Carlo Perisano

Physiopathology of spine metastasis.

The metastasis is the spread of cancer from one part of the body to another. Two-thirds of patients with cancer will develop bone metastasis. Breast, prostate and lung cancer are responsible for more than 80% of cases of metastatic bone disease. The spine is the most common site of bone metastasis. A spinal metastasis may cause pain, instability and neurological injuries. The diffusion through Batson venous system is the principal process of spinal metastasis, but the dissemination is possible also through arterial and lymphatic system or by contiguity. Once cancer cells have invaded the bone, they produce growth factors that stimulate osteoblastic or osteolytic activity resulting in bone remodeling with release of other growth factors that lead to a vicious cycle of bone destruction and growth of local tumour.

Physiopathology of Bone Modifications in β-Thalassemia

β-thalassemia major (βTM) or Cooley anemia is characterized by significantly reduced or absent synthesis of β-globin chains, which induces important pathologic consequences including hemolytic anemia, altered erythropoiesis, and bone marrow overstimulation. The pathogenesis of bone changes in patients with βTM is not yet completely understood. However, an unbalance in bone mineral turnover resulting from increased resorption and suppression of osteoblast activity has been detected in βTM patients. The abnormal regulation of bone metabolism may be related to hormonal and genetic factors, iron overload and iron chelation therapy, nutritional deficits, and decreased levels of physical activity. Here, we review the most recent findings on the physiopathology of bone abnormalities in βTM. Clinical presentation and radiological features of βTM-related bone changes are also discussed.

Treatment of lumbar curves in scoliotic adolescent females with progressive action short brace: a case series based on the Scoliosis Research Society Committee Criteria.

Study Design. A prospective interventional study. Objective. To determine the outcomes of adolescents affected by idiopathic lumbar scoliosis treated with a progressive action short brace (PASB). Summary of Background Data. The efficacy of conservative treatment of scoliosis is still debated. In a recent study, we showed that the PASB was effective in correcting deformities in adolescents with idiopathic thoracolumbar scoliosis. The purpose of the present study was to extend our preliminary findings by determining the results of PASB treatment in scoliotic adolescents with lumbar curves. Methods. Patients were 40 adolescent girls (age [mean ± SD] = 11.6 ± 0.7 yr]) with lumbar curves and a pretreatment Risser score between 0 and 2. All patients were prescribed with a full-time PASB. The minimum duration of follow-up was 24 months (mean ± SD = 41.6 ± 34.5 mo). Anteroposterior radiographs were used to estimate the curve magnitude (CM) and the torsion of the apical vertebra (TA) at 5 time points: beginning of treatment (t1), 1 year after the beginning of treatment (t2), intermediate time between t1 and t4 (t3), end of weaning (t4), and 2-year minimum follow-up from t4 (t5). Three outcomes were distinguished: curve correction, curve stabilization, and curve progression. Results. A significant reduction in CM was achieved from t1 (Cobb angle [mean ± SD] = 26.4° ± 2.8) to t5 (Cobb angle [mean ± SD] = 13.8° ± 7.9; P < 0.001). Likewise, the PASB reduced TA from Perdriolle rotation angles of 10.8° (SD = 3.7) at t1 to 7.9° (SD = 4.2) at t5 (P < 0.05). Curve correction was accomplished in 82.5% of patients, whereas curve stabilization was obtained in 17.5% of patients. None of the patients experienced curve progression. Conclusion. The PASB allows a complete curve correction in most cases. No patients exhibited curve progression.

Correlation Between Hump Dimensions And Curve Severity In Idiopathic Scoliosis Before And After Conservative Treatment

