The clinical picture of atlantoaxial subluxation changes when atlantoaxial impaction develops

ObjectivesThe objective of the study was to evaluate the clinical picture of rheumatoid patients with anterior atlantoaxial subluxation (aAAS), atlantoaxial impaction (AAI) or their combination.PatientsThere were 156 patients. aAAS was diagnosed from standard lateral-view cervical spine radiographs during flexion. AAI was diagnosed from radiographs by the Sakaguchi-Kauppi method. Cervical range of motion was measured and patients’ functional disability evaluated. Intensity of the neck pain was evaluated. Clinical data was collected from patient records.ResultsaAAS was detected in 138 (88%) of all patients and AAI in 69 (44%), respectively. Forty (48%) patients with severe aAAS had additional AAI, whereas 11 (21%) patients with slight or moderate aAAS had AAI. Range of the neck motion (ROM) was lower in patients with AAI compared with patients with aAAS alone. Rotation (p < 0.001) and lateral flexion (p = 0.006) were more limited in patients with AAI. Practically normal rotation (≥ 120 degrees) was seen in 16 (18%) of patients with aAAS and four (6%) of patients with AAI. Patients with AAI without aAAS had both limited mobility and high intensity of neck pain.ConclusionPatients with atlantoaxial disorders may be painless. Neck pain, which is induced in upright position and relieved during bed rest, is most often due to AAI. ROM may be normal in plain aAAS while rotation is typically reduced when AAI develops.     

Pediatric pelvic ring injuries: How benign are they?

IntroductionWith an incidence of less than 0.2% of all pediatric fractures, pelvic ring injuries are rare. Historically they were conservatively treated, but because malunion and long-term morbidity are associated with unstable injuries, a trend towards operative treatment can be observed. The purpose was to determine clinical and radiographic outcomes following these complex pediatric pelvic ring injuries.Patients and methodsThis Level IV retrospective analysis was completed at a private orthopaedic practice in association with a Level One teaching trauma center. There were 33 children with pelvic ring injuries with a mean age of 12.6 years (4–16) and an average follow up of 28.6 months (range 6–101). Injuries were 2 A2, 3 B1, 16 B2, 10 B3, and 2 C2 according to OTA/AO classification. Group 1 had 16 unstable, operatively treated injuries and Group 2 had 17 stable, non-operatively treated injuries. Radiographic deformity, leg length discrepancy, low back, and SI joint pain were evaluated.ResultsFor Group 1, 10 of 15 patients (67%) had a permanent ischial height difference >5 mm compared to Group 2, in which 5 of 12 (42%) had an ischial height difference of >5 mm. Group 1 had more pelvic asymmetry (12.3 mm vs. 6.6 mm) and ring width difference (6.9 mm vs. 3.9 mm) on final X-rays as compared to Group 2. Children with 5–10 mm posterior sacral displacement had significantly more pain than children with 0–4 mm displacement (p = 0.034). Thirteen children (39%) had residual low back/SI joint pain; the rate was significantly higher in the Group 1 (3/17 vs. 10/16, p = 0.008). In three (9%) children with 2 B2 and 1 B3 injury, leg length discrepancy between 5 mm to 15 mm occurred.Discussion and conclusionIn pediatric patients with pelvic ring injuries, radiographic deformity persisted and did not remodel. Pelvic ring deformity occurred more commonly with complex unstable ring injuries. The complex displaced injuries have higher rates of operative intervention, residual deformity, and low back and SI joint pain.     

The relationship of Interleukin-6 -174 G > C gene polymorphism in type 2 diabetic patients with and without diabetic foot ulcers in Turkish population

