Laura Scaramuzzo

Surgical treatment of pathologic fractures of humerus

This study evaluates different operative treatment options for patients with metastatic fractures of the humerus focusing on surgical procedures, complications, function, and survival rate. From January 2003 to January 2008, 87 pathological fractures of the humerus in 85 cancer patients were surgically treated in our institutions. Histotypes were breast (n=21), lung (n=14), prostate (n=5), bladder (n=4), kidney (n=13), thyroid (n=7), larynx (n=1), lymphoma (n=5), myeloma (n=8), colon-rectum (n=1), melanoma (n=1), testicle (n=1), hepatocellular carcinoma (n=1) and unknown tumours (n=3). Lesions of the proximal epiphysis were treated with resection and endoprosthetic replacement (n=30). The remaining 57 fractures were stabilized with antegrade unreamed intra-medullary locked nailing without (9 cases) or with resection and use of cement (48 cases). The function of the upper limb was assessed using the Musculo-Skeletal Tumor Society (MSTS) rating scale and survival rate was retrospectively analysed. The mean survival time of patients after surgery was 8.3 months. Complications of endoprosthetic replacement recorded included disease relapse (n=3), soft tissue infection (n=2) and palsy of musculocutaneous nerve (n=1) whereas, for intra-medullary locked nailing there were three cases of soft tissue infection and one case of radial nerve palsy. The mean MSTS score at follow-up was 73% for endoprosthesis and 79.2% for locked intra-medullary nailing. Endoprosthetic replacement of the proximal humerus provides a good function of the upper limb, a low risk of local relapse with a low complication rate at follow-up. Unreamed nailing provides immediate stability and pain relief, minimum morbidity and early return of function.

Percutaneous acetabuloplasty for metastatic acetabular lesions

BackgroundOsteolytic metastases around the acetabulum are frequent in tumour patients, and may cause intense and drug-resistant pain of the hip. These lesions also cause structural weakening of the pelvis, limping, and poor quality of life. Percutaneous acetabuloplasty is a mini-invasive procedure for the management of metastatic lesions due to carcinoma of the acetabulum performed in patients who cannot tolerate major surgery, or in patients towards whom radiotherapy had already proved ineffective.MethodsWe report a retrospective study in 25 such patients (30 acetabuli) who were evaluated before and after percutaneous acetabuloplasty, with regard to pain, mobility of the hip joint, use of analgesics, by means of evaluation forms: Visual Analog Scale, Harris Hip Score, Western Ontario and McMaster Universities Index of Osteoarthritis (WOMAC), Eastern Cooperative Oncology Group (ECOG). The results obtained were analysed using the χ2 Test and Fishers exact test. Significance was sent at P < 0.05.ResultsMarked clinical improvement was observed in all patients during the first six post-operative months, with gradual a worsening thereafter from deterioration of their general condition.Complete pain relief was achieved in 15 of our 25 (59%) of patients, and pain reduction was achieved in the remaining 10 (41%) patients. The mean duration of pain relief was 7.3 months. Pain recurred in three patients (12%) between 2 weeks to 3 months. No major complications occurred. There was transient local pain in most cases, and 2 cases of venous injection of cement without clinical consequences.ConclusionPercutaneous acetabuloplasty is effective in improving the quality of life of patients with osteolytic bone tumours, even though the improvement is observed during the first 6 months only. It can be an effective aid to chemo- and radiotherapy in the management of acetabular metastases.

Complications in lumbar spine surgery: A retrospective analysis

Background: Surgical treatment of adult lumbar spinal disorders is associated with a substantial risk of intraoperative and perioperative complications. There is no clearly defined medical literature on complication in lumbar spine surgery. Purpose of the study is to retrospectively evaluate intraoperative and perioperative complications who underwent various lumbar surgical procedures and to study the possible predisposing role of advanced age in increasing this rate. Materials and Methods: From 2007 to 2011 the number and type of complications were recorded and both univariate, (considering the patients’ age) and a multivariate statistical analysis was conducted in order to establish a possible predisposing role. 133 were lumbar disc hernia treated with microdiscetomy, 88 were lumbar stenosis, treated in 36 cases with only decompression, 52 with decompression and instrumentation with a maximum of 2 levels. 26 patients showed a lumbar fracture treated with percutaneous or open screw fixation. 12 showed a scoliotic or kyphotic deformity treated with decompression, fusion and osteotomies with a maximum of 7.3 levels of fusion (range 5-14). 70 were spondylolisthesis treated with 1 or more level of fusion. In 34 cases a fusion till S1 was performed. Results: Of the 338 patients who underwent surgery, 55 showed one or more complications. Type of surgical treatment (P = 0.004), open surgical approach (open P = 0.001) and operative time (P = 0.001) increased the relative risk (RR) of complication occurrence of 2.3, 3.8 and 5.1 respectively. Major complications are more often seen in complex surgical treatment for severe deformities, in revision surgery and in anterior approaches with an occurrence of 58.3%. Age greater than 65 years, despite an increased RR of perioperative complications (1.5), does not represent a predisposing risk factor to complications (P = 0.006). Conclusion: Surgical decision-making and exclusion of patients is not justified only by due to age. A systematic preoperative evaluation should always be performed in order to stratify risks and to guide decision-making for obtaining the best possible clinical results at lower risk, even for elderly patients.

