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PURPOSE: To report our experience with antegrade short locked intramedullary nail for treatment of proximal humeral fractures and to review the current literature. MATERIALS AND METHODS: From January 2012 to July 2013, 41 patients affected by two and three-part proximal humeral fractures were treated with surgical internal fixation with short locked intramedullary nails. Outcome analysis included standard clinical follow-up, Constant shoulder score and plain radiographs. The mean follow-up was 30 months (range 24-42). Moreover, a review of the literature was carried out. RESULTS: The mean Constant shoulder score was 81.5, excellent functional outcomes in 24/38 patients. All the fractures healed in an average time of 3.7 months. Five patients underwent additional operations, complications included hardware penetration into the joint (n = 2), backed out screw (n = 1), shoulder impingement due to protrusion of the nail (n = 2) and superficial infection (n = 1). The literature review showed 530 patients affected by proximal humeral fracture and treated with intramedullary nail with mean age of 65 years, mean follow-up of 22.2 months and a Constant shoulder score of 72.9 points; the major complications reported were backing out of the screws, shoulder impingement and joint protrusion of the screws. CONCLUSIONS: Antegrade short locked intramedullary nail allows stable fixation, minimal soft tissue dissection, early mobilization of the shoulder and good outcomes. It is an efficacious therapeutic solution for 2- and 3-part proximal humeral fractures.

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BACKGROUND: Sacral fractures with spinopelvic dissociation are rare, and hard to diagnose and treat. Fractures with a H- or U-shaped line are severely unstable, due to a dissociation of the spine and of the upper body of the sacrum from the pelvis. They are commonly due to high-energy trauma events, with severe neurological injuries in 80% of cases. CASES PRESENTATION: Five polytraumatized Caucasian patients, three women and two men (mean age: 34 years old) with spinopelvic dissociation were selected. All patients underwent level I-II examinations with radiographs and computed tomography total-body scans; all patients needed damage-control procedures. Sacral fractures were classified according to Denis and Roy-Camille classifications, and neurologic injuries of cauda equina according to Gibbons classification. Patients' outcome was analyzed with the Majeed score. Definitive surgical treatment was appropriate for two patients (lumbar-pelvic fixation or transverse bar). Clinical and radiographic outcomes were analyzed periodically. Four patients survived, all of them suffered severe neurologic deficits. One case of osteomyelitis was treated with the removal of the fixation implants 23 months after the accident. CONCLUSIONS: Diagnosis of spinopelvic dissociation is frequently overlooked due to the severe associated injuries affecting these patients. In cases of a fall from high height, this lesion should be investigated with a lateral sacral radiographic view and computed tomography scan of the pelvis. If untreated, it can lead to severe and progressive neurologic deficit with muskuloskeletal deformities and persistent pain. Early decompression treatment is controversial, but an early lumbopelvic fixation is recommended. A correct diagnosis and early treatment can reduce morbidity and strongly improve the outcome of these patients.

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Treatment of osteoporotic fractures leads to significant challenges for the surgeon, including poor implant fixation related to low bone quality and compromised capacity of fracture healing. This article reviews the osteosynthesis and arthroplasty results in the surgical treatment of proximal femur, proximal humerus and wrist fractures to define the current options to decrease failure in fragility fracture management.

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PURPOSE: To investigate the behavior of texture parameters derived from the gray level co-occurrence matrix from gray matter (GM) and white matter (WM) (with lesions removed) segments of magnetization transfer ratio maps from controls and patients. MATERIALS AND METHODS: Magnetization transfer ratio maps from 23 controls and patients with either a clinically isolated syndrome (CIS) (38 patients) or clinically definite multiple sclerosis (MS) (35) were scanned and texture parameters extracted. The texture parameters were compared between the groups and correlated with clinical measures of disability in the MS patients to investigate any association with disease severity. RESULTS: No significant differences were found between the texture parameters from controls and CIS patients; however, several parameters differ between MS patients and the two other groups, particularly in the GM, but also in the WM. The expanded disability status score and timed walk test correlate with GM texture measures, while the Paced Auditory Serial Addition Test 3 score, a cognitive measure, correlates with WM texture. Texture abnormalities were seen in MS WM and GM, indicating tissue damage beyond classical WM lesions, the abnormalities being more evident in GM. CONCLUSION: The findings highlight potential for texture analysis measures in classifying central nervous system demyelinating diseases that warrants further investigation.

