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Background: Intramedullary nailing (IN) seems to be the best primary surgical treatment for patients with either polyostotic fibrous dysplasia or McCune-Albright syndrome (PFD/MAS) when the femur and tibia are totally affected by fibrous dysplasia (FD) and pain, fracture and deformity are likely to occur. However, other management protocols have been applied in these cases, often leading to disabling sequelae. This study sought to evaluate if IN could also have been effective as a salvage procedure to provide patients with satisfactory results, regardless of the poor results due to the improper treatment previously performed., Materials and Methods: Twenty-four retrospectively registered PFD/MAS patients with 34 femurs and 14 tibias totally affected by fibrous dysplasia had received various treatments with unsatisfactory results in other institutions. Before the IN performed in our hospital, 3 patients were wheelchair bound; 4 were fractured; 17 limped; and many used an aid for walking. Salvage IN was performed in our hospital at a mean patient age of 23.66 ± 6.06 years (range, 15-37 years). The patients were evaluated before-except for the four fractured ones-and after IN using the validated Jung scoring system, and the data were statistically analyzed., Results: The mean length of follow-up after IN was 9.12 ± 3.68 years (range, 4-17 years). The patients' mean Jung score significantly improved from 2.52 ± 1.74 points before IN to 6.78 ± 2.23 at follow-up (p < 0.05). Ambulation was improved in ambulatory patients and restored in wheelchair users. The complication rate was 21%., Conclusions: Regardless of the high rate of complications, IN may be considered a reliable surgical procedure to salvage a failed treatment in PFD/MAS, with long-lasting satisfactory results achieved in most patients. Trial registration statement: Not applicable., Level of Evidence: IV., (© 2023. The Author(s).)

Background: In children, intramedullary nailing (IN) has been proposed as the best treatment when the femur and tibia are totally affected by fibrous dysplasia (FD). However, in younger children IN must be repeated to maintain stabilization of the affected skeletal segment during growth. We report the long-term results in a cohort of patients in whom more than two-thirds of cases had IN repeated during growth., Methods: Twenty-nine femurs and 14 tibias totally affected by FD were treated by IN in 21 patients with polyostotic FD and McCune-Albright syndrome. Thirteen patients with 35 femoral and tibial deformities had a painful limp whereas 8 presented fractures. The patients had their first IN at a mean age of 9.26±2.68 years (range: 4 to 14 y). IN was repeated during growth in the younger patients, and all the patients underwent a mean of 2.13 femoral and 1.50 tibial IN per limb. The last IN was performed at a mean age of 16.42±1.95 years (range: 11 to 19 y). Titanium elastic nails and adult humeral nails were used in younger children, whereas adult femoral cervicodiaphyseal and interlocking tibial nails were used in older children and adolescents. At the latest follow-up, the patients were evaluated with a clinicoradiographic scale. All the data were statistically analyzed., Results: The mean length of follow-up from the last IN was 6.47±3.10 years (range: 3 to 14 y), and the mean age of the patients at follow-up was 22.85±3.53 years (range: 14 to 29 y) when lower limbs were fully grown in all but 1 patient. Satisfactory long-term results were obtained in about 81% of our patients, while complications occurred in 32.5% of the 43 cases., Conclusion: Lower limb IN-that was repeated in younger children during growth-provided satisfactory long-term results in most of our patients, with fracture and deformity prevention and pain control, regardless of the high rate of complications that mainly affected the femoral cases. Missing scheduled follow-ups was the main predictor of a poor result., Level of Evidence: Level IV-case series., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Polyostotic fibrous dysplasia (PFD) generally cause deformities and fractures of femur and tibia and surgery is often required. The current surgical treatment for deformities is based on single or multiple osteotomies followed by stabilization with intramedullary nails, which are commonly used also for fractures. One of the most common surgical complications of intramedullary nailing is represented by surgical site infection with possible extension to the whole skeletal segment. In the present study we evaluated the incidence of surgical site infections in 44 patients affected by PFD in which 91 femurs or tibiae underwent intramedullary nailing to treat deformities or fractures. We never observed any infection of the operated femurs or tibiae until the final follow-up. The only post surgical infection was present in a patient with monomelic involvement at the contralateral non affected limb, which was surgically treated for limb length inequality, by femur shortening osteotomy stabilized by an intramedullary nail. The most likely hypothesis to explain the complete absence of infections in these patients may be related to the high local concentration of prophylactic antibiotic in the highly vascularized fibrodysplastic bone., (Copyright 2020 Biolife Sas. www.biolifesas.org.)

The authors reviewed 54 (58 hips) patients with acetabular dysplasia following developmental dislocation of the hip (DDH), treated by triple pelvic osteotomy according to the Tönnis technique. The aim of our study was to report the long-term clinical and radiographic results of the operation at a mean follow-up of 12 years (from 7 to 20). At diagnosis, all the hips were painful, the Wiberg angle measured less than 20°, and no radiographic signs of osteoarthritis were present. At follow-up, 82.7% of the operated hips showed either excellent or good results, according to Harris, and the Wiberg angle measured an average of 34° (from 26° to 45°). We encountered five complications: one acetabular malrotation and four asymptomatic ischial nonunions. In conclusion, we believe that, although Bernese periacetabular osteotomy is nowadays considered the gold standard for the surgical treatment of the dysplastic hip following DDH, Tönnis osteotomy represents a good treatment option: it is technically easy, enables direct visualization of the three osteotomies, leads to few complications, and its learning curve is short. The absence of radiographic signs of osteoarthritis and hip congruency before surgery are the basic requirements to achieve a successful result.

Objective: We compared two series of patients treated at our Hospital for periprosthetic hip and knee infections (PHI; PKI), in order to evaluate etiology, perioperative management (duration of spacer, antibiotic therapy, quality of life during the treatment), length of hospital stay, and costs., Patients and Methods: We included in the study 32 patients with PHI and 30 patients with PKI. The average age of the patients was 74.8 in PHI and 71.2 in PKI. Treatment consisted of a two-stage revision associated with antibiotic therapy. All patients were followed up for at least two years after surgery. We analyzed the causative microorganism responsible for the infection, duration of the spacer and antibiotic therapy, quality of life during this time, length of hospital stay, and total hospital cost of treatment., Results: The gram-negative microorganisms were more common in PHI, without any statistically significant difference compared to PKI. Duration of the spacer for PHI was 7.4 months and 5.5 months for PKI (p=0.005). Length of antibiotic therapy was 6.2 months for PHI and 4.1 months for PKI (p<0.001). Most patients in the two series had an acceptable quality of life during treatment. The mean length of hospitalization was 54 days in PHI and 26 days in PKI (p<0.001). The cost averaged 38,300 euros for PHI and 22,100 euros for PKI (p<0.001)., Conclusions: Our study showed statistically significant differences between periprosthetic hip and knee infections as regards etiology, duration of treatment and global costs. Periprosthetic hip infections are caused by more virulent microorganisms that are harder to eradicate, require a longer length of treatment and have a greater economic impact on the healthcare system.

Background: Deep wound infection in spine surgery is a debilitating complication for patients and increases costs. The objective of this prospective study was to evaluate the efficacy of wound pulse irrigation with a dilute povidone-iodine solution in the prevention of surgical site infection., Methods: 50 patients undergoing spinal surgery were randomly divided into two groups (A and B) of 25 patients each. In group A, wounds were irrigated with dilute (3%) povidone-iodine solution through a low-pressure pulsatile device. In group B, wounds were irrigated with saline solution through a bulb syringe. In both groups, specimens for bacterial culture were harvested from surgical site before and after irrigation., Results: In group A, no surgical site infection occurred; in group B, deep wound infection was observed in 3 patients. In both groups, before irrigation some cultures have been found positive for bacterial contamination., Conclusion: Our study seems to support the idea that low-pressure pulsating lavage of surgical wounds with povidone-iodine diluted to a nontoxic concentration of 3% is an effective therapeutic adjunct measure to prevent surgical site infection in spine surgery. However, the number of the enrolled patients is small and a significant statistical analysis is not practicable. This trial is registered with NCT03249363.