Study Design. Prospective study in 150 consecutive outpatients affected by adolescent idiopathic scoliosis (AIS). Objectives. The purposes were to (1) identify a correlation between hump dimensions and the severity of scoliotic curve, and (2) evaluate how the treatment influenced the main parameters of scoliosis. Summary of Background Data. The existence of a relationship between clinical deformities and curve severity in AIS is still debated. Furthemore, only a few studies have investigated the effectiveness of conservative treatment for idiopathic scoliosis taking into account both clinical and radiologic factors. Methods. 150 consecutive outpatients (mean age 12.8 ± 1.9 years) affected by AIS were subjected to conservative brace-based treatment. 134 participants completed the treatment protocol. Two parameters were considered to evaluate the treatment progress: the hump and the Cobb angle. Measurements were determined at the beginning and the end of treatment. Statistical analyses were performed in the whole sample and after dividing the study participants into 4 subgroups: patients with lumbar (n = 66) or thoracic curves (n = 68), patients ranging in age between 6 and 13 years (n = 89) and patients ≥ 14 years of age (n = 45). Results. A positive correlation was detected between the hump dimension and curve severity at the beginning and the end of treatment, except for lumbar curves at baseline. The deformity was effectively corrected by the orthotic treatment (Cobb angle: 29.4 ± 8.5° at baseline and 19.3 ± 9.8° at the end of treatment; hump severity: 11.6 ± 5.6 mm at baseline and 6.2 ± 4.6 mm at the end). In addition, our data indicate that the hump correction is more evident than that of the curve registered in Cobb degrees. Conclusion. A significant correlation exists between the hump dimension and curve severity both at the beginning and the end of treatment, except for lumbar curves at baseline. The brace treatment confirmed its effectiveness in arresting the deformity progression and inducing a remodeling both of the scoliotic curve and the hump.

Advantages of a two-step procedure for school-based scoliosis screening

PurposeTo verify if a “two step” school-based scoliosis screening procedure could reduce childhood radiation exposure and, if so, to estimate the subsequent reduction in radiogenic cancer fatalities and in socio-economic burden.Material and methodsData from two different scoliosis screening programs (A and B) performed on a total of 8,995 children (age range 9–14) were examined. Children in program A (5,731 children) were screened using a “two-step” procedure in which school physicians performed the first clinical examination and uncertain cases were referred to an orthopaedist. The school physicians were previously instructed by orthopaedists in the recognition of a number of simple clinical signs. Children in program B (3,264 children) were screened using a “one-step” procedure in which the initial clinical examination was performed directly by an orthopedist. In both programs, suspected cases of scoliosis were then ascertained by the orthopaedist with Radiography. To evaluate the lifetime attributable risk of cancer mortality the guidelines of the International Commission on Radiological Protection Publication 60 were followed. The economic cost of the performed X-ray examination was calculated assuming the current National Health Service’s reimbursement to hospitals of euro 35 per X-Ray exam. The statistic significance of the difference in these estimates between the two programs was assessed using the proportions z-test. The issues of the relative sensitivity and specificity of the two programs were also examined.ResultsIn programs A and B, 86 (1.5 %) and 95 (2.91 %) X-ray examinations were performed respectively (z=4.452, p<0.001). Based on these observations, a screening of 10,000 children directly performed by orthopaedists would result in 291 X-ray exams (2.91 %). A screening of the same number of children using a two-step procedure would result in 150 X-ray exams (1.5 %), with a savings of euro 4,935 for the National Health Care System, a reduction of 0.283 Sv of collective dose, and an estimated 50% reduction in the number of radiogenic malignant tumours.ConclusionsUsing a two-step scoliosis screening procedure provides reasonable sensitivity and specificity while reducing costs and radiation exposure to children.RiassuntoObiettivoVerificare se il ricorso ad un metodo di screening scolastico per la scoliosi “a due tappe” riduce l’esposizione a radiazioni ionizzanti e, se è così, determinare la conseguente riduzione del rischio di cancro radio-indotto e del costo economico.Materiali e metodiAbbiamo esaminato i dati relativi a due programmi di screening (A e B) attuati su 8995 ragazzi (range di età, 9–14 anni). I ragazzi del gruppo A (5731 ragazzi) sono stati sottoposti ad un programma “a due tappe”. I medici scolastici, dopo essere stati istruiti da ortopedici sulla semeiotica clinica elementare, hanno effettuato la prima valutazione clinica ed hanno inviato allo specialista tutti i casi dubbi. Per i ragazzi del gruppo B (3264 ragazzi) è stato utilizzato un programma “ad una sola tappa”, cioè, la valutazione clinica è stata effettuata direttamente dall’ortopedico. In entrambi i programmi, soltanto l’ortopedico ha richiesto gli esami radiografici. Per valutare il successivo rischio di mortalità per cancro, sono state seguite le linee guida della Pubblicazione 60 della Commissione Internazionale sulla Protezione Radiologica. Per calcolare il costo economico degli esami radiografici effettuati, ci si è basati sull’attuale rimborso del Servizio Sanitario Nazionale agli ospedali che è di 35 euro ad esame. La significatività statistica delle differenze tra i due programmi, è stato calcolata con lo z test per le proporzioni. Inoltre, è stata considerata la sensibilità e specificità dei due metodi.RisultatiNei programmi A e B sono stati eseguiti rispettivamente 86 (1,5%) e 95 (2,91%) esami radiografici (z=4,452, p<0,001). Sulla base di queste osservazioni, uno screening di 10000 bambini effettuato direttamente dall’ortopedico, comporterebbe 291 esami radiografici (2,91%). Lo screening di uno stesso numero di ragazzi, utilizzando il programma “a due tappe”, comporterebbe invece 150 esami radiografici con un risparmio di 4935 euro per il Sistema Sanitario Nazionale, una riduzione della dose collettiva di 0,283 Sv ed una riduzione stimata del 50% del numero di tumori maligni radio-indotti.ConclusioniIl ricorso al programma di screening “a due tappe” presenta una buona sensibilità e specificità, riduce i costi e, soprattutto, l’esposizione a radiazioni dei ragazzi.

