Luigi de Palma

The external rotation method for reduction of acute anterior shoulder dislocations

BackgroundShoulder dislocations account for almost 50% of all joint dislocations, and are most commonly anterior (90–98%) and occur due to trauma. This prospective study was conducted to report our experiences of using the external rotation method (ERM) in the reduction of acute anterior shoulder dislocation.Materials and methodsBetween August 2006 and April 2007, ERM was applied to 31 patients who presented with traumatic anterior shoulder dislocation to the Emergency Department of our Hospital which is a levelxa02 trauma centre. We evaluated the type of dislocation, the effectiveness of the procedure in achieving reduction, the need for premedication, the ease of performing the reduction, and complications, if any.ResultsOf the 31 patients, 29 had a successful reduction. No premedication was required in 25 patients who had a successful reduction, and the average time required for reduction in 25 was less than 2xa0min. Only five patients reported severe pain during the process of reduction. The method was not successful in two patients in whom the reduction was achieved under narcosis. We experienced a success rate of 89% at the first attempt. None of the patients encountered any complication.ConclusionsERM for the reduction of acute anterior dislocation of the shoulder is a safe and reliable method, mainly without requirement for any sedatives or opiate analgesics, that can be performed relatively painlessly for anterior shoulder dislocations. As no single method has a 100% success rate, ERM is a useful one to know.

Immunohistochemistry of the enthesis organ of the human Achilles tendon

Background: The insertional region of the Achilles tendon includes: the fibrocartilage of the enthesis at the tendon-bone junction, the sesamoid fibrocartilage in the deep surface of the tendon, and the periosteal fibrocartilage covering the superior tuberosity of the calcaneus. The mechanism by which compressive stress and low oxygen concentration modulate the phenotypical expression of cartilaginous cells in mesenchymal tissue is still unknown. Tenascin-C isoform, with its anti-adhesive properties, has been hypothesized to have a role in cellular adaptation to compression. The purpose of this study was to define the immunohistochemical localization of tenascin-C in the enthesis organ of the Achilles insertion in man. Methods: Five specimens of Achilles tendon and its insertion were obtained from adult patients during below-knee amputation surgery. To determine the histochemistry, for light microscopy, specimens were stained with hematoxylin-eosin, safranin-O, Verhoeff, alcian blue methods. For immunohistochemistry, the following antibodies were used: anti-S-100 protein; anti-chondroitin sulfate; anti-types I and II collagen, anti-type IV collagen, anti-type X collagen, and anti-tenascin-C. Results: The enthesis, sesamoid, and periosteal fibrocartilages have been defined by a separate region of immunohistochemical labeling for S-100 antibody and type II collagen and chondroitin-sulfate. The sesamoid and periosteal fibrocartilages stained for tenascin-C, which in cartilaginous areas was closely associated with rounded cells in the extracellular matrix. Conclusion: By showing a relationship between chondrocyte-like cells and immunolabeling for tenascin-C in periosteal and sesamoid fibrocartilage, the present data suggest a role in the dynamic equilibrium in the formation of fibrocartilaginous foci in tendon areas exposed to compressive stress. Clinical relevance: The data support the surgical practice of the resection of the diseased tendinous portion in case of chronic Achilles tendinitis. The decompression removed the enthesis organ that in an inflammatory environment could be altered and would not contribute to the distribution of the tensive load. After the decompression, it was hypothesized that in tendon areas exposed to compressive stress there was restoration of the fibrocartilaginous foci that constitute the enthesis organ.

