Transphyseal elbow fracture in newborn: review of literature.

Transphyseal elbow fracture is a rare entity in newborns, and in the last century, only case reports or small case series have been published; however, precise epidemiological data lack. Such fractures occur more often in emergency Caesarian section or vaginal delivery. The differential diagnosis with elbow dislocation can be challenging. Radiography, arthrography, magnetic resonance, ultrasound or a combination of these have already been described to make diagnosis, but guidelines for the management of this injury in the neonate are not well established. A review of the literature of the last century about distal transphyseal fracture of the humerus in newborns was performed. A bibliographic search was conducted accessing usual medical databases. The work-up methods, treatments, results at follow-up and the rate of complications were collected. Twenty case reports or small retrospective case series reporting a total of 33 cases were included. A posteromedial displacement of the radioulnar complex was found in 21 elbows (64 %). Four patients (12 %) underwent surgical treatment, whilst 29 (88 %) were managed without surgery. An attempt of reduction was reported in 23 cases (69 %). At follow-up, 88 % recovered completely the carrying angle and 80 % range of motion. A relationship between the type of treatment (conservative or surgical, with attempt of reduction or not) and results at follow-up could not be demonstrated. The most common complication was cubitus varus. Transphyseal elbow fractures are rare among newborns. Regardless of the treatment choice, such lesions are in most cases associated with a good prognosis.

Reverse shoulder arthroplasty without subscapularis repair for the treatment of proximal humeral fractures in the elderly.

PURPOSE: The aim of this study was to evaluate the short-term results after reverse shoulder arthroplasty (RSA) for proximal humeral fractures in elderly patients. METHODS: The same surgical technique was adopted in all patients: the procedure was performed through a deltopectoral approach, the subscapularis was always resected, and a positioning jig was used to implant the cemented humeral component in the desired height and in 20° of retroversion. Nineteen consecutive patients, affected by complex fractures of the proximal humerus, were operated in a 3-year period by the same surgeon at a single institution. All the patients were female, with a mean age of 75 years (range 70-83). RESULTS: Fifteen patients were evaluated at an average follow-up of 22 months (range 12-46 months). A postoperative infected hematoma was the only recorded complication. The absolute Constant score averaged 45.7 (range 19-69), while the relative and normalized scores averaged 65.1 (range 33-97) and 58.5 (range 24-91), respectively. The average Shoulder Pain and Disability Index (SPADI) score was 39 (range 6-89). X-rays showed healing of the greater tuberosity to the humeral diaphysis in nine shoulders. CONCLUSIONS: RSA is an established treatment option for elderly patients with proximal humeral fractures, particularly when general and local conditions are predictive of failure with hemiarthroplasty. Even though clinical results were quite variable in this series of patients, the adoption of a standardized surgical technique allowed to minimize postoperative complications. Subscapularis repair does not seem a critical factor for preventing implant dislocation, but its influence on functional results needs further investigation.

Correlations between biochemical markers in the synovial fluid and severity of rotator cuff disease.

The role of biochemical factors in the onset and natural history of rotator cuff disease is not fully understood, but it is generally recognised that they could induce tendon damage in association with mechanical and vascular factors. In this study, 5 biochemical parameters were analysed (total protein concentration, matrix metalloproteinase (MMP)-2 or gelatinase A, MMP-9 or gelatinase B, type I collagen telopeptides, hyaluronic acid) in the synovial fluid (SF) aspirated from the gleno-humeral joint of 29 patients undergoing surgical therapy for rotator cuff lesions. Four different groups of patients were identified according to the severity of the lesion: partial tear of the rotator cuff, full thickness tear involving 1 tendon and cuff tear arthropathy (CTA). The total SF protein concentration progressively increased with loss of integrity of the rotator cuff, reaching the highest levels in CTA. The absolute enzymatic activity of gelatinases was greater in full thickness tears than in partial tears, while it decreased in CTA. Conversely, the ratio between gelatinases and total protein content reached the highest level in partial tears and then progressively decreased. Collagen I telopeptides were significantly increased in full thickness tears and CTA, whereas the levels of hyaluronic acid decreased with worsening of rotator cuff disease. These findings support the hypothesis that gelatinases, which are involved in physiological tendon remodelling, intervene in the evolution of rotator cuff disease, too. Increased levels of type I collagen telopeptides give evidence that tendon tears are associated with an anatomic loss of tendon tissue and not with simple tendon retraction.

