P11.04.A Observational, prospective multicenter study on the role of body mass index (BMI) in the development of thrombotic complications in cancer patients with PICC: preliminary results

Background

Peripherally inserted central catheters (PICC) became widespread and changed substantially the approach to the patients venous system. They guarantee, both in hospital and at home, a stable and safe vascular access to administer irritants or vesicants therapies. However, the benefit provided may occasionally be affected by relevant thrombotic complications especially in patients with hypercoagulability such as oncological patients. Among the identification of independent risk factors, the role of a BMI>25 kg/m2 is now emerging in literature with conflicting results.

Material and Methods

Oncological patients with PICC were included in this multicenter prospective study. We evaluated clinical data, BMI, KPS, steroid therapies and anticoagulants at the time of PICC positioning and at regular intervals.

Results

A total of 51 patients were analyzed. The median KPS was 90 (range 80-100), and the median ECOG was 1 (range 0-3). The most common tumors were represented by: lymphomas both Hodgkin and non-Hodgkin (38%), lymphatic and myeloid leukemia (35%), neurooncological tumors including glioblastoma, primary central nervous system lymphoma, anaplastic astrocytoma and meningioma (15%), other solid cancer (breast, gastroesophageal, rectal cancer) (12%).55% patients were at first diagnoses, 12% were at the first recurrence, and the remaining were at the second or third recurrence. No malpositioning were registered. 18% of patients were on anticoagulant/antiplatelet therapy, 67% were treated with steroids. Concerning BMI, 39% was normal weight, 43% overweight and 10% obese, only 2% was considered underweight. Overall, 8% of patients developed PICC related thrombosis within a median time of 68 days (49-87) after PICC implantation mainly occurred in upper right extremity insertion sites. We therefore assessed the incidence of PICC related thromboembolic events in the groups, with 4% of event registered in the cohort of patients overweight/obese, and 14% of events in the cohort of patients with normal weight/underweight.

Conclusion

Preliminary analysis does not allow to draw firm conclusions. It will therefore be necessary to reach the sample size for achieve generalizable results and confirm the risk of developing thromboembolic events in overweight/obese patients. Meanwhile, an accurate anamnesis and a physical evaluation with particular attention to the presence of malnutrition, both over nutrition and undernutrition, could help to identify potential oncological patients at risk of developing PICC related thrombosis.

Do radiolucent lines and stress shielding of the humeral shaft really matter in shoulder arthroplasty?

The purpose of this study is to evaluate at a mid-term follow up, the radiological survival of an uncemented humeral stem in shoulder arthroplasty. One hundred and twenty-six replacements including hemi (HA), total (TSA) and reverse (RSA) implanted from 1999 to 2008 were reviewed at a mean follow up of 7.2 years (48-144 months). The same uncemented triconical stem (SMR, Lima Corporate) was implanted. There were: 23 HSA, 43 TSA, 60 RSA. An independent observer evaluated all the patients with Constant Score. A radiologic analysis by an expert radiologist and an orthopaedic surgeon was performed: humeral component-bone interface was divided in seven zones. They judged a mobilisation if a migration or tilt of the humeral implant or if≥ 2 mm radiolucent line in at least three zones was present. Chi-squared test, Fisher test and analysis of variance were performed and a p<0.05 was considered statistically significant. No major radiological signs of loosening and no tilt or migration of the humeral component were found. Only 23 (18.2%) patients had no RL around the humeral implant. In the remaining 103 (81.7%) implants: 96 (76.1%) presented RL less than 2 mm, particularly 75 (59.5%) in less than 3 zones and 21 (16.6%) in more than 3 zones. Of the remaining 7 (5.5%) implants the presence of RL of 2 mm or greater in only one zone was seen. Apart from sepsis no revision was performed for humeral component loosening. Although a high rate of RL, uncemented humeral stem has an excellent survivorship at a mid-term follow up. Relationship between presence, position and depth of RL and internal stress shielding is commonly observed but does not appear to compromise quality of fixation or clinical outcomes in shoulder arthroplasty.

Arthroscopic transosseous versus suture anchor repair: clinical outcomes in patients with bilateral rotator cuff tears

The aim of our study was to define if Arthroscopic Transosseous Rotator Cuff Techniques should have comparable results to those of the suture-anchors technique in a single row configuration. We reported the preliminary results of a consecutive population of 22 patients who underwent a rotator cuff treatment on the left and right sides for average medium-sized thickness tears with minimal fatty infiltration with the two different techniques: transosseous rotator cuff repair technique on one side and single row with suture-anchors on the other side, in different times. Subjective evaluation with DASH questionnaires, Constant Scores and Numerical Rating Scale (NRS) for pain evaluation, have been submitted pre and postoperatively after both operations. A statistical analysis was performed to assess the superiority of one technique and to compare pre and postoperative ROM data and clinical outcomes. A transosseous rotator cuff repair was performed in 7 patients on the dominant arm, while the other 15 patients had dominant arm cuff tear lesions repaired by using suture-anchors technique. At last follow-up a significant improvement, in shoulder pain and function, was referred at both sides. Also, DASH, Constant Scores and NRS for pain evaluation improved with both techniques, but no statistical difference was found between them. Arthroscopic transosseous rotator cuff repair technique shows comparable results to those of the suture-anchors technique in a single row configuration.