Operative delay and mortality in elderly patients with hip fracture: an observational study

BackgroundHip fracture is the third cause of death among the elderly and appears to be increasingly frequent. We analysed the influence of the major variables in hip fracture management in relation to 30-day mortality.Materials and methodsThe records of all patients with isolated hip fracture treated at a regional trauma centre from January 1995 to September 2008 were reviewed. Data on demographics, comorbidities, operative delay, complications, functional status at discharge and mortality were collected and subjected to univariate and multivariate analysis.ResultsThe cohort included 1,199 patients; the mortality rate was 11.7xa0%. Surgery was performed within 48xa0h of injury in 17.7xa0% and after more than 48xa0h in 82.3xa0%; the mortality rate was 9.27xa0% in the former and 10.4xa0% in the latter patients; however, at variance with previous reports, operative delay was not associated with a worse outcome in patients with comorbidities.ConclusionsOur data support the policy envisaging fracture repair within 48xa0h in stable patients and delayed surgery (>48xa0h) in those with comorbidity conditions requiring stabilization.

Intramedullary nailing versus external fixation in Gustilo type III open tibial shaft fractures: a meta-analysis of randomised controlled trials

Open tibial shaft fractures are the most common of long-bone open fractures. Management of the fracture is either by intramedullary nailing (IMN) or by external fixation (EF). Since the literature does not indicate clearly which is more effective, a meta-analysis was conducted to establish which approach is more suitable to treat Gustilo type III fractures. MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE and CINAHL databases were searched for randomised controlled trials (RCT) describing IMN and EF treatment of Gustilo type III fractures. As of 15 November 2012, five RCT involving 239 patients had been published; the outcomes examined in this study are their surgical complications. Data analysis led complications to be grouped into infection, fracture healing problems (non-union, malunion) and “other complications” (vascular injury, revision surgery, soft tissue damage, mechanical failure and tibial malalignment). IMN was associated with lower rates of infection and fracture healing problems; the differences between the two approaches for “other complications” were not significant. The data indicate that IMN is the treatment of choice for Gustilo type III fractures.

Basic Science and Injury in Growing Athletes: Muscle, Tendon, and Ligament

Physical activity and sports nowadays constitute one of the foundations for a correct psychophysical development, both in children and adolescents. It has been accounted that about 30 million children across the United States participate in organized athletic activities, and this number is increasing; the same increasing trend has been recently reported in Europe by the Olympic Committees. Even though, on the one hand, these activities lead to lifelong habits of exercising and teamwork value, on the other hand, as the competition and the technical complexity of exercises increases, training, and workout become longer and more intense with shorter rest periods. The accumulation of repetitive stress without adequate recovery time along with skeletal immaturity can cause many soft tissue injuries. In particular, sports injuries are responsible for nearly a quarter of all injuries in children and adolescents. The aim of this chapter is to provide a report on epidemiology, risk factors and basic science in soft tissue injuries (muscles, tendons, and ligaments), from trauma to recovery, involving the young “growing” athlete.

Chopart arthrodesis with graft bone from the iliac crest after a traumatic subamputation of the forefoot: surgical technique.

We present a 49-year-old man with a traumatic subamputation of the forefoot, associated with lacerated wound in correspondence of the dorsal surface of the right foot, with injuries of tendinous, ligamentous and vascular structures and with the loss of talus head. The patient underwent salvage arthrodesis of the talonavicular and calcanealcuboid joints with graft bone harvested from the iliac crest. The patient was re-evaluated during a clinical and radiographic follow-up. The arthrodesis was consolidated in ∼3 months. There were no infectious problems and the patient has resumed normal work activities. At a sixth month follow-up, the patient had returned to work and remained pain free while walking. Early anatomic reduction, stable fixation and ligament reconstruction are essential for a good outcome. Primary arthrodesis is a viable option for severe midfoot fracture dislocations, because it facilitates rehabilitation and functional recovery and obviates the need for a secondary arthrodesis should arthritis arise.

Treatment of Pseudoarthrosis After Minimally Invasive Hallux Valgus Correction

Objective: Treatment of mild and moderate hallux valgus deformities. Discussion: Minimally invasive technique enables surgeons to treat mild and moderate hallux valgus deformities with excellent and good results in the majority of patients. Nonunion of first metatarsal, moreover, has only rarely been reported. Summary: We describe the essential steps of a surgical technique for the treatment of nonunions after miniinvasive subcapital first metatarsal osteotomy reconstructed using a tricortical iliac crest bone graft.