Treatment of complex proximal tibia fractures with the less invasive skeletal stabilization system

OBJECTIVE: Proximal tibia fractures with metaphyseal comminution present a difficult treatment challenge. The Less Invasive Skeletal Stabilization (LISS) internal fixator system has theoretical advantages (minimally invasive fixed angle construct) for the treatment of these injuries. This report presents clinical results of the LISS system for treatment of complex proximal tibia fractures and illustrates the unique properties of the system. DESIGN: Prospective clinical trial. SETTING: Level I trauma center. PATIENTS: Twenty-eight consecutive patients with comminuted proximal tibia metaphyseal fractures (41A3, 41C2, or 41C3) treated with LISS plates. OUTCOME MEASUREMENTS: Healing, fracture alignment, infectious and implant-related complications, and functional outcome based on the Lower Extremity Measure (LEM). RESULTS: Average follow-up was 23 months (range 12-48). Thirty-seven of 38 patients healed their fracture after the index procedure. The other healed after implant removal without the need for further fracture repair. Postoperative fracture alignment was satisfactory in 37 of the 38 cases and was maintained in all patients at union. There were no infectious complications. The average LEM score was 88. CONCLUSIONS: The LISS internal fixator system can be used successfully to treat complex proximal tibia fractures without the need for additional medial stabilization. Surgeons attempting to use fixed angle internal fixation plating systems should familiarize themselves with the significant technical differences between these and traditional plating systems to assure satisfactory results.     

Recent advances and future perspective in neuroimaging in neuropsychiatric systemic lupus erythematosus

Involvement of the central nervous system (CNS) is one of the most important complications of systemic lupus erythematosus (SLE), occurring in 14-75% of SLE patients. Neurological and psychiatric involvement is mainly manifested as cerebrovascular disease, seizures, cognitive impairment, headaches and psychosis. However, diagnosis of brain involvement in SLE (i.e., neuropsychiatric lupus: NPSLE) as well as understanding of pathogenetic mechanisms still remains a difficult challenge. Although a wide range of neurodiagnostic tools have been used in the last decade to assess CNS involvement, no single technique has proven to be definitive or reliable. Since neurometabolic impairment, neurochemistry and perfusion abnormalities in NPSLE may precede anatomic lesions, new functional techniques such as magnetic resonance spectroscopy, diffusion and perfusion weighted imaging, and magnetization transfer imaging may be useful in order to indentify pathologic changes unrevealed by conventional imaging. So these new diagnostic tools could modify diagnostic and therapeutic approaches to this major unsolved problem, also shedding some light on the physiopathology of CNS disease in SLE.     

Polyembrioma of the testis: case report following chemotherapy for non-Hodgkin's lymphoma

Testicular tumours represent 2% of all male malignancies, mostly concerning young men (20-40 years old). The polyembryoma is one of the uncommonest lesions and just recently it has been identified as autonomous nosographic entity. The reported case is peculiar because the patient was older than the most ones described in the literature and the tumour arose after polychemotherapy for non Hodgkins' disease. The Authors analyse some aspects concerning etiology, pathology and clinical approach to such rare neoplasm.     

