Effectiveness of bone marrow aspirate concentrate (BMAC) as adjuvant therapy in the surgical treatment of congenital pseudoarthrosis of the tibia: a retrospective comparative study.

Congenital pseudoarthrosis of the tibia (CPT) is a rare disease characterised by the onset of bone anomalies or fractures, leading to deformities in paediatric patients. The aetiology of this pathology is unknown. The main theories include the presence of hamartomatous tissue related to Neurofibromatosis type 1, vascularisation deficit of the periosteum and alterations in the numbers and functions of the osteoblasts and osteoclasts in loco. Surgical treatment generally requires multiple operations during the patient's childhood and adolescence. The best outcomes seem to occur when using intramedullary nailing, vascularised fibular transplant and external fixation with the Ilizarov technique. The purpose of this paper is to evaluate the effectiveness of in-situ injections of Bone Marrow Aspirate Concentrate (BMAC) as an adjuvant therapy for congenital pseudoarthrosis of the tibia in patients treated with external fixation and that of radiographic healing over time compared to external fixation treatment alone. We performed a retrospective review of clinical and radiographic records of patients affected by CPT and treated in the Paediatric Orthopaedics and Traumatology Department of the Gaetano Pini Orthopaedic Institute with in-situ injections of bone marrow aspirate concentrate (BMAC) on the pseudoarthrosis site, in addition to pseudoarthrosis site excision and application of circular external fixator frame in compression (Group A). The time needed to reach the radiological consolidation of the resection site was recorded and compared to that needed for patients treated with only pseudoarthrosis site excision and application of circular external fixator frame in compression (Group B). There is a statistically relevant improvement of healing time in patients affected by congenital pseudoarthrosis of the tibia treated with external fixation and bone marrow aspirate concentrate compared to patients affected by the same pathology treated with external fixation only. Injection of MSC in the pseudoarthrosis site after focus removal in combination with circular external fixation achieves faster bone healing compared with external fixation only, and the lower refracture percentage may be associated with the better quality and structure of the new bone. However, it would be desirable to have a longer followup to determine if the results of the BMC as adjuvant therapy will hold up over time.

Retrospective, multicenter evaluation of complications in the treatment of diaphyseal femur fractures in pediatric patients.

INTRODUCTION: Femoral shaft fractures are the commonest major pediatric fractures. For generations, traction and casting were the standard method of treatment for children. However, over the past two decades there has been growing recognition of the advantages of fixation and rapid mobilization. METHODS: A prospective multicenter study was conducted at four Italian centers of reference for pediatric fractures (January 2005 to December 2014). The study involved 62 patients of both sexes, between 6 and 14 years of age, with closed femoral shaft fractures. The aim was to find out more about the short-term complications of titanium elastic nailing in diaphyseal femur fractures in children in order to reduce them. RESULTS: The commonest complication observed in our study was pain at the nail entry point (24.19%) due to a local inflammatory reaction. After 1 year, 3.22% had limbs of different lengths. Proximal migration occurred in 1.61% of cases. DISCUSSION: Over the last two decades, the treatment of femoral shaft fractures in pediatric patients has developed to include internal fixation using Titanium Elastic Nails (TEN). We only observed a few complications in our study, most of which were minor and associated with the surgical technique employed, particularly during the initial phase of the surgeon's learning curve. CONCLUSIONS: TEN are an excellent internal fixation system if used by an expert surgeon and have a very low rate of complications. None of them produced permanent damage in the patients. In older children weighing more than 50 kg, alternative techniques such as subtrochanteric nailing, plates, or external fixation are advisable.

[Evaluation of the combined treatment of oral viscosupplementation with hyaluronic acid intra-articular injection on symptomatic knee osteoarthritis]. / Valutazione del trattamento combinato della viscosupplementazione orale con acido ialuronico per via infiltrativa sulla gonartrosi sintomatica.

