Skeletal muscle ventricles in circulation long-term: one hundred ninety-one to eight hundred thirty-six days.

It has been shown previously that skeletal muscle ventricles fashioned from canine latissimus dorsi muscle can function as effective blood pumps. We describe four dogs that have been reported on before but have now had skeletal muscle ventricles functioning as effective aortic diastolic counterpulsators for 191 to 836 days. One dog remains well with a skeletal muscle ventricle that has been pumping in circulation for 194 days; there has been no evidence of thrombus in the skeletal muscle ventricle cavity or thromboembolism. None of the three dogs that died had evidence of peripheral embolization, although two of those dogs had thrombus within the cavity of the skeletal muscle ventricle. This study proves that skeletal muscle ventricles can function long-term in the circulation and maintain diastolic pressure augmentation beyond 2 years. To the best of our knowledge, the dog whose skeletal muscle ventricle pumped in circulation for 836 days represents the longest living laboratory animal or human with a functioning heart assist device.     

Management of nontuberculous infectious discitis. treatments used in 110 patients admitted to 12 teaching hospitals in France.

The optimal management of pyogenic discitis is not agreed on. No randomized clinical trials of short-course or oral antibiotic regimens have been published to date. To shed light on this issue, we reviewed the management of patients admitted for pyogenic discitis to one of 12 networked rheumatology departments. In this cross-sectional observational study, each department included the first ten patients admitted starting in January 1997 for treatment of pyogenic discitis. One hundred ten patients met the inclusion criteria, 67 men and 43 women, with a mean age of 60.6 +/- 13.7 years (range, 17-86 years). Mean time from symptom onset to diagnosis was 39.6 +/- 39.8 days (range, 24 h-240 days). Blood cultures were positive in 47.3% of patients, and the percutaneous discal and vertebral biopsy in 63.6% of cases; these two investigations identified the causative organism in 79 cases (72.8%). Mean duration of the rheumatology department stay was 31.3 +/- 14.1 days (range, 4-78 days). Antibiotics were given intravenously to 103 (93.6%) patients, for a mean of 25.5 +/- 17.6 days (range, 4-124 days); duration of intravenous antibiotic therapy was longer than 4 weeks in 36.5% of patients. Only seven (6.4%) patients received primary oral antibiotics with no parenteral antibiotics. One hundred patients were given oral antibiotics at the same time as and after intravenous antibiotics, for a mean duration of 87.2 +/- 43.6 day (range, 20-278 days); Bracing was used in 98 (89.1%) patients. Although antibiotic selection was rational and in agreement with current recommendations, wide differences were noted across centers regarding intravenous treatment duration, hospital stay duration, and total treatment duration.     

Management of postprocedural discitis.

BACKGROUND CONTEXT: Fortunately, the incidence of postprocedural discitis is relatively uncommon. The paucity of physical examination findings behooves the spine care practitioner to have a high index of suspicion in any patient presenting with increasing back pain after an invasive spinal procedure. The diagnosis can often be established in a timely fashion based on the history, physical examination, laboratory studies (erythrocyte sedimentation rate, C-reactive protein and blood cultures) and imaging studies (plain radiographs, magnetic resonance imaging, computed tomography and radionuclide scanning). PURPOSE: To review the English literature on the subject of postprocedural discitis. The incidence, pathophysiology, laboratory markers and imaging findings are discussed. Recommendations on treatment strategies are presented along with long-term clinical outcomes of this postprocedure complication. METHODS: A contemporary English literature search of MEDLINE and PubMed on the topic of postoperative discitis was performed. RESULTS: The incidence of postprocedural discitis is approximately 0.2%. The most common etiologic agent is Staphylococcus aureus. The C-reactive protein is the most sensitive clinical laboratory marker to assess the presence of infection and effectiveness of treatment response. Magnetic resonance imaging is the imaging modality of choice in the diagnosis of spinal infection. The majority of patients are managed adequately with organism-specific antibiotics and spinal immobilization with good long-term outcomes. Operative intervention (open biopsy followed by antibiotic treatment and spinal immobilization or debridement and reconstruction) in patients who fail to respond to nonoperative treatment or in the presence of neurologic worsening has been demonstrated. CONCLUSION: Postprocedural discitis is a rare complication after any invasive spinal procedure. It is imperative for the treating surgeon to maintain a high index of suspicion. Appropriate laboratory and imaging studies are invaluable in establishing a timely diagnosis. In the majority of patients, antibiotic treatment along with spinal immobilization has been shown to produce good long-term outcomes. Operative intervention is rarely necessary in patients failing conservative treatment.     