Recalcitrant humeral non-union is a disabling condition that is extremely difficult to treat. The use of BMP-7 has been proposed to improve bone healing. This is a report of the results obtained in 12 patients with recalcitrant humeral non-union treated using stable fixation with a long locking compression plate and BMP-7, autologous bone graft and hydroxyapatite pellets applied at the non-union site. Patients had up to three surgical attempts at non-union healing prior to our treatment. The average time from the initial fracture to our surgery was 5.2 years. Average follow-up was 5.3 years. At follow-up, non-union had healed in all patients by an average of 7.3 months. All the patients were very satisfied with their final results, despite a restricted range of motion of the elbow and a moderate muscular atrophy, which was frequently observed. Our study shows that BMP-7 associated with autologous bone grafting and hydroxyapatite pellets after stable fixation is an effective adjuvant to stimulate bone healing in the treatment of recalcitrant humeral non-union., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Introduction: Injury of femoral vessels is an extremely rare complication in intertrochanteric femoral fractures. In most cases reported, the vascular lesion involves the superficial femoral artery, whereas in very few cases does it involve the profunda femoris artery., Presentation of Case: We report a case of acute bleeding due to laceration of a perforating branch of the profunda femoris artery caused by a sharp fragment of the displaced lesser trochanter in an intertrochanteric femoral fracture; the lesion was treated by transcatheter embolization., Discussion: The arterial injury may be iatrogenic, occurring during intramedullary internal fixation, or less frequently, the injury may be due to the fracture itself, caused by a sharp bone fragment that damages the profunda femoris artery or one of its perforating branches., Conclusion: We believe that intertrochanteric femoral fractures with avulsed lesser trochanter are at risk for femoral vessel injuries caused by the displaced bone spike, and we advise meticulous clinical and laboratory monitoring pre- and post-operatively to prevent serious complications., (Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Marfan syndrome is caused by mutations in the fibrillin-1 gene ( FBN1 ). The most important features affect the cardiovascular system, eyes, and skeleton. The aim of this study was to report the most frequent musculoskeletal alterations observed in 146 patients affected by Marfan syndrome. Fifty-four patients (37%) underwent cardiac surgery and 11 of them received emergent surgery for acute aortic dissection. Ectopia lentis was found in 68 patients (47%) whereas myopia above 3D occurred in 46 patients (32%). Musculoskeletal anomalies were observed in all patients with Marfan syndrome. In 88 patients (60.2%), the associated "wrist and thumb sign" was present; in 58 patients (39.7%), pectus carinatum deformity; in 44 patients (30.1%), pectus excavatum; in 49 patients (33.5%), severe flatfoot; in 31 patients (21.2%), hindfoot deformity; in 54 patients (36.9%), reduced US/LS ratio or increased arm span-height ratio; in 37 patients (25.3%), scoliosis or thoracolumbar kyphosis; in 22 patients (15%), reduced elbow extension (170° or less). Acetabular protrusion was ascertained on radiographs in 27 patients (18.4%). Orthopaedic aspects of the disease are very important for an early diagnosis; however, we have not observed definite correlations between the extent of orthopaedic involvement and aortic complications., Competing Interests: The authors declare that there are no competing interests regarding the publication of this paper.

The authors report the results of long-term follow-up in 29 patients treated for non-union of the carpal navicular with a modified Murray technique performed through a lateral approach. Mean patient age at surgery was 22.5 years. Average time from injury to surgery for nonunion was 18 months. In 5 cases, mild signs of osteoarthritis of the radioscaphoid joint (scaphoid nonunion advanced collapse [SNAC] stage I) were present before surgery, and in 2 cases, radiographic signs of avascular necrosis of the proximal nonunion fragment were evident. In all cases, a corticocancellous nonvascularized bone graft taken from the distal part of the ipsilateral radius was used. Mean follow-up was 11.2 years. Nonunion had healed in 93.1% of cases. At follow-up, the 2 patients in whom nonunion had not healed had severe painful osteoarthritis of the wrist (SNAC stage IV). Twenty patients were asymptomatic, and 5 had occasional pain in the wrist. Wrist range of motion was restricted in all patients compared with the contralateral side. Mild osteoarthritis was observed in 6 patients (SNAC stage I). The average Disabilities of the Arm, Shoulder and Hand score was 8.7 of 100. The modified Murray technique is reliable for treating nonunion of the carpal navicular. The union rate is high, and the incidence of wrist osteoarthritis is low compared with other studies. Early diagnosis and treatment of nonunion (a short interval between fracture and surgery) can minimize the risk of degenerative joint disease. Avascular necrosis of the proximal fragment is not an absolute contraindication to surgery., (Copyright 2015, SLACK Incorporated.)

Background: During the last 35 years, the medial approach has been reported more frequently than the anterior approach for open reduction of developmental dislocation of the hip (DDH), however, few studies have followed children treated by medial open reduction to adulthood., Questions/purposes: The purposes of our study were: (1) to assess the development of 71 completely dislocated hips after medial open reduction, the incidence of additional surgery and avascular necrosis during the followup period, and the long-term radiographic and functional results; and (2) to compare our results with those obtained by others who performed open reduction either by the medial or anterior approach., Patients and Methods: We retrospectively evaluated, after the end of growth, 71 hips in 52 patients who underwent open reduction by the medial approach. The mean age of the patients was 16 months (range, 3-36 months). After surgery, the hips were immobilized in 100° flexion, 60° abduction, and neutral rotation for an average of 6 months. All patients had staged clinical and radiographic followups until skeletal maturity. The length of followup averaged 22 years (range, 13-32 years)., Results: In all the surgically treated hips, the acetabular index normalized by the end of growth, the incidence of avascular necrosis was 18%, and additional surgery was required in 15% of our cases. At the last followup, 93% of the hips were classified as Severin Classes I or II and 7% as Class III; 76% of the hips had an excellent result, 17% had a good result, and 7% had a fair result according to the McKay scale as modified by Barrett and colleagues., Conclusions: Open reduction of DDH through a medial approach provided good long-term radiographic and functional results in patients 3 to 36 months old and it was the only surgery performed in 85% of our cases. Future comparative studies are needed to confirm our results, especially in older children., Level of Evidence: Level IV, therapeutic study.

We report a case of a painful accessory ossification centre of the medial malleolus in an 11-year-old girl who was not involved in sports activities. The patient was treated conservatively, with complete clinical and radiographic healing of the medial malleolus 6 months after the first presentation. We ruled out the uncommon pathological conditions causing chronic pain in the medial malleolus during skeletal growth, such as traction apophysitis of the medial malleolus, osteochondrosis, osteochondritis or avascular necrosis of the distal tibial epiphysis. We speculate that this painful condition may be classified as an osteochondrosis of the accessory ossification centre of the medial malleolus.

Osteolytic vertebral erosion is usually related to tumours, spondylitis or spondylodiscitis. Few reports in the literature describe lytic lesions of anterior lumbar vertebral bodies resulting from abdominal aortic aneurysm or false aneurysm. We report a case of abdominal aortic false aneurysm that caused lytic lesions of the second and third vertebral bodies in an 80-year-old man who underwent endovascular aneurysm repair. Fluoroscopy guided biopsy excluded infection or tumour. We performed a posterior spinal fusion and decompression because of bone loss of the second and third lumbar vertebral bodies and central stenosis. Postoperatively the patient showed satisfactory relief in low-back and thigh pain but, unfortunately, he died 1 month after surgery because of respiratory complications. This case suggests that when a lytic lesion of a lumbar vertebral body is discovered in a patient who has undergone endovascular aneurysm repair, an abdominal aortic false aneurysm may be the cause of the vertebral erosion even in cases without infective pathogenesis.