OBJECTIVES: Numerous clinical evidences support the treatment of knee OA (KOA) with oral formulations based on hyaluronic acid (HA) and chondroitin sulfate (CS). The formulation aim of the present study (IA) combines a hydrolyzed low molecular weight collagen matrix providing high content of depolymerised HA and CS, with methylsulfonylmethane (MSM), Manganese and a milk glycoprotein. The goal was to evaluate whether combined treatment with intra - articular injection of HA and AI is more effective than treatment with HA only for the symptomatic treatment of knee OA. MATERIALS AND METHODS: Randomized, double-blind, placebo-controlled clinical trial. Patients (nr = 100), after undergoing an intra-articular injection with HA, were randomized to receive IA or placebo for 3 months. The efficacy of the treatment was assessed by measuring at baseline, 1 and 3 months, the values of the VAS pain scale, the Knee injury and Osteoarthritis Outcome Score, the Tegner Lysholm Knee Scoring Scale, Lequesne algofunctional index and the consumption of NSAIDs and analgesics. RESULTS: The treatment group HA + IA showed a positive trend compared to the group treated with HA only for all the efficacy variables observed, in particular regarding the VAS and the analgesic consumption. CONCLUSIONS: The evidences obtained in this study point out that the oral viscosupplementation with the formulation aim of the present study (IA) represents a valuable, manageable, effective and well tolerated aid, useful to maintain and extend the benefits obtained with intra - articular injection of HA, helping to significantly reduce the use of painkillers by patients.

A new way to treat forearm post-traumatic non-union in young patients with intramedullary nailing and platelet-rich plasma.

INTRODUCTION: Non-union rate in forearm fractures is generally less than 2% when a proper technique is used; this rate increases when ulnar lesions are involved. PATIENTS AND METHODS: We present a case series of seven young patients whose average age was 14 years (range 11-19 years) at the time of surgery and who presented with a forearm post-traumatic non-union that was previously treated in different ways (three isolated ulnar non-union, two isolated radial non-union and two combined). Average follow-up was 34 months (range 9-72 months). Surgical treatment began with the removal of the previous synthesis and with curettage of the non-union area. The Acumed ulnar rod, Acumed radial rod and Thalon elastic nail (all of them are unreamed and locked nails) together with autologous platelet-rich plasma (PRP) obtained with the Biomet System (concentration of 158.2×10(4) platelets/µL) were chosen to treat the patients. X-rays and clinical controls were conducted every 30 days until recovery. RESULTS: All patients recovered: average recovery was 23 weeks from operation (range 16-36 weeks) and nails were removed 3 months after complete healing. Six patients had excellent results and one patient had a good result (Patient 2, forearm pronosupination 60-0-40 degrees). DISCUSSION: The purpose of the case series was to establish a better way of treatment and to find a technique that could avoid the use of bone grafts, because obtaining autologous bone requires a further surgical procedure that can be really invasive depending on the amount of bone needed. CONCLUSION: All patients in the study showed complete recovery, with excellent clinical outcomes. Although there were only seven patients in this case series, and there is a need to analyse more patients, this study showed that the use of a specific locking nail system can provide proper stability to ulnar or radial atrophic non-union despite rotational forces, and when combined with autologous growth factors (PRP) is sufficient to promote bone healing in young patients without the necessity to take autologous bone grafts.

[Topical treatment of localized edemas of mechanical or inflammatory origin with a novel antiedema ointment. A prospective study]. / Studio prospettico di un nuovo unguento antiedemigeno nel trattamento locale di edemi localizzati di origine meccanica o infi ammatoria.

OBJECTIVE: Following traumas, muscular or articular injuries it is common to observe lesions where edema is the main finding, with local pain leading to a muscular and/or articular limitation hindering the usual activity. MATERIALS AND METHODS: In this study, a new anti-edema ointment with elevated saline concentration designed for the osmotic treatment of swelling has been evaluated. 21 subjects (mean age 34.2 yrs; range 6-73 yrs) have been enrolled and evaluated for the resolution of edema and restoration of the normal functional activity following the local application (3 times/daily) of the ointment until resolution for a maximum of 9 days (mean duration of treatment 5 days; range 2-9 days). RESULTS: After 2-3 days of application edema disappeared or was ameliorated in 13/21 cases, and in other 7/21 at 5-9 days of follow-up (p0.001 chi square for number of beneficial occurrences). Normal activity has been documented in 10/11 subjects in whom it was altered at enrollment. Local tolerability of the ointment has been optimal or good in the majority of patients, being represented only by local itching or erythema. The local application of the anti-edema ointment has allowed also a marked reduction in the use of acetaminophen or other anti-inflammatory treatments, that were infrequent and present only in 4/21 subjects. CONCLUSIONS: This study demonstrates that the local application of an anti-edema osmotic ointment allows to obtain a prompt resolution of the swelling coupled with a marginal use of anti-inflammatory therapies for the control of the local algic and inflammatory component of the disease.

