Cosimo Gigante

Musculoskeletal manifestations in pediatric acute leukemia.

Background: In children, acute leukemia (AL) at presentation can mimic several orthopaedic pathologies, so that a variable delay of the correct diagnosis is often reported. Methods: To define more clearly the clinical and radiological musculoskeletal manifestations of leukemia in children, 122 affected children referred from 1984 to 1999 to our Pediatric Onco-Hematologic Clinic were retrospectively reviewed. Average age at diagnosis was 6.6 years (from 7 months to 17 years). Seventy-three (60%) were boys and adolescent boys, 49 (40%) were girls and adolescent girls. One hundred two (83.6%) had acute lymphoblastic leukemia, 20 (16.4%) had acute myeloid leukemia. The mean follow-up was 8.2 years for the 104 survivors and 2.5 years for the 18 nonsurvivors. The &khgr;2 test was used to perform the statistical analyses. Results: At presentation, complaints related to the musculoskeletal system were frequent (38.3%), including pain (34.4%), functional impairment (22.9%), limping (12.3%), swelling (10.6%), and joint effusion (5.7%). At presentation, 40.2% of children had at least 1 radiographic abnormality. In order, they were osteolysis (13.1%), metaphyseal bands (9.8%), osteopenia (9%), osteosclerosis (7.4%), permeative pattern (5.7%), pathological fractures (5.7%), periosteal reactions (4.1%), and mixed lysis-sclerosis lesions (2.5%). Different from previous reports, late radiographic lesions were uncommon (5.7%), probably because of milder newer medication protocols. They included avascular necrosis (3.3%), vertebral collapses (1.6%), and osteolysis (0.8%). Conclusions: Both clinical and radiological changes had various and no uniform localization. Poor correlation was found between symptoms and radiological lesions. Survival rates in children with AL were 95.8% at 1 year, 89.6% at 3 years, 85.8% at 5 years, and 83.4% at 10 and at 13 years. Radiographic abnormalities (P = 0.400), type of leukemia (P = 0.291), sex (P = 0.245), and white blood cell count at presentation (P = 0.877) were not prognostic factors. The presence of multiple bone lesions did not affect the survival rate (P=0.632). As early diagnosis significantly decreases morbidity and mortality of AL, the orthopaedist should suspect AL in any child with unexplained persistent skeletal pain or radiographic alterations. Accurate history, general physical examination, and complete blood cell count tests should address the suspicion, which is confirmed by a peripheral and/or iliac crest bone marrow biopsy. Level of Evidence: Retrospective comparative study III.

A 20-year follow-up study of a case of surgically treated massive osteolysis.

Massive osteolysis of the humerus occurred in a 19-year-old male. The lesion was successfully treated with an autogenous fibular shaft transplant. During the 20-year follow-up period, humerus function was restored. Roentgenograms showed incorporation of the graft without any recurrence of the disease. This experience and reports in the literature show that only predominantly cortical autogeneic bone grafting has been successful. This could be due to the intrinsic characteristic of cortical bone. In fact, it seems that cortical bone shows greater resistance to erosion than cancellous bone to the lymphangiomatous osteolytic tissue. Therefore, autogenous bone grafting could be considered as a reasonable alternative to radiotherapy, particularly in young people with monostotic disease localized in bones that are easily operable and have no soft-tissue involvement.

Polydactyly of the foot.

Fifty-six patients with 72 duplicated toes were analysed. Postaxial duplication accounted for 79%, and the most common anatomical pattern was duplication of the proximal phalanx with a wide metatarsal head. Forty-two patients with 55 duplications were clinically and radiographically evaluated at long-term follow-up (mean 22.5 years). Results were satisfactory in 91% of the patients. Poor results were often associated with preaxial polydactyly because of persistent hallux varus. Surgical treatment is usually straightforward but must be individualized, and some anatomical and surgical details should be considered to obtain a better result.

Monoarticular Juvenile Chronic Arthritis of the Shoulder: Report of a case and review of the literature

In 20% of the cases Juvenile Chronic Arthritis (JCA) has a monoarticular onset. Usually the inflammatory process spreads out to other joints with pauciarticular or polyarticular course. Very rarely the disease persists in one joint only and this is in about 70% of the cases, the knee. We describe a case of Monoarticular JCA with isolate and persistent involvement of the shoulder never reported in the literature. The clinical, pathologic features and different diagnoses are discussed.

La prognosi dei distacchi epifisari dell’arto inferiore

Physeal fractures, which represent almost 25% of all the fractures in children, are generally classified according to the Salter Harris (S-H) classification, which is accepted worldwide thanks to its simplicity and reproducibility. However, during the last two decades several reports have questioned its prognostic value. In this review, the main prognostic factors of lower limb physeal injuries were identified on the basis of our personal experience and of the most recent literature. Although a bad prognosis may be still recognised as S-H type III and type IV, particularly when anatomic reduction of the articular fracture is not obtained, type I and type II lesions may also have a poor outcome especially in case of high-energy trauma.