Spine deformity in neurofibromatosis. A review of one hundred and two patients.

The natural history, associated anomalies, and response to operative and nonoperative treatment were reviewed in 102 patients with neurofibromatosis and spine deformity. Eighty patients were found to have curvatures associated with dystrophic changes in the vertebrae and ribs. The presence of dystrophic changes such as rib penciling, spindling of the transverse processes, vertebral scalloping, severe apical vertebral rotation, foraminal enlargement, and adjacent soft-tissue neurofibromas was found to be highly significant in prognosis and management. Brace treatment of dystrophic curves was unsuccessful. Posterior fusion, with or without internal fixation, was the procedure of choice for problems due purely to scoliosis. Patients with dystrophic kyphoscoliosis required both anterior and posterior fusion to achieve stability. Sixteen patients had compression of the spinal cord or cauda equina.     

Wagner resurfacing hip arthroplasty. The results of one hundred consecutive arthroplasties after eight to ten years

In a prospective study of 100 consecutive Wagner resurfacing hip arthroplasties in ninety-three patients, the outcomes for all hips were determined for an eight to ten-year follow-up period. By survivorship analysis, the rate of survival of the arthroplasty was calculated to be 70 per cent at five years, but only 40 per cent at eight years. The major cause of failure was aseptic loosening of the acetabular or femoral component, or both. Fracture of the neck of the femur occurred in three hips. Although the medium-term results (at fifty-six to eighty-three months) were better than those in most comparable studies of resurfacing arthroplasty, the poor long-term results (at ninety-one to 118 months) show that meaningful studies of new prosthetic designs must continue for at least eight years, and, if at all possible, must include 100 per cent follow-up. The survival curve for the resurfacing arthroplasties in this study can serve as the basis for comparison of the early, medium, and long-term results of future designs of resurfacing hip prostheses.     

Halo-pelvic distraction apparatus. An analysis of one hundred and fifty consecutive patients.

One hundred and fifty consecutive patients on whom the halo-pelvic apparatus was used were analyzed. Sixty-six per cent had tuberculous kyphosis or paralytic scoliosis. The apparatus was of great value in holding and correcting spines with tuberculous kyphosis and the results were gratifying, even though the average correction of the kyphos was only 20 per cent. In paralytic scoliosis a 46 per cent correction was obtained, but presently Dwyer and Harrington instrumentation are used for the majority of such cases. The halo-pelvic apparatus was effective in holding and correcting severe congenital curves and kyphoscoliosis secondary to neurofibromatosis, especially when there were signs of cord compression. The complication rate was high early in the series, but has been lowered by strict patient selection and close adherence to specific guidelines in the application of the apparatus. The apparatus should be reserved for severe deformities when other means of correction or stabilization are inadequate.     

Orthopaedic manifestations of familial dysautonomia. A review of one hundred and thirty-six patients