ObjectiveWe aims investigate Turkish type 2 diabetic patients with/without diabetic foot ulcers and healthy group and examined the contribution of Interleukin (IL)-6 -174 G > C gene polymorphism to the development of diabetic foot ulcers.Design and patientsThe Interleukin (IL)-6 -174 G > C genotypes were determined prospectively in 50 patients with diabetic foot ulcers and 35 without diabetic foot ulcers and a control group of 119 healthy individuals. Genotyping of the Interleukin (IL)-6 -174 G > C gene polymorphisms for all individuals was performed by PCR-RFLP method.ResultsThe genotype IL6 distribution did differ between the control group (CC 13.3%, GC 66.7%, GG 20%) and type 2 diabetic patients (CC 2.4%, GC 47.1%, GG 50.6%) (P < 0.001). The genotype IL6 distribution did not differ between type 2 diabetic patients group (CC 0%, GC 45.7%, GG 54.3%) and diabetic foot ulcers (CC 4%, GC 48%, 48%) (P > 0.05). The frequency of the polymorphic G allele in between the control group and type 2 diabetic patients was no similar for the groups (58.4% and 74.1%, respectively) (p < 0.05). The frequency of the polymorphic G allele in between the type 2 diabetic patients and diabetic foot ulcers was similar for the groups (77.1% and 72%, respectively) (p > 0.05).ConclusionThe gene polymorphism of Interleukin-6 -174 G > C and G allele are an risk factor for diabetes, but gene polymorphism of Interleukin-6 -174 G > C is not an independent risk factor for diabetic foot. Genetic factors in the pathogenesis of diabetic foot may also show any changes in different populations.     

Post wall fixation by lag screw only in associated both column fractures with posterior wall involvement

PurposeTo evaluate the quality of reduction, clinical outcomes and complications of associated both column acetabular fractures with posterior wall involvement that are treated through single ilioinguinal approach and fixation of posterior wall by lag screws only.MethodsWe conducted a retrospective review involving ninety-nine consecutive patients with associated both column fractures of acetabulum treated through single ilioinguinal approach. Patients were divided into two groups. The first group consisted of 35 patients presented with both column fractures with posterior wall involvement that fixation performed with lag screws. This group was compared to a second group of 64 patients with both column fractures without posterior wall involvement. The quality of reduction was assessed using criteria described by Matta. The size of posterior wall fragment was measured. Functional outcome was evaluated using Modified Postel Merle D’Aubigne score. Radiographs at the latest follow up were analyzed for arthritis (Kellgren-Lawrence classification), and femoral head avascular necrosis (Ficat/Arlet classification).ResultsThe study showed no significant differences in all preoperative variables (P > 0.05). While intraoperative blood loss and operative time in group 1 were increased compared to group 2, the difference was not statistically significant (P > 0.05). The height, relative depth and peripheral length of posterior wall respectively were 27.8 ± 2.5 mm (range: 24–35 mm), 71.5 ± 5.4% (range: 65–88%), 23.0 ± 2.3 mm (range: 17–28 mm). The mean posterior wall fracture displacement is 5.0 ± 3.2 mm (range: 0–11 mm). There was no difference regarding the quality of reduction between the two groups (P > 0.05). The excellent to good clinical outcome was around 71.4% in the group 1 versus 73.4% in the group 2 at the final follow-up, this difference was not statistically significant (P > 0.05). There was no difference in rate of complications between the two groups (P > 0.05).ConclusionsLag screws fixation of posterior wall through single ilioinguinal approach in associated both column fractures of acetabulum is a safe and effective method. Our results shown that the presence of posterior wall fracture in cases of associated both column fractures does not compromise the clinical outcomes.     

When does intraoperative 3D-imaging play a role in transpedicular C2 screw placement?

IntroductionThe stabilization of an atlantoaxial (C1-C2) instability is demanding due to a complex atlantoaxial anatomy with proximity to the spinal cord, a variable run of the vertebral artery (VA) and narrow C2 pedicles. We perfomed the Goel & Harms fusion in combination with an intraoperative 3D imaging to ensure correct screw placement in the C2 pedicle. We hypothesized, that narrow C2 pedicles lead to a higher malposition rate of screws by perforation of the pedicle wall. The purpose of this study was to describe a certain pedicle size, under which the perforation rate rises.Patients and methodsIn this retrospective study, all patients (n = 30) were operated in the Goel & Harms technique. The isthmus height and pedicle diameter of C2 were measured. The achieved screw position in C2 was evaluated according to Gertzbein & Robbin classification (GRGr).ResultsA statistically significant correlation was found between the pedicles size (isthmus height/pedicle diameter) and the achieved GRGr for the right (p = 0.002/p = 0.03) and left side (p = 0.018/p = 0.008). The ROC analysis yielded a Cut Off value for the pedicle size to distinguish between an intact or perforated pedicle wall (GRGr 1 or ≥2). The Cut-Off value was identified for the isthmus height (right 6.1 mm, left 5.4 mm) and for the pedicle diameter (6.6 mm both sides).ConclusionThe hypothesis, that narrow pedicles lead to a higher perforation rate of the pedicle wall, can be accepted. Pedicles of <6.6 mm turned out to be a risk factor for a perforation of the pedicle wall (GRGr 2 or higher). Intraoperative 3D imaging is a feasible tool to confirm optimal screw position, which becomes even more important in cases with thin pedicles. The rising risk of VA injury in these cases support the additional use of navigation.     