Concordance in the reporting of intimate partner violence among male-male couples

Intimate partner violence (IPV) among male couples is increasingly recognized as a public health concern. Research on IPV in opposite sex couples indicates frequent underreporting of IPV and high levels of discordance in reporting among dyads. Concordance studies inform refinement methods to measure the experience of IPV among dyads; however the lack of dyadic studies of male couples impedes our understanding of the extent to which IPV is differentially reported in male-male dyads. This study utilized baseline data from a randomized controlled trial of a behavioral intervention to optimize antiretroviral therapy (ART) adherence among 160 sero-discordant male couples in three US cities and provides the first analysis of concordance in reporting IPV among male couples. Low degrees of concordance in the reporting of IPV were identified among male dyads, with a greater proportion of men reporting violence perpetration than experiencing violence. The greater reporting of IPV perpetration may be linked to adherence to concepts of masculinity. The results underscore the unique experiences of IPV among male couples and the need to reexamine current IPV measurement and intervention strategies.

Dynamic brace is a good option to treat first anterior shoulder dislocation in season

PURPOSE

We evaluate the ability of in-season competitive athletes to return to competition after an anterior shoulder instability treated conservatively with a new dynamic brace combined with a specific rehabilitation program.

METHODS

Twenty soccer players affected by traumatic anterior shoulder dislocation have been enrolled in the "Footballer In Season Fast Rehab" project during 2 consecutive football seasons. We excluded patients affected by rotator cuff tears and the bony defect over 25%. All the players have been treated the day after the first dislocation with a new dynamic brace used until the end of the second month after the first glenohumeral dislocation combined with a specific rehab protocol. Athletes were evaluated for the time necessary to completely resume sport activities, to complete the season, and for the recurrence of dislocation.

RESULTS

All the athletes enrolled in this study were able to come back on the ground in approximately 40 days after the dislocation except 2 of them. Only two athletes claimed a slight discomfort at the return to play. One athlete had a traumatic relapse of the instability, 50 days after the dislocation. Another athlete claimed to have had a subluxation during a training session 45 days after the dislocation. 90% of the athletes were able to end the season without any shoulder discomfort.

CONCLUSIONS

The dynamic brace combined to the rehabilitation protocol represents the solution that allows a quick start of resumption of training while maintaining a stable pain-free shoulder.

LEVEL OF EVIDENCE

Level 4.

Reverse shoulder arthroplasty with glenoid bone grafting for anterior glenoid rim fracture associated with glenohumeral dislocation and proximal humerus fracture

BACKGROUND

Large fractures of the anterior glenoid rim can result in persisting instability and osteoarthritis of the glenohumeral joint When this fracture is associated with a glenohumeral dislocation and proximal humerus fracture could be a concern. The goal of this paper was to evaluate the clinical and radiological outcomes and complications of reverse shoulder arthroplasty (RSA) and glenoid bone graft in cases with a significant anterior glenoid fracture associated with a proximal humerus fracture.

HYPOTHESIS

RSA and step bone graft harvested from proximal humeral head could be a viable option in the treatment of this complex injury.

DESIGN

Retrospective case series.

MATERIAL AND METHODS

Twenty-six patients underwent RSA and glenoid bone graft in a single stage procedure were evaluated at an average 32 months postoperatively. There were 18 women and 8 men with a mean age of 68.5 years (range 63-75 years). Reverse shoulder arthroplasty with a contoured glenoid bone graft placed underneath the baseplate using humeral head autograft was utilized in all cases. Clinical outcomes were evaluated with range of motion, Constant score and self-reported subjective outcome rated as excellent, good, fair or poor. Radiographic evaluation was performed to evaluate for baseplate displacement or loosening, bone graft union, resorption or collapse.

RESULTS

At final follow-up, average active elevation was 135° (range 110°-145°), abduction 122° (range 60°-160°), and external rotation 30° (range 0 to 45°). The mean Constant score was 68.2 (range 54-83). The clinical results were rated as excellent by 15 patients, good by 9, and fair by 2. Radiographic evaluation showed the disc of cancellous bone graft healed without any signs of graft resorption or migration in all 26 cases. No reoperation was performed on any patient in this series.

DISCUSSION/CONCLUSION

RSA with glenoid bone grafting produces satisfactory short-term outcomes with acceptable complication rates for treatment of patients greater than 60 years old with proximal humerus fractures associated with an anterior glenoid rim fracture. Further studies are necessary to determine the extended viability of this procedure.

LEVEL OF EVIDENCE

III.

