Antonio Berizzi

Bone transport using the Ilizarov method: a review of complications in 100 consecutive cases.

We present the results of treatment of 100 patients (72 men, 28 women) by the Ilizarov method of bone transport using circular (55) and monolateral external fixators (45). A total of 26 femurs (18 monolateral, 8 circular) and 74 tibias (49 circular, 25 monolateral) was examined. There were no significant differences between the circular fixator and the monolateral fixator with regard to treatment time, complications in the treated bone segments or compliance with the presence of the fixator. The main complications (pseudoarthrosis at bone contact points after transport, insufficient ossification of lengthened bone, knee stiffness) were resolved with further treatment for all patients with the exception of one case which continued with repeated infections. The circular fixator allows for deformity corrections during bone transport but the monolateral fixator is tolerated better by patients, especially in those with femoral defects.

Activated T cells sustain myeloid-derived suppressor cell-mediated immune suppression

The expansion of myeloid derived suppressor cells (MDSCs), a suppressive population able to hamper the immune response against cancer, correlates with tumor progression and overall survival in several cancer types. We have previously shown that MDSCs can be induced in vitro from precursors present in the bone marrow and observed that these cells are able to actively proliferate in the presence of activated T cells, whose activation level is critical to drive the suppressive activity of MDSCs. Here we investigated at molecular level the mechanisms involved in the interplay between MDSCs and activated T cells. We found that activated T cells secrete IL-10 following interaction with MDSCs which, in turn, activates STAT3 phosphorylation on MDSCs then leading to B7-H1 expression. We also demonstrated that B7-H1+ MDSCs are responsible for immune suppression through a mechanism involving ARG-1 and IDO expression. Finally, we show that the expression of ligands B7-H1 and MHC class II both on in vitro-induced MDSCs and on MDSCs in the tumor microenvironment of cancer patients is paralleled by an increased expression of their respective receptors PD-1 and LAG-3 on T cells, two inhibitory molecules associated with T cell dysfunction. These findings highlight key molecules and interactions responsible for the extensive cross-talk between MDSCs and activated T cells that are at the basis of immune suppression.

Psoas muscle pyogenic abscess in association with infected hip arthroplasty: a rare case of simultaneous bilateral presentation

Simultaneous bilateral presentation of psoas abscess with prosthetic joint involvement is extremely rare. A 68-year-old woman presented to us with bilateral dull aching groin pain of 6 months’ duration, which flared up in the past month, associated with pyrexial symptoms. She had undergone bilateral hip replacements in the past with uneventful recovery. MRI showed bilateral psoas muscle collection in communication with the hip joints. Preoperative hip aspirate demonstrated frank pus with positivity on Gram stain and radiographs confirmed prosthetic loosening of bilateral hips. The patient subsequently underwent two-stage revision arthroplasty of both infected hip implants. At 5-year follow-up, the patient remains asymptomatic with good functional outcome and no recurrence on serial MRI.

Extra-articular shoulder resections: outcomes of 54 patients

BACKGROUND The survival of patients with tumors around the shoulder treated with extra-articular resection, the rates of reconstructions-related complications, and the function of the shoulder cannot be estimated because of limited available data from mainly small published related series and case reports. METHODS We studied 54 patients with tumors around the shoulder treated with extra-articular shoulder resections and proximal humeral megaprosthetic reconstructions from 1985 to 2012. Mean tumor volume was 549 cm3, and the mean length of the proximal humeral resection was 110 mm. Mean follow-up was 7.8 years (range, 3-21 years). We evaluated the outcomes (survival, metastases, recurrences, and function) and the survival and complications of the reconstruction. RESULTS Survival of patients with malignant tumors was 47%, 38%, and 35%, at 5, 10, and 20 years, respectively. Rates for metastasis and local recurrence were 60% and 18.5%, respectively. Survival was significantly higher for patients without metastases at diagnosis, tumor volume <549 cm3, and type IV resections. Survival of reconstructions was 56% at 10 years and 48% 20 years. Overall, 19 patients (35.2%) experienced 30 complications (55.5%), the most common being soft tissue failures that required subsequent surgery without, however, implant removal. The mean Musculoskeletal Tumour Society score was 25 points, without any significant difference between the types of extra-articular resections. CONCLUSION Tumor stage and volume as well as type of resection are important predictors of survival of patients with malignant tumors around the shoulder. Survival of the reconstructions is satisfactory; nevertheless, the complication rate is high. The Musculoskeletal Tumour Society score is similar with respect to the type of resection.