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Thrombosis of the anonymous vein can compromise the arteriovenous fistula in chronic renal patients on hemodialysis. Clinical manifestations include edema of the arm, stasis acrocyanosis, tugor of the neck and shoulder veins, and severe headache. The fistula may have to be closed to achieve symptom relief, requiring a catheter for dialysis until an new arteriovenous fistula becomes functional. In case of stenosis or occlusion of the brachiocephalic venous axis, the goal is to preserve a functional fistula yet resolve symptoms. Self-expanding stents have been used but results have been less than satisfactory or short-lived. Different surgical bypass techniques have been proposed. We report an anterior jugular-internal jugular bypass used to salvage a dialysis arteriovenous fistula.

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Aneurysm of the celiac trunk is uncommun, accounting for 6% of all splanchnic artery aneurysms. Atherosclerosis is the main cause, other causes include fibrodysplasia and more rarely mycotic or post-stenotic conditions. Usually asymptomatic, detection is generally fortuitous. Ultrasound, angiography and CT scan provide the positive diagnosis. Rupture is the most serious complication. The risk is about 13% per year with high mortality (80%). Cure can be achieved by conventional or endovascular surgery. We report an aneurysm of the bifurcation of the celiac trunk in a 70-year-old woman. Diagnosis was fortuitous. The aneurysm was sacciform with a 2.5 cm diameter and a large collar. Because of its locations and shape, no endovascular procedure could be attemped. Reconstruction with a patch was achieved with conventional surgery. The post-operative period was uneventful. Ultrasound at 3, 6, 12 and 36 months showed a normal caliber with regular blood flow in the reconstructed vessels.

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The acute thrombosis of inverted venous graft, although less frequent than of the alloplastic prosthesis graft, represents a problem for the vascular surgeon that on one hand wants to restore the flow and on the other to preserve, as much as possible, the integrity of the venous endothelium without damaging the valvular apparatus. The two objectives are not possible, using a traditional Fogarty balloon catheter: the introduction from the proximal anastomosis, the only possible way for the presence of the valves, requires that, for the removal of the thrombotic material, the instrument is drawn back in a contrary way with unavoidable damage of the valves. Such disadvantage is eliminated using a modified Fogarty catheter, that allows to introduce the instrument in cranio-caudal direction and to draw it back in the same way, with impossibility to stop into the bottom of the valvular border and with a minimal trauma of parietal and valvular endothelium. On the other hand, distal introduction of the traditional Fogarty catheter is difficult, if not impossible, due to the presence of the valves. The use of the Fogarty catheter from the top to the bottom of the graft is feasible after appropriate modifications of the traditional catheter that allow its introduction from the tail and to draw it back towards the periphery (with inflated balloon) according to the direction of the flow. Such modifications of the Fogarty catheter are easily feasible even on the operating table and they don't require particular devices. The technique is simple, does not require additional costs (this particular modified catheter can be, like the traditional, reusable) and allows the graft patency if the thrombosis cause is eliminated.

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We report our experience with four cases of popliteal vein aneurysms treated over the last five years. The pathogenesis of these rare lesions is unknown. The inner wall of true venous aneurysms exhibit a reduced number of muscle fibers and fragmented elastic fibers replaced by fibrous tissue. The most dangerous risk related to popliteal vein aneurysm is pulmonary embolism. Diagnosis is based on phlebography and duplex Doppler findings. Surgery can provide cure and prevent complications. We treated our four patients with an asymptomatic aneurysm of the popliteal vein with aneurysmectomy using an atraumatic clamp and direct suture. Oral anticoagulants were given and elastic compression was maintained for six months, with satisfactory results.

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A retrospective study concerned 8 aneurysms of the renal artery. There were 6 females and 2 males with a mean age of 50.7 years. Diagnosis was obtained angiographically in all cases, in 7 during a reno-vascular work-up for hypertension and fortuitously in 1 after angiography for arteriopathy of the lower limbs. The aneurysm was due to fibromuscular dysplasia in 5 cases and to atheromatous lesions in 3. Reconstruction techniques and their indications were analyzed on the basis of a review of the literature. Outcome for hypertensive patients are the same for the different techniques.

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The authors report an investigation of 331 consecutive patients submitted to major surgery to evaluate the reliability of temperature monitoring in different body sites in relation to central temperature. After having considered the minimal temperature changes and the difficulties due to the different techniques used, it is concluded that the measurement at the middle 3rd of the oesophagus is the most reasonable measurements site.

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The authors report the use of a total intravenous anaesthesia in CABG. An association of propofol-fentanyl-pancuronium with a bolus at induction, then with continuous perfusion was used. Hemodynamic and oxymetric data obtained from the right heart and radial artery samples show good hemodynamic stability during surgery. It is underlined that, in order to reduce possible hemodynamic changes it is very important to use, during the surgical procedure, the lowest drug concentration.