Methods for Collection of Participant-aided Sociograms for the Study of Social, Sexual and Substance-using Networks Among Young Men Who Have Sex with Men

In this study, we adapted and tested a participant-aided sociogram approach for the study of the social, sexual, and substance use networks of young men who have sex with men (YMSM); a population of increasing and disproportionate risk of HIV infection. We used a combination of two interviewer-administered procedures: completion of a pre-numbered list form to enumerate alters and to capture alter attributes; and a participant-aided sociogram to capture respondent report of interactions between alters on an erasable whiteboard. We followed the collection of alter interactions via the sociogram with a traditional matrix-based tie elicitation approach for a sub-sample of respondents for comparison purposes. Digital photographs of each network drawn on the whiteboard serve as the raw data for entry into a database in which group interactions are stored. Visual feedback of the network was created at the point of data entry, using NetDraw network visualization software for comparison to the network structure elicited via the sociogram. In a sample of 175 YMSM, we found this approach to be feasible and reliable, with high rates of participation among those eligible for the study and substantial agreement between the participant-aided sociogram in comparison to a traditional matrix-based approach. We believe that key strengths of this approach are the engagement and maintenance of participant attention and reduction of participant burden for alter tie elicitation. A key weakness is the challenge of entry of interview-based list form and sociogram data into the database. Our experience suggests that this approach to data collection is feasible and particularly appropriate for an adolescent and young adult population. This builds on and advances visualization-based approaches to social network data collection.

Destructive septic arthritis of shoulder in adults

BACKGROUND

Late sequelae of septic arthritis of the glenohumeral joint are very rare and represent a potentially devastating condition that can result in irreversible changes at the level of joint and surrounding soft tissues.

MATERIALS AND METHODS

Between January 2001 and December 2010, ten patients were treated at our institution for late sequelae of septic arthritis of the shoulder. There were eight men and two women with a mean age of 67.9 years (range 62-74 years). Eight of ten patients had previously received three or more intra-articular or subacromial injections. Surgical treatment consisted of open joint debridement, humeral head resection and implantation of an antibiotic spacer followed by a 6-8-week course of intravenous antibiotics.

RESULTS

White blood cell count, C-reactive protein and erythrocyte sedimentation rate normalized between 6 and 8 weeks postoperatively in all patients. No recurrent infection was observed in any patient. Postoperatively, the mean Constant score was 37 (range 28-46) and mean DASH score was 54 (range 40-69), demonstrating a very limited function in these patients. There was a trend toward improved outcome scores in patients who underwent early surgical debridement. Five patients underwent delayed reconstruction with a reverse shoulder prosthesis, and at minimum 1-year follow-up, the mean Constant score was 56 (range 47-69) and mean DASH score was 33 (31-38).

CONCLUSIONS

Antibiotic spacers are able to deliver antibiotics locally to the infected tissue while reducing the dead space and stabilizing the glenohumeral joint. An early, aggressive management of the infection is essential to maximize clinical outcomes and avoid either significant destruction or ankylosis of the shoulder joint.

Liver melanomacrophage centres as indicators of Atlantic bluefin tuna, Thunnus thynnus L. well-being

Melanomacrophage centres (MMCs), located in different organs of non-mammalian vertebrates, play a role in the destruction, detoxification or recycling of endogenous and exogenous materials. Cytochrome P450 monoxygenase 1A (CYP1A) is involved in xenobiotics biotransformation, and its liver expression is considered as a biomarker for detecting exposure to environmental pollutants. Atlantic bluefin tuna (ABFT), Thunnus thynnus L., liver samples were collected from: wild animals caught in the eastern Atlantic; juveniles reared in the central Adriatic; juveniles reared in the northern Adriatic; adults reared in the western Mediterranean. The samples were processed for basic histology, histochemistry and for CYP1A immunodetection. An unexpected high density of MMCs, containing ferric iron and lipofuscin-ceroids, was detected in the juveniles sampled in the northern Adriatic Sea. These individuals showed also a strong anti-CYP1A immunopositivity in hepatocytes and in the epithelium of bile ducts. This study supports the utility of MMCs as biomarkers of fish 'health status' and gives concern for a potential contaminant accumulation in ABFT.

Metalloproteases and their inhibitors are altered in both torn and intact rotator cuff tendons

BACKGROUND

We evaluated the role of matrix metalloproteases (MMPs) and their inhibitors which are involved in extracellular matrix remodeling and degradation, in the pathogenesis of chronic rotator cuff tears.

MATERIALS AND METHODS

Tendon samples were harvested from 13 patients who underwent arthroscopic repair of a rotator cuff tear. Supraspinatus biopsy specimens were harvested en bloc from the arthroscopically intact middle portion of the tendon more than 1 cm from the torn edge, from the lateral edge of the tear, and from the superior one third of the macroscopically intact subscapularis tendon used as control. Histological analysis and an evaluation of the activity of specific metalloproteases and the tissue inhibitors of metalloprotease (TIMP-1, TIMP-2) was done blindly by multiplex sandwich ELISA (Search-Light technology) in each specimen

RESULTS

Histological evidence of tendinopathy was present in all patients with a tear of the rotator cuff, and not in the macroscopically intact subscapularis tendon. There was a significant increase in MMP 1, MMP 2, MMP 3 and in TIMP-1, TIMP-2 levels in all specimens examined, including the macroscopically intact portion of the supraspinatus tendon and in the control specimens

CONCLUSIONS

The tissue in the ruptured area of the supraspinatus tendon undergoes marked rearrangement at molecular levels. This involves the activity of MMP 1, 2 and 3, and supports the critical role of MMPs in the tendon physiology. Seemingly intact parts of the injured supraspinatus tendon can present tendinopathic features, with altered cellular metabolism.

