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In pediatric patients, proximal humeral physeal fractures are uncommon injuries compared with distal physeal fractures. Usually, the growth plate is the most vulnerable site of fracture in the proximal humerus. We describe a case of proximal humerus Salter–Harris (S-H) type II physeal fracture in a ten-year- old girl, successfully treated by a minimal trans-deltoid access and fixation with Kirschner (K-wires), under image guidance. She had satisfactory functional outcome 4 months after surgery with painless near total range of motion. Treatment is based on patient age, fracture displacement and remodeling capacity. Nonoperative management is successful in younger patients or in less displaced fractures, while operative management is mostly considered in older patients with more displaced fractures. The majority of pediatric shoulder trauma will result in a good outcome.

Infection after orthopaedic oncology surgery is a relatively frequent complication. Infection rate ranges in the literature between 3.7% and 19.9%, increasing up to 47% after pelvic resection and reconstruction. It represents a challenging topic when occurring in oncologic patients because of the delay of systemic and local treatments, influencing prognosis. Infection is a major concern in terms of both prevention and treatment. The aim of our review was to analyze data reported in the literature about strategies and new materials for infection prevention in musculoskeletal oncology surgery.We reviewed the literature focusing on the use of new materials that can reduce the risk of infection, avoiding biofilm formation on the implant surface.New materials are available to try to reduce the risk of infection. Iodine-coating, DAC-coating or silver-coating, are the more promising technologies available at today. Initial results with DAC-coating in non-oncological patients are interesting; however, studies about its efficacy in preventing infection in orthopaedic oncology are not present in literature. On the other side, iodine-coating implants or silver-coating prostheses demonstrated efficacy against early infections, associated with lower risk of implant removal and amputation as final surgery.Post-operative infections in orthopaedic oncology surgery are still frequent, and their diagnosis and treatment are demanding. According to the literature, silver-coated prostheses should be considered as the best option in case of revision surgery due to infection. However, there is no evidence that these new materials are effective to decrease the risk of infection drastically. Further studies with numerous series and long-term follow up are required.

OBJECTIVE: Purpose of this retrospective study was (1) to evaluate overall survival and survival to local recurrence of patients with unifocal and multifocal tumor and (2) to evaluate survival to local recurrence after intralesional or wide surgery. MATERIAL AND METHODS: We reviewed 62 patients with epithelioid hemangioendothelioma of bone, treated from 1985 to 2010. Histological sections and immunohistochemistry were evaluated. Tumor presented as unifocal in 49 patients and as multifocal in 13. RESULTS: Mean follow-up was 9 years. Five patients (10%) with unifocal tumor progressed to multifocal. Overall survival was 92% at 10 years. Survival with unifocal tumor was significantly higher than survival with multifocal tumor. Survival to local recurrence was 76% at 10 years, significantly higher after wide resection than after intralesional surgery, while there was no statistical difference comparing unifocal and multifocal tumor. At multivariate analysis both variables showed no statistically significance. CONCLUSION: Wide surgical excision reduces the risk of local recurrence, but functional results and morbidity need to be considered individually when defining surgical indications. Due to the risk of radiation-induced sarcomas, radiation therapy should be reserved to those cases not amenable to wide surgery or when lesions are seated locations difficult to treat. J. Surg. Oncol. © 2014 Wiley Periodicals, Inc. © 2014 Wiley Periodicals, Inc.

En la década de los setenta, la introducción de la quimioterapia preoperatoria en el tratamiento del osteosarcoma proporcionó mejoras dramáticas en los resultados obtenidos a largo plazo, en cuanto a la supervivencia libre de enfermedad y los procedimientos de salvación de miembros. En el presente trabajo se describe la experiencia acumulada en el Instituto Rizzoli, con la aplicación de varios protocolos activados sucesivamente. Igualmente, se describen los distintos factores pronósticos, la necrosis inducida por quimioterapia, dosis/intensidad y niveles séricos de metotrexato. In the seventies, the introduction of preoperative chemotherapy in the treatment of osteosarcoma dramatically improved the results in terms of disease-free survival and limb salvage procedures. This paper reports the experience at the Rizzoli Institute showing the results obtained with several successively activated protocols. Different prognostic factors, including chemotherapy induced necrosis, dose/intensity, methotrexate serum concentration are also discussed.