Two-stage revision surgery to treat an infected hip implant. A comparison between a custom-made spacer and a pre-formed one.

A retrospective study was conducted to evaluate the results of two-stage surgical treatment for infected hip implant using two different spacers in antibiotic-impregnated cement, one custom-made and one pre-formed. Out of a total of 20 patients treated between 1995 and 2003, the temporary implant of one custom-made spacer was carried out in 8 cases, while in the remaining 12 cases we resorted to using a pre-formed spacer (Spacer G). In both groups we observed one recurrence of infection, for an overall 90% success rate in terms of eradication of the infection. Custom-made spacers had a greater incidence of local complications (1 breakage, 1 dislocation, 1 sinking of the revision stem) as compared to pre-formed ones (1 dislocation). The clinical results evaluated using the Harris Hip Score showed a statistically significant difference (p < 0.05) in both groups as compared to the preoperative score. The use of a pre-formed spacer, although more costly as compared to that custom-made one, was advantageous in some ways, for example in terms of standardization of the implant method, the lower incidence of mechanical complications and the better functional results.

Partial prosthetic replacement of the shoulder in fractures and fracture-dislocations of the proximal humerus.

A total of 48 patients submitted to partial shoulder replacement for fracture and fracture-dislocation of the proximal humerus were evaluated after a mean follow-up of 5.2 years (range 2 to 10 years). The absolute mean Constant score was 57.8, relative score 76.8% and corrected score 80.4%. A mean of 8.8 points were totalled in the Simple Shoulder Test. Out of 45 patients evaluated radiographically, tuberosity consolidation in the anatomical site was evident in 25 shoulders (55%) and the subacromial space appeared to be preserved in 20 shoulders (44%). More than 90% of the patients declared that he or she was satisfied with treatment. A comparative study on subgroups of patients in an attempt to identify the prognostic value of several factors was conducted. Better functional results were obtained in subjects aged under 70 years, in fracture-dislocations, in shoulders with whole rotator cuffs, in patients with dedicated modular prostheses.

The normalization of data in the Constant-Murley score for the shoulder. A study conducted on 563 healthy subjects.

The study was conducted in order to evaluate the theoretical design of the Constant-Murley system and to reveal any difficulties in obtaining data when it is used in 563 subjects not affected with shoulder pathology. The total mean score for the subjects examined was 85.2 points (minimum 75, maximum 100 points). Values revealed a decreasing trend beginning at 50 years of age for men and 30 for women. Only 4 subjects achieved a maximum score of 100. The measurements taken allowed us to elaborate a reference table based on sex and age, which was required to calculate the correct score. These values differ from those reported by the inventors of the system and they reveal the need to compile personal tables for the normalization of scores.

Autologous chondrocyte implantation using a bilayer collagen membrane: a preliminary report.

OBJECTIVE: To present preliminary clinical experience with Matrix-induced autologous chondrocyte implantation, a new tissue-engineering technique for treatment of deep cartilage defects, in which autologous chondrocytes are seeded on a tridimensional scaffold provided by a bilayer type I-III collagen membrane. METHODS: From December 1999 to January 2001, 13 patients underwent implantation procedure for deep cartilage defects. Age of patients ranged from 18 to 49 years (mean age, 35 years). The mean defect size was 3.5 cm(2) (range, 2.0-4.5 cm(2)). Clinical and functional evaluation were performed using various score systems for the ankle and the knee, and magnetic resonance imaging was performed at 6 and 12 months postoperatively. Membrane structure and cellular population were investigated by light microscopy, scanning electron microscopy, and electrophoresis before implantation. RESULTS: The mean follow-up was 6.5 months (range, 2-15 months). No complications were observed in the postoperative period. The 6 patients with a minimum follow-up of 6 months showed an improvement in clinical and functional status after surgery. Magnetic resonance images showed the presence of hyaline-like cartilage at the site of implantation; there was evidence of chondroblasts and type II collagen inside the seeded membrane. CONCLUSION: Matrix-induced autologous chondrocyte implantation offers several advantages with respect to the traditional cultured cell procedure. These include technical simplicity, short operating time, minimal invasiveness, and easier access to difficult sites. It appears to be a reliable method for the repair of deep cartilage defects.