Utilidad clínica de la medición del área máxima del trazado del detrusor en el estudio urodinámico en el paciente pediátrico con vejiga neuropática: estudio piloto

IntroductionNeuropathic bladder (NB) is a lower urinary tract dysfunction (LUTD) that may lead to kidney failure. Urodynamic study is the gold standard for its diagnosis and follow-up. A classic prognostic parameter to predict the risk of upper urinary tract damage (UUTD) is the detrusor leak point pressure (DLPP) > = 40cmH2O, although this factor alone may lack prognostic value. The area under the curve (AUC) of the detrusor pressure tracing has been recently described as a prognostic factor.AimTo analyze the clinical utility of the AUC of the detrusor pressure tracing in the pediatric population (<15 years).MethodsRetrospective study of urodynamic recordings in pediatric population with NB from 2011 to 2020. The following variables were evaluated: detrusor leak point pressure > = 40cmH2O, voiding dysfunction, bladder compliance and overactivity. The sample is classified according to clinical-radiological findings at the time of the UD. AUC is calculated using Newton-Cotes rules (trapezium, Simpson's rule) and its indexes are calculated according to bladder capacity (TI: Trapezium Index, SI: Simpson Index). Statistical significance: P<.05.ResultsFifty-five recordings are analyzed. Unfavorable clinical condition was identified in 41.8% (n = 23) patients. Voiding dysfunction, low compliance and both indexes were associated with an unfavorable clinical condition (P<.05). ROC analysis showed the following AUC for the new indexes: TI (0.736, P=.0006), SI (0.755, P=.0001) with a cut-off value of 10,69 and 8 cmH2O s/cc, respectively. We did not find differences in the diagnostic performance between them (P>.05).ConclusionsThe analyzed indexes are useful in the diagnosis of patients with NB and unfavorable clinical condition.     

Ultrasonographic anatomy of the long thoracic nerve: A reappraisal using high frequency (24-MHz) probe

PurposeThe purpose of this study was to analyze the potential of ultrasound with a high frequency probe (24-MHz) in the assessment of the long thoracic nerve (LTN) and describe ultrasonographic landmarks that can be used for standardization.Material and methodsUltrasonography analysis of the LTN was done on 2 LTNs in a cadaver specimen and then on 30 LTNs in 15 healthy volunteers (12 men, 3 women; mean age, 28.8 ± 3.8 [SD] years; age range: 24–39 years) by two independent radiologists (R1 and R2) using a 24-MHz probe. Interrater agreement was assessed using Kappa test (K) and intraclass correlation coefficient (ICC).ResultsIn the cadaver, dissection confirmed that the India ink was injected near the LTN in the middle scalene muscle. In volunteers, visibility of the LTN above the clavicle was highly reproducible for the branches arising from C5 (R1: 87% [26/30]; R2: 90% [27/30]; K = 0.83) and from C6 (R1: 100% [30/30]; R2: 97% [29/30]; K = 0.94). Where the nerve emerged from the middle scalene muscle, the mean diameter was 0.85 ± 0.24 (SD) mm (range: 0.4–1.6 mm) for R1 and 0.9 ± 0.23 (SD) mm (range: 0.4–1.7 mm) for R2 (ICC: 0.96; 95% CI: 0.92–0.98%). Along the thoracic wall, where LTN run along the lateral thoracic artery, the mean diameter was 0.83 ± 0.19 (SD) mm (range: 0.5–1.27 mm) for R1 and 0.89 ± 0.21 (SD) mm (range: 0.6–1.2 mm) for R2 (ICC: 0.86; 95% CI: 0.72–0.93%).ConclusionThe LTN can be analyzed with ultrasound using high-frequency probe by using the C5 and C6 roots, the middle scalene muscle above the clavicle and the lateral thoracic artery on the chest wall as landmarks.     