BACKGROUND: Familial dysautonomia is a hereditary multisystemic disease primarily affecting people of Ashkenazi Jewish descent. Musculoskeletal problems are related to gait disorders, spinal deformities, foot deformities, fractures, and arthropathies. METHODS: The charts and radiographs of 136 patients who ranged in age from three months to forty-six years (mean, sixteen years) were reviewed. Sixty-four patients were available for follow-up examination. RESULTS: Spinal deformity was the most common orthopaedic problem and was diagnosed in seventy-eight patients starting at the age of four years, with a prevalence of 86 percent (forty-eight of fifty-six) by the age of fifteen years. Forty-one (53 percent) of the seventy-eight patients had scoliosis only, thirty-four (44 percent) had kyphoscoliosis, and three (4 percent) had kyphosis only. Bracing was accompanied by emotional, pulmonary, and skin problems, leading to a high rate of noncompliance and progression of the curve. Twenty-four patients had an operation at a mean age of thirteen years (range, five to eighteen years): twenty patients had posterior spinal arthrodesis, and four had combined anterior and posterior arthrodesis. Fifteen patients had a total of nineteen complications, of which seven were systemic and twelve were related to the spinal fixation. Eight patients had revision surgery. At the time of the surgery, scoliosis was corrected from a mean of 55 degrees to a mean of 35 degrees and kyphosis was corrected from a mean of 69 degrees to a mean of 61 degrees. After a mean duration of follow-up of sixty-five months, scoliosis measured 49 degrees (range, 18 to 62 degrees) and kyphosis measured 67 degrees (range, 30 to 115 degrees). Postoperative progression of the deformity was caused by failure of the instrumentation or progression in unfused segments. Walking was delayed in 72 percent (ninety-four) of the 130 patients who were of walking age. All sixty-four of the patients who were examined had an ataxic gait. Foot deformities were found in sixteen patients, six of whom were treated surgically. Two patients had Charcot joints. Fifty-five patients sustained at least one fracture before skeletal maturity, with a mean of 1.5 fractures per patient. All but one of the fractures was treated nonoperatively, and fracture-healing was often accompanied by profuse callus formation. CONCLUSIONS: Spinal deformity is common in patients with familial dysautonomia. Bracing is of questionable benefit, and surgical intervention should be considered once curve progression is well documented. Arthrodesis should be extended as far proximally as possible to prevent junctional kyphosis. Swelling and warmth in a limb should raise suspicion of an undiagnosed fracture.     

Natural history of congenital kyphosis and kyphoscoliosis. A study of one hundred and twelve patients.

BACKGROUND: Congenital kyphosis and kyphoscoliosis are much less common than congenital scoliosis. However, they are potentially more serious because compression of the spinal cord and paraplegia sometimes develop. The goals of the present study were to document the natural history of congenital kyphosis and kyphoscoliosis and to determine the stage at which the natural progression should be interrupted by treatment. METHODS: We reviewed the medical records and radiographs of the spine of 112 consecutive patients. Sixty-eight patients had a type-I kyphosis due to an anterior failure of vertebral-body formation, twenty-four had a type-II kyphosis due to an anterior failure of vertebral-body segmentation, and twelve had a type-III kyphosis due to a combination of anomalies; the deformities of the remaining eight patients could not be classified. Eighty-five skeletally immature, untreated patients were first evaluated at a mean age of six years and nine months (range, two months to sixteen years and three months), and twenty-seven patients were skeletally mature at the time of the first visit. Sixty-three of the eighty-five skeletally immature patients were observed without any treatment for a mean period of six years and six months (range, one to sixteen years) before skeletal maturity, and the remaining twenty-two patients had a posterior arthrodesis of the spine soon after the initial visit. At skeletal maturity, forty-one patients had not been treated and sixty-eight had had an arthrodesis of the spine. The remaining three patients had not yet reached skeletal maturity at the time of the most recent follow-up. RESULTS: The apex of the kyphosis was seen at all levels but was most frequent between the tenth thoracic and the first lumbar level (seventy-four patients; 66 percent). There was no relationship between the severity of the kyphosis and its location in the spine. Progression of the curve was most rapid during the adolescent growth spurt and stopped only at skeletal maturity. Progression was most rapid and the magnitude of the curve was the greatest in type-III kyphosis (twelve patients) followed by type-I kyphosis due to a posterolateral quadrant vertebra (thirty-nine patients), a posterior hemivertebra (eight patients), a butterfly vertebra (fifteen patients), and a wedged vertebra (six patients). A kyphosis due to two adjacent type-I vertebral anomalies progressed more rapidly and produced a more severe deformity than did a similar single anomaly. The prognosis for type-II kyphosis was variable and was much more severe when an anterolateral unsegmented bar had produced a kyphoscoliosis (nine patients) than it was when a midline anterior bar had produced a pure kyphosis (fifteen patients), which usually progressed slowly. Spontaneous neurological deterioration due to compression of the spinal cord occurred in ten patients (seven of whom had a type-I kyphosis and three of whom had an unclassifiable anomaly) at a mean age of thirteen years and eight months, and one other patient (with an unclassifiable anomaly) had spastic paraparesis at the age of twenty-eight years. CONCLUSIONS: Congenital kyphosis and kyphoscoliosis are uncommon deformities with the potential to progress rapidly, resulting in severe deformity and possible neurological deficits. A thorough knowledge of the natural history is essential in the planning of appropriate and timely treatment to prevent progression of the deformity and neurological complications.     

