Biomedical subjects
Publications and source records attributed to M Mercuri.
The authors describe the technique of vertebral resection combined with resection and reconstruction of the dura mater for bone tumor. The literature relevant to this topic is reviewed.
We reviewed our experience as concerns 588 patients treated by resection for bone tumor and reconstructed by massive bank bone implant. The period taken into consideration goes from 1984 to 2001. The mean age of the patients was 24 years with a minimum of 1 and a maximum of 77 years: in 186 cases (31.6%) age was lower by 14 years. Most of the patients were referred for a diagnosis of malignancy (85%), and of these, 70% had undergone antiblastic therapy postoperatively according to the modalities of the protocols. Of the cases that were not treated by chemotherapy there are 16 that had a homoplastic graft after failure of a previous one. In a high number of cases (189) surgery included reconstruction of an intercalar segment of a long bone. Of these, 106 were in the femur, 69 in the tibia, and 14 in the humerus. One joint reconstruction was carried out in 128 cases of which 52 in the knee, 49 in the shoulder, 10 in the elbow, 11 in the wrist, 3 in the ankle, and 3 in the metatarsals. Fusion, which was one of the most frequent indications in the eighties, is used less today; overall it was carried out in 91 cases of which 65 in the knee, 14 in the hip, 9 in the ankle and 3 in the wrist. This type of implant may also be used in the pelves, and this took place in 56 cases using different procedures of reconstruction. The most current method of reconstruction for a joint is composite prosthesis, and this was used in 124 cases of which 67 around a knee, 53 in the hip, 4 in the shoulder. Finally, in 78 cases a vascularized fibula transplant was associated with an intercalar graft, fusion, or osteoarticular graft to increase the mechanical capacity of the implant together with a more rapid integration of the implant, particularly at the osteotomic lines. Despite the excellent results demonstrated in the first 3 years of follow-up, infection, resorption, delay in consolidation and fracture led to 18% failures of the implant. Massive homoplastic graft is still a good means of reconstruction that allows for excellent functional results, but despite this intense research activity is required to improve its mechanical hold in time together with better and complete integration.
A consecutive series of 57 patients treated by knee resection arthrodesis for malignant or aggressive tumor around the knee was reviewed. Infection was present only after repeated surgery for other complications, delayed union or non-union occurred in 50% of the cases that could be evaluated, but were still easy to manage. Fracture incidence was higher than expected (32.6%) even occurring after 10 years; this was difficult to deal with and it often led to failure. The best possible method of fixation is still being debated, but locked nail and allograft cementation is often advised. Several satisfactory functional results were however achieved when surgery was performed in young patients; final results can be less satisfactory when there is leg length discrepancy and poor acceptance on the part of the patient. In recent years this type of surgery has been limited to younger male patients (10 to 14 years of age) in whom extra-articular knee resection was required or when most of the quadriceps muscle must be removed.
Surgery used to treat chest wall sarcomas requires preoperative evaluation in order to document their margins, and to reveal any nodules of recurrence. Because of its considerable sensitivity and specificity ultrasound was associated with routine imaging techniques. The results obtained are useful in defining superficial and lateral tumor margins, but particularly in determining micro-nodules of recurrence which would otherwise go unrecognized. Based on the data obtained using routine methods of diagnosis and ultrasound, we submitted patients to excision that each and every time proved to be wide on histological examination. A particular surgical method was used for reconstruction, involving a polypropylene mesh fixed to one or two mouldable plates. This method exploits the elasticity of polypropylene, which is indispensable for the correct respiratory dynamics of the rib cage, thus avoiding paradoxical or harmful movement. Oncological and functional results were satisfactory.
The authors discuss the reconstructive methods used after curettage and/or vertebral resection possibly associated with removal of surrounding muscular, visceral and nervous structures.
Sapho syndrome is characterized by synovitis, acne, pustulosis, hyperostosis and osteitis. It is a rare disease, with a benign prognosis; at the osteoarticular level it is painful and is characterized by episodes of arthritis of an intermittent and at times disabling nature. The etiopathogenesis of Sapho syndrome is still not clearly defined: some authors suggest a probable correlation with an infective agent, others instead include Sapho among seronegative spondylites. The treatment of symptomatic skeletal injuries (hyperostosis, osteitis) is controversial and not classified. In the rare cases reported in the literature surgical treatment has not proven to be more effective than conservative treatment. The authors report the poor evolution of the disease in a patient affected with Sapho syndrome who came to our observation after being submitted to medullary decompression of the femoral diaphysis because of the presence of metaphyseal hyperostosis of the left femur.