Management and treatment of femoral neck stress fractures in recreational runners: a report of four cases and review of the literature

Total knee replacement is a common treatment for advanced knee osteoarthritis. The most common and widespread method is cemented arthroplasty. As in the prosthetic hip a gradual transition from cemented to uncemented fixation techniques occurred over time, increasing interest is growing also around cementless knee fixation, with the theoretical advantages of preserving the bone stock and obtaining a biological fixation avoiding cement fragmentation. On the basis of the actual knowledge, the uncemented knee prosthesis represents an interesting alternative especially for the patient under 65 years of age, with viable bone quality, in which a biological bone-prosthesis fixation is desirable, while avoiding the drawbacks of cement fragmentation and of the possible future revision of a cemented implant. However the weak link remains the tibial fixation, so that technical tips are important to avoid micromovements with subsequent lack of osteointegration. In our experience, gap balancing, mobile bearings and no haemostatic tourniquet well combine with this kind of implant.Injuries of collateral ligaments of MCPs joints are often underdiagnosed but have to be considered serious traumas of the hand. In many cases they concern thumb and rarely long fingers. Closed rupture of the deep transverse metacarpal ligament (DTML) is an unusual parallel injury. Both lesions present similar symptoms included local pain, swelling, ecchymosis and deviation of the finger in flexion and can be misdiagnosed. We describe the treatment of a 34 years old woman who sustained a complex lesion of the soft tissues of third metacarpophalangeal joint with complete close tear of the radial collateral and deep transverse metacarpal ligament following a fall during a walk thus leading to a multiplanar instability. Surgery consisted in mini anchor repair or the collateral ligament tear, direct resorbable suture of DTML and a double k-wire stabilization. Follow up at 11 months has shown excellent functional outcomes.

Megaprosthesis of the knee in tumor and revision surgery

Background and aim of the work : The international literature and analysis of the prosthetic registers highlight a significant relationship between the alignment of the components and the survival of prosthetic implants of the knee. The patient specific instrumentation (PSI) technology exploits the data obtained with the MRN for the production of cutting blocks (CB) useful to a TKA. Revisiting the recent international literature, comparing the results of the conventional method and PSI, numerous studies confirm a statistically significant difference of inliers (± 3 degrees) for HKA. The purpose of this retrospective study was to investigate whether these statistically significant difference is also present in our group. Methods : Postoperative radiographic measures of alignment based on a mechanical limb axis (hip-knee-ankle angle, HKA) of 180° were sought. A range of 180° ± 3° varus/valgus was defined as optimal for mechanical axis. Results: The percentage of knees that had a HKA within ±3° of the desired value was 92.2. Conclusion: the CB did accurately produce the desired HKA. The PS system is an effective and reproducible, whose organizational effort is fully justified.

Le fratture di avambraccio

Fractures of the forearm in the growing skeleton in a common event, accounting for 10% of the overall fracture and at the third place for long bone fractures. Most of these fractures present a simple line. There are several classification but the most widely use is the anatomo-radiological one. The majority of the fracture require closed reduction and immobilization in a long arm cast, with the elbow flexed at 90°, since residual defect that can occur are well tolerate. Under the age of nine angulation deformities lesser than 15° have the possibility to remodell completely. Over the age of nine the toleration is lower than 10°. The time of immobilization has to be at least of 8 weeks, in order to reduce the high risk of refracture. The surgical management of these fracture must to be reserved in case of unstable fractures or impossibility to gain good reduction by closed means. The best surgical solution nowadays is stabilization with elastic stable intramedullary nail. Open reduction and plate osteosynthesis must to be reserved for late adolescent, very near to skeletal maturity. External fixation has limited indication, expecially in politrauma and very high grade of open fractures.

The challenging management of a delayed union midshaft clavicle fracture complicated by an acute pseudoaneurysm of the subclavian artery in a superelderly diabetic patient

Clavicle fractures are among the most common fractures, accounting for 2.6–4% of all adult fractures and for 35–44% of those of the shoulder girdle [1]. Up to 80% occur at the midshaft. Nowadays, the majority of these fractures tend to be treated non-operatively, even when displaced, using an arm supporting sling or a “figure-of-eight” bandage, with good clinical outcomes and an acceptable rate of nonunion. On the contrary, operative treatment is commonly performed in cases of open fractures, skin tenting with the potential for progression to open fracture, “floating shoulder,” and associated acute neurovascular injuries. Despite the proximity of the clavicle to the subclavian vessels, vascular complications in closed clavicle fractures are uncommon, with an incidence of 0.4% [2]. Nevertheless, their prompt diagnosis and proper knowledge is essential because of the high morbidity and mortality rates associated. This report describes the clinical, diagnostic, and therapeutic approaches to address an acute subclavian artery pseudoaneurysm caused by a closed displaced clavicle fracture, complicated by delayed union, in a comorbid octogenarian patient. Presentation of case

L’uso delle megaprotesi nella chirurgia di revisione dell’arto inferiore

Tumor megaprostheses are modular systems commonly used for joint reconstructions following bone resection. In the last two decades, indications on the use of modular prostheses have progressively increased even in non-cancer patients, mainly as a review of implants, in particularly favorable conditions for hip and knee and with severe bone loss. Aim of this study is to define the current indications in the use of megaprostheses as revision implant in non-cancer patients, based on the experience of a reference cancer center and the data reported in the literature.

Current megaprostheses options

The introduction of a multidisciplinary approach with chemotherapy and radiotherapy, and the advances and improvements in surgical and diagnostic techniques now allow limb salvage surgery in most patients with bone sarcomas instead of amputation. Megaprostheses have been used more frequently in the last 3 decades and are now the most common method of reconstruction after segmental resection of the long bones in extremities. Several types of megaprosthetic implants are currently available for limb salvage surgery. The aim of this study was to report the advantages and disadvantages of the most frequently used current megaprosthesis systems to date.