Trigger finger is a rare condition in children. In this paper, we report on a 2-year-old boy with multiple congenital bilateral trigger digits. The patient had no history of perinatal trauma, viral or bacterial infections, or metabolic disorders. The patient was treated with physiotherapy for one year. At the one-year follow-up, the boy presented with six trigger fingers (3 on the right hand, 3 on the left hand). Neither thumb was involved. The six trigger fingers were treated surgically: first, the right-hand trigger fingers and, six months later, those of the left hand. After each operation, a 4-week brace in extension was applied to the operated hand. The symptoms were completely resolved after surgical treatment. Many authors have recommended surgical release for the treatment of trigger finger in children; empirical treatment with physiotherapy may be an option when symptoms present or appear at an older age.

The purpose of this study was to report the medium-term results in 28 patients affected by closed displaced fractures of the neck of the fifth metacarpal bone (boxer's fracture) with an associated severe swelling of the hand, who were treated with percutaneous transverse K-wire pinning, to verify the effectiveness of this surgical treatment. We opted for this treatment in all cases in which malrotation of the fifth finger and volar angulation of the metacarpal head greater than 30° were associated with a severe swelling of the hand. All the patients were reviewed clinically and radiologically at an average of 25 months after surgery. At the final follow-up, no patient reported residual pain. All patients had full extension of the fifth finger, except two in whom we observed a limitation of the extension of the fifth metacarpophalangeal (MP) joint of about 10°, without significant impairment of hand function. All patients had at least 90° flexion of the fifth MP joint and full range of motion of the interphalangeal (IP) joints. No patient had rotational deformity of the fifth finger with a deficit of grip strength. At the final follow-up, a residual palmar angulation of the head of the fifth metacarpal was found in three patients, with a mean of 7°. The disabilities of the arm, shoulder and hand (DASH) scale had a mean value of 5, and all patients considered their result as good or excellent. We recommend percutaneous transverse pinning in all boxer's fractures in which operative treatment is indicated, especially in patients with severe soft-tissue swelling. The surgical procedure is easy to perform, and surgical results are generally good., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

We report the clinical and radiographic medium-term results obtained for 20 patients (24 fingers) treated surgically for post-traumatic malunion of the proximal phalanx of the finger. In all cases we performed a corrective osteoclasia or osteotomy at the site of malunion, followed by miniplate and screw fixation or by screw fixation only. The corrective osteoclasia was performed when malalignment was addressed within six weeks after injury. Two patients who had two fractures underwent additional surgery (tenolysis and/or capsulolysis) to improve function and ROM. At the final follow-up, at a mean of 24 months after corrective surgery, good or excellent clinical and radiographic results were obtained in all the patients. The pseudoclaw deformity disappeared in all cases in which a volar angulation deformity was present. An average improvement of about 30% in the range of motion of the MP and PIP joints was observed; only 4 patients complained of mild pain at the maximum degrees of articular excursion of the MP and PIP joints. All the patients presented an improvement in grip strength. The mean DASH score in our series was 5 points. In two of the four cases treated by an intra-articular corrective osteotomy, mild radiographic signs of osteoarthritis at the MP joint were present. The data for this study confirm that "in situ" osteotomy stabilized by miniplates and/or screws is an effective procedure to correct post-traumatic malunions of the proximal phalanges of the fingers.

Background: Magnetic resonance imaging (MRI) is often used to evaluate low back pain; however, MRI in the supine position does not always reveal degenerative spondylolisthesis. The existence of a linear correlation between increased fluid in the facet joints seen on the supine axial T2 MRI of the lumbosacral spine and lumbar instability seen on standing lateral flexion-extension lumbosacral radiographs has recently been reported. The objective of this prospective study was to determine the incidence of increased fluid in the lumbar facet joints seen on the supine axial T2 MRI, and to evaluate the correlation of this finding with radiographic evidence of lumbar instability., Materials and Methods: We prospectively analyzed weight-bearing flexion-extension lumbosacral radiographs and lumbosacral MRI in the supine position for 52 patients (mean age 64.7 years) seen at our institution for low back pain and/or radiculopathy. The statistical analysis was performed with Fisher's exact test. A difference was considered statistically significant if P < 0.05., Results: In all but 5 of the 52 patients, degenerative disc disease and facet joint disease were observed on the supine MRI of the lumbosacral spine. Fifteen patients had exaggerated fluid in the lumbar facets on the axial T2 MRI (28.8%). Radiographic signs of degenerative lumbar spondylolisthesis were observed in 12 patients (23.1%), and the degenerative spondylolisthesis was not evident on the supine sagittal MRI in 10 of these 12 patients (83.3%). Among these 12 patients, the axial T2 MRI showed exaggerated fluid in the facet joints at the corresponding level in 8 patients (66%). Increased fluid in the lumbar facet joints was present on the supine axial T2 MRI in 7 patients (13.4%), even though there were no radiographic signs of corresponding lumbar instability., Conclusion: We observed a statistical correlation between increased fluid in the lumbar facet joints on the supine axial T2 MRI and degenerative spondylolisthesis seen on standing lateral flexion-extension lumbosacral radiographs.

We report two cases of a giant extrasynovial osteochondroma of the knee located in the infrapatellar fat pad region, in two females who were 58 and 71 years old respectively. Both patients had noticed the mass many years before our first clinical observation. In both patients, at physical examination a solid, firm and hard mass was palpable in the anterior part of the knee in Hoffa's fat pad region, and the range of motion of the knee was severely restricted and painful. CT scan examination with 3D-reconstruction showed two large, calcified neoformations behind the patellar tendon, between the apex of the patella and the proximal third of the tibia. In both cases, the mass was completely resected surgically through an anterior longitudinal approach. At histological examination, the excised masses consisted of an outer layer of hyaline cartilage without significant chondrocyte atypia and an inner region of bone trabeculae formed by endochondral ossification. At follow-up, 8 and 4 years after the operation, both patients were pain-free, with complete recovery of the range of motion of the knee and without any clinical or radiographic evidence of recurrence. The authors believe that intra-articular extrasynovial osteochondroma of the knee is a primary metaplasia of Hoffa's fat pad. Usually, the tumor develops slowly and asymptomatically over many years. The treatment of choice is a marginal resection of the mass, although a biopsy should be considered in some cases. Recurrences are extremely rare.

A rare case is reported of bilateral physeal lesions of the proximal tibia classified as Salter-Harris type II, which occurred simultaneously after a "flexion type" injury in a 14-year-old boy. Treatment was conservative on the nondisplaced side and surgical, by closed reduction and internal fixation, on the displaced side. There was no previous diagnosis of Osgood-Schlatter disease. After reviewing all the cases described previously, which occurred either consecutively or simultaneously, we conclude that less resistance of the growth plate, typical of late adolescence, likely represents the cause of this type of lesion.

The objective of this paper is to report clinical and radiographic long-term results of a neglected fracture of the medial humeral epicondyle, which was entrapped into the elbow joint. At follow-up, 48 years after the trauma, the patient complained of occasional discomfort around the elbow, but the joint had a normal range of motion and good stability. Radiographs showed that the epicondylar fragment was fused to the medial border of the olecranon. The authors conclude that an old fracture of the medial humeral epicondyle, presenting a fusion of the fragment to the olecranon with normal range of motion and without pain, may be managed expectantly.