Surgical treatment of impending and pathological fractures of tibia

Advances in adjuvant and neoadjuvant therapies have improved the prognosis of cancer patients leading to an increasing incidence of bone metastases and consequent long bone fractures. In the present study the authors consider the indications and the different surgical options of treatment of tibial pathological lesions. 13 patients (14 lesions, 6 pathological fractures), treated according to histotype and lesion localisation, were retrospectively evaluated. Using generic outcome instruments such as the Eastern Cooperative Oncology Group (ECOG) and Quality of life questionnaire of European Organization for Research and Treatment of Cancer (QLQ-C30) pain, mobility and use of analgesics were evaluated before and after surgery. In all patients, mechanical stabilisation of the osteolytic lesion was achieved. There were no pathological fractures, and no implant mechanical failure. All patients reported pain relief, with a relevant reduction in the amount of analgesics used. Surgical treatment of tibial metastases has to be decided taking into consideration the histotype, localisation of the metastases and life expectancy. The treatment has to be all-encompassing in a solitary lesion in patients with a good prognosis but less invasive in plurimetastatic patients with poor prognosis. Acquisition of good mechanical stability is crucial for a successful outcome.

Posterior percutaneous reduction and fixation of thoraco-lumbar burst fractures

BACKGROUND Treatment of A3 thoraco-lumbar and lumbar spinal fractures nowadays remains a controversial issue. Percutaneous techniques are becoming very popular in the last few years to reduce the approach-related morbidity associated with conventional techniques. HYPOTHESIS Purpose of the study was to analyze the clinical and radiological outcome of patients who underwent percutaneous posterior fixation without fusion for the treatment of thoraco-lumbar and lumbar A3 fractures. MATERIALS AND METHODS Sixty-three patients, having sustained a single-level thoraco-lumbar fracture, underwent short segment percutaneous instrumentation and were retrospectively analyzed. sagittal index (SI) was calculated in all patients. Clinical and functional outcome were evaluated by Visual Analog Scale (VAS), Oswestry Disability Index (ODI) and Short Form General Health Status (SF-36). RESULTS Average operative blood loss was 82 mL (50-320). Mean pre-operative SI in the thoraco-lumbar segment was 13.3° decreased to 5.8° in the immediate postoperative with a mean deformity correction of 7.5. Mean pre-operative SI in the lumbar segment was 16.5° decreased to 11.3° in the immediate postoperative with a mean deformity correction of 5.2. Not statistically significant correction loss was registered at 1-year minimum follow-up. Constant clinical conditions improvement in the examined patients was observed. CONCLUSION Percutaneous pedicle screw fixation for A3 thoraco-lumbar and lumbar spinal fractures is a reliable and safe procedure. LEVEL OF EVIDENCE Level IV. Retrospective study.

Morphological Modifications in Osteoarthritis: A Scanning Electron Microscopy Study

The chondrocyte, the only cellular component of adult articular cartilage, plays a key role in the pathogenesis of osteoarthritis (OA). The evolution of this process is very slow: the first changes involve the cell-matrix morphofunctional unit known as chondron. In this study we analyzed the cartilage of 10 patients with primary osteoarthritis. The cartilage was retrieved during total knee replacement (TKR) and maxillofacial surgery procedures. All patients presented an osteoarthritis of at least grade III. The preparation of the specimens was made by taking cartilage from both well-preserved and macroscopically degenerated areas. Specimens underwent histological evaluation with conventional staining and ultrastructural analysis. Age appeared to be a high risk factor in the development of articular cartilage damages. Depth of injury was also found to be age-related as more extensive lesions were found in the elderly, either in the knee or in the mandibular condyle. Whatever the cause of possible damage, Scanning Electron Microscopy (SEM) observations showed that at the beginning most degenerative changes in articular cartilage involved the chondron unit, a concept first introduced by Benninghoff. These changes generally go through three phases. During OA progression all degenerative changes begin from the chondron, which is why it is extremely important to understand the molecular anatomy and physiology of this pericellular microenvironment and its form, function and failure in adult articular cartilage. It is also fundamental to understand the mechanism of adaptation of the cartilage and bone disruptions, given the physiological relationship between these tissues, essential to maintain normal joint structure and function.