Correlation between hump dimensions and side deviation in idiopathic scoliosis before and after a conservative treatment.

Methods 134 patients (13 males and 121 females) with an average age of 12.83 ± 1.93 years (range 6-18 years) affected by adolescent idiopathic scoliosis (AIS) were treated with bracing until complete skeletal maturity (72 Lionese, 41 P.A.S.B., 4 Milwaukee -13 mixed treatment P.A.S.B. + lionese, 3 Milwaukee+Lionese,1 P.A.S.B.+Milwaukee). Evaluation of treatment progress took into account two parameters: the hump (clinically measured with a humpmeter) and the Cobb angle (measured by x-rays of whole spine under load). Measurements were taken at the beginning and end of the treatment. Statistical analysis was performed using non parametrical tests to compare averages and make linear regressions between parameters. The same evaluations were made later, dividing the whole group into 4 sub-groups: patients with lumbar curves (66), thoracic curves (68), patients with age over 14 years (45), and under 13 years (89).

A case of parosteal osteosarcoma with a rare complication of myositis ossificans

We report the case of a parosteal osteosarcoma of the distal ulna, treated with wide resection without reconstruction. The patient developed lung metastasis and a mass in the interosseus membrane of the forearm proximally to the osteotomy. The lung mass was found to be a metastasis from parosteal osteosarcoma and the biopsy of the forearm mass revealed a myositis ossificans. The suspicion of a recurrence of parosteal osteosarcoma, already metastatic, led to a second wide resection with no reconstruction. A slice of the radial cortex was taken during this second procedure. From a histological point of view, good margins were achieved and diagnosis of myositis ossificans was confirmed. Two months later, a radius fracture occurred and a synthesis, with plate and screws, as added with poly(methyl methacrylate) (PMMA) to reconstruct the bone loss, was performed. Indication of the reconstructive technique and the complication after distal ulna resection in oncologic surgery are discussed in this paper.

Evaluation of conservative scoliosis treatment compliance

Methods We examined 106 patients (96 females, 10 males) affected by AIS. The patients were treated with different types of orthoses (Lionese, Milwaukee, P.A.S.B., Lionese+P.A.S.B., Milwaukee+P.A.S.B., Milwaukee+Lionese). In order to evaluate the compliance and the final results related to the patients behavior, we considered the following: the patients compliance as related to bracing method, sex, trend of the spine curve, and age; the degree of scoliosis; and the duration of treatment.

Anterior Knee Pain

Anterior knee pain (AKP) is a prevalent musculoskeletal condition characterised by a mechanical pain perceived in the anterior region of the knee exacerbated by activity and relieved by rest. AKP often has a poor prognosis and can significantly impact daily activities as well as participation in physical activity.

A study of vertebral geometry before and after conservative treatment in thoracic Scheuermann's disease

Background The study of the vertebral changes in Scheuermanns disease during conservative treatment is generally based upon the magnitude of the curve according to the Cobb method and the magnitude of the vertebral deformation in the sagittal plane. In the present study, an X-ray analysis of vertebral changes before and after bracing has been performed to assess whether additional radiographic parameters may aid in assessing the impact of the disease and the response to conservative treatment.