Severe osteoporosis treated with teriparatide in a patient affected by recessive epidermolysis bullosa dystrophica

In this work, we describe the clinical and instrumental results of our experience, the first reported in the literature, of the administration of teriparatide to treat severe osteoporosis secondary to epidermolysis bullosa. Already after 2 months of therapy, the patient, a 20-year-old affected by a recessive form of epidermolysis bullosa dystrophica, had less pain and a functional recovery resulting in an improved autonomy; a satisfactory increase in the densitometric values was documented.

Mental health of lesbian, gay, and bisexual youth: A developmental resiliency perspective

Research suggests that lesbian, gay, and bisexual (LGB) youth are at increased risk for both victimization and internalizing mental health problems, but limited research has studied their association or factors that increase resilience. The sample included 425 LGBs between the ages of 16 and 24 year. The majority had disclosed their sexual orientation to family or friends (98%) and 97% had someone in their lives who was accepting. Racial/ethnic minority and female participants in general reported lower levels of disclosure and acceptance. Most participants reported some form of sexual orientation-related victimization (94%). Victimization was associated with psychological distress, but a compensatory model indicated that in the context of this victimization both peer and family support had significant promotive effects. A test of a protective model found social support did not ameliorate negative effects of victimization. The positive effects of family support decreased with age. Peer and family support were particularly important, but they did not significantly dampen the negative effects of victimization. Our findings suggest that mental health professionals working with LGB youth should address social support and that public health approaches are needed to reduce levels of victimization.

Mid-term results of a metal-backed glenoid component in total shoulder replacement

Total shoulder replacement is a successful procedure for degenerative or some inflammatory diseases of the shoulder. However, fixation of the glenoid seems to be the main weakness with a high rate of loosening. The results using all-polyethylene components have been better than those using metal-backed components. We describe our experience with 35 consecutive total shoulder replacements using a new metal-backed glenoid component with a mean follow-up of 75.4 months (48 to 154). Our implant differs from others because of its mechanism of fixation. It has a convex metal-backed bone interface and the main stabilising factor is a large hollow central peg. The patients were evaluated with standard radiographs and with the Constant Score, the Simple Shoulder Test and a visual analogue scale. All the scores improved and there was no loosening, no polyethylene-glenoid disassembly and no other implant-related complications. We conclude that a metal-backed glenoid component is a good option in total shoulder replacement with no worse results than of those using a cemented all-polyethylene prosthesis.

[Functional analysis after Achilles tendon repair]

The Achilles tendon rupture (ATR) is a severe injury and requires a surgical treatment which can result in functional impairment, limiting unprofessional sports activities. In order to evaluate this potential impairment 20 subjects (SG) who had received surgical treatment for ATR and 20 healthy subjects (CG) were required to execute vertical jump according to counter movement jump and squat jump protocol. For both groups the flying time (Tv) of each foot has been acquired, adopting accelerometric transducers positioned posteriorly at the level of malleolar axis. The SG's Tv is significantly lesser than the CG's one, demonstrating an inferior global performance respect to healthy people and the operated leg has a Tv 6% higher than the contralateral, while in the CG there are no statistical difference between the Tv of the limbs. For seven operated subjects Tv values are lesser than threshold values obtained from CG. For them sports activity which implies high and cyclic stress on the lower limbs could be dangerous. Functional evaluation, consequently, allow to assess impairments not differently estimable.

A new clinical test in diagnosing quadriceps tendon rupture

INTRODUCTION

Extensor mechanism ruptures might be easily overlooked and misdiagnosed, and delayed diagnosis of quadriceps tendon rupture is frequent. However, the literature recommends early surgical repair within 72 h.

PATIENTS AND METHODS

This paper describes a new simple clinical diagnostic test that directly evaluates the integrity of the distal 5 cm of the quadriceps tendon itself. It consists of inserting a needle in the tendon, proximal to the suspected rupture and mobilising the knee joint.

RESULTS

The suspected ruptured quadriceps tendons with a positive 'needle' diagnostic test were confirmed intra-operatively.

CONCLUSIONS

This minimally invasive and easily available technique should be considered in the diagnostic work-up and treatment planning of patients with suspected tears of the quadriceps tendon.

Spontaneous reduction of a traumatic L2-L3 subluxation without fracture in a 14-year-old boy

OBJECTIVE

To report a rare case of lumbar vertebral subluxation associated with spontaneous reduction in an adolescent treated conservatively.

CLINICAL PRESENTATION AND INTERVENTION

A 14-year-old male victim of a snowboard accident, which caused a lumbar spinal injury, was referred to the emergency room with significant lumbar pain. Neurologic examination was normal. Radiographic assessment at admission showed a unilateral left lateral subluxation of the L2-L3 vertebrae without associated fractures. These findings were confirmed by CT scan and a surgical management was decided. The preoperative MRI performed 24 h after the accident, however, revealed the spontaneous reduction of the subluxation, and an associated tear of the quadratus lumborum and the psoas muscles on the right side at the level of L2, L3 and L4. Following these findings conservative treatment with a plaster brace for 2 months was carried out. The brace was removed after 2 months. The patient had no pain and the range of motion of his lumbar spine was normal. Three months after injury, sports activities were resumed. At follow-up of 24 months, the patient was free of pain and radiographs showed a right positional bending without rotational or translation anomaly.