Combined positor emission cronography using Gallium 68 with computer tomography and use of antibiotics containing Hydrops Apatite pellets in the treatment of bone infections

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PURPOSE: To determine the survival and failures of cemented vs cementless endoprostheses. METHODS: We retrospectively studied 232 patients treated with lower limb salvage surgery and reconstruction using cementless and cemented endoprostheses from 2002 to 2007. We compared survival and failures of the endoprostheses regarding age, gender, body mass index (BMI), diagnosis, site of reconstruction, radiation therapy, chemotherapy, and stem fixation. RESULTS: The mean patient follow-up was 28 months (median 24; range 12-84). The overall survival of cemented and cementless endoprostheses at 60 months was 64 and 78%, respectively (p=0.0078). Survival at 60 months of cemented and cementless endoprostheses to infection was 68 and 82%, respectively (p=0.0248). Survival of cemented and cementless endoprostheses to aseptic loosening at 60 months was 94 and 96%, respectively (p=0.1493). The only significant univariate and multivariate predictor of survival was the cementless type of stem fixation. CONCLUSION: Cementless endoprostheses have higher overall survival and survival to infection compared to cemented endoprostheses. Survival to aseptic loosening is not different. Stem fixation is the only significant variable for survival.

INTRODUCTION: Computerized Decision Support Systems (CDSSs) connect health care professionals with high-quality, evidence-based information at the point-of-care to guide clinical decision-making. Current research shows the potential of CDSSs to improve the efficiency and quality of patient care. The mere provision of the technology, however, does not guarantee its uptake. This qualitative study aims to explore the barriers and facilitators to the use of CDSSs as identified by health providers. METHODS: The study was performed in three Italian hospitals, each characterized by a different level of familiarity with the CDSS technology. We interviewed frontline physicians, nurses, information technology staff, and members of the hospital board of directors (n=24). A grounded theory approach informed our sampling criteria as well as the data collection and analysis. RESULTS: The adoption of CDSSs by health care professionals can be represented as a process that consists of six "positionings," each corresponding to an individual's use and perceived mastery of the technology. In conditions of low mastery, the CDSS is perceived as an object of threat, an unfamiliar tool that is difficult to control. On the other hand, individuals in conditions of high mastery view the CDSS as a helpful tool that can be locally adapted and integrated with clinicians' competences to fulfil their needs. In the first positionings, the uptake of CDSSs is hindered by representational obstacles. The last positionings, alternatively, featured technical obstacles to CDSS uptake. DISCUSSION: Our model of CDSS adoption can guide hospital administrators interested in the future integration of CDSSs to evaluate their organizational contexts, identify potential challenges to the implementation of the technology, and develop an effective strategy to address them. Our findings also allow reflections concerning the misalignment between most Italian hospitals and the current innovation trends toward the uptake of computerized decision support technologies.

Gaspare Tagliacozzi's innovative surgical technique, which consisted of reconstructing parts of the face by grafting, was masterfully described in the work that made him famous, "De Curtorum Chirurgia per Insitionem." It was published by Gaspare Bindoni the Younger in 1597 in Venice, who was granted the exclusive right to print it by the Senate. However, in the same year in Venice Roberto Meietti published an unauthorized edition; nevertheless, this edition was soon discovered. The great demand for the text even abroad was soon testified by a 3rd edition published in Frankfurt in 1598, similar to the Bindoni edition but in another format and with a different title. This has caused confusion among bibliographers and Authors. Two centuries later, in 1831 in Berlin, a 4th edition was printed, thus suggesting renewed interest in rhinoplasty procedures, which surgeons Van Graefe and Dieffenbach promoted in Germany. However, few people know that the integral text of Tagliacozzi's De Curtorum was also published by Jacques Manget in his "Bibliotheca Chirurgica," printed in Venice in 1721. The name of the illustrator of the three fourteenth-century editions, whose illustrations in the text are compared, is not known. Instead the name of the artist, Tiburzio Passerotti, who painted Tagliacozzi's portrait holding his De Curtorum open at the ninth woodcut shortly before it was printed, is well known. The impact of Tagliacozzi's technique on modern surgery is supported by experience of the last century as well as recent years, mostly in musculoskeletal oncology reconstruction.

The authors report 12 cases of osteoid osteoma of the elbow. They emphasize the peculiarity of the clinical, radiographic and histological pictures and discuss the criteria for differential diagnosis with other tumours, pseudotumours and inflammatory lesions of bone. The results obtained are discussed in the light of data emerging from a review of the literature on the subject.