The authors take into consideration all types of treatment used at the Rizzoli Orthopaedic Institute and in associated centers over the last 40 years for soft tissue sarcoma of the limbs. For each clinical study the most up-to-date results are reported with statistical evaluations. From the first protocol that used adriamycin alone and up to the beginning of the eighties, we then go on to a second-generation study in the nineties that used adriamycin and ifosphamide at a high dosage. The pilot study that was used at the end of the nineties to evaluate the validity of the use of chemotherapy and radiotherapy is considered, as is the study currently being conducted by the Italian Sarcoma Group. Conclusions based on our vast previous experience lead us to believe that adjuvant chemotherapy must be used for all patients with high-risk soft tissue sarcoma within clinical trials.
The need for a better roentgenographic evaluation of implant behavior in long-term prosthetic replacement of the proximal femur was considered. The authors present the results of a group of 13 patients belonging to a wide range of ages, with more than ten-years follow-up after tumor resection, and replacement characterized by bipolar cup and non-cemented stem. A new X-ray film acquisition and evaluation method was devised. Results confirmed the good behavior of bipolar reconstructions in patients of different ages, whose sockets were still intact. In younger patients, the prevalent bipolar movement was in the outer bearing, thus limiting polyethylene particulate debris formation. However, debris formation did not significantly affect the bone/stem relationship as only one loose stem was observed in a bone submitted to radiotherapy.
Carotid chemodectoma is a tumor that affects the bifurcation of the carotids. It is not a frequent event, but it has great importance for surgical and diagnostic problems involved. In this article three cases of chemodectoma observed and surgically treated are reported.
Osteoid osteoma is a small benign tumor, with a ''nidus'' that rarely exceeds 15 mm in diameter. It is relatively common in males, especially teenagers and young adults. It involves mainly the appendicular skeleton, the femur in particular, and rarely the axial skeleton. It requires treatment because it causes intense pain. In recent years alternative, less invasive, treatments have been proposed, such as drilling combined with ethanol injections, and thermal ablation with laser or radiofrequency. This study assesses 117 patients affected by osteoid osteoma, treated by radiofrequency thermal ablation between June 2001 and November 2003. We describe the patient recruitment procedure, CT-guided technique, the percutaneous approach, thermal ablation, and the instruments used. Data were analyzed thoroughly, and modifications that have improved the effects of treatment have been highlighted. The results achieved since the method was perfected have been extremely encouraging, confirming that the technique is very effective if performed correctly. For that reason radiofrequency thermal ablation has become the treatment of choice for non-spinal osteoid osteoma at Rizzoli Orthopaedic Institute.
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Osteosarcoma is a rare tumor. In multicentric trials on the neoadjuvant treatment of this neoplasm many of the single institutions involved have the opportunity to treat a small number of cases (the average for all of the studies was less than 1 case per year). In order to verify whether this can change the percentage of amputations avoided and prognosis, a review of the current literature was carried out, concerning neoadjuvant treatment of osteosarcoma of the extremities. The results obtained in 9 multicentric trials and in 12 mono-institutional trials were evaluated. It was observed that in mono-institutional studies the percentage of patients treated by conservative surgery instead of aggressive surgery (73% vs 55%) and the disease-free survival 5 years after surgery (73% vs 55%; p < 0.0001) are significantly higher as compared to what was observed for patients treated in multicentric trials. Based on these differences, the authors conclude that it would be opportune to direct patients with osteosarcoma of the extremities to the best centers that each year treat large numbers of patients with musculoskeletal tumors.
The authors describe a variation in the method of vertebral hemi-resection used for the treatment of neoplasms that present a wide invasion of the vertebral canal. This is followed by a review of the literature on the subject.