CONCLUSION

To date, this is the first case of subluxation without fracture in a child, presenting without neurological deficit and where spontaneous reduction occurred. In this case, conservative treatment was effective and the outcome at 2-year follow-up was excellent.

Transolecranon anterior fracture dislocation

Between January 1996 and July 2003, 93 consecutive patients operated on with a diagnosis of olecranon fractures were identified from our trauma unit files. Fourteen transolecranon fracture-dislocations were found after a retrospective X-radiographic evaluation. Eight patients were women and six were men, with a mean age of 54 years. There were 4 noncomminuted olecranon fractures, treated with K-wires and single tension-band wiring. The remaining 10 fractures were complex fractures, treated in 3 cases with multiple K-wires and single tension-band wiring, in 2 by use of one-third tubular plates, in 1 with a 3.5-mm dynamic compression plate, and in the remaining 4 with 3.5-mm reconstruction plates. Ligament repair was not performed in any case. Three patients needed reoperation because of early failure of primary fixation. Patients were reviewed at a mean follow-up of 3.6 years. Two reported difficulties in daily activities, none with any symptoms of elbow instability. According to the Broberg and Morrey score, 4 patients had excellent results, 6 had good results, 2 had fair results, and 2 had poor results. Four patients showed signs of degenerative arthritis on the radiographs obtained at follow-up. We conclude that transolecranon fracture-dislocation is an underreported and misdiagnosed injury. Various fixation techniques can restore the anatomic relationships and contour of the trochlear notch; the imperative goal is to obtain a good stable primary fixation and allow early active mobilization.

Arthroscopic biceps tendon tenodesis: the anchorage technical note

Treatment of long head biceps (LHB) tendon pathology has become an area of renewed interest and debate among orthopaedic surgeons in recent years. The background of this manuscript is a description of biceps tenodesis which ensure continual dynamic action of the tendon which depresses the head and impedes lateral translation. A new technique has been developed in order to treat LHB tendon irreversible structural abnormalities associated with cuff rotator lesions. This technique entails the construction of a biological anchor between the LHB and supraspinatus and/or infraspinatus tendons according to arthroscopic findings. The rationale, although not supported by biomechanical studies is to obtain a triple, biomechanical effect. The first of these biomechanical effects which we try to promote through the procedure of transposition is the elimination of the deviation and oblique angle which occurs as the LHB completes its intra-articular course prior to reaching the bicipital groove. Furthermore, we have found this technique extremely useful in the presence of large ruptures of the rotator cuff with muscle retraction. The most common complication associated to this particular method, observed in less than 3%, is failed biological fixation which manifests as subsidence of the tenodesis and consequent descent of the tendon with evident aesthetic deformity.

Two minimal incision fasciotomy for chronic exertional compartment syndrome of the lower leg

Chronic exertional compartment syndrome (CECS) of the leg is a pathological condition often related to overuse in subject who engage repetitive physical activities. Fascial release is the mainstay of surgical management. The purpose of this study was to evaluate the results obtained with a double incision decompressive fasciotomy. Eighteen consecutive athletes with a diagnosis of anterior and/or lateral CECS of the leg were operated on with a minimal double incision fascial release after a mean period of 4 months after onset of symptoms. In 11 cases (61%) CECS was bilateral. Surgery was performed without tourniquet and active mobilization was starting immediately. Sports activities were resumed gradually at a mean period of 25 days. The athletes were followed until 2 years. All resumed pre-injury level sports activity. Two patients (18%) of the 11 who underwent to bilateral fasciotomy referred a sensation of leg weakness for an average period of 3 months. The surgical technique presented in this paper seems to be a good mean to treat anterior and lateral leg CECS. The use of tourniquet is deconselled to obtain an accurate intraoperative haemostasis so reducing the risk of post-operative haematoma.

Tuberculosis of the greater trochanter. Report of four cases

OBJECTIVE

To present four cases of tuberculosis of the greater trochanter.

CASE PRESENTATION AND INTERVENTION

The four cases (3 females and 1 male), aged 45-70 years, presented with mechanical pain in the trochanteric area associated with progressive swelling in the 3 female patients in whom mobility was also restricted. X-ray revealed a mass in 2 females; CT scan and MRI exhibited an abscess in the 3 females. Histological and bacteriological examinations showed Mycobacterium bovis in the 3 females and M. tuberculosis in the male. In the females, tritherapy and surgery were performed, while in the male quadritherapy and surgery. All the patients recovered and were followed up for 4-9 years.

CONCLUSION

These cases show that both chemotherapy and surgery must be synergic if tuberculosis is diagnosed and an abscess is confirmed by imaging.

Percutaneous retrograde screwing for stabilisation of acetabular fractures

OBJECTIVES

To evaluate the results of retrograde percutaneous screw fixation (PSF) in minimally or undisplaced acetabular fractures in a geriatric population.

