Laparoscopic Treatment of Celiac Artery Compression Syndrome: Case Series and Review of Current Treatment Modalities

Introduction  Compression of the celiac artery by the diaphragmatic crura, the median arcuate ligament, or the fibrous periaortic ganglionic tissue results in a rare constellation of symptoms known as celiac artery compression syndrome (CACS). Anatomy  First described in 1963 by Harjola in a patient with symptoms of mesenteric ischemia, it remains an elusive diagnosis. Clinical Presentation  Patients commonly present with a wide variety of symptoms resulting in multiple diagnostic tests. Diagnosis  A firm diagnosis is difficult to establish, and treatment is equally challenging. These challenges are illustrated by the following case series, and evidence supporting current treatment modalities is reviewed. Treatment  We describe a laparoscopic approach to decompression of the celiac artery facilitated by intraoperative ultrasound.     

Ablative Therapies for the Treatment of Small Renal Masses: a Review of Different Modalities and Outcomes

The widespread utilization of abdominal imaging has led to an increase in incidentally detected small renal masses. Although partial nephrectomy is still considered the gold standard treatment for these masses, there are risks associated with surgical excision, potentially limiting treatment for older patients with multiple comorbidities. A variety of ablative techniques have developed over the past several decades, altering the management of small renal masses. It is likely that improvements in technology will only broaden the applications of ablative therapy. This article provides an update on the various ablative techniques and outcomes.     

Minimally Invasive Vascular Surgery: Review of Current Modalities

The concept of a minimally invasive approach to the treatment of vascular pathology was realized nearly 30 years ago when Charles Dotter described dilatation of atherosclerotic stenoses. Since that time biotechnology and therapeutic innovation have progressed to the point where entire medical subspecialties are based on the endoluminal treatment of diseases of the blood vessels. The most rapid progress has been made in the area of endoluminal treatment of vascular lesions, with angioplasty, stent, and stent graft deployment becoming an increasingly common method of treating various vascular lesions. Extraluminal endoscopic treatment of vascular disease has been gaining popularity, particularly for management of perforator vein incompetence associated with venous stasis disorders. Endoscopic saphenous vein harvest has become an accepted method for minimizing the length of incision required for saphenectomy. Vascular imaging has followed similar trends, with more detailed information being derived from tiny intravascular ultrasonic catheters. This article summarizes the current state of minimally invasive vascular surgery to provide the reader with an understanding of the efficacy of the various modalities. It also discusses future directions in the field.     

Stem Cell Therapy for the Treatment of Hip Osteonecrosis: A 30-Year Review of Progress

Avascular necrosis of the femoral head is caused by a multitude of etiologic factors and is associated with collapse with a risk of hip arthroplasty in younger populations. A focus on early disease management with the use of stem cells was proposed as early as 1985 by the senior author (PH). We undertook a systematic review of the medical literature to examine the progress in cell therapy during the last 30 years for the treatment of early stage osteonecrosis.     

A Review of Adolescent Obesity: Prevalence, Etiology, and Treatment

Much of adult obesity has its roots in childhood. One of the tragedies of the current obesity epidemic is the significant and increasing prevalence of obesity in the young. One principal predictor of adult obesity is childhood obesity. We describe here the classification, epidemiology, causality, comorbidities, and treatment of adolescent obesity, both pharmacologic and surgical.     

Treatment of Pre-Collapse Stages of Osteonecrosis of the Femoral Head: a Systematic Review of Randomized Control Trials

Background

Treatment for osteonecrosis of the femoral head (ONFH) remains controversial. Current reviews include low-level evidence studies evaluating the treatment of both pre-collapse and collapse stages of the disease.

Questions/Purposes

The purpose of the current study is to systematically review the literature evaluating core decompression (CD) with bone marrow mesenchymal cells (BMMCs), CD alone, and bisphosphonate treatment in pre-collapse ONFH by focusing just on randomized clinical trials (RCTs) reporting functional and radiologic outcomes. We aim to determine if the literature provides evidence supporting any single approach.

Methods

Using PubMed and EMBASE databases, we reviewed the clinical evidence of treatments for pre-collapse ONFH following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Twelve RCTs met the inclusion criteria.

Results

Results showed that CD with BMMCs has lower risk of femoral head collapse when compared to the CD alone excluding hips lost to follow-up (relative risk (RR) [95% CI]:0.25 [0.11, 0.60]; p?=?0.002) and when assumed that hips lost to follow-up experienced collapse (RR [95% CI]: 0.11 [0.03, 0.47]; p?=?0.003). Neither CD nor bisphosphonate treatments showed lower risk to femoral head collapse when compared to control treatments (p?=?0.46 and 0.31, respectively)

Conclusion

Current literature shows that there is a lower risk of femoral head collapse in patients with ONFH treated with CD combined with BMMCs when compared to CD alone; however, there is no robust evidence to determine the effect on functional outcomes. More RCTs assessing new combination therapies and using standardized outcome measures are required.