Management of midclavicular fractures: comparison between nonoperative treatment and open intramedullary fixation in 80 patients.

BACKGROUND: The aim of this study was to compare the results achieved in two groups of 40 patients, treated for uncomplicated midclavicular fractures. METHODS: Group 1 (mean age, 37.2 years) underwent nonoperative treatment with a figure-of-8 bandage, whereas group 2 (mean age, 30.2 years) underwent open reduction and intramedullary fixation with a 2.5-mm threaded pin. The groups were similar with respect to fracture type. RESULTS: A high rate of complications occurred in group 2, including eight superficial infections, three refractures, two delayed unions with pin breakage, and two nonunions. Return to daily activities was undertaken after an average of 16.7 days from trauma in group 1, and after 40.7 days in group 2 (p = 0.00). Also, return to heavy and sport activities was more rapid for patients treated conservatively: 2.6 months versus 3.2 months (p = 0.014). At follow-up, which averaged 63.7 months, clinical evaluation according to the Constant rating scale did not show significant differences between the two groups. The absolute score averaged 84.8 in group 1 and 82.9 in group 2, whereas the mean relative scores were 94.9% and 95%, respectively. Thirty patients of each group were completely satisfied with the treatment received. The most common cause of dissatisfaction was represented by the unaesthetic appearance of the clavicle, because of subcutaneous bone prominence or dystrophic surgical scars. CONCLUSION: According to our experience, we conclude that nonoperative treatment appears more advantageous than open intramedullary fixation for the management of most midclavicular fractures.

The Mitchell bunionectomy: a prospective study of 60 consecutive cases utilizing single K-wire fixation.

The authors prospectively evaluated 45 patients (60 feet) affected by hallux valgus and treated with a distal metatarsal osteotomy. The surgical procedure consisted of a modified Mitchell osteotomy, in which fixation was achieved with a Kirschner wire that was driven into the proximal osteotomy fragment and buttressed the distal one. Early weightbearing was allowed without a cast. Follow-up averaged 25 months. The mean American Orthopedic Foot and Ankle Society clinical hallux score increased from 44.6/100 preoperatively to 83.2/100. Radiographic evaluation showed that mean metatarsophalangeal and intermetatarsal angles decreased respectively from 31.7 degrees to 16.9 degrees, and from 15.4 degrees to 8.6 degrees. Short-term loss of correction occurred in three cases (4%). Six feet (10%) had unrelieved metatarsalgia that was related to excessive shortening of the first metatarsal and/or inappropriate orientation of the metatarsal head. Stabilization of the Mitchell osteotomy with a Kirschner wire proved safe and effective for the surgical correction of mild to moderate hallux valgus.

Resection arthroplasty of the sternoclavicular joint.

The results of resection of the medial end of the clavicle to treat a painful sternoclavicular joint in fifteen patients were retrospectively reviewed. The patients fell into two groups: eight patients who had had a primary arthroplasty of the sternoclavicular joint in which the costoclavicular ligament was left intact (group I), and seven patients who had had revision of a failed arthroplasty of the sternoclavicular joint and in whom the costoclavicular ligament had to be reconstructed (group II). The results for these two groups were compared at an average of 7.7 years postoperatively. All eight patients in group I had an excellent result. In sharp contrast, three patients in group II had an excellent result, three had a fair result, and one had a poor result. We conclude that preservation or reconstruction of the costoclavicular ligament is essential at the time of resection of the medial portion of the clavicle in order to obtain a satisfactory result.

Tibial component in total knee arthroplasty: To cement or not to cement?

Loosening of the tibial component is a major cause of failure in total knee arthroplasty. Implant stability is a key element for achieving long term successful results and relies on the interplay of several factors which include the method of fixation, prosthesis design, surgical technique, bone quality and patient characteristics.The analysis of these aspects may provide some guidelines for the choice of fixation, but an ultimate solution of the problem can not be found in the past experience with total knee replacement. A better understanding of the biological and mechanical changes induced in bone tissue by the joint disease as well as by the prosthesis, will probably allow us to adopt the most appropriate solution for every patient.

Cefodizime modulates in vitro tumor necrosis factor-alpha, interleukin-6 and interleukin-8 release from human peripheral monocytes.

