We retrospectively reviewed 11 consecutive patients with an infected reverse shoulder prosthesis. Patients were assessed clinically and radiologically, and standard laboratory tests were carried out. Peroperative samples showed Propionbacterium acnes in seven, coagulase-negative Staphylococcus in five, methicillin-resistant staphylococcus aureus in one and Escherichia coli in one. Two multibacterial and nine monobacterial infections were seen. Post-operatively, patients were treated with intravenous cefazolin for at least three days and in all antibiotic therapy was given for at least three months. Severe pain (3 of 11) or severe limitation of function (3 of 11) are not necessarily seen. A fistula was present in eight, but function was not affected. All but one patient were considered free of infection after one-stage revision at a median follow-up of 24 months, and without antibiotic treatment for a minimum of six months. One patient had a persistent infection despite a second staged revision, but is now free of infection with a spacer. Complications included posterior dislocation in one, haematoma in one and a clavicular fracture in one. At the most recent follow-up the median post-operative Constant-Murley score was 55, 6% adjusted for age, gender and dominance. A one-stage revision arthroplasty reduces the cost and duration of treatment. It is reliable in eradicating infection and good functional outcomes can be achieved.
We reviewed our experience in the surgical treatment of 12 cases of proximal ulna nonunion. The primary injuries were 2 fracture-dislocations of the olecranon, 6 Monteggia lesions and 3 isolated fractures of the proximal ulna. According to the type of primary injury and its anatomical site, the nonunions were classified into 2 groups, considering that the nonunions nearest to the humerus-ulna joint present a more disabling clinical profile and are more difficult to treat: group A (6 patients - nonunion within 5 cm from the olecranon tip of the olecranon) and group B (6 patients - nonunion between 5 and 10 cm from the olecranon tip of the olecranon). In all cases, after fibrous callus debridement and bone surface remodelling, fixation was performed with plate and screws and homoplastic cortical bone graft (orthogonal or parallel to the plate) and an intercalary bone cylinder when the bone defect was severe. In 3 patients (group A), where the defect was smaller than 1 cm, fixation of the ulna was combined with a resection of the radial neck. Clinical-radiographic healing was achieved in all patients followed for a mean of 27 months. Complications included a case of nonunion due to failure of the intercalary graft with plate breakage. The patient healed after a new surgery performed with same technique. The score, according to the Broberg-Morrey scoring system, was 78 in group A patients and 93 in group B patients. The use of homoplastic cortical bone graft represents an effective technique to improve the mechanical properties of the fixation and supports biological union, even when the bone defect is severe.
Our study shows that mini-open access and fixation with two suture anchors achieved in medium-term excellent functional and cosmetic results needed short rehabilitation times and is minimally invasive.
We report the case of a 67-year-old woman who presented with a persisting corneal erosion after blunt injury. Six years later, a highly prominent corneal tumor had developed at the site of the initial erosion. Histological analysis revealed a malignant melanoma. This case provides evidence that malignant melanoma may be a long-term complication of corneal epithelial disorders.
ELBOW REPLACEMENT FOR ACUTE DISTAL HUMERAL FRACTURESDistal humeral fractures are rare in adults but often very difficult to treat because of poor bone quality and intra-articolar comminution; fixation may results in failure. For these reasons, elbow replacement is becoming a more popular solution. The aim of this paper is to analyze the clinical and functional results and the complication rate of the patients treated in our orthopaedic department with elbow replacement (Total Elbow Arthroplasty and Distal Humeral Hemiarthroplasty) of distal humeral fracture. Pubblicato online: 15 settembre 2015 © Springer-Verlag Italia 2015 IntroduzioneLe fratture della paletta omerale sono rare e si verificano in meno del 2% di tutte le fratture [1] con un'incidenza riferita di 5,8-6 casi su 100.000 abitanti [2,3]. Anche se rare, tali fratture però, sono spesso complesse e in letteratura si dibatte su quale sia il trattamento migliore soprattutto nell'anziano con osso fragile. Uno studio finlandese ha evidenziato come nelle donne di età superiore a 60 anni l'incidenza di queste fratture sia raddoppiata da 1970 al 1995 con un'aspettativa di triplicare i casi del 1995 entro il 2030 [4]. Il trattamento di scelta è sempre stata l'osteosintesi con placche; tuttavia, in caso di comminuzione della frattura e di osteoporosi, la stabilità del costrutto poteva essere compromessa con fallimento della sintesi e scarsi risultati funzionali [5]. Negli ultimi 20 anni, la protesi di gomito su frattura nell' anziano, è diventata sempre più popolare grazie al miglioramento delle tecniche chirurgiche, del disegno protesico e delle tecniche di cementazione. Nel 1997 Cobb e Morrey [6] riportarono buoni risultati clinici con l'utilizzo della protesi totale di gomito (Total Elbow Arthroplasty, TEA) nelle fratture dell'omero distale e da allora tale tecnica è stata ampiamente accettata come una valida opzione di trattamento (Fig. 1). Fino ad oggi, però, la TEA è stata utilizzata nei pazienti di età superiore ai 70 anni a causa dei timori legati alla mobilizzazione asettica dell'impianto [7], ai rischi di fratture periprotesiche [8] e alla produzione di frammenti di usura del polietilene nelle protesi vincolate [9]. Inoltre, i pazienti con TEA devono mantenere uno stile di vita sedentario, sacrificando spesso la capacità di usare l'arto in tutte le attività sottoposte a carico. La protesi della paletta omerale o emiartroplastica (Distal Humeral Hemiarthroplasty, DHH), si articola direttamente con l'olecrano, senza necessità della componente ulnare e, quindi, dell'interposizione del polietilene. Recentemente le indicazioni alla TEA in acuto sono state ampliate spingendo i chirurghi a intraprendere questa procedura anche in pazienti più giovani. Secondo Amjid Ali et al. [10], le indicazioni alla protesizzazione per le fratture dell'omero distale in acuto sono le seguenti:1. pazienti senza artrite reumatoide di età superiore ai 75 anni 2. pazienti con artrite reumatoide di ogni età 3. pazienti con ridotta aspettativa di vita di ogni età 4. pazienti con oss...
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