     

Treatment Modalities for Pathologic Fractures of the Proximal Femur Pertrochanteric Region: A Systematic Review and Meta-Analysis of Reoperation Rates

Background

The proximal femur represents the most common site of metastatic bone disease in the appendicular skeleton, and associated pathologic pertrochanteric femur fractures contribute to cancer-related morbidity and mortality. Controversy exists as to whether these injuries are best managed with intramedullary nailing (IMN) or with arthroplasty.

Giant Keratoacanthoma of the Upper Extremity Treated with Mohs Micrographic Surgery: A Case Report and Review of Current Treatment Modalities

Keratoacanthomas are fast-growing, solitary, cutaneous neoplasms that usually show spontaneous regression. The development of giant variants and aggressive behavior have been described. Clinically, a keratoacanthoma larger than 20 to 30mm is classified as a giant keratoacanthoma. A major challenge in dealing with these neoplasms is the difficulty of clinically and histologically differentiating them from squamous cell carcinoma. The authors report a practical approach using Mohs micrographic surgery for evaluation of large tumors. With this method, the lateral margins are evaluated and cleared prior to excision of the bulk of the tumor. The authors also describe alternative therapies for giant keratoacanthomas and present a case of a 61-year-old woman with a rapidly growing tumor on her left arm. Skin biopsy was consistent with a well-differentiated squamous cell carcinoma with focal features of a keratoacanthoma. The patient underwent Mohs micrographic surgery using the described approach, and no recurrence has been noted in four years. Surgical excision remains the treatment of choice for giant keratoacanthomas. Mohs micrographic surgery is a logical treatment option for giant keratoacanthomas. This case illustrates a useful approach that may prove valuable when treating large specimens during Mohs micrographic surgery.The authors present a case of a previously healthy 61-year-old Caucasian woman who presented to the dermatology clinic for evaluation of a rapidly growing exophytic tumor on her left arm. She first noticed the lesion two months prior to presentation and reported that it had nearly doubled in size over a period of three weeks. There was no history of trauma to the left arm. She had no significant past medical history and took no medications.Physical examination revealed a well-demarcated, 5x6cm plaque with raised margins and central ulceration involving the left lateral arm (Figure 1). The overlying skin was diffusely erythematous. There was no evidence of regional lymphadenopathy or hepatosplenomegaly. The rest of the examination was unremarkable. All preoperative laboratory tests, including wound cultures, were unremarkable.Open in a separate windowFigure 1Clinical presentation on initial evaluation. On the left arm, there is a well-demarcated, 5x6cm plaque with raised margins and central ulceration.Preoperative biopsy revealed a well-differentiated squamous cell carcinoma (SCC) (Figure 2). Histologically, this tumor also shared features characteristic of a keratoacanthoma (KA) with squamous cell metaplasia, lymphohistiocytic infiltrate, and keratinocyte atypia.Open in a separate windowFigure 2Photomicrograph of the preoperative biopsy showing a well-differentiated squamous cell carcinoma with focal areas suggestive of keratoacanthomasThis case illustrates a distinct approach to the management of a giant KA using Mohs micrographic surgery (MMS) and summarizes the current treatment modalities for giant KAs.     

Bisphosphonate-induced Osteonecrosis of the Jaws: Review, Clinical Implications and Case Report

The introduction of bisphosphonates has increased in the last decade following their indication for metastatic bone diseases, osteoporosis, hypercalcaemia of malignancy and Paget’s disease. Although bisphosphonates have been used clinically for more than three decades there have been no documented long-term complications of their effects on the jaws until recently, where there is now growing evidence of the influence of bisphosphonates on osteonecrosis of the jaws. The aim of this paper is to report a case of this newly described complication, to review this phenomenon, including the clinical implications and to reiterate current clinical guidelines for management of patients in which bisphosphonate therapy is indicated. To the best of our knowledge this is the first reported case of bisphosphonate-induced necrosis of the jaw in South Africa.     

The Post‐mastectomy Pain Syndrome—A Systematic Review of the Treatment Modalities

Post‐mastectomy pain syndrome (PMPS) is a chronic neuropathic pain condition, affecting many women who have undergone breast cancer surgery. The development of PMPS is complex and the treatment options are limited. In this systematic review, we have analyzed the existing treatment modalities of PMPS. Six studies on five treatments were carefully selected, critically evaluated, and presented. The treatments were: antidepressants, anti‐epileptics, topical capsaicin, and autologous fat grafting. Four of these treatments had a significant effect on PMPS. However, most of the studies had several flaws and therefore larger studies of high quality should be performed in the future.     

