Federico Mancini

Physeal Fractures of the Distal Radius and Ulna: Long-term Prognosis

OBJECTIVES The long-term prognosis of injuries to the distal physis of forearm bones, including complications such as radioulnar length discrepancy and styloid nonunion, has not been extensively studied. Reliable radiographic prognostic criteria to predict physeal disturbance at trauma are also lacking. The aim of this study is to investigate both issues. DESIGN Retrospective study. SETTING University hospital. PATIENTS/PARTICIPANTS One hundred sixty-three lesions to the distal physis of the forearm bones in 157 patients were available for a long-term follow-up. Seventy-seven injuries of the distal radial physis were radiographically isolated, 54 were associated with a fracture of the ulnar styloid, and 26 with a fracture of the distal ulnar metaphysis. Of the six injuries of the distal ulnar physis, five were associated with a fracture of the distal radial metaphysis, and one was an isolated injury of the distal ulnar physis. INTERVENTION Treatment consisted of wrist immobilization in a long-arm plaster cast for 6 weeks. Dorsal or volar displacement was reduced using general anesthesia. MAIN OUTCOME MEASUREMENTS All patients had both clinical and radiographic evaluation, with an average follow-up of 25.5 years (range 14-46 years). The average age of the patients at injury was 11.6 years (range 5-17 years), whereas their average age at follow-up was 35.5 years (range 22-56 years). Both the Salter and Harris and the Ogden classifications were used to classify physeal injuries. RESULTS According to Salter and Harris, of the 157 radial lesions, 18 were type 1 and 139 type 2. According to Ogden, 14 were type 1A, 4 type 1C, 84 type 2A, 13 type 2B, 17 type 2C, and 25 type 2D. Of the 6 ulnar lesions, 2 were Salter and Harris type 1 (Ogden type 1A), 3 type 2 (Ogden type 2A), and 1 type 4 (Ogden type 4A). Fifty-four radiographically evident fractures of the ulnar styloid associated with injuries of the distal radial physis were classified as Ogden type 7A. At follow-up, all of our patients were fully asymptomatic, except for those who had forearm bone growth failure of more than 1 cm. Shortening of the previously injured forearm bones ranging from 1 to 6.5 cm was observed in 2 open and subsequently infected lesions as well as in 5 uncomplicated lesions of the 157 distal radial physeal injuries (4.4%), and in 3 of the 6 distal ulnar physeal injuries (50%). Shortening of 1 cm or more was observed in the uncomplicated lesions of radial physeal injury with Ogden type 1C, 2B, and 2D lesions, and in ulnar physeal injuries Ogden type 1A, 2A, and 4A. Thirty-eight additional patients had radioulnar length discrepancy that ranged from 2 to 9 mm, and 53 patients had styloid nonunion, but all of them were asymptomatic. CONCLUSIONS None of the patients reviewed at follow-up, including those with radioulnar length discrepancy of less than 1 cm and those with styloid nonunion, complained of any symptom related to their previous injury, not even those engaged in heavy manual labor. Of the 10 patients with either radial or ulnar shortening of more than 1 cm, only 2 with radial growth arrest and marked radioulnar length discrepancy had severe functional problems. Growth disturbances of more than 1 cm following distal radial physeal injury occurred only in Ogden type 1C, 2B, and 2D lesions, whereas in distal ulnar physeal injuries, growth disturbances occurred regardless of the Ogden classification type.

Pisiform bone fracture-dislocation and distal radius physeal fracture in two children.

We report two children with a Salter-Harris type 1 and 2 distal radius physeal fracture associated with a fracture-dislocation of the pisiform bone. The two patients were treated with closed reduction of both the distal radius and dislocated pisiform under general anaesthesia. Then a long-arm cast was applied for 30 days resulting in full healing of the fractures. The patients were re-evaluated after 30 years, and the wrists did not show any functional impairments. On radiographic evaluations, there were no signs of osteoarthritis or misalignment between the pisiform and the triquetral, in contrast to what has been reported in adult carpal fractures.

Notochordal inclusions in the vertebral bone marrow.

Nontumoral notochordal inclusions in vertebral bone marrow give rise to MRI‐detectable lesion without osteolysis, and their detection may cause concern or overtreatment. These lesions likely arise from dislocation of notochordal cells from the nucleus pulposus early in life, followed by growth in a permissive bone marrow microenvironment.

Aseptic lysis L2–L3 as complication of abdominal aortic aneurysm repair

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.

Videothoracoscopic Approach to the Spine in Idiopathic Scoliosis

Surgical treatment of idiopathic scoliosis has classically included posterior, anterior, or combined open surgical techniques. In recent years, a videothoracoscopic approach to the spine has been increasingly employed either in combination with the posterior open approach or as a stand-alone treatment including anterior release and fusion. Proponents of videothoracoscopic approaches believe that they allow clinical outcomes comparable to those of open surgery with minimized surgical trauma and postoperative pain, superior cosmetic effects, and less impairment of respiratory function. Periodic technological refinements continue to be proposed and are likely to render these surgical options simpler, safer, and more effective. This article reports on the current state of the art of the videothoracoscopic approaches most commonly employed for the surgical treatment of thoracic idiopathic scoliosis.

Orthopaedic Aspects of Marfan Syndrome: The Experience of a Referral Center for Diagnosis of Rare Diseases.

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.

Intraoperative Disinfection by Pulse Irrigation with Povidone-Iodine Solution in Spine Surgery

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.