Strength of fixation of Ludloff metatarsal osteotomy utilizing three different types of Kirschner wires: a biomechanical study

Static biomechanical studies have demonstrated that the Ludloff shaft metatarsal osteotomy is significantly more stable than other commonly used proximal (basilar) osteotomies, such as the proximal crescentic and the proximal chevron. High average static bending failure moments have been recorded for the screw fixation Ludloff osteotomy construct. The objective of the current study was to find a reasonable alternative method of fixation in cases where a short osteotomy may not be amenable to adequate screw fixation and in cases where an inadvertent intraoperative fracture of the metatarsal occurs and subsequent screw fixation is precarious due to inadequate bone stock. A Ludloff osteotomy was performed on 24 matched pairs of cadaveric specimens to compare the strength of fixation of three different types of Kirschner wires (smooth, threaded, and SOC threaded). Biomechanical testing with plantar force was carried out, and failure load and stiffness were measured for each specimen. The current results indicate that the threaded pin construct provides adequate strength for fixation of the Ludloff osteotomy in the clinical setting.     

Axillary artery to left anterior descending coronary artery bypass with an externally stented graft: a technical report

With the proliferation of minimally invasive cardiac surgery a number of alternative inflow sites for coronary artery bypass grafting have been utilized, especially in higher risk patients. The use of axillary-coronary artery bypass is a safe and effective alternative especially in the case of patients requiring redo coronary revascularization. However, the length and convoluted course of the axillary-coronary vein graft makes is susceptible to twisting, trauma and neointimal hyperplasia. We therefore report a case of an axillary-coronary artery bypass in a high risk patient in which a Dacron conduit was used to externally support and protect the vein graft to the left anterior descending artery. Surgical technique and considerations are presented and discussed.     

The question of futility and Roger C. Bone

Medical futility, one of the most debated end-of-life issues in medical ethics, has been discussed among physicians and scholars for years but remained an unresolved question. Roger C. Bone (1941–1997), an outstanding pulmonologist and critical care specialist, devoted his last years to ethical issues of terminal care, while facing himself metastatic renal cancer. Criticising the abuse of technology in terminal care and the administrative and financial interference on medical decisions, he bequeathed important points on futility, bringing also patients’ views into attention. He stressed the importance of physician-patient relationship and prompted physicians to remain honest with their patients and stand with them till their very last moments. Roger Bone’s insight of futility, terminal care and physician-patient relationship remains an important legacy for health care professionals and for families and patients facing end-of-life issues.     

Use of the Stingray® guidewire and the Venture® catheter for crossing flush coronary chronic total occlusions due to in‐stent restenosis

We report two cases of flush chronic total occlusion due to in‐stent restenosis, in which percutaneous coronary intervention attempts via over‐the‐wire balloons and microcatheters failed to cross the lesion. Using the Venture® catheter for support and the Stingray® guidewire for enhanced penetration capacity, both lesions were successfully crossed and stented. © 2010 Wiley‐Liss, Inc.     

Allogeneic transplant outcomes are not affected by body mass index (BMI) in patients with haematological malignancies

Bone marrow transplantation is frequently used as a consolidation therapy in patients with haematological malignancies to improve the outcome of these patients. Obese individuals have larger absolute lean body and fat masses than non-obese individuals of the same age, gender and height, which might lead to altered pharmacokinetics of chemotherapeutic agents. Data on the impact of body mass on transplant outcome is conflicting. This study included 331 patients (M, 230; F, 101) with 336 allogeneic transplant episodes from two large teaching hospitals in the West Midlands region in United Kingdom. A total of 105 patients had acute myeloid leukaemia, 83 had non-Hodgkin’s lymphoma, three had myeloma, 21 had Hodgkin’s lymphoma, 34 had acute lymphoblastic leukaemia, 19 had chronic myeloid leukaemia, 22 had chronic lymphocytic leukaemia, 24 had myelodysplasia, seven had T cell non-Hodgkin’s lymphoma, six had aplastic leukaemia and seven had myelofibrosis. At transplantation, 40% (N?=?133) of the patients had normal and 60% (N?=?198) had high body mass index (BMI) with 14% of the patients being obese (BMI >30). After a median follow-up of 24 months (range, 2–79), the mean overall survival (OS) in patients undergoing allograft with normal BMI was 31 months as compared to 39 with high BMI (p:0.06). The mean progression free survival (PFS) in patients undergoing allograft with normal BMI was 33 months as compared to 38 with high BMI (p?=?0.13). Of the patients in the high and obese BMI group, 16% developed acute GvHD with 8% grade III–IV and 28% in the normal BMI group with 14% grade III–IV acute GvHD (p?=?0.11). Of the patients in the high BMI group, 17% developed chronic GvHD and 30% of the patients in the normal BMI group (p?=?0.09). However, higher infection rates and more days of inpatient stay in the first year post-transplant were observed in the high BMI and obese patients, but there was no difference in ITU admissions. This study shows that high BMI and obesity does not adversely impact on either OS or PFS in patients undergoing allogeneic transplantation for haematological malignancies, but it does have a significant impact on infection rates and hospitalisation of high BMI and obese patients. We recommend that patients with high BMI should not be excluded from allogeneic transplantation; however, good supportive care and careful patient selection on the basis of comorbidity index should be undertaken in order to avoid the risks from the increased rates of infection.