Functional outcome after isolated acetabular fractures

OBJECTIVE: To evaluate objectively the effectiveness of current surgical management of displaced acetabular fractures. To provide insight into how these evaluation methods can be used to identify areas in which improvements in surgery and rehabilitation can be pursued to improve patient outcomes. DESIGN: Consecutive case series. SETTING: University medical center. PATIENTS: Fifteen patients were studied, each with an isolated, displaced acetabular fracture treated with a Kocher-Langenbeck approach. MAIN OUTCOME MEASURES: Primary outcome measures included hip muscle strength, including work (Joules/minute) and maximum torque (30 degrees/second) for abductors/adductors and flexors/extensors. Gait analysis of patients and able-bodied cohorts, including stride length, speed, and cadence, were also assessed. Motion analysis during gait was also studied for each body segment, including the trunk, pelvis, hip, knee, and ankle, in the sagittal, frontal, and axial planes. Motion data for the affected side was compared with motion data for the unaffected side, and linear gait findings for the study patients were compared to able-bodied cohorts. An assessment of clinical outcome was performed by completion of a validated Musculoskeletal Function Assessment (MFA) questionnaire and the were results correlated with muscle strength and gait analysis. Secondary outcome measures included adequacy of fracture reduction, radiographic grade, the presence and severity of heterotopic ossification at the time of the most recent follow-up, and passive range of motion of the affected and unaffected hips. RESULTS: No statistical differences in muscle strength for each of the major muscle groups were found when the affected limb was compared with the unaffected limb. No statistical differences were found between the study patients and the able-bodied cohorts with regards to stride length, gait speed, and cadence. The only significant difference found in body segment position was trunk inclination. When the study patients were compared with able-bodied cohorts, the patients tended to walk with greater forward inclination of their trunks; this was true for all phases of gait. Total MFA scores averaged 22 (range, 0-57). Patients could be separated into two separate groups based on their total MFA score. One group (n = 6) had an average MFA score of 7 (range, 0-10), while a second group (n = 9) had an average MFA score of 32 (range, 12-57). The scores of study patients as a whole, and those of each individual group of patients, were compared with known MFA scores for nonpatients and patients in the Orthopaedic Trauma Association/Association for the Study of Internal Fixation (OTA/AO) injury group (hip and thigh). When the muscle strengths of these two groups of patients were compared, all hip flexion and extension variables were significantly weaker in the group with an average MFA score of 32, whereas none of the gait variables were different between the two groups. At an average follow-up of 24 months, seven patients had an excellent radiographic grade, four patients had a good grade, two patients had a fair grade, and two patients had a poor grade. These radiographic grades were in contrast to achieving an anatomic reduction in eleven patients, a satisfactory reduction in three patients, and an unsatisfactory reduction in one patient. Heterotopic ossification was found in eight patients, four patients had Grade 1, and four patients, had Grade 2. No statistically significant differences were observed when each MFA group was compared with each of these radiographic variables. Passive hip range of motion was not statistically different when the affected hip was compared with the unaffected hip. CONCLUSIONS: Standardized muscle strength determination, gait, and motion analysis, and completion of an MFA questionnaire provided a thorough and revealing evaluation of patients who have undergone open reduction and internal fixation (ORIF) of a displaced acetabular fracture. Minimal alterations in body posture and affected limb motion were present in patients displaying relatively normal gait parameters, including stride length, speed, and cadence. Despite dissection of the hip musculature during surgery, normal muscle strength recovery was possible after operative repair of these acetabular fractures. However, functional outcome, as determined by MFA scores, was considerably poorer in those patients with significantly weaker hip flexion and extension strength, compared with those of patients with more desirable MFA scores. Based on the current data, it appears that the use of these and similar evaluation instruments can allow determination of factors that negatively affect outcome (hip flexion and extension strength), which otherwise may remain unknown. It is possible that identification and treatment of these factors will improve the quality of life for patients after this type of injury.     

Assessment of articular fragment displacement in acetabular fractures: a comparison of computerized tomography and plain radiographs

OBJECTIVES: Quantitatively evaluate plain radiographs, relative to computed tomography (CT) scans, for assessment of articular fragment displacement (step and gap) in displaced acetabular fractures and in canine osteotomized acetabular specimens. DESIGN: Retrospective evaluation of a consecutive series of CT scans and plain radiographs of patients with displaced acetabular fractures and canine acetabulae osteotomized to represent acetabular fractures with displacement. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Computed tomography scans and plain radiographic images of 62 consecutive patients with displaced acetabular fractures were reviewed; 20 patients met the inclusion criteria regarding location, fracture pattern, availability of plain radiographs and CT scans, and the position of the femoral head at the time of radiographic assessment. The hemipelvi of five adult mongrels underwent osteotomy of the acetabulum and similar radiographic evaluation. INTERVENTION: Three independent reviewers measured step and gap deformity on plain radiographs and CT scans utilizing a standardized measurement technique. MAIN OUTCOME MEASUREMENTS: Sensitivity and specificity of plain radiographs for detecting step and gap displacement (2 mm and 4 mm) relative to CT scans were determined. Intraclass correlation coefficient and intraobserver reliability was also calculated. For the canine specimens, sensitivities of each imaging method were determined relative to actual fragment displacement measurements. RESULTS: In the clinical images, when compared to CT, plain radiographs showed poor sensitivity at detecting step deformity (sensitivity = 25%). When analyzed by fracture type, plain radiographs were particularly poor at detecting step deformities in fractures involving a single column of the acetabulum (sensitivity = 0%). Excellent intraobserver and intraclass reliability existed among the three reviewers. Computed tomography scans were considerably more accurate in measuring step and gap displacement relative to actual measurements than plain radiographs in the canine specimens. CONCLUSIONS: 1) Plain radiographs showed poor sensitivity for the detection of step and gap deformities in patients with acetabular fractures and in osteotomized canine specimens, relative to CT scans; 2) differences between CT and plain radiographs in both specimen types were greatest with the most clinically relevant deformity-i.e., step; and 3) CT scans are essential and should continue to be used in conjunction with plain radiographs in the preoperative evaluation of displaced acetabular fractures and perhaps should be considered in the postoperative assessment of fracture reduction.     

