeastern Oncology Cooperative Group-Ovarian Cancer Cooperative Group Study.

PURPOSE: The usefulness of extensive and repetitive surgery for patients with ovarian cancer still remains unproven (at least for some conditions). We planned an accurate prospective test of the hypothesis that patients with advanced-stage disease, after they had reached a clinical complete remission (CR), may benefit from surgical second look (SSL). PATIENTS AND METHODS: One hundred two patients in CR (as assessed by clinical findings, markers, and visualization by computed tomographic [CT] scan and laparoscopy), after initial debulking and first-line chemotherapy, were randomized to two arms, which were well balanced for predictive criteria such as age, stage at presentation, histology, grading, date of randomization, and residua after first surgery. Forty-eight patients were randomly assigned to receive follow-up evaluation only, while 54 were assigned to receive second surgery (eight of them refused). Of 46 surgical patients, 35 had negative and 11 positive surgical findings (24% clinically false-negative). RESULTS: Despite the microscopic residua found at open surgery, and the fact that the patients were then treated with second-line chemotherapy, SSL did not increase the probability of survival in this setting. In an analysis of the results according to the intention-to-treat criteria, after a 60-month follow-up period, the overall survival rates in the two groups of patients (SSL v no SSL) were 65% and 78%, respectively (P = .14). Multivariate analysis according to predictive criteria confirmed there was no significant difference between the two groups (P = .39). CONCLUSION: Our study shows the following: (1) our second-line treatment is scarcely effective; (2) SSL accurately defines complete responders to first-line chemotherapy; (3) SSL per se does not prolong survival; and (4) if confirmed, a less invasive procedure could replace SSL as a valuable method in new first-line regimens in ovarian cancer patients with clinical CR confirmed by laparoscopy.

Phase I-II intraperitoneal mitoxantrone in advanced pretreated ovarian cancer.

36 previously treated patients (25 with anthracyclines) with advanced epithelial ovarian cancer have been treated with intraperitoneal (i.p.) mitoxantrone (M) at increasing doses. The response was evaluated through repeated laparoscopy with multiple biopsies and serial measurement of Ovarian Cancer Antigen 125 (CA 125); 11/36 patients had a complete (6 patients) or partial (5 patients) response. Toxicity (both local and general) was observed starting from 25 mg/m2 of M per cycle. The amount of drug reaching systemic circulation was monitored by measuring M plasma value after i.p. treatment. This study showed wide variations in serum levels obtained after i.p. doses ranging from 23 to 36 mg/m2. The area under the curve (AUC) of mitoxantrone plasma samples, did not correlate with the i.p. administered dose. Conversely, a correlation seems to exist between the plasma AUC and the responder status. Patients who showed clinical responses to i.p. treatment with mitoxantrone had AUCs and plasma peak levels of the drug that were significantly higher than those in non-responders (P = 0.03, Fisher's exact test).