Biomedical subjects
Publications and source records attributed to D Tigani.
When confronted by a soft tissue neoplasm it is necessary to ask, before operation, whether it is malignant or benign. In this study of 6 cases of lipoma and 8 cases of liposarcoma of the limbs, the authors show that with the aid of computerised tomography the differential diagnosis can be made with certainty, based on densitometric evaluation.
PURPOSE: To assess the efficacy of percutaneous CT-guided biopsy in the diagnosis and therapeutic planning of neoplastic and flogistic diseases of the pelvis. MATERIAL AND METHODS: From July 1990 to December 1999 193 patients (113 males, 80 females: mean age 49, standard deviation 16) were submitted to CT-guided percutaneous biopsy of the pelvic region; 117 biopsies (61%) were performed at iliac, pubic and ischial segments and 76 (39%) at sacral region; 107 patients were admitted to the hospital and 86 were in clinic. Needles were 8 G (4 mm), 10 to 15 cm long. Approach to pelvic lesions was performed according to the specific site. Lesions of the lateral pelvic region have always been approached through the lateral surgical incision according to Enneking. Lesions of the posterior pelvic region have always been approached by the introduction of the needle along the posterior surgical incision according to Enneking. Lesions of the anterior region have always been approached through the anterior surgical incision according to Enneking. From July 1990 to May 1997 pelvic percutaneous biopsies have been carried out with a CT Sytec 3000. From May 1997 to December 1999 the device was replaced by a High Speed CTi. The introduction of spiral CT allowed reduction of performance mean time from 45 minutes (standard deviation 15) to 30 minutes (standard deviation 10). RESULTS: In 154 patients (80%) we observed a neoplastic, inflammatory or not classified degeneration. In 8 patients (4%) the retrieved material ended to be inadequate for a diagnosis. In 31 patients (16%) no disease was revealed at the histological examination. Such patients with negative histological examination have been kept under clinical and radiological control in the following period in order to verify the manifestation or the presence of an alteration previously not observed. On 31-3-2000 none of them had been submitted to a new percutaneous biopsy of the pelvic region. The overall mean accuracy has been 96% considering the negative patients as really negative. In 5 cases (2.6%) we have had complications represented by pain at the introduction and penetration site of the needle. DISCUSSION AND CONCLUSIONS: The choice of the needle, the approach to the lesion and the position of the patient are conditioned by the site of the tumor, its extension, the distance skin-neoplastic disease and by the respect of the incision lines of Enneking, in order not to complicate the job of the orthopaedic surgeon spreading tumoral cells outside the chosen surgical approach. The mean time of the procedure is 30 minutes (standard deviation 10). There are no absolute contraindications to percutaneous biopsy except the suspect or the presence of an hydatideal cyst. The risks have to be compared with those correlated with alternative methods or with the more concerning risk of a missed diagnosis. Complications in the literature range from 0% to 10%, the incidence varying according to the location; pain is the most frequent complication. Altogether the most negative event, although not a true complication, is the retrieval of an inadequate sample: the only drawback of percutaneous biopsy in comparison with incisional biopsy. The accuracy rate of percutaneous biopsy varies in relation to the involved anatomical region, to the pathological process, to the experience of the user, to the amount of the retrieved tissue and to the cooperation of the patient. Our experience shows that, in selected patients, percutaneous biopsy is a virtually safe and almost painless procedure which saves the patient from a surgical procedure in regional or general anestesia as for an incisional biopsy, and allows immediate planning and scheduling of a correct therapy for primitive or secondary neoplastic lesions.
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The authors present the method known as proximal tibial osteotomy for the treatment of genu procurvatum. The importance of an accurate preoperative study, particularly aimed at avoiding negative repercussions on the position of the patella, and of a correct anatomical exposure with isolation of the peroneal nerve for any iatrogenic lesions, must be emphasized; a condylic plate was used to stabilize osteotomy was stabilized, adapting well to the anatomy of the region, and allowing us to obtain correction of any associated deformities on the frontal plane.
The authors describe two cases of supracondylar fracture of the femur occurring following total knee arthroplasty. By reviewing the literature, they analyze causal factors indicating the constant presence, observed also in the cases presented, of an erroneous resection of the anterior cortex of the femur. In association with other predisposing factors, this condition favors an anomalous distribution of the load forces in this site, reducing torsion resistance of the femur by about 30%: what results is greater susceptibility for the risk of fracture for a long period of time, even for trauma of moderate entity.
