Papillomavirus umano e carcinomi del tratto aerodigestivo: il punto sulle evidenze nella babele dei dati scientifici

I carcinomi squamosi dell'orofaringe associati all'infezione da papillomavirus umano (HPV) costituiscono ormai una entità ben caratterizzata, che interessa prevalentemente maschi, giovani adulti o di mezza età, non fumatori. Essi hanno generalmente una prognosi più favorevole rispetto alla controparte non associate ad infezione, e per questo è stato proposto di dedicare a questo gruppo di pazienti un approccio terapeutico meno aggressivo. L'incidenza dei carcinomi dell'orofaringe associati a HPV è in rapido aumento nella maggior parte dei paesi occidentali, ma per quanto riguarda la popolazione italiana non sono disponibili dati epidemiologici in merito. Per quanto riguarda le altre regioni del distretto testa-collo, una più modesta porzione di lesioni displastiche di alto grado e di neoplasie appare essere correlata all'infezione da HPV, mentre il ruolo del virus nei tumori della laringe è stato parzialmente ridimensionato. HPV determina la trasformazione neoplastica delle cellule infettate tramite l'espressione dei suoi due oncogeni, E6 ed E7, che interagiscono con i meccanismi di apoptosi e regolazione del ciclo cellulare della cellula ospite. L'unica metodica in grado di documentare con certezza l'espressione degli oncogeni virali è attualmente l'amplificazione dell'RNA messaggero trascritto dai due oncogeni. Il consenso riguardo la strategia per l'identificazione dei pazienti affetti da carcinoma dell'orofaringe associato a HPV dal punto di vista clinico e diagnostico è tuttora limitato. Le metodiche diagnostiche più utilizzate, singolarmente o in combinazione, comprendono l'immunocolorazione con anticorpi diretti contro p16, l'ibridazione in situ per genotipi virali ad alto rischio e l'amplificazione del DNA virale mediate PCR. La possibilità di ottenere una diagnosi precoce grazie all'identificazione dell'infezione virale nelle cellule epiteliali esfoliate dal cavo orale o dall'orofaringe non ha finora fornito risultati soddisfacenti, tuttavia la persistenza del virus nel cavo orale in pazienti trattati per carcinoma dell'orofaringe ha dimostrato una significativa associazione con il rischio di recidiva del tumore. Non sono ancora disponibili sufficienti dati che documentino in maniera dettagliata la storia naturale dell'infezione a la sua progressione verso lo sviluppo di una neoplasia, e che definiscano con chiarezza le modalità di trasmissione e i fattori di rischio, comunque è chiaro che i comportamenti sessuali hanno un peso rilevante nel determinare il rischio di sviluppo di neoplasia dell'orofaringe HPV-correlata. La progressive diffusione nelle giovani generazioni del vaccino contro HPV, e soprattutto la sua estensione agli adolescenti di entrambi i generi è sicuramente destinata a modificare in maniera rilevante anche l'epidemiologica dei tumori HPV-correlati nel distretto testa-collo nel prossimo futuro

Modular tapered conical revision stem in hip revision surgery: mid- term results

Background: The aim of this paper is to evaluate the clinical and radiological outcomes of a fluted tapered modular distal-fixation stem at medium to long-term follow-up. The hypothesis of this investigation was to verify if the use of this implant design may have provided potential advantages in femoral revisions and post-traumatic instances where the restoration of the anatomy was the prime concern. Methods: We retrospectively reviewed 62 cases of femoral revision surgeries, performed in Paprosky type IIIA and IIIB bone defects between January 2001 and December 2011 with a mean follow-up of 8.5 ± 1.5 years (range 5.1–15.9 years) where a modular fluted stem was used. The clinical assessment was performed with the Harris Hip Score (HHS), and the radiographic evaluation was carried in order to assess the stability of the femoral component. Intra-operative and postoperative complications were recorded, and the rates of complications and revisions for any cause were determined. Results: Mean HHS improved 35.4 points from the preoperative assessment. Radiographic evaluation showed a stable stem anchorage in 90.3% of the cases at the last follow-up. Five (8%) implants required additional surgery. Neither breakage of the stem nor loosening of the taper junction were recorded. Kaplan-Meier survivorship was 89.4% (CI: 88.8–90%) for any complication and 92.3% (CI: 91.8–92.7%) according to revision for any causes at 81 months follow-up. Conclusions: Our findings suggest that this stem design is a reliable option in cases of complex femoral bone defects, as well as in cases with high functional deficiencies, with promising survivorship