PATIENTS AND METHODS

Between July 1998 and July 2001, 21 consecutive patients with an acetabular fracture underwent fluoroscopic guided percutaneous fixation. The mean age was 81 years (range 67--90 years). In all cases, the fracture was minimally or undisplaced (<2mm). Two cannulated cancellous 7.3mm screws were inserted in a retrograde fashion to stabilise the posterior and the anterior column. Bed to chair transfer began after 24h. Weight bearing as tolerated was allowed at 4 weeks.

RESULTS

Eighteen patients were reviewed at a mean of 3.5 years (range 2--5 years). Soft tissue dissection was minimal. There were no intraoperative or postoperative complications. At the latest follow-up there was no radiographical evidence of secondary displacement of fragments, degenerative changes, or screw failure. Fractures healed at a mean time of 12 weeks (range 8--15 weeks). Clinical results were satisfactory in 17 patients.

CONCLUSION

Our results show that percutaneous screw fixation under fluoroscopic control is a safe technique to treat some pattern of acetabular fracture.

Minimal invasive surgery for coronoid fracture: technical note

Operative treatment of coronoid fracture often requires a large dissection of soft tissue, resulting in elbow stiffness and functional limitation. The authors present a minimal invasive, safe technique, useful in the case of isolated coronoid fracture associated with elbow dislocation. This technique does not require soft tissue dissection and allows an early unlimited resumption of sports activities.

Modified triangular posterior osteosynthesis of unstable sacrum fracture

We report preliminary results for unstable sacral fractures treated with a modified posterior triangular osteosynthesis. Seven patients were admitted to our trauma center with an unstable sacral fracture. The average age was 31 years (22-41). There were four vertical shear lesions of the pelvis and three transverse fracture of the upper sacrum. The vertical shear injuries were initially treated with an anterior external fixator inserted at the time of admission. Definitive surgery was performed at a mean time of 9 days after trauma. The operation consisted in a posterior fixation combining a vertebropelvic distraction osteosynthesis with pedicle screws and a rod system, whereby the transverse fixation was obtained using a 6 mm rod as a cross-link between the two main rods. Late displacement of the posterior pelvis or fracture was measured on X-ray films according to the criteria of Henderson. The patients were followed-up for a minimum time of 12 months. Four patients who presented with a pre-operative perineal neurological impairment made a complete recovery. No iatrogenic nerve injury was reported. One case of deep infection was managed successfully with surgical debridement and local antibiotics. All patients complained of symptoms related to the prominence of the iliac screws. The metalwork was removed in all cases after healing of the fracture, at a mean time of 4.3 months after surgery. No loss of reduction of fracture was seen at final radiological follow-up. The preliminary results are promising. The fixation is sufficiently stable to allow an immediate progressive weight-bearing, and safe nursing care in polytrauma cases. The only problem seems to be related to prominent heads of the distal screws.

Reverse HAGL: a possible complication of a tight anterior gleno-humeral stabilization

Recently the posterior humeral avulsion of the glenohumeral capsule (Reverse HAGL or RHAGL) has been reported in the orthopaedic literature as another possible cause of posterior traumatic shoulder instability. In the present paper we describe three patients in whom a RHAGL was probably a consequence of a tight open anterior shoulder stabilisation. The main complaint of these patients was a stiff shoulder after an open anterior stabilisation. A progressive and worsening discomfort was reported by patients in spite of an accurate rehabilitation program. At persistence of symptoms arthroscopy was performed with evidence of RHAGL that was repaired in association with an anterior release. Clinical and functional improvement was observed but the final outcome seems to be related to range of motion recovery and not only to the posterior repair.

Die Behandlung von Acetabulumfrakturen bei geriatrischen Patienten mittels modifizierter Kabelcerclage und prim�rer H�fttotalprothese

This prospective study addresses early results of the treatment of acute acetabular fractures in elderly patients by total hip arthroplasty and cerclage wiring. Fifteen patients with an average age of 81 years were treated at our institution between February 1998 and December 2000. There were two transverse fractures, eight T-shaped fractures, two transverse fractures with associated posterior wall fracture, two posterior column fractures with associated posterior wall fracture, and one fracture of both columns. Treatment consisted of cerclage wiring of the fracture and primary non-cemented total hip replacement. All of the patients were followed for a mean of 36 months. Although there was one patient with three hip dislocations during the first 10 months after the operation, we found an excellent or good result for the entire group. During this relatively short follow-up period, we have not found a radiological loss of fracture reduction of more than 1 mm or a cup migration of more than 3.2 mm. All of the fractures healed and no loosening of the implant was evident. Primary total hip arthroplasty combined with internal fixation is a valid treatment option for acetabular fractures in the elderly. Preliminary results are convincing, but a bigger patient population and a longer follow-up time are necessary before we are able to draw final conclusions.