A case of lung metastasis in myxoinflammatory fibroblastic sarcoma: analytical review of one hundred and thirty eight cases

Purpose

Myxoinflammatory fibroblastic sarcoma (MIFS) is a rare soft tissue tumour first identified at the end of the 1990s. This study presents our experience and literature reviews focusing on risk of recurrence.

Methods

Rizzoli Orthopaedic Institute database and literature were searched for patients with MIFS observed from 1997 to 2012. Data were analysed in a new database.

Results

Five patients underwent surgery at our institute, and 133 cases were retrieved from the literature. Not all clinicopathological data were available: 76/138 were men (55 %), median age was 45 [interquartile range (IQR) 34–56] years, median tumour size was three (IQR two to five) centimetres. Common sites of occurrence were hand (24 %), fingers (23 %) and foot (20 %). Pain was present at diagnosis in 14/82 patients (17 %), with a median duration of seven (IQR three to 12) months. Surgery was performed for a suspected benign tumour in 88 patients (74 %). Resection was incomplete in 45/71 cases (63 %); re-excision was performed in 32/45 (71 %). At a median follow-up of 26 months, 26/118 patients (22 %) developed recurrent disease; median time to recurrence was 15 months (IQR seven to 26). Actuarial relapse-free survival (RFS) at one, three and five years was 93 %, 72 % and 67 %, respectively. At univariate analysis, only symptom duration of six months or less was significantly associated with a worse RFS (p = 0.046). Metastatic disease to lymph nodes and/or lungs was observed in four patients (3 %).

Conclusions

Clinicopathological findings confirm the low-grade nature of MIFS. However, local recurrence occurs, and patients may be affected by aggressive forms with a potential for distant metastases. Follow-up is strongly advised.     

Isolated coronary artery bypass grafting in one hundred consecutive octogenarian patients. A multivariate analysis.

One hundred consecutive patients aged 80 or older underwent isolated coronary artery bypass grafting for New York Heart Association functional class III (24%) or IV (76%) disease in our institution from 1985 to 1989. The operations were elective in 36 patients, urgent in 52, and emergent in 12. Twenty-eight patients had significant disease of the left main coronary artery, with the remainder having an average of 2.8 diseased coronary vessels. Preoperative left ventricular ejection fraction was considered good (greater than 50%) in 62 patients, fair (30% to 50%) in 24 patients, and poor (less than 30%) in 14 patients. An average of 2.8 grafts were performed per patient, and the internal mammary artery was used in 10 patients. Univariate analysis of 36 perioperative factors followed by multivariate logistic regression analysis of the significant variables (p less than 0.05) revealed that the urgency of the operation and left ventricular ejection fraction were independent predictors of operative mortality. There were 12 in-hospital deaths, and the mortality was significantly lower in the elective cases (2.8%) than in the urgent (13.5%) and emergent cases (33.3%). Major complications occurred in 14% of the elective cases, in 21% of the urgent cases, and in 67% of the emergent cases. The operative mortality rates for good, fair, and poor left ventricular ejection fraction were 4.9%, 12.5%, and 42.9%, respectively. Long-term follow-up averaging 22 months revealed a 77% actuarial probability of survival at 24 months and 51% at 48 months, with only two cardiac-related deaths. We conclude that coronary artery bypass grafting can be performed in octogenarians with a favorable outcome when done electively in patients with normal to moderately depressed left ventricular function.