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The great risk of severe infectious diseases transmission through blood transfusion, has increased during the last years the effort to reduce the bank blood and its derivates use. Many techniques have proposed to achieve this purpose during and post cardiopulmonary bypass: normovolemic hemodilution, perioperative blood autotransfusion, postoperative return of extra corporeal circuit and chest drains blood and the particular use of some drugs. In the last few years several reports have been presented in the literature concerning the reduction of intra and postoperative bleeding in cardiac surgery by high dose Aprotinin administration. A randomized study with the use of this pharmacologic agent is presented: a group of patients was treated with Aprotinin (shared in two subgroups receiving respectively a different dose of the drug) and a control group. The results were highly encouraging both because of the reduction of peri and postoperative bleeding and because of the bank blood use important reduction.

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A patent ductus arteriosus in adults is a rare eventuality. After correct diagnosis, an accurate evaluation of pulmonary vascular resistances is necessary with, in case of normality, a straightforward indication to surgery, because the evolution of the disease cannot be predicted. In case of pulmonary hypertension irreversible pulmonary vascular damage must be excluded. Haemodynamic data such as pressures, flows and resistance ratios are not reliable. According to the majority of Authors the value of pulmonary resistances seems to be more accurate, and when more then 8 u/m2 an histological specimen must be obtained. In our experience a comparative study between the Health and Edwards method and the Yamaki et al., one shows, confirmed by postoperative follow-up, a greater reliability of the second one.

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A drastic reduction in homologous blood or plasma transfusion becomes necessary to prevent the risks of severe infections disease transmission. The authors studied the possibility of homologous blood save in cardiac surgery by peroperative autotransfusion. This procedure, although it diminished the average blood bank requirements, above all for an unexplained decrease in postoperative bleeding, did not obtain the good results that other authors had with the technique of 2 or 3 preoperative withdrawal, storage and postoperative reinfusion. In future our trend is to associate preoperative and intraoperative withdrawals to take advantage of both techniques.

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In clinical practice SVC syndrome is an important problem, given both the nature of the disease and its fast lethal evolution. Therapy must be instituted as soon as possible because the chances of a positive result are directly related to the staging of the primary illness. Surgery, chemotherapy and high energy therapy can be used. From the literature, although controversial, the superiority of surgical therapy is clear; particularly if up-to-date vascular reconstruction techniques are employed. From March 1980 to March 1988 8 cases of SVC syndrome were observed in which the aetiology was as follows: Hodgkin's disease (2 cases); secondary catheter thrombosis (1 cases); lung carcinoma (5 cases). The 2 cases of Hodgkin's disease were treated by chemotherapy; the secondary thrombosis by open thrombectomy. In the other 5 cases an innominate vein right appendage by-pass was used (3 PTFE, 2 pericardial grafts). The results were encouraging: complete, long-term remission was observed in the Hodgkin and thrombectomy patients. A PTFE graft thrombosis occurred in 2 cases but in the other cases the by-pass is functioning well at a mean 13 months follow-up.

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Six cases of popliteal entrapment syndrome are presented with emphasis on the diagnostic difficulties related to this disease in its initial functional phase. The utility of Doppler ultrasonography associated with dynamic angiography is underlined. Normally surgical treatment of the disease is problem-free. The important determining factor seems to be medial gemellus hypertrophy. In this case the procedure of choice is thought to be vascular reconstruction associated with the disinsertion of this muscle followed by its reimplantation in a lower and medial position on the semi-membranous tendon muscle in order to avoid any secondary arterial compression.

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Over a 3-year period 21 patients underwent "in situ" saphenous vein by-pass graft for lower extremity arterial occlusive disease, all of them with critical ischemia for limb salvage. The proximal anastomosis was performed in all patients end to end to the first segment of the previously endarterectomized superficial femoral artery. The distal graft was taken to the popliteal artery below the knee in 8 cases, to the tibial-peroneal trunk in 4, to the posterior tibial artery in 3, to the peroneal artery in 3, to the anterior tibial artery in 2 and last a sequential posterior tibial-peroneal by-pass graft was performed. The perioperative mortality was nil. The immediate patency rate was 90.5%, while the cumulative patency rate at 36 months was 71.4% overall, 87.5% for the popliteal grafts and 61.1% for the infrapopliteal ones. If we consider that was successful for limb salvage in more than 80% and if the encouraging preliminary results of this technique will be confirmed at a longer follow-up, we believe that this technique could become the procedure of choice for limb salvage even in the high risk patients group.

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