[Complications of leg diaphyseal fracture in a pediatric patient: case report]. / Complicanze di una frattura diafisaria di gamba in un paziente in età pediatrica. Caso clinico.

Fractures in pediatric age have a prominent role when the growth plates are involved, which represent the point of least resistance of the skeleton in children. Traumas in these regions can, therefore, cause chondroepiphysary detachments and alterations of vascularisation which can result in growth anomalies. The aim of this paper is to stress how an early diagnosis combined with a correct therapeutic approach can avoid the onset of deformations and serious disabilities. The case of a 14-year-old boy with an evident deformation and functional impotence of the ankle joint associated with a 7.5 cm heterometry is described. Clinically limping, widespread muscular hypotrophy and a vast zone of trophic suffering of the skin were observed. Anamnesis revealed combined a tibia/fibula fracture due to a trauma caused by crush at the age of 4 years, treated in another hospital by the implant of an intramedullary nail. Upon removal of the nail, relatives referred a progressive deformation of the articulation. Radiographic view showed the presence of an antero-medial epiphysiodesis zone of the distal tibial physis. For this condition the patient underwent a double osteotomy associated with elongation of the same limb by way of Ilizarov external fixator which was removed after 7 months resulting in an evident correction of the axis and the length of the limb. The patient was kept under observation for a follow-up of 2 years with clinical and radiographic controls.

[Risk of arrhythmias in hemodialysis patients vs healthy people]. / Rischio aritmologico in pazienti emodializzati vs soggetti normali.

PURPOSE: Hemodialysis (HD) patients present an elevated risk of ventricular arrhythmias and sudden death. This risk is correlated with QTc dispersion, assessed as the difference between maximum and minimum QT recorded on 12 leads. Our study aimed to estimate the difference between QT, QTc, QT dispersion and QTc in HD patients on standard HD and online hemodiafiltration (HDF) in pre- and post-dialysis vs. normal controls. METHODS: Nineteen uremic patients on standard HD (13 males, six females) and nine patients (six males, three females) treated with on-line HDF were studied. Seven normal subjects were the control group, matched for age and sex. No one was taking drugs that could interfere with electrocardiographic morphology and QT value. Basal anthropometric parameters were taken and simultaneous 12-lead electrocardiograms (ECGs) were recorded before and 30 min after HD. Serum concentration of creatinine (Cr), urea and electrolytes (Na, K, Mg, Ca, Pi) were monitored before and 30 min after HD, in the short interval section. QT interval was measured according to the Bazett formula, in the presence of different heart rates: QTc=QT/RR(0.5) (heart rate corrected QT interval). RESULTS: Anthropometric parameters were similar among the groups. Before dialysis, standard HD patients had lower calcium and higher potassium than the controls (Student's t-test): (p<0.01, p<0.004). ECGs in the two groups did not show essential differences. After dialysis calcium was higher and magnesium lower in HD patients than in controls: (p<0.0006, p<0.000); QT and QTc dispersion was higher in HD patients than in controls: (p<0.01, p<0.04). Before dialysis on-line HDF patients had lower magnesium (p<0.01) than controls; while there were no electrocardiographic differences between them. In the post-dialytic phase, calcium was higher and phosphates, magnesium and potassium were lower than in controls: (p<0.001, p<0.01, p<0.002, p<0.01); QT and QTc dispersion was higher in HD patients (p<0.03, ns). Controls did not demonstrate any correlation between electrolyte and electrocardiographic parameters; while QTc dispersion and phosphates positively and directly correlated in uremic standard HD patients after dialysis (r=0.48, p<0.02), and then QTc dispersion correlated negatively to Ca/P ratio (r=-0.63, p<0.003).