Post-traumatic overload or acute syndrome of the os trigonum: a possible cause of posterior ankle impingement

The purpose of this paper is to discuss the post-traumatic overload syndrome of the os trigonum as a possible cause of posterior ankle impingement and hindfoot pain. We have reviewed 19 athletes who were referred to our foot unit between 1995 and 2001 because of posterior ankle pain, and in whom a post-traumatic overload syndrome of os trigonum was diagnosed. All these patients were followed up over a period of 2 years. In 11 cases a chronic repetitive movements in forced plantar flexion was found. In the other eight cases the pain appeared to persist after a standard treatment of an ankle sprain in inversion plantar flexion. The diagnosis was based on clinical history, physical examination and X-rays that revealed a non-fused os trigonum. The confirmation of diagnosis was carried-out injecting local anaesthetic under fluoroscopic control. In all cases a corticosteroid injection as first line treatment was performed. In 6 cases a second injection was necessary to alleviate pain because incomplete recovery with the first injection. Three cases (16%) were recalcitrant to this treatment and in these three cases a surgical excision of the os trigonum was carried out. Our conclusion is that after some chronic athletic activity or an acute ankle sprain the os trigonum, if present, may undergo mechanical overload, remain undisrupted and become painful. Treatment by corticosteroid injection often resolves the problem.

Fracture of the non fused os trigonum, a rare cause of hindfoot pain. A case report and review of the literature

A case of "astrigonum" fracture is described. The Authors described the history, clinical signs, radiographic picture of this lesion. Conservative treatment lead to healing with good result, when the diagnosis is promptly made.

Manipulative therapy in the treatment of benign cervicobrachialgia of mechanical origin

The authors compared two methods of rehabilitation, traditional physical therapy and manual therapy, in the treatment of benign cervicobrachialgia of mechanical origin, typical of young subjects, generally consequent to mild and moderate trauma, occasional strain or incorrect posture repeated in time. A MID (minor intervertebral deficit) is at its origin, characterized by the absence of objective instrumental signs (X-ray, CT scan, MRI) and it is only diagnosed based on clinical history and accurate physical examination of the spine segment involved. A sample of 80 patients was divided at random into two groups: the first group was submitted to traditional physiotherapy, the second to manipulative therapy carried out according to the French method of R. Meigne. The results obtained, which were evaluated by univaried ANOVA and Student's "t" test statistical analysis, showed the greater effectiveness of manipulative treatment, in the short term and in the long term.

The surgical treatment of hallux valgus using distal metatarsal osteotomy and stabilization with a hallux splint. Preliminary results

The preliminary results of the surgical treatment of hallux valgus using subcapitate chevron-type osteotomy of the 1st metatarsal modified using a dynamic interfragmentary device are reported. The method satisfies the need to restore angular metatarsophalangeal and intermetatarsal values and improves metatarsal pain caused by hallux valgus correction, which influences the cosmetic results.

Sub- or intertrochanteric fracture following screw fixation of an intracapsular proximal femoral fracture: true complication or technical error?

PURPOSE

To review, retrospectively, the possible causes of sub- or intertrochanteric fractures after screw fixation of intracapsular fractures of the proximal femur.

METHODS

Eighty-four patients with an intracapsular fracture of proximal femur were operated between 1995 and 1998 by using three cannulated 6.25 mm screws. The screws were inserted in a triangular configuration, one screw in the upper part of the femoral neck and two screws in the inferior part. Between 1999 and 2001, we use two screws proximally and one screw distally.

RESULTS

In the first series, two patients died within one week after operation. Sixty-four fractures healed without problems. Four patients developed an atrophic non-union; avascular necrosis of the femoral head was found in 11 patients. Three patients (3.6%) suffered a sub- and/or intertrochanteric fracture after a mean postoperative time of 30 days, in one case without obvious trauma. In all three cases surgical revision was necessary. Between 1999 and 2001 we did not observe any fracture after screwing.

CONCLUSION

Two screws in the inferior part of the femoral neck create a stress riser in the subtrochanteric region, potentially inducing a fracture in the weakened bone. For internal fixation for proximal intracapsular femoral fracture only one screw must be inserted in the inferior part of neck.

[Hemilithotomy position for intramedullary nailing of the femur and compartment syndrome of the healthy leg]

The well leg compartment Syndrome following long procedures in the dorsal lithotomy or hemi-lithotomy position is a rare complication. Its diagnosis is usually late and the neurological deficit are often permanent. We report two cases of femoral nailing complicated by Compartment Syndrome of the contralateral leg. We review the published literature on 40 cases which suggests a clear relationship between these positions, the duration of the intervention and the degree of leg elevation. Given the potentially severe sequel, prevention is a must and a high degree of suspicion is the key to an early diagnosis. A modified hemi-lithotomy position is proposed. That avoids extreme elevation of the leg and diminishes the hip and knee flexion required while allowing adequate fluoroscopy.

Lumbar disc herniation and cauda equina syndrome. Considerations on a pathology with different clinical manifestations

The authors describe six cases of cauda equina syndrome (CES) with different clinical manifestations, etiopathogenetic causes, and degrees of disc prolapse. In three of the cases, the clinical onset was dramatic and acute, in the others it was a hemisyndrome (with acute onset in only 1 case). The site of the disc prolapse was L4-L5 in 3 patients, L3-L4 in 2 patients, and L5-S1 in 1 patient. The authors emphasize the need for the early recognition of the syndrome with a careful clinical examination and history of the patient, as well as timely treatment within 24 hours. For the sake of prevention, and particularly when the hernia is large, the authors suggest monitoring of the stability of the residual disc during surgery and postoperatively the use of a brace for at least one month.