We report the short- and mid-term results in six patients (seven feet) affected by markedly comminuted intra-articular calcaneal fractures (Sanders type IV), treated by primary subtalar arthrodesis. The average age at surgery was 40 years. In all patients, arthrodesis of the subtalar joint was performed using a limited lateral approach to the calcaneus; it was stabilised with two or three cannulated screws. No patient had a preliminary reduction and internal fixation of the fracture. The time from injury to surgery averaged 20 days because all of the patients had associated visceral and/or other skeletal injuries. All of the patients were followed up clinically and radiographically 2 times, at an average of 12 months and 53 months after surgery. At the short-term follow-up, the mean AOFAS score was 70 points; the X-rays showed a complete fusion of the subtalar joint in all seven feet, without any sign of osteoarthritis of the calcaneo-cuboid and the talo-navicular joints. In all cases, an altered shape of the calcaneus was present. At the mid-term follow-up, the mean AOFAS score increased to 85 points; in one patient, radiographic signs of osteoarthritis of the calcaneo-cuboid and the talo-navicular joints were present and, in another patient, only talo-navicular joint was present, although both patients were free from pain. The difference between the two AOFAS scores was statistically significant. We believe that primary subtalar arthrodesis performed for markedly comminuted Sanders type IV calcaneal fractures yielded good mid-term results, and it is especially indicated when surgical treatment is delayed for whatever reason. A preliminary open reduction and internal fixation to restore the normal height of the calcaneus before performing the subtalar arthrodesis, as suggested by several authors, does not seem indispensable to obtain good clinical results., (2009 Elsevier Ltd. All rights reserved.)

Background: Surgical treatment is usually mandatory in displaced bimalleolar and trimalleolar fractures. Some authors have recommended early mobilization of the ankle joint after surgical treatment of these lesions. In this study, we evaluate the effect of immediate postoperative continuous passive motion in the management of displaced bimalleolar and trimalleolar fractures treated surgically., Materials and Methods: Two series of 22 patients each, who had had a Weber type A, B or C ankle fracture treated surgically, were followed up at least 10 years after the injury. In the first series, immediately after surgery, a continuous passive motion machine was applied to the operated ankle for 3 weeks, whereas in the second series, after surgery a plaster splint or a plaster cast was applied for 3 weeks., Results: At follow-up, all patients were evaluated clinically and radiographically using the AOFAS Ankle Hindfoot Score System (Kitaoka, Foot Ankle 15:349-353, 1994). The average final score for the first series of patients was 95.7 points (range 87-100 points, standard deviation 3.42 points). Of this series, at radiographic examination, in two patients we observed minor signs of osteoarthritis of the ankle joint. The average final score for the second series was 88 points (range 68-100 points, standard deviation 10.60 points). At radiographic examination, in six patients we observed minor signs of osteoarthritis of the ankle joint, whereas in another one the osteoarthritis was severe., Conclusions: Continuous passive motion started immediately after surgery seems to be an effective method both for allowing complete and quick recovery of the range of motion of the ankle and for reducing the risk of early degenerative joint disease. Immediate passive ankle motion can be applied only after adequate reduction and stable internal fixation.

Background: Distal chevron osteotomy is a procedure widely performed for the surgical treatment of painful hallux valgus. The risks and benefits of a lateral capsular release and adductor tenotomy combined with chevron osteotomy are still debated. The aim of our study was to report the clinical and radiographic outcomes of this combined procedure in mild and moderate incongruent bunion deformities, with a hallux valgus angle (HVA) up to 40 degrees and an intermetatarsal angle (IMA) up to 20 degrees., Materials and Methods: Forty-two patients (52 feet) who consecutively underwent chevron osteotomy combined with lateral release and adductor tenotomy were reviewed 24-36 months after surgery. The mean age of the patients was 53.5 (range, 43 to 64) years. All the deformities were mild to moderate, with a mean preoperative value of 28 degrees in the HVA (range, 16 degrees to 40 degrees) and of 13 degrees in the IMA (range, 9 degrees to 20 degrees)., Results: At followup, the AOFAS hallux score improved from an average of 46 to an average of 88. The HVA and IMA had an average postoperative decrease respectively of 12 degrees and 6 degrees; lateral sesamoid displacement decreased by a mean of 15%. In no case did we observe infection or nonunion of the osteotomy. In one case, painless avascular necrosis of the first metatarsal head developed., Conclusion: Our short-term results show that distal chevron osteotomy combined with lateral release and adductor tenotomy is a feasible surgical option to address mild to moderate hallux valgus deformity, even with an IM angle between 15 and 20 degrees. Clinical and radiographic outcomes are generally good and patient satisfaction is generally high.

A 73-year-old woman presented with a very long-standing anterior dislocation of her right shoulder. She had no pain, mild impairment of active shoulder motion and clinical features suggesting no tear of the rotator cuff. CT 3D reconstructions showed a newly formed glenoid cavity below the coracoid process. This case indicates that an anterior shoulder dislocation lasting even decades may be compatible with an almost normal shoulder function.

Five patients with isolated Madelung's deformity were reviewed with an average follow-up of 34 years after surgery. All the patients were female and their average age at surgery was 12.7 years, whereas the average age at follow-up was 53 years. The deformity was bilateral in four patients and unilateral in one, for a total of nine deformities. At diagnosis, in all the patients the typical radial deviation of the hand was observed, with dorsal prominence of the distal end of the ulna. Pain and limitation of the range of motion were present in all the wrists except two, which were painless but presented marked functional impairment. In no patient did we observe growth disorders of the other bones or deformities typical of osteochondrodysplasias. Surgical correction was sought by both the families and the patients mainly for functional reasons, although cosmetic improvement was also expected. The operation consisted of closing-wedge osteotomy of the distal radial metaphysis and either shortening osteotomy or resection of the distal ulna. At follow-up, the range of motion of the wrists was improved, and all the patients were pain-free and satisfied with the final results. No significant radiographic osteoarthritis was present in any of the operated wrists, although four of the five patients were above 50 years of age.

Two series of patients with relapsing congenital clubfoot were treated by transfer of the anterior tibial tendon to the third cuneiform under the extensor retinaculum. The two series were reviewed at the end of skeletal growth to evaluate the effectiveness of the surgical procedure. The first series included 19 clubfeet and the second 16. The two series of clubfeet were initially treated by two different manipulative techniques and two different complementary soft tissue release operations. In relapsing clubfeet, the foot dorsiflexion/eversion activity of the tibialis anterior was suppressed and the muscle functioned as an invertor. At follow-up the functional results of the second series of patients, in whom the relapsing deformity was passively correctable at the time of surgery, were better than those of the first series of patients, in whom the relapsing deformity was sometimes less passively correctable. None of the operated patients had a further relapse. In both series, the angles formed by the longitudinal axis of the navicular and the first cuneiform, the calcaneus and the fifth metatarsal, and the calcaneus and the cuboid, evaluated both by plain radiographs and by CT scan, were smaller than in normal feet and in the clubfeet that did not relapse. Transfer of the anterior tibial tendon to the third cuneiform underneath the extensor retinaculum corrects and stabilizes relapsing clubfeet by restoring their normal function of foot dorsiflexion/eversion. As a consequence, the cuneiforms and the cuboid were shifted more laterally than normal, as shown by both x-rays and CT scan.

We performed CT to investigate how treatment may modify the basic skeletal pathology of congenital club foot. Two homogenous groups of patients treated by one of the authors (EI) or under his supervision were studied. The first included 32 patients with 47 club feet reviewed at a mean age of 25 years and treated by manipulation, application of toe-to-groin plaster casts and an extensive posteromedial release. The second included 32 patients with 49 club feet reviewed at a mean age of 19 years and treated by the Ponseti manipulation technique, application of toe-to-groin plaster casts and a limited posterior release. At follow-up the shape of the subtalar, talonavicular and calcaneocuboid joints was found to be altered in many feet in both groups. This did not appear to be influenced significantly by the type of treatment performed. Correction of the heel varus and the increased declination angle of the neck of the talus was better in the club feet of the second group, whereas reduction of the medial subluxation of the navicular was better in the first. There was a marked increase in the external ankle torsion angle in the first group and a moderate increase of this angle in the second group, in which medial subluxation of the cuboid on the anterior apophysis of the calcaneum was always corrected. Equinus was corrected in both groups but three-dimensional CT reconstruction of the whole foot showed that cavus, supination and adduction deformities were corrected much better in the second group.