Staged lengthening in the prevention of dwarfism in achondroplastic children: a preliminary report.

We present our experience, since 1983, in lower-limb lengthening for the treatment of achondroplasic dwarfism. We stress the importance of our method, staged lengthening, which includes two separate operations on the tibia, at the ages of 5 and 10, and two on the femurs, at the ages of 6 and 12. This method allows an overall increase in height varying from 30 to 35 cm and has the advantage of minimizing complications, since children tolerate the lengthening-related problems far better. In 9 years 28 children have undergone limb lengthening, and six of these patients have now completed the first three stages, obtaining a total increase in length from 18 to 23 cm. We discuss the staged lengthening program, pointing out advantages and disadvantages of the method.

Levels of circulating intercellular adhesion molecule 1 and E-selectin in serum and synovial fluid of juvenile chronic arthritis patients.

OBJECTIVE: To measure the levels of two adhesion molecules (AM), soluble intercellular adhesion molecule 1 (sICAM-1) and soluble E-selectin (sE-selectin), in serum and synovial fluid (SF) of patients with juvenile chronic arthritis (JCA). METHODS: Both soluble AM levels were tested, in serum and synovial fluid (SF) samples, with an enzyme-linked immunosorbent assay (ELISA) method. RESULTS: Serum levels of sICAM-1 and sE-selectin in JCA patients were not significantly different from those of a control group. Synovial fluid levels of sICAM-1, but not of sE-selectin, assayed significantly higher (p < 0.05) in JCA patients than in controls. Moreover SF levels of both molecules correlated negatively with disease duration, being higher in the earliest phases. No significant correlations were found between JCA sICAM-1 and sE-selectin levels and leukocyte count or ESR. CONCLUSIONS: These observations may signify a more important role of ICAM-1 than E-selectin in the migration of inflammatory cells into JCA SF. The negative correlation of both AMSF levels in JCA patients with disease duration could reflect a higher expression of ICAM-1 and E-selectin during the earliest phases of the disease.

Severe osteoporosis and multiple vertebral collapses in a child during treatment for B-ALL.

The incidence of bone lesions at diagnosis of childhood acute lymphoblastic leukemia (ALL) is relatively high. However, no cases of severe osteoporosis with multiple vertebral collapses secondary to treatment in children with ALL have been reported. We report the case of a 9-year-old-boy with B-ALL, with no bone lesions at the diagnosis that, following the 4th block of aggressive chemotherapy (protocol B-ALL BFM 86), presented severe back pain and functional impairment with diffuse osteoporosis and vertebral collapses. He was treated with calcitonin, vitamin D, calcium, physical therapy and orthopedic corset. Osteoporosis progressed slowly during the following 2 months of chemotherapy and the boy developed dorsal kyphosis. After discontinuing antiblastic treatment progressive clinical improvement was observed, with complete resolution of kyphosis in about 6 months. An almost complete bone recovery was seen on X-ray survey at 26-months follow-up.

Methods for the study of bone regeneration in lengthening of the limbs.

In addition to standard radiography the authors used two other methods, echography and dichromatic bone densitometry, in the evaluation of bone regeneration in patients submitted to lengthening of the lower limbs. They report their findings and conclusions on the value of these methods.

A study of the interface between human bone and hydroxylapatite. A morphological and morphometric investigation.

The results are reported of clinical experiments conducted on four volunteers suffering from fractures of the tibia. Dense hydroxylapatite screws were used in association with conventional internal fixation. On removal of the plates and screws at periods varying from 4 to 12 months after implantation, the hydroxylapatite screws were removed together with a core of surrounding bone in order to study the bone hydroxylapatite relationship. Conventional and scanning electron microscopy was used, as well as dichromatic bone mineralometric tests. The results confirmed the excellent biocompatibility of hydroxylapatite with human bone. Arising out of this, the possible future clinical application of dense hydroxylapatite is discussed.