The diagnosis of osteoid osteoma is usually not difficult. In typical forms of the disease, with diaphyseal localization, the clinical course and radiographic findings are so typical that diagnosis may be considered certain even when there is no histological confirmation. In some localizations, nonetheless, such as in the cancellous or short bones, or when the lesion involves a joint, diagnosis may be difficult, uncertain and late. Between January 1991 and April 1997 a total of 91 patients who had been diagnosed as having osteoid osteoma were submitted to computed tomography. Of these patients, there were 34 females, and 57 males, and age ranged from a minimum of 2 to a maximum of 69 years. Localizations are reported in Table I. For the purposes of our study, several cases with atypical features have been selected from these. We found it interesting to emphasize the importance of a correct diagnostic procedure with the purpose of accurately identifying the lesion.
Osteochondritis dissecans (OD) is a rare occurrence. In the knee, the most common localization is the lateral region of the internal femoral condyle. Involvement of the external condyle only occurs in 15% of cases, but its features are such that the situation is an entity in itself. The lesion is generally localized in the posterior site, and it is more extensive and more symptomatic as compared to medial localizations; moreover, early and rapid arthritic progression is observed. Reported here are 2 cases of OD of the lateral femoral condyle with atypical features in terms of clinical findings and progression of the disease as compared to more frequently occurring medial localizations.
The authors present the results observed in 12 patients affected with post-traumatic stiffness of the elbow treated by an external fixator in distraction to obtain functional recovery of range of movement; in all of the cases anterior and posterior release and resection of the apex of the olecranon was carried out, while in 2 cases interposition arthroplasty with freeze-dried dura madre was associated. The series includes 12 cases with a long-term follow-up that ranges from 8 to 33 months after surgery. The mean arch of movement during the preoperative phase was 35 degrees (minimum 0 degree-maximum 90 degrees) in flexion extension and 80 degrees (minimum 0 degree-maximum 150 degrees) in pronosupination. Recovery of mean joint excursion in flexion-extension was 91 degrees and in pronosupination it was 127 degrees. Complications included loosening of the nails in 2 cases, breakage of the nails in 1 case, and transitory deficit of the ulnar nerve in 4 cases. A total of 11 patients (91.66%) declared that they were satisfied with the considerable improvement in their ability to do daily activities. The results of arthroplasty in distraction in the elbow are satisfactory even if much attention must be paid to the selection of the patients because of the intense collaboration that is required during postoperative rehabilitation.
The authors report the results of a retrospective study conducted on 30 cases of fracture of the tibia and femur submitted to external fixation and subsequently to intramedullary osteosynthesis, treated between 1991 and 1999. Intramedullary osteosynthesis was used in 24 cases (5 in the femur and 19 in the tibia) as treatment subsequent to external fixation for nonunion or delays in consolidation. Sequential nailing was used as planned treatment in the remaining 6 cases. In 83.3% of cases the fracture was open (Gustilo Anderson type I (30%), type II (20%), type III (33.3%). The mean duration of external fixation was 13.24 weeks, and infection occurred in 4 cases (13.33%) during that time. Removal of the external fixator and intramedullary osteosynthesis were carried out during the same surgical session in 40% of the cases, while nailing was preceded by a period in plaster lasting an average of 4 weeks in the remaining 60% of cases. All of the cases achieved consolidation an average of 31 weeks after trauma, and 14.7 weeks after intramedullary synthesis. We observed the occurrence of infection in 3 cases (10%), but this did not keep consolidation from occurring.
Conjoined fracture-dislocation of the elbow were first described by Marotte in 1982. In this study, a total of 41 patients treated between 1975 and 1995 at the Rizzoli Orthopaedic Institute and 4 patients treated between 1997 and 2000 at the Division of Orthopaedics at the Maggiore Hospital are evaluated. Based on the Marotte classification, the patients are divided into 4 groups, by site of dislocation of the radial capitellum and amount of comminution of the fracture of the ulna. A clinical and radiographic evaluation was made after a mean follow-up of 5.3 years based on Anderson criteria. The results obtained were excellent in 17 patients (37.8%) satisfactory in 13 (28.9%), dissatisfactory in 12 (26.7%); 3 patients were considered to be failures (6.7%), the best results were obtained in type I anterior dislocations.
