Carlo Milano

Unilateral laminectomy for bilateral decompression of lumbar spinal stenosis: a prospective comparative study with conservatively treated patients.

The authors performed single- or multiple-level unilateral laminectomy to treat lumbar spinal stenosis in patients with mild to moderate leg pain and compared the results with those from patients treated with conservative therapy in a prospective study. This decompression technique produced a 68% rate of improvement compared with a 33% rate for conservatively treated patients. The surgical group exhibited significant and sustained improvement, whereas the functional and clinical status of the conservatively managed group had returned to baseline during the same period. The preoperative dural sac cross-sectional area at the level of the most stenosis was 70.76 +/- 28.2 mm(2) for the surgical group, whereas on postoperative scans it was 108.12 +/- 31.5 mm(2), with an average correction rate of 65%. Neither new degenerative spondylolisthesis nor any evidence of instability was detected in any patient during the study.

Factors influencing the outcome of degenerative lumbar spinal stenosis

The objective of this study was to evaluate the influence of decreased dural sac cross-sectional area and baseline clinical parameters on the outcome of patients treated surgically or conservatively for lumbar spinal stenosis. Computed tomography or magnetic resonance imaging scans of 37 patients were digitized and the dural sac cross-sectional area was calculated. This parameter and baseline clinical, socioeconomic, and anthropometric data of the patients were correlated with 1-year and 2-year follow-up data. The decrease in dural sac cross-sectional area negatively affected walking capacity on follow-up controls in patients treated conservatively, whereas such a relation was not observed among surgically treated patients. Female sex was the main parameter that worsened the global outcome of degenerative lumbar spinal stenosis, particularly after surgical treatment.

Relationship between alterations of the lumbar spine, visualized with magnetic resonance imaging, and occupational variables

Although the effect of physical workload on the occurrence of low back pain (LBP) has been extensively investigated, few quantitative studies have examined the morphological changes visualized via magnetic resonance imaging (MRI) in relation to occupational variables. The relationship between the severity of some abnormalities such as lumbar spinal stenosis or spondylolisthesis and physical or psychosocial occupational risk factors has not been investigated previously. In this cross-sectional study patients fulfilled the following inclusion criteria: (1) long-standing (minimum 1-year) LBP radiating down the leg (or not); (2) age more than 40 years; (3) willingness to undergo an MRI of the lumbar spine; and (4) ability to speak Italian. Primary objective of the study was to investigate the association between occupational exposure and morphological MRI findings, while controlling for the individual risk factors for LBP. Secondarily, we looked at the influence of this exposure and the degenerative changes in the lumbar spine on clinical symptoms and the related disability. Lumbar MRI scans from 120 symptomatic patients were supplemented by the results of structured interviews, which provided personal, medical, and occupational histories. All occupational factors were arranged on scales of increasing exposure, whereas pain and disability were assessed using ad hoc validated questionnaires. Evidence of intervertebral disc narrowing or herniation and the occurrence and severity of spinal stenosis and spondylolisthesis was obtained from the MRI scans and a summative degenerative score was then calculated. We detected a direct association between increasing age and the global amount of degenerative change, the severity of intervertebral disc height loss, the number of narrowed discs, stenosis, the number of stenotic levels, and spondylolisthesis. Physical occupational exposure was not associated with the presence of lumbar disc degeneration and narrowing per se, but a higher degree of such an exposure was directly associated with a higher degree of degeneration (P=0.017). Spondylolistesis and stenosis were positively related to heavy workload (P=0.014) and the manual handling of materials (P=0.023), respectively. Psychosocial occupational discomfort was directly associated to stenosis (P=0.041) and number of stenotic levels (P=0.019). A heavier job workload was the only occupational factor positively related to the degree of disability at the multivariate analysis (P=0.002). Total amount of degeneration in the lumbar spine directly influenced pain duration (P=0.011) and degree of disability (P=0.050). These results suggest that caution should be exercised when symptomatic subjects with evidence of degenerative changes on MRI scans engage in strenuous physical labor.

Minimum 20-year follow-up results of Harrington rod fusion for idiopathic scoliosis.

We evaluated the outcome of spinal fusion with a single Harrington distraction rod in patients with idiopathic scoliosis. At follow-up visits a minimum of 20 years post-surgery, we studied 24 patients who had been operated on by the same surgeon. The Scoliosis Research Society (SRS) Instrument and an additional questionnaire of our own, along with an invitation for a follow-up visit, were originally mailed to 28 consecutive patients of the surgeon. The SRS Instrument has seven domains dealing with back pain, general self-image, self-image after surgery, general function, function in terms of level of activity, function after surgery, and degree of satisfaction with the surgery. The length of time between surgery and the follow-up visit averaged 22.9 years (20.2–27.3). The mean age at surgery and follow-up were 15.8 (13–22) and 38.8 (35–48) years, respectively. Twenty-four patients sent back the completed questionnaires and 16 of them participated in the clinic and radiographic follow-up. To assess the meaning of the questionnaires’ results, a control group of the same sex, age and geographic provenance was selected from our outpatients without scoliosis. The average follow-up score on the SRS Instrument for the patients was 100.8 (78–110). When we compared the study and control groups, no significant differences in the single SRS domain scores were observed. The mean Cobb angle and rib cage deformity before surgery were 70.46° (40–120) and 36.4 mm (20–60 mm), respectively, whereas on follow-up they were 41.23° (16–75) and 22.3 mm (5–50 mm), respectively. These long-term results lead us to consider Harrington fusion a procedure that produces a long-lasting high degree of self-reported post-operative satisfaction.

