Gianfranco Fraschini

This study reviews the data regarding clinical and ultrasound (US) examinations, collected during an 11-year period, in a DDH dedicated outpatient clinic. The material was analysed in order to verify the importance of US hip examination and Ortolani's test for early DDH diagnosis, to select dysplastic, unstable hips, to identify the role of the labrum in DDH, and to analyse the treatment strategy. Of the 21709 newborns (43418 hips) examined with US and Ortolani's manoeuvre for DDH diagnosis, 431 patients (356 F; 75 M; average age 42+/-33 days) had 574 unstable, dysplastic hips (1.32%). The hips identified according to Graf's classification were: 298 type D, 252 type IIIa, 4 type IIIb, 20 type IV. In 73.09% of the patients, no risk factors were identified; 18.56% had positive family history for DDH, 5.57% had breech presentation, 2.78% had both risk factors. Only 10.63% had a positive Ortolani's test. The diagnosis was made in 21.5% of cases by the 2nd week of life, i...

To show the efficiency and safety of a surgical treatment in both acute and chronic acromio-clavicular junction (ACJ) dislocations. Retrospective. Department of Orthopedics and Traumatology at IRCCS San Raffaele Hospital. This study was performed on 37 subjects classified as Rockwood grade III-V or Tossy III ACJ dislocation. The surgical treatment was carried out by placing a vascular graft (GorePropaten(®)) between the tip of the coracoid process and the mid-lateral side of the clavicle with two temporary percutaneous K-wires positioned in a parallel manner in the AC ligament through the acromion and clavicle for 30 days to improve stability. Outcomes were assessed using the Constant Shoulder (CS) score, DASH score, subjective satisfaction, and stability of AC joint at 24 months. UCLA scores taken preoperatively and at 15-month follow-up were used to perform statistical analysis significance using a control group treated conservatively. Postoperative X-rays were examined to assess joint stability after 24 months. Preoperative CS score was 51 ± 12 in the acute group and 55 ± 15 in the chronic group. Follow-up mean CS score was 88 ± 11 in the acute group and 82 ± 20 in the chronic group at 24 months. Preoperative DASH score was 19 ± 3 in the acute group and 14 ± 5 in the chronic group. Mean DASH score was 3.60 ± 7 in the acute group and 6.42 ± 6 in the chronic group. Preoperative UCLA scores were 14.6 ± 2 and 15 ± 7 in the acute group and chronic group, respectively. At 15-month follow-up, UCLA scores of 28.1 ± 1.9 and 27.7 ± 1 in the acute and chronic group, respectively, showed a significant improvement (p < 0.05) compared with UCLA scores taken preoperatively and at 15 months in the control group treated conservatively of 15.8 ± 0.9 and 16.2 ± 0.9, respectively. Results were good to excellent in 10 patients from the acute group and 23 patients from the chronic group who presented clinical stability of the AC joint without pain. Postoperative radiography showed anatomical repositioning of the ACJ and joint stability in 35 cases, but only two patients showed a partial re-dislocation at the 24-month X-ray follow-up. No infections, either deep or superficial, or nerve palsies were reported. Given the results obtained during the study and the response of the patients in both acute and chronic groups, the authors found that the employment of a vascular graft combined with temporary percutaneous K-wires is able to improve the patient's clinical outcome following an acromio-clavicular joint dislocation.

One of the crucial points for a successful tissue-engineering approach for cartilage repair is represented by the level of in vitro maturation of the engineered tissue before implantation. The purpose of this work was to evaluate the effect of the level of in vitro maturation of engineered cartilaginous samples on the tissue quality after in vivo implantation. Samples were obtained from isolated swine articular chondrocytes embedded in fibrin glue. The cell-fibrin composites were either cultured in vitro or directly implanted in vivo for 1, 5, and 9 weeks. Other experimental samples were precultured for either 1 or 5 weeks in vitro and then implanted in vivo for 4 additional weeks. All the samples were analyzed by histology, immunohistochemistry, biochemistry, and gene expression. The results strongly suggest that the in vivo culture in this model promoted a better tissue maturation than that obtained in the in vitro condition, and that 1 week in vitro preculture resulted in the primary structuring of the engineered composites and their subsequent maturation in vivo, without affecting the cell viability and activity, while a prolonged in vitro preculture caused a cell and matrix degeneration that could not be rescued in vivo.