The purpose of this study was to evaluate the influence of age on the outcome of liver resections. One hundred five consecutive hepatic resections were divided into two groups: > or = 65 years old [old group (O-group)] and < 65 years old [young group (Y-group)]. The two groups were first compared to evaluate the distribution of the variables potentially affecting the postoperative course, including primary diagnosis, concomitant diseases, previous upper abdominal surgery, type of operation (major or minor resection), associated procedures, presence and length of portal clamping, intraoperative blood losses and transfusions, and length of operation. The outcome of hepatic resections in the two groups was comparatively evaluated in terms of postoperative mortality, morbidity, transfusions, and length of postoperative hospitalization. The Y-group included 61 resections in 60 patients, mean age 52 +/- 10 years (mean +/- SD), range 23-64 years, whereas the O-group included 44 resections in 43 patients, mean age 71 +/- 4 years (mean +/- SD ), range 65-82 years. The O-group included more hepatocellular carcinomas (45.4% vs 18.0%, P = 0.002) and chronic liver diseases (40.9% vs 18.7%, P = 0.017); the median length of operation was slightly higher in the Y-group (300 minutes vs 270 minutes, P = 0.003). Both O-group and Y-group were comparable (P = n.s.) when evaluated for all other listed variables. As far as concerns the outcome of hepatic resections in the two groups, the length of postoperative hospitalization was identical (median 9 days, 5-60 days), whereas transfusions of packed red cells (O-group vs Y-group: 25.0% vs 16.3%, P = 0.30) or fresh frozen plasma (O-group vs Y-group: 13.6% vs 6.5%, P = 0.053) were not statistically different. Postoperative mortality included one case among young patients whereas no deaths were recorded among elderly patients. Postoperative morbidity was higher in Y-group than in O-group (31.5% vs 20.5%, P = 0.59). The age factor does not negatively affect the outcome of liver resections.

Twenty-four patients (37 feet, 51 toes) affected by hammertoe deformity of the lesser toes and treated surgically by arthrodesis of the proximal interphalangeal joint, stabilized with an intramedullary titanium cannulated screw, were reviewed 1-4 years after the operation. At follow-up, the arthrodesis was fused in 48 toes; three toes showed an asymptomatic radiographic nonunion, and in one of them the screw was broken. In seven toes, the cannulated screw was removed because of persistent pain at the tip of the toe where the head of the screw was located. In one case only, there was a late infection, with toe malalignment. All the patients were able to use street shoes 2 weeks after surgery. The average AOFAS score at follow-up was 86.54 points. Compared to the conventional temporary stabilization with an intramedullary Kirschner wire, the stabilization with a cannulated screw decreases the risk of infection, of radiographic nonunion, and of mallet toe deformity.

The aim of this retrospective study was to evaluate the influence of age on the outcome of liver resection. A total of 129 consecutive liver resections were divided into two groups: > or = 70 years old [old group (O-group)] and < 70 years old [young group (Y-group)]. The two groups were first compared for the variables potentially affecting the postoperative course, including diagnosis, concomitant diseases, previous abdominal surgery, type of operation (major or minor resection), associated procedures, presence and length of portal clamping, intraoperative blood losses and transfusions, and length of operation. The outcome of liver resections was evaluated in terms of postoperative mortality, morbidity, transfusions, and length of hospitalization. The Y-group included 97 resections in 95 patients, aged 55.9 +/- 10.5 years (mean +/- SD; range: 23-69 years), and the O-group included 32 resections in 32 patients, aged 73.7 +/- 3.2 years (mean +/- SD; range: 70-82 years. The O-group included more hepatocellular carcinomas (46.9% versus 20.6%, p = 0.002) and cardiovascular diseases (15.2% versus 1.0%, p = 0.004). The two groups were comparable (p > 0.05) when evaluated for all other listed variables. As regards the postoperative outcome, the length of hospitalization was similar (median, range: 9.5 days, 5-60 days in the Y-group and 9 days, 5-48 days in the O-group) and the need for postoperative transfusions were not statistically different. Mortality included one case among young patients, while no deaths were recorded among elderly patients. Postoperative morbidity was higher in Y-group than in O-group (21.6% versus 9.4%, p = 0.2). In conclusion, the age factor does not negatively affect the outcome of liver resections.

Objective: To compare the radiographic features of two series of congenital clubfeet to determine whether a different treatment protocol may influence the radiographic results at the end of skeletal growth., Design and Patients: Two series of patients with congenital clubfeet, treated by two different manipulative techniques and by two different complementary soft tissue release operations, were radiographically studied at skeletal maturity. Twenty-one normal feet of the unilateral cases in both series served as controls. Anteroposterior and lateral radiographs of the feet were taken with the patient standing, and several radiographic parameters were studied., Results and Conclusions: The size of the talus and calcaneus and the height of the talar trochlea were smaller than normal in all cases of clubfeet, were similar in both series and were not influenced by treatment, whereas all the other radiographic parameters studied were more or less different between the two series and seemed to be influenced by treatment. In no treated clubfoot of either series was a normal radiographic foot anatomy restored, not even in those feet that had an excellent clinical result.

Background: Long-term follow-up studies of adults who had been treated for congenital clubfoot as infants are rare. The purpose of this study was to review and compare the long-term results in two groups of patients with congenital clubfoot treated with two different techniques. In both groups, treatment was started within the first three weeks of life by manipulation and application of toe-to-groin plaster casts, with a different technique in each group. At the end of the manipulative treatment, a posteromedial release was performed when the patient was between eight and twelve months of age in the first group and a limited posterior release was performed when the patient was between two and four months of age in the second group., Methods: At the follow-up evaluations, all patients were interviewed and examined, and standing anteroposterior and lateral radiographs and computed tomography scans of the foot were made. The results of treatment were graded according to the system of Laaveg and Ponseti. Numerous angular measurements were made on the radiographs, and the measurements in the two groups were compared., Results: The first group, which included thirty-two patients (forty-seven clubfeet), was followed until an average age of twenty-five years. The second group, with thirty-two patients (forty-nine clubfeet), was followed until an average age of nineteen years. In the first group, there were two excellent, eighteen good, eleven fair, and sixteen poor results. In the second group, there were eighteen excellent, twenty good, six fair, and five poor results. According to the system of Laaveg and Ponseti, the mean rating in the first group was 74.7 points and that in the second group was 85.4 points., Conclusions: In the second group, use of Ponseti's manipulation technique and cast immobilization followed by an open heel-cord lengthening and a limited posterior ankle release gave much better long-term results than those obtained in the first group, treated with our manipulation technique and cast immobilization followed by an extensive posteromedial release of the foot. In our hands, this operation did not prevent relapse, and neither cavovarus nor forefoot adduction was completely corrected.

This study examines the long-term results of 22 patients treated between 1938 and 1974 either surgically or by observation. Fourteen patients (16 scapulas) were treated by observation, seven patients (seven scapulas) were treated surgically by various methods, and one bilateral case was treated conservatively on one side and surgically on the other. The average follow-up was 26 years (range, 10-55) and the average age at follow-up was 32 years (range, 18-67). Shoulder abduction and cosmesis did not change appreciably over the years for the patients that did not undergo surgery, but the surgical patients did demonstrate an average improvement in shoulder abduction of 38 degrees. Seven of eight patients treated surgically reported a subjective improvement in the cosmetic appearance at follow-up, although four patients had an unsightly surgical scar. Pain in the affected shoulder was uncommon at follow-up in either group. We feel that the final result should be assessed from the viewpoint of the functional outcome and cosmetic appearance, independent of the radiographic aspect. Surgical treatment for patients with Sprengel's deformity is indicated when patient and family expectations are either improved cosmesis or improved function.