The authors report a series of 20 patients affected with metastatic lesions of the proximal humerus (19 cases) or scapula (one case) treated by intra-or extra-articular resection of the humerus and successive reconstruction with an I.O.R. type shoulder modular prosthesis. This method is indicated for the treatment of patients with extensive destruction of the epiphysis and cortical bone and limited invasion of the surrounding soft tissues. Prosthetic implant does not contraindicate the use of postoperative radiotherapy, and the cement used to anchor the endomedullary shaft contributes to the sterilization of any metastatic microfoces present by means of an intense esothermic polymerization reaction. The results obtained were satisfactory, with regression of pain and good functional recovery of the limb. There were no postoperative complications.

One-hundred patients affected with non-metastatic osteosarcoma of the limbs were treated according to a new adjuvant chemotherapy protocol. Preoperative treatment consisted in high doses of methotrexate (i.v.), followed after one week by cisplatin continuous intra-arterial infusion for 72 hours and adriamycin in intravenous infusion for 8 hours. There was good clinical and radiographic response in all of the cases, and conservative treatment was used in 86 cases (86%). A postsurgery histological examination of the segment showed "good" necrosis (greater than 90%) in 75 patients (75%). The incidence of "good" necroses obtained with this protocol was significantly higher as compared to that observed previously at our Center when a preoperative chemotherapy scheme was used, which involved methotrexate and cisplatin alone. Up until now, patients with a good histological response to preoperative chemotherapy have always had an excellent prognosis. Thus, it is our belief that the 23% increase in good histological responses observed must correspond to an increase in the percentage of healing. The preliminary results (83% of patients with no signs of disease) seem to encourage our hypothesis.

Background: Advanced Computerized Decision Support Systems (CDSSs) assist clinicians in their decision-making process, generating recommendations based on up-to-date scientific evidence. Although this technology has the potential to improve the quality of patient care, its mere provision does not guarantee uptake: even where CDSSs are available, clinicians often fail to adopt their recommendations. This study examines the barriers and facilitators to the uptake of an evidence-based CDSS as perceived by diverse health professionals in hospitals at different stages of CDSS adoption. Methods: Qualitative study conducted as part of a series of randomized controlled trials of CDSSs. The sample includes two hospitals using a CDSS and two hospitals that aim to adopt a CDSS in the future. We interviewed physicians, nurses, information technology staff and members of the boards of directors (n=30). We used a constant comparative approach to develop a framework for guiding implementation. Findings: We identified six clusters of experiences of, and attitudes towards CDSSs, which we label as ‘positions’. The six positions represent a gradient of acquisition of control over CDSSs (from low to high) and are characterized by different types of barriers to CDSS uptake. The most severe barriers (prevalent in the first positions) include clinicians’ perception that the CDSSs may reduce their professional autonomy or may be used against them in the event of medical-legal controversies. Moving towards the last positions, these barriers are substituted by technical and usability problems related with the technology interface. When all barriers are overcome, CDSSs are perceived as a working tool at the service of its users, integrating clinicians’ reasoning and fostering organizational learning. Discussion: Barriers and facilitators to the use of CDSSs are dynamic and may exist prior to their introduction in clinical contexts; providing a static list of obstacles and facilitators, irrespective of the specific implementation phase and context, may not be sufficient or useful to facilitate uptake. Factors such as clinicians’ attitudes towards scientific evidences and guidelines, the quality of inter-disciplinary relationships and an organizational ethos of transparency and accountability need to considered when exploring the readiness of a hospital to adopt CDSSs., This work is supported by the Italian Ministry of Health (GR-2009-1606736), Regione Lombardia (D.R.G. IX/4340 26/10/2012), and the Wellcome Trust (WT097899).

The authors reviewed 121 cases of aneurysmal cysts of the long bones treated at the Tumour Centre of the Rizzoli Institute of Orthopaedics of which 103 had been followed up for more than one year. A classification is proposed based on 5 morphological groups and 3 grades of aggression. All except 4 of these lesions were treated by curettage or resection (2 were treated by radiotherapy alone, and 2 only had biopsies). The overall results showed a recurrence rate of 13%, none of which were in the inactive group. There was no prognostically significant difference in the recurrence rate between the active and aggressive groups. In the morphological groups there were significant prognostic differences. The authors therefore advise a programme of treatment based on an assessment of the morphological type and aggressiveness of these tumours.