ABSTRACT Fracture of the humerus represents a common problem among the young and elderly populations. Although humerus fractures usually heal uneventfully, nonunions can sometimes occur. We present a case of humeral nonunion managed with shock wave therapy in the outpatient setting. A 62-year-old woman with a closed comminuted fracture of the proximal third of the humerus came to our attention 6 months after the trauma with a hypertrophic nonunion. Radiographs showed a hypertrophic callus with a fracture gap of 4 mm. We performed ten shock wave treatments in the outpatient department, with an interval of 60 days between each single treatment. Each session consisted of 2000 impulses at 0.86 mJ/mm2 applied in two planes. No anesthesia was given during the treatment. The patient received a sling to support the treated arm during the first days following each treatment. Follow-up assessment by radiographic and physical examination, performed after 4 weeks and at 3, 6, 12, 18 and 24 months, showed complete bony union and cortical bridging, achieved at the end of the treatment. We believe that this method is a safe and effective alternative to surgery for the treatment of chronic hypertrophic nonunions. Moreover, in case such treatment is unsuccessful, subsequent surgery is not precluded.

One of the main topics of regenerative medicine and tissue engineering is to address the problem of lesions involving articular cartilage. In fact, these lesions do not heal spontaneously and often lead to osteoarthritis, which causes chronic pain and worsens quality of life. Moreover, the only available treatment for osteoarthritis is symptomatic therapy and prosthetic replacement, with far from satisfactory

Abstract The aim of this study is to evaluate the functional performance after total knee replacement (TKR). Two groups of patients, one with mobile (n= 9) and one with fixed bearing (n= 8) total knee prosthesis, were compared by means of motion analysis. A ...

Prospective, randomized, single blind. To compare the effects of sevoflurane and propofol on lumbar-paraspinal-muscles regional blood flow, as well as bleeding when controlled hypotension is used. Controlled hypotension is the technique of choice to reduce blood loss during spine surgery, but changes in blood flow occurring to lumbar paraspinal muscles during controlled hypotension with propofol and sevoflurane, as well as the entity of bleeding, are unknown. Blood flow was assessed by means of a laser Doppler flowmeter during the prehypotensive and hypotensive (defined as a 15% reduction of baseline mean arterial pressure) period in 28 patients (aged 28-73 years, American Society of Anesthesiologists (ASA) I-II) undergoing lumbar spine surgery. Patients were randomized to receive either sevoflurane or propofol as main anesthetic agent to achieve hypotension. At the end of the surgery, blood loss was calculated and intraoperative bleeding (Visual Analogue Scale ranging from 0 to 100) was evaluated by the surgeon. RESULTS.: Peripheral Blood flow was significantly greater in the propofol group both before and during the hypotensive period (median values of 32.7 FU vs. 7.7 and 38.5 FU vs. 10.5, respectively). Despite this fact, blood loss and intraoperative bleeding were significantly reduced when propofol had been used (P < 0.05). Despite the greater blood flow when it is used, propofol causes less bleeding than sevoflurane during spine surgery and could be more indicated to produce hypotension during anesthesia. Moreover, it is possible to explain our findings hypothesizing a selective vasodilation of propofol (postcapillary, venous vasodilation), different from that of sevoflurane (precapillary, arteriolar vasodilation).

The use of autologous chondrocytes seeded onto a biological scaffold represents a current valid tool for cartilage repair. However, the effect of the contact of blood to the engineered construct is unknown. The aim of this work was to investigate in vitro the effect of blood on the morphological, biochemical and biomechanical properties of engineered cartilage. Articular chondrocytes were enzymatically isolated from swine joints, expanded in monolayer culture and seeded onto collagen membranes for 2 weeks. Then, the seeded membranes were placed for 3 days in contact with peripheral blood, which was obtained from animals of the same species and diluted with a standard medium. As controls, some samples were left in the standard medium. After the 3 days' contact, some samples were retrieved for analysis; others were returned to standard culture conditions for 21 additional days, in order to investigate the "long-term effect" of the blood contact. Upon retrieval, all seeded samples showed increasing sizes and weights over time. However, the samples exposed to blood presented lower values with respect to the controls. Biochemical evaluation demonstrated a reduction in the mitochondrial activity due to blood contact at the early culture time (3 days post blood contact), followed by a partial recovery at the longer culture time (21 days post blood contact). Histological evaluation demonstrated evident cartilage-like matrix production for both groups. Biomechanical data showed a reduction of the values, followed by stabilization, regardless of the presence of blood. Based on the data obtained in this study, we can conclude that blood contact affects the chondrocyte activity and determines a delay in the dimensional growth of the engineered cartilage; however, at the experimental times utilized in this study, this delay did not affect the histological pattern and the biomechanical properties of the construct.