Muscle relaxant facilitates i-gel insertion by novice doctors: A prospective randomized controlled trial

Study objectiveThis study aimed to determine whether muscle relaxants facilitates insertion efficacy of the i-gel supraglottic device (i-gel) by novice doctors in anesthetized patients.DesignRandomized clinical trial.SettingOperating room.PatientsSeventy adult patients scheduled for elective surgery under general anesthesia.InterventionsSeventy adult patients were assigned to the rocuronium (MR group; 35 patients) or control group (C group; 35 patients). Anesthesia was induced with propofol and remifentanil, and 0.9 mg kg^− 1 rocuronium was administered in the MR group.MeasurementsThe number of attempts to successful insertion, sealing pressure, and subjective difficulty of insertion were compared between the groups.Main resultsThe total number of insertion attempts were as follows: one (MR group, 17 cases; C group, 4 cases), two (MR group, 13 cases; C group, 14 cases), three (MR group, 4 cases; C group, 14 cases), and failure (MR group, 1 case; C group, 3 cases), which was significantly different (P < .001). Sealing pressure was significantly higher in the MR group than in the C group (MR group, 22.1 ± 5.4 cmH₂O; C group, 18.7 ± 3.2 cmH₂O, P < .001). Subjective difficulty of insertion was significantly lower in the MR group than in the C group (C group, 72.4 ± 19.0 mm; MR group, 29.4 ± 18.3 mm; P < .001).ConclusionsOur randomized clinical trial suggests that muscle relaxation facilitates i-gel insertion efficacy in anesthetized patients, as assessed by successful insertion rate, sealing pressure, and subjective difficulty of insertion.     

Evaluation of lumpectomy surgical specimen radiographs in subclinical,in situ and invasive breast cancer,and factors predicting positive margins

PurposeTo determine the diagnostic performance of radiological evaluation of the margins of surgical specimens from lumpectomies for subclinical malignant breast lesions.Materials and methodsRetrospective study in two French hospitals including all patients who had a non-palpable in situ (ISDC) or invasive (IDC) ductal carcinoma treated by lumpectomy after radiological localisation. For the analysis, the lesions were divided into two groups depending on the majority component in the definitive histological examination: ISDC or IDC. The radiological margin considered was 10 mm.ResultsFor the 178 lumpectomies studied, the sensitivity of the radiographs of the surgical specimen was 33.3% for ISDC and 50% for IDC. The surgical revision rate was 27.41% for ISDC and 12.64% for IDC. The significant predictive factors for positive margins were the radiological size of the lesions (> 10 mm) for ISDC (P = 0.02) and radiologically positive margins for IDC (P = 0.01). Correlation was found between the histological and radiological sizes of the lesion for IDC, but not for ISDC.ConclusionRadiological examination of surgical specimens does not provide a satisfactory evaluation of the histological margins, in particular for ISDC, even with a radiological threshold of 10 mm.     

CT-guided biopsy of lung nodules with pleural contact: Comparison of two puncture routes

PurposeThe purpose of this study was to retrospectively compare two puncture routes (transpleural vs. transpulmonary) for computed tomography (CT) fluoroscopy-guided cutting needle biopsy of lung nodules with pleural contact.Patients and methodsA total of 102 patients (72 men; mean age, 71.1 ± 9.5 [SD] years) were included and 102 biopsies of 102 lung nodules (mean size, 16.7 ± 5.9 [SD] mm; range, 6.0–29.4 mm; mean length of pleural contact, 10.1 ± 4.2 [SD] mm; range, 2.8–19.6 mm) were analyzed. All procedures were classified as biopsies via the direct transpleural route or the transpulmonary route. The patient-, lesion-, and biopsy-related variables, diagnostic yields, and incidence of complications were compared between the two routes.ResultsBiopsy was performed via the direct transpleural route (n = 59; 57.8%) and transpulmonary route (n = 43; 42.2%). In the transpulmonary route group, the mean distance of the intrapulmonary pathway was 17.7 ± 9.4 [SD] mm (range: 4.1–47.6 mm; P < 0.001) and the introducer needle trajectory angle of < 45° was significantly observed (8.5% [5/59] vs. 60.5% [26/43]; P < 0.001). There was no significant difference in diagnostic accuracy between the direct transpleural and transpulmonary routes (93.2% [55/59] vs. 90.7% [39/43]; P = 0.718). The frequencies of all complications (64.4% [38/59] vs. 97.7% [42/43]; P < 0.001), pneumothorax (33.9% [20/59] vs. 65.1% [28/43]; P = 0.003), pneumothorax with chest tube placement (3.4% [2/59] vs. 18.6% [8/43]; P = 0.016), and pulmonary hemorrhage (47.5% [28/59] vs. 76.7% [33/43]; P = 0.004) were significantly lower in the direct transpleural group.ConclusionDirect transpleural route is recommended for CT fluoroscopy-guided biopsy of lung nodules with pleural contact because it is safer and yields similar diagnostic accuracy than transpulmonary route.     