Health care issues of gay and lesbian youth

Gay and lesbian youth are adolescents who, in many ways, are no different from their peers. What distinguishes homosexual youth from other adolescent populations is the emotional, psychological and physical trauma resulting from the homophobia they experience in their daily lives. Although suicide, HIV infection, substance use, and violence appear to disproportionately affect this population, most homosexual youth grow up healthy and happy. Frequently lost in discussions of risk and risk behaviors is an appreciation of the strengths very much present in these young people. Health care providers must remain aware of the unique issues and health risks of homosexual youth but must also remember to address each patient as an individual within the context of general adolescent development. By doing so, pediatricians can play a vital role in preserving and enhancing the health of this "at-risk" population.

Management of the asymptomatic HIV-infected patient: an update

Guidelines for initiating antiretroviral therapy in asymptomatic patients continue to be debated. Physicians and patients should decide whether drug treatment is advisable after jointly considering psychosocial issues as well as measurements of immune function and HIV burden. Other components of care include appropriate immunizations, screening for other sexually transmitted infections, safer-sex counseling, and referral for substance abuse treatment, if indicated.

[The usefulness of the association of clinical probability, rapid plasma measurement of D-dimer, compression echography of the lower limbs and echocardiography in the diagnosis of acute pulmonary embolism]

BACKGROUND

The aim of this study was to investigate the diagnostic utility of clinical probability, rapid plasma D-dimer assay, compression ultrasonography (CUS) and transthoracic echocardiography (TTE) in patients with suspected pulmonary embolism.

METHODS

One hundred forty consecutive outpatients with suspected pulmonary embolism were enrolled in a prospective trial. We evaluated sensitivity, specificity, positive and negative predictive value of a combination of clinical probability, D-dimer, CUS and TTE using perfusion lung scan and pulmonary angiography as a combined gold standard for determining the presence or absence of pulmonary embolism. Clinical probability was assessed in accordance with the PIOPED criteria. The D-dimer (Nycocard) level was considered as abnormal > 0.3 mg/l, the CUS if incompressibility of the leg veins was showed, and the TTE if right ventricular dilation was present, in the absence of chronic pulmonary disease. The combination of these tests was considered consistent with the presence of pulmonary embolism if D-dimer plus CUS and/or TTE showed abnormal results. A pulmonary embolism was excluded if D-dimer and CUS showed normal findings or a low clinical probability was associated with normal findings of CUS and TTE.

RESULTS

One hundred eleven patients were evaluated. Pulmonary embolism was present in 45/111 (40%) patients. The combination of tests showed positive findings in 39/39 patients with pulmonary embolism, negative findings in 47/50 without pulmonary embolism and non-diagnostic results in 22/111 (20%) patients (95% confidence interval--CI 12-28%). There were three false positive and no false negative results. Sensitivity and specificity were 100 and 94% respectively (95% CI 92-100% and 87-100%); positive and negative predictive values were 93 and 100% (95% CI 85-100% and 93-100%). None of these tests, separately, showed enough sensitivity and specificity.

CONCLUSIONS

The combination of clinical probability, D-dimer, CUS and TTE was highly accurate to confirm or rule out pulmonary embolism.

Sexual orientation and risk of suicide attempts among a representative sample of youth

OBJECTIVE

To examine whether sexual orientation is an independent risk factor for reported suicide attempts.

DESIGN

Data were from the Massachusetts 1995 Centers for Disease Control and Prevention Youth Risk Behavior Survey, which included a question on sexual orientation. Ten drug use, 5 sexual behavior, and 5 violence/ victimization variables chosen a priori were assessed as possible mediating variables. Hierarchical logistic regression models determined independent predictors of suicide attempts.

SETTING

Public high schools in Massachusetts.

PARTICIPANTS

Representative, population-based sample of high school students. Three thousand three hundred sixty-five (81%) of 4167 responded to both the suicide attempt and sexual orientation questions.

MAIN OUTCOME MEASURE

Self-reported suicide attempt in the past year.

RESULTS

One hundred twenty-nine students (3.8%) self-identified as gay, lesbian, bisexual, or not sure of their sexual orientation (GLBN). Gender, age, race/ethnicity, sexual orientation, and all 20 health-risk behaviors were associated with suicide attempt (P<.001). Gay, lesbian, bisexual, or not sure youth were 3.41 times more likely to report a suicide attempt. Based on hierarchical logistic regression, female gender (odds ratio [OR], 4.43; 95% confidence interval [CI], 3.30-5.93), GLBN orientation (OR, 2.28; 95% CI, 1.39-3.37), Hispanic ethnicity (OR, 2.21; 95% CI, 1.44-3.99), higher levels of violence/ victimization (OR, 2.06; 95% CI, 1.80-2.36), and more drug use (OR, 1.31; 95% CI, 1.22-1.41) were independent predictors of suicide attempt (P<.001). Gender-specific analyses for predicting suicide attempts revealed that among males the OR for GLBN orientation increased (OR, 3.74; 95% CI, 1.92-7.28), while among females GLBN orientation was not a significant predictor of suicide.

CONCLUSIONS

Gay, lesbian, bisexual, or not sure youth report a significantly increased frequency of suicide attempts. Sexual orientation has an independent association with suicide attempts for males, while for females the association of sexual orientation with suicidality may be mediated by drug use and violence/victimization behaviors.