Articular cartilage lesions have a poor intrinsic healing potential. The repair tissue is often fibrous, having insufficient biomechanical properties, which could frequently lead to the development of early osteoarthritis. In the last decade, tissue engineering approaches addressed this topic in order to restore joint function with a differentiated and functional tissue. Many biomaterials and techniques have been proposed and some of them applied in clinical practice, even though several concerns have been raised on the quality of the engineered tissue and on its integration in the host joint. In this study, we focused on engineering in vitro a biphasic composite made of cellular fibrin glue and a calcium-phosphate scaffold. Biphasic composites are the latest products of tissue engineering applied to articular cartilage and they seem to allow a more efficient integration of the engineered tissue with the host. However, a firm in vitro bonding between the two components of the composite is a necessary condition to validate this model. Our study demonstrated a gross and microscopic integration of the two components and a cartilage-like quality of the newly formed matrix. Moreover, we noticed an improvement of this integration and GAGs production during the in vitro culture.

Research in tissue engineering has been focused on articular cartilage repair for more than a decade. Some pioneristic studies involved the use of hydrogels such as alginate and fibrin glue which still possess valuable potential for cartilage regeneration. One of the main issues in cartilage tissue engineering is represented by the ideal maturation of the construct, before in vivo implantation, in order to optimize matrix quality and integration. The present study was focused on the effect of in vitro culture on a fibrin glue hydrogel embedding swine chondrocytes. We performed an evaluation of the immunohistochemical and biochemical composition and of the biomechanical properties of the construct after 1 and 5 weeks of culture. We noticed that chondrocytes survived in the fibrin glue gel and enhanced their synthetic activity. In fact, DNA content remained stable, while all indices of cartilage matrix production increased (GAGs content, immunohistochemistry for collagen II and safranin-o staining). On the other hand, the biomechanical properties remained steady, indicating a gradual substitution of the hydrogel scaffold by cartilaginous matrix. This demonstrates that an optimal preculture could provide the surgeon with a better engineered cartilage for implantation. However, whether this more mature tissue will result in a more efficient regeneration of the articular surface still has to be evaluated in future investigations.

The aim of this study was to investigate the in vitro effect of different concentrations of blood on the morphological and biochemical properties of engineered cartilage. Previous studies have demonstrated a negative effect of blood on native cartilage; however, the effect of the contact of blood on engineered cartilage is unclear. Articular chondrocytes were isolated from swine joints, expanded in monolayer culture, and seeded onto collagen membranes. The seeded membranes were cultured for 3 days in the presence of different concentrations of peripheral blood. Some samples were retrieved at the end of the blood contact, others after 21 additional days of standard culture conditions, in order to investigate the "long-term effect" of the blood contact. All seeded samples showed an increase in the weight and an evident cartilage-like matrix production. A concentration-dependent reduction in the mitochondrial activity due to blood contact was shown at the earlier culture time, followed by a partial recover at the longer culture time. A blood contact of 3 days affected the chondrocytes' activity and determined a delay in the maturation of the engineered cartilage. These findings have clinical relevance, as autologous chondrocytes seeded onto biological scaffolds has become an established surgical method for articular cartilage repair. Therefore, further investigation into material sciences should be encouraged for the development of scaffold protecting the reparative cells from the blood insult.

ABSTRACT The efficacy of surgical anaesthesia and postoperative analgesia after elective orthopaedic foot surgery was evaluated in 200 healthy patients, randomly allocated to receive either a bilateral spinal anaesthesia (group BSA, n=50), a unilateral spinal anaesthesia (group USA, n=50), or a combined sciatic–femoral nerve block performed with 2% mepivacaine (group SFM, n=50) or 0.75% ropivacaine (group SFR, n=50). Similar duration of surgery was reported in the four groups (median 50 min, range 20–90 min), without differences in times of thigh tourniquet. Surgeon satisfaction was 92% in group SFM and 90% in group SFR, 94% in group BSA and 94% in group USA (P=0.18). Tourniquet pain during surgery was reported in two SFM patients and three SFR patients, while two patients in each group required anaesthetic implementation. No urinary retention was reported in SFM and SFR groups, but seven BSA patients (14%) and one USA patient (2%) required bladder catheterization (P=0.005). Postoperative analgesia was longer in group SFR (13.4 h) than in the SFM (4.6 h), BSA (3.1 h), and USA (3.2 h) groups (P=0.0005), with reduced analgesic consumption (P=0.0005). When providing anaesthesia for foot and ankle procedures, the combination of sciatic and femoral nerve blocks is as effective and safe as spinal anaesthesia with less urinary retention. Longer postoperative analgesia is provided by ropivacaine than mepivacaine.