BACKGROUND: A trend toward avoidance of a defunctioning colostomy at emergency large-bowel surgery has been placed in recent years. The surgical management of patients with acute colonic disease has been evolving from multiple to single operations with a reduced use of colostomy. METHODS AND RESULTS: One hundred four consecutive non-selected patients underwent surgery for left-sided large bowel emergencies between 1980-2003. Defunctioning colostomy was performed in 10 out of 58 resection-anastomosis procedures. Thirty-seven patients underwent Hartmann procedure, 9 received only diverting colostomy. Postoperative morbidity was 28.8%. Postoperative mortality 8.2%. Anastomotic leak occurred in 1 and 6 patients with and without defunctioning colostomy respectively. Four out of the 6 patients without colostomy needed reintervention, while patient with covering colostomy underwent conservative treatment. Six (10.5%) out 56 patients with colostomy experienced major stoma related complications and underwent reintervention. DISCUSSION: Although there is general acceptance of one-stage surgery for right-sided colon emergencies, the surgical management of left-side large bowel obstruction and peritonitis remains controversal. Risk of anastomotic dehiscence associated with large-bowel anastomosis in unfavourable circumstance must be balanced against the high complications and low closure rates of a temporary colostomy. CONCLUSION: Primary resection and anastomosis without diverting colostomy for left-sided acute obstruction and peritonitis may be performed in selected patients. Diffuse purulent and faecal peritonitis are contraindications to one-stage surgery being necessary a two- stage procedure with loop or end colostomy. Colostomy remain a valid surgical option when high risk of dehiscence is suspected.
Bone grafting procedures are widely used to repair large defects successfully in humans, but new surgical therapies can be designed to improve allograft integration. The objective of this study was to investigate the best surgical procedure to study bone graft integration in a large animal model. An osteoperiosteal defect of 3 cm in the tibia or in the metatarsal was made in 15 adult crossbreed sheep to investigate osteo-integration of a homologous bone graft in an intercalary critical defect. DCP plates, alone or in association with Scotchcast or external fixator were used as fixation devices. The Scotchcast as was applied after surgery and left for 2 months to avoid torsion stress of the limb during the stand up movement. Metatarsal defect fixed with 7-hole DCP plate and protected with Scotchcast was the best surgical approach to avoid early or late implant failures, and provided good radiographic results after 4 months.
Malondialdehyde (MDA) plasma concentrations (marker of lipid free radical peroxidation) and the unfractionated leucocyte and erythrocyte filterability rates (through 5 micron Nuclepore filters in a positive pressure filtration system) were determined during a partial ischaemia induced by two consecutive treadmill tests in 64 stage II peripheral vascular disease (PVD) patients and in 32 matched controls. Transcutaneous oxygen pressure (tcPO2) was monitored constantly throughout the walking tests and recovery periods. In the PVD patients impairments in the flow properties of leucocytes and erythrocytes were associated with increases in MDA plasma concentrations which correlated significantly with a lengthening of the tcPO2 half recovery times--index of the worsening of ischaemia. Patients could be divided into two sub-groups on the basis of these impairments and their half recovery times, suggesting this experimental model may provide a means to identify those stage II PVD patients most likely to develop critical limb ischaemia.
One-hundred patients affected with non-metastatic osteosarcoma of the limbs were treated according to a new adjuvant chemotherapy protocol. Preoperative treatment consisted in high doses of methotrexate (i.v.), followed after one week by cisplatin continuous intra-arterial infusion for 72 hours and adriamycin in intravenous infusion for 8 hours. There was good clinical and radiographic response in all of the cases, and conservative treatment was used in 86 cases (86%). A postsurgery histological examination of the segment showed "good" necrosis (greater than 90%) in 75 patients (75%). The incidence of "good" necroses obtained with this protocol was significantly higher as compared to that observed previously at our Center when a preoperative chemotherapy scheme was used, which involved methotrexate and cisplatin alone. Up until now, patients with a good histological response to preoperative chemotherapy have always had an excellent prognosis. Thus, it is our belief that the 23% increase in good histological responses observed must correspond to an increase in the percentage of healing. The preliminary results (83% of patients with no signs of disease) seem to encourage our hypothesis.
The authors discuss 18 cases of acute capsuloligamentous lesions of the external compartment of the knee submitted to surgical treatment. The results obtained by separately studying the progression of the various types of anatomical lesions revealed a relationship between the entity of the lesion and the results. Positive results were as follows: 100% in isolated lesions of the EC, 70% in lesions of the EC and ACL, 40% in lesions of the EC + ACL + PCL. In grade I distorsion trauma surgery is not indicated; in grade II lesions treatment is based on an objective examination in narcosis, and surgery should be performed when dynamic tests are positive; in grade III lesions surgery is always indicated. An objective examination in narcosis (rarely arthroscopy) is thus of essential importance to therapeutic indications.