The aim of the study was to evaluate the effects of preoperative intra-arterial hepatic chemotherapy (IAHC) on the outcome of liver resections for hepatic metastases from colorectal cancer. Twelve patients (IAHC group) treated by IAHC with fluorodeoxyuridine (FUdR) and subsequent liver resection and 40 patients who underwent liver resection without preliminary IAHC (non-IAHC group) were analysed comparatively in terms of age, gender, concomitant diseases, previous abdominal surgery, type of hepatic resection, use of portal clamping, and associated surgical procedures. For the purposes of the study, length of operation, intraoperative blood losses, perioperative transfusions, length of hospitalisation, complications and mortality were also recorded. The two groups were comparable (p = n.s.) for those variables affecting the perioperative course. As regards the end points of the study, no significant differences were recorded in length of operation, intraoperative blood losses, perioperative transfusions [except for more postoperative plasma transfusions in the IAHC group (16.7% vs 5.0%, p = 0.009)] and postoperative complications (9.1% vs 17.5%, p = 0.415). Postoperative mortality consisted in one patient in the IAHC group. Postoperative hospitalization was significantly longer in the non-IAHC group (median: 8 vs 10, range: 6-13 vs 5-33 days; p = 0.004). IAHC does not negatively affect the outcome of subsequent liver resection.

Thirty-nine patients, who had received a fracture of the olecranon at an average age of 7.4 years, were reviewed at an average age of 32 years, in order to evaluate the results of treatment. All patients had reached skeletal maturity at follow-up. Thirty-four fractures were treated conservatively and five, surgically. Of the 34 fractures treated conservatively, six also had surgical treatment of associated fractures. We identified five patterns of fracture on the basis of the anatomic site of the fracture line, the interfragmentary displacement and the presence of an associated lesion. According to our grading scale, 34 patients had a good result, two a fair result and three a poor result. We observed poor results in only 7.6% of cases, even though 85% of the patients had received an intraarticular fracture. We believe that the long-term prognosis of olecranon fractures in children is related to the anatomic site of the fracture line, to the interfragmentary displacement and to the presence of an associated lesion. Conservative treatment may be indicated when the interfragmentary displacement is less than 2 mm. The presence of an associated lesion is a negative prognostic factor.

Background/aims: Intra-arterial hepatic chemotherapy based on floxuridine infusion is an effective treatment for hepatic metastases from colorectal cancer. The aim of the present study is the comparative analysis of surgical and percutaneous transaxillary approaches to implant a catheter into the hepatic artery for intra-arterial hepatic chemotherapy with floxuridine., Methodology: Fifty-six patients received an arterial device for intra-arterial hepatic chemotherapy. Twenty-eight patients (LPT group) underwent laparotomy to implant the catheter into the hepatic artery, the other 28 patients (PCT group) received a percutaneous catheter into the hepatic artery through a transaxillary percutaneous access. Safety and efficacy of surgical and percutaneous transaxillary approaches were comparatively analyzed in terms of number of intra-arterial hepatic chemotherapy cycles administered, device-related complications causing suppression of intra-arterial hepatic chemotherapy, and biological costs of the procedures., Results: Mean postoperative hospitalization was 8.2 +/- 2.2 days in the LPT group and 1.8 +/- 0.7 days in the PCT group (P < 0.0001), while mean analgesic requirements were 9.7 +/- 3.2 doses in the LPT group and 2 +/- 0.9 doses in the PCT group (P < 0.0001). Mean number of intra-arterial hepatic chemotherapy cycles administered was 6.5 +/- 4.2 in the LPT group and 4.3 +/- 3.4 in the PCT group (P = 0.038). The overall incidence of device-related complications causing suppression of intra-arterial hepatic chemotherapy was 42.7% in the PCT group and 7.1% in the LPT group (P = 0.005)., Conclusions: Surgical implantation is still recommended when laparotomy has to be performed for other contextual procedures, such as colorectal or hepatic resection, while percutaneous transaxillary catheter placement is indicated for palliative or neoadjuvant intra-arterial hepatic chemotherapy.

Seven patients affected by McCune-Albright syndrome with polyostotic fibrous dysplasia were operated on either for fracture fixation or for correction of bone deformity. Ten femurs, three tibiae, and one humerus were stabilized by intramedullary titanium nailing with a modified unreamed femoral nail (UFN) and standard unreamed tibial (UTN) and humeral (UHN) nails. The age of the patients at operation ranged from 8 to 30 years, with an average of 17 years, and the length of follow-up ranged from 8 months to 4 years, with an average of 2 years. Before operation, each patient had suffered from a minimum of three fractures to a maximum of 12, with an average of six fractures. The femur was the most affected skeletal segment. Before surgery, two patients were wheelchair-dependent owing to their severe lower limb bone deformities. At follow-up, all the patients were painless and all were able to walk even though one had to wear a bilateral long leg brace and another had to ambulate with the aid of two crutches. No patient had had additional fractures after surgery. The main intra-operative technical problems of this demanding surgical procedure were: a) reaming of a new medullary canal through the fibrodysplastic bone; b) the amount of blood loss in femoral surgery that ranged from 800 to 2,500 ml.

To evaluate the influence of age on the outcome of liver resections, 105 consecutive patients undergoing hepatic resection were divided into two groups: age > or = 65 years [Old Group (O-Group)] and age < 65 years [Young Group (Y-Group)]. O-Group and Y-Group patients were analyzed comparatively in terms of primary diagnosis, concomitant diseases, previous surgery, type of operation (major or minor resection), associated procedures, presence and length of portal clamping, intraoperative blood losses and transfusions, and length of operation. The end points of the study were postoperative mortality, morbidity, transfusions, and length of post-operative hospitalization. The Y-Group included 61 resections in 60 patients, with a mean age of 52 +/- 10 years (mean +/- SD), range 23-64 years, and the O-Group 44 resections in 43 patients, with a mean age of 71 +/- 4 years, range 65-82 years. The O-Group included more cases of hepatoma (45.4% vs 18%, p = 0.002) and cirrhosis (40.9% vs 18.7%, p = 0.017). Median length of operation was slightly higher in the Y-Group (330 vs 270 minutes, p = 0.003). The O- and Y-Groups were comparable (p = n.s.) when evaluated for all other variables listed. As regards the end points of the study, length of post-operative hospitalization was identical in both groups (median 9 days, range 5-60 days) and neither PRBC transfusions (O-Group vs Y-Group: 16% vs 25%) nor FFP transfusions (O-Group vs Y-Group: 13.6% vs 6.5%) showed any statistically significant difference. Postoperative mortality consisted in 1 death among the younger patients while no deaths were recorded among the older patients. Postoperative morbidity was higher in the Y-Group than in the O-Group (31.1% vs 20.5%, p = 0.59). Advanced age does not negatively affect the outcome of liver resections.

Background: The treatment of isolated, displaced fractures of the medial humeral epicondyle in children is controversial. Both plaster cast immobilization without reduction and open reduction and internal fixation have been advocated. The purpose of this long-term retrospective study was to analyze the functional and radiographic results of both nonsurgical and surgical management of these injuries., Methods: Forty-two patients who had had an isolated fracture of the medial humeral epicondyle with displacement of >5 mm at an average age of twelve years (range, eight to fifteen years) were evaluated at an average age of forty-five years (range, thirty to sixty-one years). The patients were divided into three groups that were comparable with regard to the amount of fracture displacement, age at the time of the fracture, age at the time of follow-up, sports activities and occupation, and duration of follow-up. In Group I (nineteen patients), the fracture had been treated with a long-arm plaster cast without reduction of the displaced medial epicondyle. In Group II (seventeen patients), open reduction and internal fixation with either Kirschner wires or a T-nail had been performed. In Group III (six patients), the epicondylar fragment had been excised with suture reattachment of the tendons and the medial collateral ligament., Results: According to a functional grading scale, there were sixteen good and three fair results in Group I. All but two patients were seen to have nonunion of the fragment on follow-up radiographs, but all had a normal result on valgus stress-testing of the elbow. The range of motion of the elbow was either normal or minimally decreased, and the grip strength of the ipsilateral hand was normal. There were fifteen good and two fair results in Group II. All patients had union of the medial epicondyle, with various radiographic deformities of the medial epicondyle, but the functional results were similar to those of the Group-I patients. The Group-III patients had four poor and two fair results. Four had constant pain at the elbow and paresthesias in the distribution of the ulnar nerve. One patient had a restricted range of motion of the elbow, four patients had an unstable elbow, and three patients had decreased grip strength of the ipsilateral hand., Conclusions: In our study, nonsurgical treatment of isolated fractures of the medial humeral epicondyle with between 5 and 15 mm of displacement yielded good long-term results similar to those obtained with open reduction and internal fixation. The nonunion of the epicondylar fragment that was present in most patients who had been treated only with a cast did not adversely affect the functional results. Surgical excision of the medial epicondylar fragment should be avoided because the long-term results are poor.