Radiographic parameters in gravity stress view of the ankle: Normative data

BackgroundIn rotational ankle injury with isolated fibular fracture, deltoid integrity is important for determining stability of ankle. Medial clear space and superior clear space in gravity stress view are parameters widely used to predict deltoid ligament tear. The purpose of this study is to report radiographic parameters in gravity stress view in normal population.Methods120 persons were enrolled. Non weight-bearing ankle mortise and gravity stress view were obtained. Radiographic measurements were made by 2 investigators, including medial clear space (MCS), superior clear space (SCS), tibiofibular overlaps, tibiofibular clear space and talocrural angle. Statistical analysis included mean, mean difference, SD, 95%CI, paired T-test were calculated and subgroup analysis by foot length. Intraclass correlation coefficients were used to determine intra/interobserver reliability of measurement.ResultsMean MCS in gravity stress view was 3.19 mm (95%CI 3.1–3.31). This compared to mean MCS of 3.01 mm (95%CI 2.9–3.12) in mortise view which was statistically significant (P = 0.02). Mean difference was 0.18 mm (95%CI 0.07–0.3). SCS in gravity stress view was 3.29 mm (95%CI 3.19–3.39) and when compared to MCS in gravity stress view, no statistical significance was found (P = 0.158). Mean difference was 0.1 mm (95%CI 0.03–0.21). In subgroup analysis by foot length, no significant difference was found in any parameters.ConclusionsThis study provides normative radiographic data for a gravity stress radiograph and supports that if measurable MCS >4 mm on gravity stress view, it should be aware of an unstable ankle in supination-external rotation injury.     

Diagnosis of Peripheral Pulmonary Lesions With Radial Probe Endobronchial Ultrasound-Guided Bronchoscopy

IntroductionThe diagnosis of peripheral pulmonary lesions (PPLs) is a challenging task for pulmonologists. Radial probe endobronchial ultrasound (R-EBUS) has been developed to enhance diagnostic yield. The objective of this study was to evaluate the effectiveness of R-EBUS in the diagnosis of PPLs.MethodsA retrospective study was conducted on 174 patients diagnosed with PPLs who underwent EBUS-guided bronchoscopy. Histological examination of specimens obtained by transbronchial lung biopsy (TBLB) and cytological examinations of brushing smear, brush rinse fluid and bronchoalveolar lavage fluid (BALF) were evaluated for the diagnosis.ResultsThe mean diameter of the PPLs was 25.1 ± 10.7 mm. The final diagnoses included 129 malignancies and 45 benign lesions. The overall diagnostic yield of EBUS-guided bronchoscopy was 79.9%. Neither size nor etiology of the PPLs influenced the diagnostic performance of EBUS-guided bronchoscopy (82.9% vs 74.6% for PPLs >20 mm and PPLs ≤20 mm; P=.19, and 82.9% vs 71.1% for malignancy and benign diseases; P=.09). TBLB rendered the highest yield among these specimens (69.0%, 50.6%, 42.0%, and 44.3% for TBLB, brushing smear, brush rinse fluid, and BALF, respectively; P<.001). The combination of TBLB, brush smear, and BALF provided the greatest diagnostic yield, while brush rinse fluid did not add benefits to the outcomes.ConclusionR-EBUS-guided bronchoscopy is a useful technique in the diagnosis of PPLs. To achieve the highest diagnostic performance, TBLB, brushing smear and bronchoalveolar lavage should be performed together.     