Among third-generation cephalosporins, cefodizime (CFDZ) has shown to modulate many functions of the host defense system against infections. The aim of the present study was to assess the in vitro CFDZ-dependent modulation of interleukin (IL)-6, tumor necrosis factor-alpha (TNF-alpha) and IL-8 release from lipopolysaccharide (LPS)-stimulated human peripheral mononuclear cells (MNCs). Two other third-generation cephalosporins: ceftriaxone (CFX) and ceftazidime (CFT), were also tested under the same experimental conditions. At concentrations ranging from 200 to 50 micrograms/ml, CFDZ significantly decreased TNF-alpha and IL-6 release from maximally (LPS 1 microgram/ml) stimulated MNCs (42% inhibition of TNF-alpha release with 100 micrograms/ml of CFDZ). On the other hand, CFDZ revealed a marked stimulatory effect on IL-8 release (200 micrograms/ml of CFDZ induced 51.5% enhancement of IL-8 release). On the contrary, both CFX and CFT failed to exert any significant effect on TNF-alpha, IL-6 or IL-8 release.

Spondylosis and lumbar instability: pathologic changes.

The degenerative processes of the lumbar spine generally initiate from the intervertebral disc, at the level of which progressive biochemical and structural changes take place leading to a modification in its physical properties of elasticity and mechanical resistance. Disc lesions cause pathological changes in the vertebral bodies, where osteophytes appear, and in the posterior joints. In more severe forms of the process the severe deformation of joint shape may lead to a condition of spondylolisthesis.

Ossification of a perineal haematoma consequent to dislocation of the symphysis pubis.

The authors discuss an unusual complication of dislocation of the symphysis pubis in a female aged 11 years, consisting of an ossified perineal haematoma on one side of the vagina and in the corresponding labrum minore. The most probable pathogenetic hypothesis is that fragments of the periosteum of the pubis remained included in the haematoma, and this was followed by gravitation towards the more dependent tissues.

Bactericidal activity of meropenem and interactions with other antibiotics.

MICs of meropenem for selected clinical isolates of bacteria were determined. Killing curves were performed on strains of methicillin-sensitive Staphylococcus aureus, methicillin-resistant Staph. aureus (MRSA), methicillin-resistant Staph, epidermidis, Escherichia coli, Klebsiella spp., Enterobacter cloacae, Pseudomonas aeruginosa, Citrobacter freundii and Acinetobacter spp. A reduction of greater than or equal to 3 x log10 in viable cells was observed at 4 and 6 h of exposure to 4 and 8 x MIC, and this was usually maintained at 24 h (with a few exceptions for methicillin-resistant Staph, epidermidis and Ent. cloacae). At the MIC and twice the MIC regrowth tended to occur at 24 h although this varied from strain to strain. The interaction with other antibiotics was determined by the chequerboard technique. Usually an additive or synergistic effect was observed when meropenem or imipenem was used in combination with an aminoglycoside against Gram-negative species, while in a few cases antagonism occurred in combination with beta-lactams. Against Staph, aureus, MRSA and Staph, epidermidis synergism was usually obtained with combinations with teicoplanin or vancomycin and either synergism or addition with combinations with rifampicin, co-trimoxazole or ciprofloxacin.

Evaluation of systemic host defense mechanisms in chronic bronchitis.

Seventy-six chronic bronchitis patients were studied in order to determine the possible presence of disorders in their systemic defense mechanisms. No significant difference in lymphocyte subsets, in serum immunoglobulin and complement component (C3 and C4) levels was found in chronic bronchitis patients compared to normal adult controls. Skin tests for delayed hypersensitivity revealed a high frequency (39%) of hypoergic patients (with 1-2 positive reactions) in comparison to normal subjects. Altered values of many functional properties of both neutrophils and monocytes were demonstrated. The percentage of patients with intermediate (between 1 and 2 SD below the mean of controls) and defective (lower than 1.96 SD) values of chemotaxis, phagocytosis index and Candida killing was about 50%. Phagocytosis frequency and nitroblue tetrazolium reduction frequency were less frequently impaired.

The medium-term results of cementless Lord-type hip prosthesis.

The results of 58 cementless total hip prostheses (Lord madreporous type) were evaluated 4 to 7 years after implantation. The functional results were generally satisfactory, although in approximately half the cases some pain was still present. Radiographic examination allowed us to analyse the response of the diaphyseal bone to the different situations of the endomedullary implant. Acetabular wear, which is one of the factors which may influence the long-term results, was also evaluated.