Fernando De Maio

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.

Clinical Vignette: Monostotic Fibrous Dysplasia of the Proximal Femur and Liposclerosing Myxofibrous Tumor: Which One Is Which?†

Clinical, histological, and genetic studies of two cases of isolated fibro‐osseous lesions of the femur in adults show the overlap between monostotic fibrous dysplasia (MFD) of the proximal femur and the so‐called liposclerosing myxofibrous tumor. The two cases highlight how the incomplete understanding of the natural history of MFD may result in diagnostic pitfalls or incorrect classification of individual lesions.

CT Study on the Effect of Different Treatment Protocols for Clubfoot Pathology

In congenital clubfoot, residual deformities are not well-documented and they may change depending on different treatments. To identify the treatment that provides better outcome at maturity, we studied the computed tomography of two cohorts of patients affected with congenital clubfoot who were treated using two distinct protocols. Forty-seven clubfeet were treated according to the traditional protocol of our hospital and 61 were treated according to the Ponseti technique. The normal feet of the unilateral deformities served as controls. All patients were followed to skeletal maturity. The ankle torsion angle and the declination angle of the neck of the talus were higher than normal but different only in patients treated with the traditional method. The calcaneocuboid angle was lower but only in patients treated with the Ponseti method. The shape of the talar joints was altered in many feet regardless of protocol. The CT images suggest the modifications of the torsion angle of the ankle, the declination angle of the neck of the talus, and the calcaneocuboid angle at maturity are related to the treatment protocol followed. The Ponseti manipulative technique provided better anatomical results in comparison to our traditional technique.

Radiographic classification of coronal plane femoral deformities in polyostotic fibrous dysplasia

BackgroundFibrous dysplasia of bone is a skeletal dysplasia with a propensity to affect the femur in its polyostotic form, leading to deformity, fracture, and pain. The proximal femur is most commonly involved with a tendency to distal progression, thereby producing the typical shepherd’s crook deformity. However, there are few data on the spectrum and progression of femoral deformities in polyostotic fibrous dysplasia.Questions/purposesThe purposes of this study were (1) to develop a radiographic classification for polyostotic fibrous dysplasia; (2) to test this classification’s intra- and interobserver reliability; and (3) to characterize the radiographic progression of polyostotic fibrous dysplasia in a population of patients with the condition who were treated with a variety of approaches at several centers.MethodsWe retrospectively reviewed radiographs of 127 femurs from 84 adult patients affected by polyostotic fibrous dysplasia. Fifty-nine femurs had undergone one or more operations. The radiographs were evaluated in the coronal plane for neck-shaft angle and angular deformities along the whole femoral shaft down to the distal epiphysis. Four observers evaluated each film two times at intervals; intra- and interobserver reliability testing was performed using the kappa statistic. Eighty-nine femurs (70%) were available for followup to evaluate for progression at a mean of 10 years (range, 6–20 years).ResultsSix reproducible patterns of deformity were identified in both untreated and operated femurs: type 1 (24%), normal neck-shaft angle with altered shape of the proximal femur; type 2 (6%), isolated coxa valga with neck-shaft angle > 140°; type 3 (7%), isolated coxa vara with neck-shaft angle < 120°; type 4 (20%), lateral bowing of the proximal half of the femur associated with normal neck-shaft angle; type 5 (14%), like in type 4 but associated with coxa valga; and type 6 (29%), like in type 4 but associated with coxa vara. Interobserver and intraoberver kappa values were excellent, ranging from 0.83 to 0.87. In 46 of the 89 femurs (52%) for which longitudinal radiographic documentation was available, there was progressive worsening of the original deformity, although the pattern remained the same; types 1 and 2 tended not to progress, whereas types 3 to 6 did.ConclusionsA reproducible radiographic classification of polyostotic fibrous dysplasia-associated femoral deformities is proposed, which can serve as a tool for assessing and treating these deformities. After reviewing the radiographs of 127 femurs, we identified six reproducible patterns of femoral deformities.Level of EvidenceLevel III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

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.

Congenital unilateral posteromedial bowing of the tibia and fibula: insights regarding pathogenesis from prenatal pathology. A case report.

C ongenital posteromedial bowing of the tibia and fibula, in which both bones are medially and posteriorly bowed at either the middle or distal third of the shaft, is an uncommon anomaly of unknown etiology and pathogenesis1-3. A calcaneovalgus alignment of the ipsilateral foot usually coexists1-6. Although the angular deformities spontaneously resolve with growth, residual shortening (3 to 7 cm) of the tibia and fibula is typically present by skeletal maturity1,3,5-8. The pathogenesis of congenital posteromedial bowing is poorly understood. To the best of our knowledge, no description of the morphological changes in the tibia and fibula has been reported in the literature. We report the pathological findings in the tibia and fibula of a fetus with congenital posteromedial bowing of the tibia and fibula, which was legally aborted during the twenty-fourth week of gestation. We propose a possible relationship between these findings and the etiology of this deformity. ### History A white male fetus was referred to the central postmortem facility of our hospital to be subjected to autopsy on a routine basis. Information accompanying the referral indicated that the fetus was the product of the second pregnancy of nonconsanguineous, healthy parents. The mother was thirty-six years old, and the father was fifty years of age. There was no family history of skeletal dysplasias, musculoskeletal abnormalities, or known exposure to teratogenic drugs. Ultrasound examination performed during the eighteenth week of gestation had revealed normal fetal biometry (biparietal diameter, head circumference, abdominal circumference, and femoral length) and unilateral congenital posteromedial bowing of the right tibia and fibula as well as calcaneovalgus alignment of the ipsilateral foot. An amniocentesis had been performed. The volume of amniotic fluid had been reported to be normal. Repeat ultrasound examinations in …

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.