Controversy: supporting patellar resurfacing in total knee arthroplasty – do it

Patellar resurfacing during total knee arthroplasty remains a controversial topic. Some surgeons routinely resurface the patella to avoid the increased rates of postoperative anterior knee pain and reoperation for secondary resurfacing, whilst others selectively resurface based on the presence of preoperative anterior knee pain, damaged articular cartilage, inflammatory arthritis, isolated patellofemoral arthritis, and patellar subluxation and/or maltracking. A third group of surgeons never resurface the patella. The anatomy and biomechanics of the patellofemoral joint as well as the advances in surgical techniques and prosthetic design must be taken into account when making a decision about whether to resurface the patella. Accurate component implantation if the patella is resurfaced becomes crucial to avoid complications. In our institution before 2008 we were performing a selective resurfacing of the patella, but in the last decade we have decided to always resurface it, with good outcomes and low complication rate. A reproducible surgical technique may be helpful in reducing the risk of postoperative anterior knee pain and complications related to implants. In this article we analyse the current trend and controversial topics in dealing with the patella in total knee arthroplasty, and discuss the available literature in order to sustain our choice

Advanced carcinoma of the hypopharynx: functional results after circumferential pharyngolaryngectomy with flap reconstruction

Surgical treatment of advanced cancers of the hypopharynx inevitably impairs swallowing, respiration and phonation. The purpose of this study was to analyze the functional results after circumferential pharyngolaryngectomy (CPL) and flap reconstruction, in order to offer decisional guidelines for the choice of the most effective reconstructive method. We performed a retrospective analysis on the medical records of patients submitted to reconstructive surgery after CPL from July 1991 to November 2011. 75% of the 94 patients underwent reconstruction with a free flap (group A), while 25% underwent reconstruction with a pedicled flap (group B); 80% of patients in group A and none in group B were discharged with a free diet; 14% of patients in group A and 26% in group B were unable to resume oral feeding and were discharged with NG-tube or PEG. None of the patients acquired a satisfactory oesophageal voice; 17% of patients in group A and 7% in group B underwent voice restoration with tracheo-oesophageal voice-prosthesis. In conclusion, free flaps should be considered the first choice for reconstruction of the hypopharynx after CPL because of the better functional results obtained. Pedicled flaps represent a valid alternative in patients with contraindications to microvascular surgery

Flap reconstruction of the hypopharynx: a defect orientated approach

The present retrospective analysis evaluated the outcomes of different flap reconstructions for several hypopharyngeal defects in 136 patients who underwent hypopharyngeal reconstruction with a free or pedicled flap after excision of pharyngeal or laryngeal carcinoma.Functional and oncological outcome were the main measures. Nine patients had a type I-a hypopharyngeal defect (partial with larynx preserved), 33 type I-b (partial without larynx preserved), 85 type II (circumferential), 5 type III (extensive superior) and 4 vertical hemipharyngolaryngectomy. The flaps used to reconstruct these defects were pectoralis major (n = 34), free radial forearm (n = 25), jejunum (n = 72), pedicled latissimus dorsi (n = 2), sternocleidomastoid (n = 1), lateral thigh (n = 1) and deltopectoral (n = 1). Twelve defects (9%) needed a secondary flap reconstruction. Surgical and medical complications were seen in 29% and 8% of patients, respectively; 18% of patients developed a fistula. No difference in complication rate or admission days was found for pre-operative versus no previous radiotherapy, type of defect or free versus pedicled flap. After 12 months follow-up, 38% of patients had a tracheo-oesophageal voice prosthesis, in 82% a fully oral diet was obtained and the average body weight gain was 0.9 kg. Five-year overall and disease-specific survival rates were 35% and 49%, respectively, while local and regional control rates were 65% and 91%, respectively. Considering these results, a defect orientated approach may be helpful for deciding which flap should be used for reconstruction of the hypopharynx. An algorithm is proposed with similar functional and oncological outcomes for the different groups. The choice of flap should be based on expected morbidity and functional outcome

New frontiers and emerging applications of 3D printing in ENT surgery: A systematic review of the literature

3D printing systems have revolutionised prototyping in the industrial field by lowering production time from days to hours and costs from thousands to just a few dollars. Today, 3D printers are no more confined to prototyping, but are increasingly employed in medical disci- plines with fascinating results, even in many aspects of otorhinolaryngology. All publications on ENT surgery, sourced through updated electronic databases (PubMed, MEDLINE, EMBASE) and published up to March 2017, were examined according to PRISMA guidelines. Overall, 121 studies fulfilled specific inclusion criteria and were included in our systematic review. Studies were classified according to the specific field of application (otologic, rhinologic, head and neck) and area of interest (surgical and preclinical education, customised surgical planning, tissue engineering and implantable prosthesis). Technological aspects, clinical implications and limits of 3D printing processes are discussed focusing on current benefits and future perspectives