Background: The aim of the present study was to evaluate the safety and the efficacy of hepatic resection in the treatment of hepatolithiasis with intrahepatic biliary strictures., Experimental Design: retrospective study., Setting: University hospital, Italy., Patients: 6 consecutive patients with single lobe hepatolithiasis operated on during the 4-year period 1994-98 inclusive., Interventions: major hepatic resections (3 left hepatectomies, 2 left lobectomies, 1 right hepatectomy)., Main Outcome Measures: type and duration of the surgical procedure, intra/postoperative blood losses, intra/postoperative course and complications, pathology, and hepatolithiasis recurrence., Results: Mean operative time was 3.34+/-0.02 hrs (range 3.0-4.3 hrs). Mean blood loss was 233+/-150 ml (range 100-500 ml). No patient required intra/postoperative blood transfusions. No intraoperative complication was recorded. Mean postoperative hospitalization was 17+/-7 days (range 6-28 days). Postoperative course was uneventful in 4 (66%) cases. No postoperative mortality was recorded. One pancreatitis and 1 biliary fistula occurred, for an overall postoperative morbidity of 33%. Pathology showed cholangiocarcinoma in 2 cases (33%). During the follow-up period (range 3-48 months, mean 19.1+/-16.4 months), 1 patient had recurrent cholangitis due to right lobe lithiasis and 1 patient died for cholangiocarcinoma., Conclusions: Hepatic resection is the treatment of choice in patients with single lobe hepatolithiasis and unreversible biliary strictures or possible presence of cholangiocarcinoma. An early indication for surgery may reduce the mortality/morbidity rates of hepatic resection for hepatolithiasis.

To clarify the ventilatory effects of a 5-cm H2O positive end expiratory pressure (PEEP) in healthy men during incremental exercise in normoxic conditions, 22 subjects were subjected to a constant workload (0 W, 50 W, 100 W, 150 W and 200 W) on a cycle ergometer for periods of 8 min each, both with and without 5-cm H2O PEEP. Results show that PEEP increases inspiratory (TI) and expiratory (TE) duration and tidal volume (VT) and decreases breathing frequency (fB) at rest (p < 0.05). During exercise, TI is higher at 50 W and 100 W (p < 0.05), but not at 150 and 200 W. TE only increases at 50 W (p < 0.05). An increased VT (p < 0.05 at 50, 100 and 150 W) and a decreased fB (p < 0.05 throughout the experiment) were observed. However, mean inspiratory flow (VT/T1) and duty cycle (TI/TT) were unaffected by PEEP. In conclusion, this study shows that a 5-cm H2O PEEP slightly modifies the ventilatory parameters in healthy subjects during incremental exercise in normoxic conditions.

Intraarterial hepatic adjuvant chemotherapy after radical hepatic resection for liver metastases from colorectal carcinoma lowers the rate of liver disease relapse. The technique for catheter implantation in the right hepatic artery for subsequent intraarterial hepatic adjuvant chemotherapy after right hepatectomy is herein described and recommended as an effective alternative approach to the standard catheter implantation in the gastroduodenal artery in cases of hepatectomies for liver metastases from colorectal cancer.

Introduction. Intra-Arterial Hepatic Chemotherapy (IAHC) based on floxuridine (FUdR) infusion is an effective treatment for hepatic metastases from colorectal cancer. A percutaneously implanted intra-arterial device may overcome the surgical stress of the laparotomic placement allowing an increase in the number of patients treated by IAHC. The aim of the present study is the comparative analysis of surgical and percutaneous transaxillary approaches to implant the catheter into the hepatic artery (HA) for IAHC. Materials and Methods. Between September 1993 and February 1999, 56 patients received an implantable infu-sion system [SynchroMed(R) (Medtronic, USA) or Port-a-cath(R) (Deltec, USA) connected to an external infusion pump (CADD(R) , Deltec, USA)] for IAHC. Twenty-eight patients (LPT group) underwent laparotomy to implant the catheter into the HA, the other 28 patients (PCT group) received a percutaneous catheter into the HA through a transaxillary percutaneous access. Indications for the laparotomic placement were: 1) synchronous metastases not suitable [technically unresectable or large (>40% of liver parenchyma) or multiple (> 3) metas-tases] for hepatic resection during colorectal surgery; 2) metachronous metastases treated by radical hepatic resection and subsequent adjuvant IAHC. Indications for percutaneous placement were: 1) metachronous metastases not suitable [see above] for hepatic resection; 2) metachronous metastases suitable for hepatic resection after neoadjuvant IAHC for tumor downstaging. All patients received IAHC based on continuous infusion of FU-dR (dose escalation 0.15-0.30 mg/kg/day for 14 days every 28 days) plus dexamethasone 28 mg. For the purpose of the study, the LPT group and the PCT group were comparatively analyzed in terms of age, gender, primary diagnosis, vascular anatomy of HA, ligation/embolization of aberrant HA, previous intestinal or hepatic surgery, contextual systemic chemotherapy, concomitant diseases. Safety and efficacy of surgical and percutaneous transaxillary approaches were then comparatively analyzed in terms of number of IAHC cycles adminis-tered, device-related complications causing temporary or definitive suppression of IAHC, biological costs of the procedures (procedure-related complications, postoperative pain and hospitalization). LPT cases without concomitant surgical procedure other than catheter placement (Cath-LPT group - 10 cases) were also compared with the PCT group for the same end points of the study. Results. LPT group and PCT group were comparable (p=n.s.) when evaluated for all the above listed variables. As for the end points of the study, mean postoperative hospitalization was 8.2+/-2.2 days in the LPT group and 1.8+/-0.7 days in the PCT group (p<0.0001), while mean analgesic requirements were 9.7+/-3.2 doses in the LPT group and 2+/-0.9 doses in the PCT group (p<0.0001). Mean number of IAHC cycles administered was 6.5+/-4.2 in the LPT group and 4.3+/-3.4 in the PCT group (p=0.038). Device-related complications causing temporary or de-finitive suppression of IAHC included catheter displacement in 10 cases (35.7%), HA thrombosis in 1 case (3.5%) and catheter occlusion in 1 case (3.5%) in the PCT group, while in the LPT group 1 case (3.5%) of catheter occlusion and 1 case (3.5%) of HA thrombosis occurred. The overall incidence of device-related complications causing temporary or definitive suppression of IAHC was 42.7% in the PCT group and 7.1% in the LPT group (p=0.005). Comparison of Cath-LPT group and the PCT group showed mean postoperative hospitalization of 5.5+/-0.7 days in the Cath-LPT group and 1.8+/-0.7 days in the PCT group (p<0.0001), and mean anal-gesic requirements of 8+/-3.1 doses in the Cath-LPT group and 2+/-0.9 in the PCT group (p<0.0001). Conclusions. Surgically implanted indwelling catheters for IAHC present lower incidence of device-related complications than percutaneous transaxillary implanted catheters. In spite of its irreversibility and significant biological costs, surgical implant is still advised when laparotomy has to be performed for other contextual procedures, such as colorectal or hepatic resection, while percutaneous transaxillary catheter placement is indicated for palliative or neoadjuvant IAHC.