Prolactin Secreting Pituitary Adenomas: Analysis of 429 Surgically Treated Patients, Effect of Adjuvant Treatment Modalities and Review of the Literature

Summary ? Objective. We performed this retrospective analysis to determine the efficacy of surgery and radiotherapy over hormonal and volumetric control of prolactinomas, many of which had failed during dopa-agonist therapy. In the same analysis, the efficiency of topical bromocriptine application as a preliminary study was compared with standard treatment modalities.  Materials and Methods. Between 1982–1997, 429 prolactinoma patients who underwent surgery at Hacettepe University Neurosurgery Department and at Bayındır Medical Center were included in this study. All patients were classified according to Hardy's classification scheme and were further divided into `invasive' and `non-invasive' groups based on this radiological classification system. The mean follow-up time was 38.4 months. One hundred and thirty five patients had peroperative bromocriptine application into the sellar cavity¹ and these, either receiving radiotherapy (RT) or not, were analysed separately from the other 294 patients. In the early postoperative period, 104 of these patients were given conventional radiotherapy with median dose of 4500 cGy. We focused on the effects of surgery and radiotherapy over volumetric and hormonal tumour control on the basis of invasion characteristics and the early results of topical bromocriptine application in macroprolactinoma patients; and compared our results with the literature.  Results. Statistical analysis revealed that radiotherapy was not effective over hormonal and volumetric tumour control for prolactinomas. We did not observe any correlation to dural invasion of the sellar floor, recurrence, and the disease-free survival time. Topical bromocriptine application seemed to improve the volumetric control in 135 selected macroprolactinoma patients but not hormonal response compared with the standard treatment modalities.  Conclusion. Conventional radiotherapy is not as effective as expected for prolactinomas and should not be preferred considering its adverse effects. Tumoural infiltration of the sellar dura mater is not a prognostic criterion for recurrence expectation and, therefore, should not be a criterion for radiotherapy after surgery. After subtotal removal, postoperative dopa-agonist therapy should be considered even if the patient was intolerant or resistant to previous treatment since surgery seems to improve patients' drug tolerance and cooperation due probably to the lower dose requirement. The early results of topical bromocriptine application seem to improve volumetric tumour control but this should not be accepted as a judgement since we need to wait for later results and to expand the sample size for more reliable interpretation.     

Prevalence and Treatment Outcomes of Hand and Wrist Injuries in Professional Athletes: A Systematic Review

HSS Journal ® - Injuries to the hand and wrist constitute up to 25% of all athletic injuries, yet not much information is available on the effects of such injuries on the careers of...     

Osteonecrosis of femoral head: Treatment by core decompression and vascular pedicle grafting

Background:

Femoral head-preserving core decompression and bone grafting have shown excellent result in preventing collapse. The use of vascularized grafts have shown better clinical results. The vascular pedicle bone graft is an easy to perform operation and does not require special equipment. We analyzed and report a series of patients of osteonecrosis of femoral head treated by core decompression and vascular pedicle grafting of part of iliac crest based on deep circumflex iliac vessels.

Materials and Methods:

The article comprises of the retrospective study of 31 patients of osteonecrosis of femoral head in stage II and III treated with core decompression and vascular pedicle grafting by using part of iliac crest with deep circumflex iliac vessels from January 1990 to December 2005. The young patients with a mean age 32 years (18–52 years) with a minimum follow-up of five years were included for analysis. Sixteen patients had osteonecrosis following alcohol abuse, 12 patients following corticosteroid consumption, 3 patients had idiopathic osteonecrosis. Nine patients were stage IIB, and 22 patients were stage IIIC according to ARCO''s system. The core decompression and vascular pedicle grafting was performed by anterior approach by using part of iliac crest with deep circumflex iliac vessels.

Results:

Digital subtraction arteriography performed in 9 patients at the end of 12 weeks showed the patency of deep circumflex artery in all cases, and bone scan performed in 6 other patients showed high uptake in the grafted area of the femoral head proving the efficacy of the operative procedure. Out of 31 patients, only one patient progressed to collapse and total joint replacement was advised. At the final follow up period of 5–8 years, Harris Hip Score improved mean ± SD of 28.2 ± 6.4 (p < 0.05). Forty-eight percent of patients had an improvement in Harris Hip Score of more that 28 points.

Conclusion:

The core decompression and vascular pedicle grafting reduces the intraosseous tension to achieve early revascularization of ischemic femoral head. The high percentage of marrow and osteogenic cells survive within a vascularized pedicle graft, which helps in early vascularization and we have been able to achieve good outcome.     

Emerging Ideas: Treatment of Precollapse Osteonecrosis Using Stem Cells and Growth Factors

Background  

Osteonecrosis (ON) of the femoral head is a devastating disease affecting young patients at their most productive age, causing major socioeconomic burdens. ON is associated with various etiologic factors, and the pathogenesis of the disease is unknown. Most investigators believe the disease is the result of secondary microvascular compromise with subsequent bone and marrow cell death and defective bone repair.