Arthroscopic-guided balloon tibioplasty in schatzker iii tibial plateau fracture

Purpose The study aims to present the results at a mean 28-months follow-up of arthroscopic-guided balloon tibioplasty and to spot some technical tricks and some practice using tools and materials. Methods The study relates to six patients with tibial plateau fractures type Schatzker III with tibial plateau depression more than 4 mm at preoperative computed tomography scan (CT-scan). The follow-up period ranged from 22 to 33 months, with a mean of 28 months. No patients were lost to follow-up. The patients were evaluated clinically using the Rasmussen score system and Lysholm score systems at 6 to 12 and 24 months, postoperatively. Radiographic evaluations (standard X-rays) were done preoperatively at 1, 3, and 12 months postoperatively while a CT-scan with 3D reconstruction was performed preoperatively, at the first day and 6 months, postoperatively. Results The mean Rasmussen clinical score at 6 months postoperatively was 26.3 while at 1-year postoperatively the mean Rasmussen clinical score was 28.33. At 2-year postoperatively the mean Rasmussen clinical score was 28.83. Statistically significant difference was found in 6-months and 2-years results (p < 0.05). CT-scan achieved the first postoperative day showed the recovery of approximately 70% of the area of the interested tibial plateau, restoring of the joint surface without articular bone free fragments. Conclusion The described surgical procedure, if correctly performed with proper indications (Schatzker III), respect the principles mentioned above and the clinical and radiological results confirm our purpose. Level of Evidence This is a therapeutic case series, level IV study

The role of the anterolateral ligament in knee’s biomechanics: a case–control retrospective study

Purpose: The aim of this study was to assess the functional and clinical results of patients who underwent ACL reconstruction surgery and were divided into subpopulations related to ACL-associated lesions and focused on ALL-associated lesion. Methods: Our retrospective analysis included 62 patients who underwent standard ACL reconstruction surgery in our hospital from 2014 to 2016. The mean follow-up period was 21 months (range 11–35). We divided the sample into two subpopulations due to the presence or absence of ALL tear at the preoperative MRI. In 42 patients out of 62 (68%), ALL lesion was evident. We evaluated in both subpopulations the ACL failure rate, the functional outcomes rated with IKDC, KOOS, Lysholm scores and the clinical assessment of anteroposterior and rotatory instability with the Lachman test and pivot-shift test. Results: The overall re-injury rate in our cohort of patients was 4.8% with a smaller but not a significant difference between the two groups. A statistically significant difference was observed for the three functional scores, favoring the isolated ACL-lesion group (p < 0.05). Similarly, a better Lachman score was observed in the isolated ACL-lesion group, without statistical significance (p = 0.77); overall, the rate of positive test was lower in the isolated ACL-lesion group. We observed a significant difference of residual rotatory instability (positive pivot-shift test) in the two subpopulations (p = 0.036), and 9% of patients in the ACL + ALL lesion group showed residual jerk or subluxation. Conclusion: The additional ALL reconstruction/repair surgery should always be considered in patients with evident ALL tear at the preoperative MRI

The progression of hemophilic arthropathy: The role of biomarkers

Background: Hemophilia A and B are X-linked congenital bleeding disorders characterized by recurrent hemarthroses leading to specific changes in the synovium and cartilage, which finally result in the destruction of the joint: this process is called hemophilic arthropathy (HA). This review highlights the most prominent molecular biomarkers found in the literature to discuss their potential use in the clinical practice to monitor bleeding, to assess the progression of the HA and the effectiveness of treatments. Methods: A review of the literature was performed on PubMed and Embase, from 3 to 7 August 2020. Study selection and data extraction were achieved independently by two authors and the following inclusion criteria were determined a priori: English language, available full text and articles published in peer-reviewed journal. In addition, further articles were identified by checking the bibliography of relevant articles and searching for the studies cited in all the articles examined. Results: Eligible studies obtained at the end of the search and screen process were seventy-three (73). Conclusions: Despite the surge of interest in the clinical use of biomarkers, current literature underlines the lack of their standardization and their potential use in the clinical practice preserving the role of physical examination and imaging in early diagnosis

Cetirizine modifies quality of life and symptoms in children with seasonal allergic rhinitis: A pilot study

Background and aim: Seasonal allergic rhinitis (SAR) is a common disease in childhood that is characterized by bothersome symptoms and impaired quality of life (QoL). As histamine is the pivotal pathogenic mediator in SAR, antihistamines are the first-line option in the treatment. Cetirizine is a well-known effective antihistamine. This real-life pilot study aimed to investigate the effectiveness of a 4-week continu-ous cetirizine treatment in a group of Italian children with SAR. Methods: Total symptom score (TSS) and the Pediatric Rhinoconjunctivitis Quality of Life Questionnaire (PRQLQ) were assessed at baseline and the end of the treatment. Results: Cetirizine significantly improved QoL (in all domains) and symptom severity (p<0.001 for both). Conclusions: The present preliminary study showed that a 4-week cetirizine treatment was able to improve QoL significantly. Cetirizine treatment also significantly reduced symptom severity in Italian children with SAR and was safe