This prospective, randomized study was conducted to compare unilateral spinal block using small doses of hyperbaric bupivacaine and single-agent anaesthesia with sevoflurane in elderly patients undergoing hip surgery. Thirty patients (> 65 yr) undergoing hip fracture repair were randomly allocated to receive unilateral spinal anaesthesia with hyperbaric bupivacaine 7.5 mg 0.5% (Group Spinal, n = 15) or volatile induction and maintenance anaesthesia with sevoflurane (Group SEVO, n = 15). General anaesthesia was induced by increasing the inspired concentration to 5%. A laryngeal mask airway was placed without muscle relaxants, and the end-tidal concentrations of sevoflurane were adjusted to maintain cardiovascular stability. Hypotension (decrease in systolic arterial pressure > 20% from baseline), hypertension or bradycardia (heart rate < 50 beats min(-1)) requiring treatment, and the length of stay in the postanaesthesia care unit was recorded. Cognitive functions were evaluated the previous day, and 1 and 7 days after surgery with the Mini Mental State Examination test. Hypotension occurred in seven patients of Group Spinal (46%) and in 12 patients of Group SEVO (80%) (P = 0.05). Phenylephrine was required to control hypotension in three spinal patients (21%) and four SEVO patients (26%) (n.s.). SEVO patients had lower heart rates than spinal patients from 15 to 60 min after anaesthesia induction (P = 0.01). Bradycardia was observed in three SEVO patients (22%). Discharge from the postanaesthesia care unit required 15 (range 5-30) min in Group Spinal and 55 (15-80) min in Group SEVO (P = 0.0005). Eight patients in Group Spinal (53%) and nine patients in Group SEVO (60%) showed cognitive decline (Mini Mental State Examination test decreased > or = 2 points from baseline) 24 h after surgery (n.s.). Seven days after surgery, confusion was still present in one patient of Group Spinal (6%) and in three patients of Group SEVO (20%) (n.s.). In elderly patients undergoing hemiarthroplasty of the hip, induction and maintenance with sevoflurane provide a rapid emergence from anaesthesia without more depression of postoperative cognitive function compared with unilateral spinal anaesthesia. This technique represents an attractive option when patient refusal, lack of adequate co-operation or concomitant anticoagulant therapy contraindicate the use of spinal anaesthesia.

Metastatic bone disease is the most common cause of malignancies to the skeleton in adults. The treatment of bone metastases is frequently palliative aiming to achieve a satisfactory control of pain and to prevent or to treat pathological fractures. In selected cases the resection of a single bone metastasis may improve the survival of the patients. Our experience with bone metastases located in the appendicular skeleton, between 1992 and 2004, is retrospectively reviewed here. We report a series of 154 patients (95 females and 59 males) treated with prosthesis for metastatic bone disease. Lower limb localization was more frequent with 117 cases, while upper limb was affected in 37 cases. Metastatic breast and renal carcinoma predominated and accounted for 66% of the lesions. Indications to surgery were reported, oncologic outcome was evaluated and functional results were obtained by the Musculoskeletal Tumor Society scoring system. Follow up ranged from 6 months to 12 years (median 26 months). One-year survival was 69.5%, 2-years survival was 44.8%, 5-years survival was 19.5%; and 5 (3.2%) died in the early post surgical period. Functional results were good or higher in 73.8% of patients for the proximal femur, in 50% of patients for the knee and 30.6% of patients for the proximal humerus. In this series, satisfactory results were achieved with few complications. We emphasized the importance of giving the patient a definitive treatment and preventing pathological fractures as they determine disability and a spreading of the tumor in the soft tissues, leading to an increased probability of local recurrence. Prosthetic replacement contributes to an improved quality of life and limb functionality and, in selected cases; this radical surgical approach is indicated as it may improve patient's life expectancy.

... Solitary psoas muscle metastasis from renal cell carcinoma. Francesco Camnasio MD 2 ,; Celeste Scotti MD 1,2 ,; Anna Borri MD 3 ,; Francesca Fontana MD 2 ,; Gianfranco Fraschini MD 2. Article first published online: 1 JUN 2010. DOI: 10.1111/j.1445-2197.2009.05195.x. ...