The authors report the results obtained in 16 patients affected with displaced fracture of the acetabulum treated surgically and mobilized passively immediately after surgery by means of a continuous passive mobilization apparatus for the hip. The age of the patients at the time of trauma ranged from 21 to 54 years. The posterior wall was involved in 12 cases, while the anterior column was also involved in 4. Excellent or good reduction of the fracture was obtained in all of the cases. Immediately after surgery, a continuous passive motion apparatus for the hip was applied to be used for approximately 3 weeks. At final follow-up, which was obtained after a mean time of 5 years, all of the patients except 2 had obtained good results. Moderate joint deficit was present in 1 case, while sciatic nerve palsy that had already been observed prior to surgery persisted in another. Evident radiographic signs of coxarthrosis were not present in any of the cases. Based on the opinion of Salter et al. (1980), who in an experimental study had observed better healing of the cartilaginous lesions in the joints submitted to movement, immediately after surgery we applied a continuous passive motion apparatus for the hip in a group of patients affected with fracture of the acetabulum. As none of the patient followed-up by us presented evident signs of hip arthrosis, the authors hypothesize that continuous passive movement, immediately carried out after osteosynthesis, plays a significant role in preventing post-traumatic arthrosis of the hip. In truth, small irregularities of the acetabular cavity, possibly present after an apparently anatomical reduction, could be minimized by the plasmating effect of the head of the femur in movement.

Purpose: Subcutaneous Infusion Ports (SIPs) for prolonged venous access are useful tools for drug administration in a wide range of chronic diseases. An extensive use of these devices has to be balanced against the potential complications worsening the length and the quality of life of frequently compromised patients. The aim of the present study is the prospective evaluation of early and late complications of the technique for the blind placement of totally implantable devices for prolonged venous access., Methods: Between April l, 1991 and September 30, 1999, 980 SIPs were implanted in 967 patients. Thirteen patients received 2 SIPs. The surgical procedure, the catheter through peel-away technique after infraclavicular approach to the right or left subclavian vein, was performed without intraoperative fluoroscopy (blind placement technique) in the operating room under local anaesthesia. A postoperative chest radiography to rule out any procedure- related complications and to check the position of the catheter tip was obtained in all cases. For the purpose of the study, intraoperative complications as well as all SIP-related complications were recorded during the follow-up period and classified as major and minor complications., Results: The study population consisted of 524 males/443 females, with a mean age of 56.3 +/- 11.4 years (range 19-85 years). Primary diagnosis was malignancy in 916 patients (94.7%), acquired immunodeficiency syndrome (AIDS) in 44 patients (4.5%), and short gut syndrome secondary to subtotal small bowel resection in 2 cases (0.2%), others in 5 cases (0.5%). Perioperative complications were recorded in 12.9% of the 980 insertion pro-cedures, including 77 cases of arterial puncture (7.8%) of the subclavian artery, 1 case of hemoptysis (without clinical and radiological evidence of pneumothorax) (0.1%), 23 cases of pneumothorax (2.3%), 20 of which (86.9%) required chest drainage, 10 cases of unsuccessful progression of the J-wire after the venepuncture (1%), 16 cases of catheter malposition (1.6%). As for the follow-up, 919 patients (95.0%) who had received 942 SIPs turned out to be suitable for long-term analysis, while 48 patients (5.0%) were excluded due to missing data. Seventy-seven SIPs (8.2%) were removed during the follow-up period, 13 of which received a second SIP. Long-term complications were recorded in 9.5% of the 942 SIPs, including mechanical complications (2.9%), infections (4.4%) and venous thrombosis (1.2%). Minor and major complication rates were 7.3% and 2.2% respectively. The overall incidence of SIP-related complications was 22.1%, including 44 major complications (4.5%) and 173 minor complications (17.6%)., Conclusions: Given the low rate of major complications, SIPs should be considered safe and effective devices, representing the first choice approach for prolonged venous access. Blind placement technique performed by full-trained operators yields adequate success rate to be suggested as a routine procedure.

The ventilatory effects of a 5-cm H2O positive end expiratory pressure (PEEP) and its influence on the breathing pattern during short hypoxic exposure both at rest and during physical exercise were studied. There were 22 healthy subjects who were submitted to normoxia and to 4-h of hypoxia in a hypobaric chamber (4500 m, PB = 589 hPa) both at rest and during an 8-min cycle ergometer exercise (100 W) without and with a 5 cm H2O PEEP. The results show that hypoxia compared with normoxia induces increases in tidal volume (VT) (+28.5%, p < 0.05 at rest; and +19.4%, p < 0.01 at 100 W) and in respiratory frequency (f) at 100 W (p < 0.05), and significant decreases in inspiratory (tI) (p < 0.05 at rest and at 100 W), and expiratory (tE) durations (p < 0.05 at 100 W). However, the breathing pattern expressed as duty cycle (tI/tt) is unchanged, whereas an increased mean inspiratory flow (VT/tI) is observed (p < 0.01 at rest and at 100 W). This study also demonstrates that PEEP during a 4-h hypobaric hypoxia significantly increases VT (+22.2% p < 0.01 at rest, +8.9% p < 0.05 at 100 W), tI, and tE at rest (p < 0.05), but not during exercise and tends to decrease f (p = 0.06 at rest and at 100 W). However, PEEP does not alter the breathing pattern in hypoxia since VT/tI and tI/tt are unchanged. Heart rate and arterial O2 saturation are also unaffected by PEEP. In conclusion, this study shows that a 4-h hypoxia modifies ventilatory parameters and mean inspiratory flow (VT/tI) at rest and during exercise (100 W), whereas a 5-cm H2O PEEP does not alter the breathing pattern despite changes in ventilatory parameters are observed.

In 13 joints of 12 patients who sustained traumatic brain injury, heterotopic ossifications of the hip were surgically excised at an average of 15 months after the patients' recovery from coma. All of the patients were referred by neurologists of the postcoma unit who deemed surgery necessary to speed up the rehabilitation program of the patients. Before surgery, three patients were able to ambulate, whereas nine were not ambulatory. Eight hips were ankylosed, whereas five had a severe painful limitation of joint motion. All of the patients were checked at regular intervals after the operation, and the final followup averaged 38 months. In an attempt to prevent postoperative recurrence of ossification, 100 mg of indomethacin was administered daily after surgery for 6 weeks. At followup, 10 patients could ambulate, and two were able to sit in a wheelchair. Patients with poor neuromuscular control tended to lose part of their postoperative range of motion, and heterotopic periarticular ossification recurred in two of them (three hips). No correlation was found between recurrence and the time that elapsed from head injury to the operation, but old ossifications continued to show osteogenic activity at the histologic level.

Background: Patients who are comatose after a traumatic brain injury often have heterotopic periarticular ossification that can be treated with excision to improve the range of motion of the joint., Methods: Areas of periarticular ossification were resected at an average of twenty-three months after recovery from a coma in seven knees of five patients who had a traumatic brain injury. Before the procedure, all of the knees were fixed in a flexed position that ranged from 10 to 40 degrees and they had a painful arc of motion that ranged from 20 to 70 degrees of flexion. None of the patients could walk, and some of them could barely sit in a wheelchair. At the end of the operation, the arc of motion was markedly improved in all of the knees (0 to 130 degrees in three knees, 0 to 120 degrees in three, and 10 to 120 degrees in one). In an attempt to prevent postoperative loss of motion and recurrence of the ossification, continuous passive motion was applied to the involved knee for six weeks before a full rehabilitation program was started. The latest follow-up evaluation was at an average of thirty-four months (range, twenty-five to sixty months)., Results: At the time of follow-up, all of the patients could walk and all of the knees were pain-free. One knee had an arc of flexion of 0 to 90 degrees; two, an arc of 10 to 100 degrees; one, an arc of 5 to 110 degrees; two, an arc of 0 to 120 degrees; and one, an arc of 0 to 130 degrees. Ossification did not recur in any of the knees., Conclusions: Patients with good neuromuscular control had the best general functional result. The routine use of a continuous-passive-motion machine was associated with no recurrence of ossification, and there was some late loss of motion after its use was discontinued.