Degenerative facet joint changes in lumbar percutaneous pedicle screw fixation without fusion

BACKGROUND Aim of the study was to evaluate degenerative lumbar facet-joints changes after percutaneous pedicle screw fixation (PPSF) in the treatment of lumbar fractures. MATERIALS AND METHODS Thirty patients underwent short PPSF without fusion. CT-scan was performed in the pre- and post-operative time at four, eight and 12 months. The six zygapophyseal joints adjacent the fractures level were evaluated. RESULTS At four months patients showed no differences between pre- and post-operative joint radiographic aspect. At eight and 12 months, CT-scan demonstrated a progressive degeneration only in the middle joints respectively in 21.42% and in 76.92% of the cases. All 10 disrupted facet joints showed progressive degenerative changes at eight and 12 months. CONCLUSION Lumbar percutaneous fixation without fusion induces little degenerations essentially collocated in the middle joints close to fracture level at eight and 12 months. In the proximal and distal joints adjacent the screws degenerative changes can be seen only when associated to pedicle-screw encroachment.

Onset of a Charcot spinal arthropathy at a level lacking surgical arthrodesis in a paraplegic patient with traumatic cord injury

The study design included a case report of Charcot spinal arthropathy treated with posterior and anterior spinal instrumentation. The objective of the study was to report an unusual case of Charcot spinal arthropathy as a late complication of traumatic spinal cord injury in a patient previously treated with a long posterior thoraco-lumbar instrumentation and postero-lateral fusion. A 33-year-old man with T10–T11 complete paraplegia presented with focal low back pain, kyphotic deformity of the lumbar region with L2–L3 fracture–dislocation and hardware failure. Our treatment consisted of a circumferential arthrodesis performed with a combined anterior and posterior approach. Spinal stabilization was achieved and the patient was pain free and able to resume a sitting posture. This report suggests that the development of a Charcot spine arthropathy must always be considered as a late complication of a spinal cord injury. Moreover, we would emphasize the fundamental role of a strict clinical and radiological follow-up in order to detect an early Charcot spine complication.

Cervical myelopathy due to ossification of the transverse atlantal ligament: A Caucasian case report operated on and literature analysis.

One case of cervical myelopathy associated to ossification of transverse atlantal ligament (OTAL) and C1 posterior arch hypoplasia in a Caucasian adult female is reported. A 53-year-old female affected by cervical myelopathy was treated with C1 laminectomy and posterior arthrodesis. CT scan demonstrated that the distance between ossification of the ligament and anterior cortex of the posterior arch of atlas was 6,2mm leading to consistent space reduction for spinal cord at this level. Patient underwent spinal cord decompression and fixation with C1 poliaxial screws in lateral masses and two bilateral crossing C2 laminar screws with an improvement of neurological functions at 4-years follow-up. The association between OTAL and C1 hypoplasia was reported in very few cases. The treatment with C1 laminectomy without fusion is reported in medical literature with good clinical outcome. Our patient obtained a neurological improvement at midterm follow-up with spinal cord decompression and fusion.

Response to the letter by Minghui Peng, MD, Baohua Jiao, MD

Firstly, the authors would like to thank Dr Jiao for his interest in ur study and his interesting questions. The authors agree about the need of a CT scan exam in order to etect a burst fracture. All our patients underwent a CT scan exam t their hospital arrival in order to classify the fracture type and to ecide the appropriate treatment. Only when the authors identify n A3 fracture at CT scan, they decide to perform a percutaneous edicle screw fixation. The case reported in the Fig. 6 is surely a case of multilevel fracures. As said, all patients in our study underwent a preoperative T scan. In this case, the CT scan points out the fractures both in L1 nd L2, which are both A1.1 fractures and a single A 3.1 fracture in 3, which the authors decide to surgically treat. Exclusion criteria efer only to single A 3 fractures, without considering A1 fracture hich treatment is generally conservative. Exclusion criteria are lso represented by the association with more complex fractures n which a percutaneous pedicle screw fixation is an insufficient reatment.