Results of the Italian multicenter study on 239 super-obese patients treated by adjustable gastric banding

Background: Laparoscopic adjustable gastric banding (LAGB) is the most common bariatric operation. This study is a retrospective analysis of the multicenter Italian experience in patients with BMI >50 over the last 4 years. Methods: An electronic data sheet made for LAGBoperated patients since January 1996, was mailed and e-mailed to all surgeons involved in this kind of procedure in Italy. Items regarding patients with BMI >50 were selected. Analysis used Fisher's exact test and logarithmic regression analysis (P<0.05 significant). Data were expressed as mean ± SD. Results: 239 patients (13.3%), out of 1,797 LapBand^? operated patients entered the study (179F / 60M), with mean age 37.6±11.3 years (19-69) and mean BMI 54.6±4.8 (50.1-83.6). Laparotomic conversion rate was 5.4% (44/239). Postoperative complications occurred in 24 / 239 patients (9.0%). Follow-up was obtained in 218 / 218, 198 / 198, 121 / 147, 75 / 93, 30 / 38 LAGB patients at 6, 12, 24, 36, and 48 months respectively. At these time periods, mean BMI was 46.7, 43.9, 42.2, 41.9, and 39.3 kg/m². At the same intervals, mean %EWL was 24.1, 34.1, 38.8, 38.9, and 52.9%.The number of patients with <25% EWL at 12, 24, 36, and 48 months follow-up were 34, 10, 4, and 0. Serious co-morbidities (189 in 124 of 239, 57%) had completely resolved 1 year postoperatively in 74 / 124 of the patients (59.6%). Conclusion: Although super-obese patients following the LAGB remain obese with BMI >35, in the short-term most lose their co-morbidities, with a very low morbidity and mortality rate.     

Domperidone is more effective than cisapride in children with diabetic gastroparesis

BACKGROUND: Disorders of gastrointestinal motility are commonly detected in patients with insulin-dependent diabetes mellitus and are associated with significant morbidity. They contribute to poor metabolic control of diabetes. AIM: To assess the effect of an 8-week course of domperidone or cisapride on gastric electrical activity, gastric emptying time and dyspeptic symptoms in children with insulin-dependent diabetes mellitus and gastroparesis. METHODS: Dyspeptic symptoms were assessed by a score system, gastric emptying time was measured by ultrasonography and gastric electrical activity was obtained by electrogastrography. Fourteen children received domperidone and 14 received cisapride. The median (range) ages were 11.6 years (5-15 years) and 12 years (6-16.9 years), respectively. Symptom assessment, ultrasonography and electrogastrography were repeated at the end of the trial. Fasting and fed (180 min after feeding) glycaemia and haemoglobin A, C (HbA1c) levels were also measured. RESULTS: At the end of the trial both groups showed a significant decrease in symptomatic score; however, the score was markedly lower in the domperidone group than in the cisapride group (P < 0.01). Domperidone was significantly more effective than cisapride in reducing the gastric emptying time (P < 0.05), normalizing gastric electrical activity (P < 0.05) and decreasing the prevalence of episodes of gastric dysrhythmia (P < 0.01). Domperidone was also more effective than cisapride in improving diabetic metabolic control. No potentially drug-related adverse effects occurred. CONCLUSIONS: In children with insulin-dependent diabetes mellitus complicated by dyspeptic symptoms and gastroparesis, domperidone is superior to cisapride in reversing gastric emptying delay and gastric electrical abnormalities, as well as in improving dyspeptic symptoms and diabetic metabolic control.     

The reduction of broken appointment rates through an automated appointment confirmation system

Broken appointments continue to be an important productivity, quality assurance, and access gauge for private dental practices and academic dental centers. In November 2001, the University of Rochester Eastman Dental Center, an urban academic dental center, installed an automated confirmation system to address a high incidence of broken appointments. Following the installation of the system, the Eastman Dental Center experienced a marked decrease in the broken appointment rate. Over a twelve-month period, the center's overall broken rate declined from 23.42 percent to 19.17 percent. The general dentistry rate declined from 23.67 percent to 19.77 percent, and the pediatric dentistry rate declined from 29.42 percent to 25.25 percent.