Dynamic cervical flexion/extension atlantodental interval and functional outcome of the Harms technique for posterior C1/2 fixation: A retrospective analysis of 16 atlantoaxial subluxation cases in a tertiary medical center

BackgroundThe aim of this study was to assess the relationship between the atlantodental interval (ADI) on dynamic flexion/extension cervical radiographs and functional outcomes of posterior spinal fixation by the Harms technique for atlantoaxial subluxation (AAS). Dynamic flexion/extension on cervical radiographs is a standard assessment for evaluation of C1/2 instability in AAS patients. Most studies focused on postoperative ADI and functional outcome, including pain and fusion rate; only few studies compared dynamic ADI change pre- to post-operatively.Material and methodsRetrospectively, we reviewed the medical records of 16 patients who underwent posterior spinal fixation in our center from 2018 to 2019. We used dynamic cervical flexion/extension radiographs to assess the pre- to postoperative change at 12 months in ADI of flexion (ADI_f), ADI of extension (ADI_e), ADI between flexion/extension (ADI_Δ), C1/2 fusion rate and functional outcomes measured by the modified Japanese Orthopaedic Association scale (mJOA scale). Postoperative CT at 3～12 months assessed screw positioning on the Gertzbein and Robbins classification.ResultsIn the 16 patients included in this study, ADI_f, ADI_e and ADI_Δ were significantly reduced, from respectively 8.0 mm, 5.0 mm and 3.0 mm preoperatively to 4.6 mm, 3.8 mm and 0.8 mm at 12 months’ follow-up. The fusion rate was 81% and the mJOA score recovery rate was 34.9 ± 14.7%. Although the screw malposition rate was higher than in other studies in C1(10%) and C2(20%), there were no new neurologic deficits or worsening of symptoms at follow-up.ConclusionsThe ADI_Δ showed significant reduction, showing that the Harms technique of posterior spinal fixation can effective in maintaining the stability of the atlantoaxial joint and improving functional outcome.     

Implementación de un programa de cribado del malestar emocional en un servicio de cirugía torácica

IntroductionThe aim of the present study was to examine the diagnostic accuracy of screening tests in detecting cases requiring psychological intervention among patients referred for thoracic surgery.MethodsEmotional distress was evaluated in 105 patients referred for thoracic surgery by means of a diagnostic psychological interview (criterion variable). The screening ability of the following methods was analyzed: the physician's opinion (Yes/No), Hospital Anxiety and Depression Scale (HADS), single-item interview: «Are you depressed?» (Depression Question, ADEP) (1-5) and the single-item interview: «Are you anxious?» (Anxiety Question, ANXQ) (1-5).ResultsAccording to the clinical interview, 34% of the patients were clinical cases requiring psychological intervention. The total HADS (cut-off point of 10) showed a sensitivity = 0.89, specificity = 0.75 and AUC = 0.883; the ADEP scale (>1) showed a sensitivity = 0.79, specificity = 0.74 and AUC = 0.795; the ANXQ scale (>1) showed a sensitivity = 0.78, specificity = 0.41 and AUC = 0.690; and the physician's opinion showed a sensitivity = 0.47 and specificity = 0.86.ConclusionsA high percentage of patients referred for thoracic surgery required psychological intervention. The best instrument to identify those patients requiring psychological care, taking a psychological interview as the criterion variable, was the total HADS score. This test is brief, simple and well accepted by patients; it is easy to implement within a thoracic surgery service and has a good diagnostic accuracy.     

Treatment of Complex Aneurysmal Disease with Fenestrated and Branched Stent Grafts