The authors report the results they obtained in a retrospective comparative study conducted on two systems of osteosynthesis used to treat trochanteric fractures: the sliding-compression screw-plate (CHS), and the Gamma nail. Two series were included in the study, each of which was made up of 50 cases; these were comparable in terms of fracture type, age of the patients, associated pathologies, and minimum follow-ups of 6 months. The parameters compared were: surgical trauma, average amount of time before a standing position could be resumed, resumption of motor activity previous to trauma, mechanical behavior of the instrumentation. The results show that both of the means of synthesis are capable of effectively stabilizing pertrochanteric fractures, avoiding the mechanical complications instead observed when more dated instrumentation, such as the screw-plate or nail-plate, are used, systems which are not characterized by a sliding cervico-cephalic screw. The amount of time before walking is resumed is quicker when the Gamma nail is used. There was no significant difference in terms of resumption of motor activity. Surgical trauma was the same in both series when the instrumentation was applied after reduction of the fracture in closed surgery, while blood loss was greater when fracture reduction required by application of the plate was performed in open surgery.
The authors reviewed the literature as well as their own cases in order to discuss the indications, advantages and disadvantages relative to the methods used to treat bone defects in primary knee arthroplasty. An analysis shows that the use of cement represents the most unfavorable method from a mechanical point of view and it should thus be limited to defects that are not too deep and extensive. Bone grafts, both homoplastic and autoplastic, are preferred in younger patients. The former in lesions that are smaller, the latter in those that are larger. Currently, modular prostheses are diffusedly used because of their versatility and relatively low cost if we compare them with prostheses that are custom made. Finally, the authors emphasize the need to use intramedullary stems in bone defect with the purpose of reducing stress in the metaphyseal region.
The occurrence of heterotopic ossifications constitutes a rare but possible complication in knee arthroplasty surgery. The authors retrospectively reviewed data for more than 250 patients submitted to knee arthroplasty with the purpose of ascertaining the incidence of the occurrence of heterotopic ossifications after surgery and of understanding any clinical repercussions and possible risk factors. A total of 14 cases of heterotopic ossifications were observed out of 276 knee arthroplasties (4.7%). Lesions were grade 1: 4, grade II: 3, grade III: 7. The authors stress the importance of local factors as compared to general ones and the need to adopt a respectful surgical method, avoiding notching or excessive trauma to the periosteum, as well as the need to define parameters in order to single out subjects at risk and in whom prophylaxis should be administered.
Degenerative spondylolisthesis may manifest itself with different clinical pictures depending on the phase of the spondylotic disease. Based on pathophysiological criteria 24 patients affected with degenerative spondylolisthesis were divided into three groups: group I: those with spondylotic instability; group II: those with lumbar stenosis and current or potential segmental instability; group III: those with lumbar stenosis and naturally stabilized spondylolisthesis. Group I was treated by posterolateral fusion; group II by laminectomy, removal of the medial portion of the facets and posterolateral fusion; group III by laminectomy and removal of the medial portion of the facets. Long-term results were positive in 100% of the cases in group I, 90% in group II and 83% in group III, with no statistically significant differences between groups, because of the limited series of cases. The authors conclude that surgery for the treatment of degenerative spondylolisthesis must be based on age, symptoms, and the phase of the disease, and that when these indications suited to the clinical-radiographic picture are taken into account, good results may be obtained with different operations.
The authors report their preliminary experience in the use of substitutive bone compounds in order to fill the bone cavity after curettage. The material used is constituted by a biphasic compound, made up of tricalcium phosphate and hydroxyapatite. Twenty-one patients were submitted to surgery because of the presence of a benign or low-grade malignant tumor. After removing the neoplastic tissue the residual cavity was filled with: tricalcium phosphate/hydroxyapatite (5 cases); tricalcium phosphate/hydroxyapatite plus autogenous bone (8 cases); tricalcium phosphate/hydroxyapatite plus bone allografts (8 cases). A radiological evaluation obtained 12 months after treatment showed that the incorporation of the compound in granular form was nearly complete in most of the cases, while the blocks revealed partial remodelling which was more evident in the angles. Finally, bone resorption in the site of the compounds used was not observed.
The authors report on 30 fractures of the femur and tibia treated with the Grosse-Kempf locked nail in patients aged more than 60 years. Neither nonunion nor severe complications were observed; surgical trauma was well sustained. Functional results were particularly satisfactory; most patients began walking within the first week after fixation.
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