Platelet Gel Supplementation in Long Bone Nonunions Treated by External Fixation

Objective: The aim of the present study was to evaluate the use of previously frozen, thawed platelet gel supplementation to accelerate the healing of long bone nonunions treated by external fixation. Design: Prospective case series with historical controls. Setting: University Hospital. Patients: Twenty patients affected by tibial, humeral, or forearm atrophic nonunions were treated by percutaneous stabilization with unilateral external fixators and injection of autologous platelet gel. The healing time was compared to the result obtained in a historical control group treated without platelet gel supplementation. Main Outcome Measurements: Consolidation rate and radiographic healing time of nonunions in the 2 groups were assessed by independent blinded observers. The nonunion was judged to be healed when bridging callus formation on both radiographic views was observed on at least 3 of 4 cortices. Results: The healing rate of nonunion was 90% (18/20) in platelet gel cases and 85% (17/20) in controls, respectively (P = 0.633). The mean time until radiographic consolidation in nonunions supplemented with platelet gel (147 ± 63 days) was not different to the result in the control group (153 ± 61 days; P = 0.784). Analyzing the mean healing time for separate segments, no differences were noted between study and control group-that is, tibia: 112 ± 43 and 130 ± 5 days, respectively (P = 0.382); humerus, 225 ± 36 and 202 ± 70 days, respectively (P = 0.530). Conclusion: The present study failed to show the clinical usefulness of isolated percutaneous platelet gel supplementation in long bone nonunions treated by external fixation; however, caution should be exercised in interpreting this result because the actual numbers are small and the statistical power is limited.

Distribution of Borrelia burgdorferi sensu lato genomic groups in Europe, a review

The present study was designed to investigate relationships between urinary free pyridinolines (F-Pyr), serum osteocalcin (OC) and appendicular bone mineral density (BMD). Furthermore, possible correlations between such variables and putative risk factors for low bone density were also analysed. We were not able to find any relationships between biochemical markers of bone turnover and appendicular BMD or putative risk factors for osteoporosis at multivariate analysis. Multivariate analysis showed a significant decrease of BMD when age increases (p < 0.001), with menopause and time since menopause (p < 0.001), while number of pregnancies (p = 0.018) was associated with a higher value of BMD. Age, menopause and time since menopause were significantly associated with urinary excretion of F-Pyr. Indeed age was an inverse effect modifier of the relationship between urinary excretion of F-Pyr and time since menopause.The present study was designed to investigate relationships between urinary free pyridinolines (F-Pyr), serum osteocalcin (OC) and appendicular bone mineral density (BMD). Furthermore, possible correlations between such variables and putative risk factors for low bone density were also analysed. We were not able to find any relationships between biochemical markers of bone turnover and appendicular BMD or putative risk factors for osteoporosis at multivariate analysis. Multivariate analysis showed a significant decrease of BMD when age increases (p < 0.001), with menopause and time since menopause (p < 0.001), while number of pregnancies (p = 0.018) was associated with a higher value of BMD. Age, menopause and time since menopause were significantly associated with urinary excretion of F-Pyr. Indeed age was an inverse effect modifier of the relationship between urinary excretion of F-Pyr and time since menopause.

An Enlarging Distal Tibia Osteochondroma in the Adult Patient

The extensive enlargement of a solitary osteochondroma in a skeletally mature patient is rare and might result from malignant transformation. Excision of such a lesion in the distal and lateral aspect of the tibia is difficult because of the risk of injury to the neurovascular structures and the possible functional consequences with respect to ankle stability. We present a case of an active osteochondroma arising from the posterolateral distal tibia in an adult patient. The tumor was successfully excised by using a transfibular approach with fibular reconstruction. No signs of recurrence were noted 2 years after surgery.

A comparative study on medium-term results of cementless acetabular components with metal-on-metal and metal-on-polyethylene articulations

The purpose of this study was to evaluate the medium-term clinical and radiological outcomes of two metal-backed acetabular cups with metal-on-metal and metal-on-polyethylene joint couples, in patients unselected for age. Seventy-five metal-on-polyethylene CLS expansion cups were implanted in 70 patients and 66 metal-on-metal Fitek cups were implanted in 65 patients. The average age at surgery in the two groups was 63 years (range, 25 to 72 years) and 58 years (range, 32 to 68 years), respectively. Data regarding 64 of 75 CLS cups (85%) and 58 of 66 Fitek cups (88%) were collected at a minimum 36-month and maximum 144-month follow-up. The Harris hip score showed excellent results in 86% of the CLS cups, good results in 7%, and fair results in 7%. No poor results were recorded. For metal-on-metal acetabular components, excellent results were recorded in 84% of the cups, good results in 8%, fair results in 5%, and poor results in 3%. Fifty-five patients with 57 of 64 CLS cups (89%) and 50 patients with 51 of 58 Fitek cups (88%) were fully satisfied with their prosthesis. No acetabular reconstructions were revised for aseptic loosening. No radiolucent lines greater than 2 mm were observed, either about CLS or Fitek cups, and low incidence of osteolysis and polyethylene wear was noted in metal-on-polyethylene articulations. Post-operative three-phase bone scanning was obtained in 51 patients and this examination did not show increased uptake in blood pool or bone phase indicating aseptic loosening of CLS and Fitek cups. In conclusion, we found similar rates of excellent and good results using two acetabular components with different bearing surfaces, in patients of unselected age. Therefore, the less expensive implant should be selected for total hip arthroplasty in elderly or low-demand patients.