ObjectivesTo describe our experience of treating juxtarenal (JRAAA's <4 mm neck) and thoracoabdominal aortic aneurysms (TAAA's) using fenestrated and branched stent graft technology.DesignProspective single centre experience.MethodsSince 2005, 29 fenestrated/branched procedures have been performed. 15 patients are studied with JRAAAs (n = 7; median neck length 0 mm (IQR 0–3.8)) or TAAAs (type I (n = 2), III (n = 2), IV (n = 4)). ASA grade III in 12/15. Maximum diameter of aneurysm 64 mm (56–74 mm). Aneurysms were excluded using covered stents or branches from the main body to patent visceral vessels (40 target vessels total). Pre-operative and follow-up CT scans (1, 3, and 12 months) were analysed by a single Vascular Interventional Radiologist.ResultsTechnical success for cannulation and stenting of target vessels was 98%. In-hospital mortality was 0%. One patient underwent conversion to open repair. Five had major complications including one paraplegia (type III TAAA) with subsequent recovery. Median length of stay was 9 days (IQR 7–18.75).At a median follow-up of 12 months (9–14), CT confirmed 36/37 (97%) target vessels remain patent. Sac size increased >5 mm in one patient only. There were no type I endoleaks, three type II endoleaks (one embolised, two under surveillance) and three type III endoleaks (two successfully treated percutaneously, one aneurysm ruptured 18 months after endografting and died).ConclusionIn selected patients, fenestrated and branched stents appear to be a safe and effective alternative to surgery for juxtarenal and thoracoabdominal aneurysms. The complication and mortality rates are low. The long-term durability of this procedure, however, needs to be proven.     

Detrusor wall thickness compared to other non-invasive methods in diagnosing men with bladder outlet obstruction: A prospective controlled study

IntroductionThe current study aims to compare the diagnostic accuracy of detrusor wall thickness to other noninvasive, tools, using pressure flow studies as a reference, in the assessment of bladder outlet, obstruction among men presenting with lower urinary tract symptoms.Patients and MethodsMen aged 50 or older presenting with lower urinary tract symptoms were evaluated for bladder outlet, obstruction using detrusor wall thickness (measured by a transabdominal 7.5 MHz ultrasound) and, other non-invasive tools (namely uroflowmetry, post-void residual, and prostate volume), and the results were compared to pressure flow study.ResultsDetrusor wall thickness ranged from 0.7 mm to 7 mm (mean ± SD of 2.39 ± 1.64 mm), and 21 patients, were classified as obstructed (thickness ≥ 2 mm). Based on pressure flow study 23 patients had, bladder outlet obstruction. Detrusor wall thickness had the highest accuracy (88.0%), the highest, specificity (92.6%) and the highest positive predictive value (90.5%) among the non-invasive tests.ConclusionsDetrusor wall thickness measurement can be used to diagnose and quantify bladder outlet obstruction, non-invasively in men with lower urinary tract symptoms, with an accuracy approaching that of the standard pressure flow studies.     

Accuracy of multi-detector computed tomographic angiography assisted by post-processing software for diagnosis atheromatous renal artery stenosis

PurposeTo compare the diagnostic performance of MDCTA versus renal angiography in the detection of > 50% renal artery stenosis in patients suspected of reno-vascular hypertension.Materials and methodsBetween January 2005 and January 2010, 92 MDCTA and renal arteriographies were retrospectively analysed. Renal angiographies were read by one interventional radiologist. Three blinded independent readers (two senior radiologists and one technician) scored MDCTA images using three different approaches. Reader 1 scored stenosis using only MPR and MIP. Reader 2 (technician) used only proprietary automatic arterial segmentation software. Reader 3 used the cited software, using manual diameter measurements.ResultsA total of 92 patients, (235 renal arteries) were assessed in which 48 significant stenosis were found by arteriography. Sensitivity, specificity, of MDCTA compared to renal arteriography were respectively per patient for reader 1: (88%; 80%); for reader 2: (58%; 80%); for reader 3: (96%; 90%) (P < .02).ConclusionWhen using automated vessel analysis software edited by a radiologist, MDCTA studies had a Sensibility/Specificity of 96%/90% to detect > 50% renal artery stenosis.     

Serum tobramycin levels following delivery of tobramycin (Tobi®) via eFlow® advanced nebuliser in children with cystic fibrosis

BackgroundSafety and toxicity data for nebulised tobramycin are mainly derived from use of the Pari LC® Plus nebuliser, yet many centres are now using advanced nebulisers, such as the eFlow®.MethodsTen children (ages 2–16 years) receiving 300 mg TOBI® via eFlow® for clinical reasons participated. Serum tobramycin levels were obtained 1 h post nebulisation. Nine provided samples for urinary NAG, and 10 underwent audiology.ResultsTobramycin levels were > 1 mg/L in 3 children (maximum 3.8, 2 children aged 2 years). Urine NAG/creatinine levels were raised (> 0.94 μmol/min/mmol) in 5 children, 1 of these had a tobramycin level of > 1 mg/L. One patient had high frequency hearing loss.ConclusionSerum tobramycin levels over 1 mg/L can occur 1 h post 300 mg TOBI® delivered by eFlow®. Raised urinary NAG levels suggest that some children may have some associated early renal toxicity.     

Galeazzi fractures: Is DRUJ instability predicted by current guidelines?

IntroductionClinically significant distal radioulnar joint (DRUJ) injuries can occur with radial shaft fractures. Several radiographic methods of diagnosis, such as radial shortening of >5 mm or fracture line within 7.5 cm from the lunate facet, have been proposed but not clinically validated. The purpose of this study was to compare radiographic measurements of radial shaft fractures associated with and without clinically significant DRUJ injury (i.e., true Galeazzi fracture-dislocation) in order to evaluate the predictive value of reported parameters of DRUJ injury.Patients and methodsA retrospective record and radiographic review was performed of 66 consecutive skeletally mature patients with isolated radial shaft fractures from 2004 to 2014 treated at one level 1 academic trauma center. Intraoperatively determined DRUJ instability after radial shaft fixation was used as the gold standard for diagnosis of a Galeazzi fracture-dislocation.ResultsAverage age was 34 years old (range: 18–90). By thirds, there were 10 proximal (15%), 27 middle (41%), and 29 distal (44%) fractures. 13 (20%) had an associated ulnar styloid fracture. 7 (11%) patients had DRUJ instability after radial fixation. Radial shortening averaged 4.4 ± 5.2 mm (−2.6–22), and 21 had shortening of >5 mm. Twenty-six (39%) fractures were within 7.5 cm of the wrist joint. Previous guidelines were only moderately accurate. Even greater shortening did not predict instability (3/7 patients with >10 mm shortening had a true injury). Four out of 7 cases with instability had ulnar styloid fractures (p = 0.02).Discussion and conclusionsUsing a larger data set than has historically been evaluated, previously reported radiographic guidelines are only moderately accurate. The presence of an ulnar styloid fracture can be helpful. Surgeons should be aware of these associations but rely primarily on intraoperative assessment of the DRUJ after radial fixation to determine treatment.     

Periarticular raft constructs and fracture stability in split-depression tibial plateau fractures

ObjectivesTo evaluate relative fracture stability yielded by screws placed above a lateral plate, as well as locking and non-locking screws placed through a plate in a split depression tibia plateau fracture model.MethodsCadaver tibia specimens (mean age 74.1 years) were randomised across 3 groups: Groups 1: raft-construct outside the plate, 2: non-locking raft screws through the plate, and 3: locking raft screws through the plate. Displacement of the depressed fragment was recorded with force values from 400 N to 1600 N in increasing 400 N increments. The force required to elicit lateral plateau fragment displacement of 5 mm, 10 mm, and 15 mm was also recorded.ResultsNone of the mechanical testing results demonstrated statistical significance with p-values of <0.05. Cyclic testing of Groups 1, 2, and 3 at 400 N revealed displacements of 0.54 mm, 0.64 mm, and 0.48 mm, respectively. At 800 N, displacements were 1.36 mm, 1.4 mm, and 1.4 mm, respectively. At 1200 N, displacements were 2.4 mm, 1.9 mm, and 2.1 mm, respectively. At 1600 N, displacements were 2.8 mm, 2.5 mm, and 2 mm, respectively. Resistance to displacement data demonstrated the mean force required to displace the fracture 5 mm in Groups 1, 2, and 3 were 250 N, 330 N, and 318 N, respectively. For 10 mm of displacement, forces required were 394 N, 515 N, and 556 N, respectively. For 15 mm of displacement, forces required were 681 N, 853 N, and 963 N, respectively. Compared to combined groups using screws through the plate, Group 1 demonstrated lower displacement ≤800 N, but demonstrated greater displacement >800 N. Group 2 demonstrated greatest resistance to plateau displacement of 5 mm compared to Group 1 or 3, while Group 3 was most resistant to greater displacement. The combined group using screws through the plate (Groups 2 + 3) was consistently more resistant than Group 1 at all levels of displacement.ConclusionsDesigns utilising screws through the plate trended towards statistically significant improved stability against plateau displacement relative to utilising screws outside the plate. Our study also suggests that there is no significant benefit of locking screws over non-locking screws in this unicondylar tibia plateau fracture model.