Arthroscopic physeal sparing all inside repair of the tibial avulsion fracture in the anterior cruciate ligament: technical note

We describe a new and effective arthroscopic physeal sparing repair of the tibial eminence avulsion fracture using all an inside repair technique. The treatment of ACL avulsion is controversial, especially in skeletally immature patients, with concerns about physeal damage, and a more reliable way of fixation is still being pursued for small or comminuted fragments. Screw fixation and suture cerclage has some limitations, especially in the small fragment or skeletally immature patients. We fixed avulsion fragment using all inside repair between the distal portion of the ACL and transverse ligament and periosteum. A crescent suture hook loaded with NO. 0 PDS is introduced and the suture hook pierces the transverse intermeniscal ligament and periosteum. The half length of the PDS is now advanced out through the hook and the end is brought out to the anterolateral portal. With the suture hook located intra-articularly and loaded with half the length of the original PDS, the suture hook repierces the transverse intermeniscal ligament at 5 mm on the side and the remaining half length of PDS is now advanced out through the hook and the end is brought out to the anterolateral portal. After that procedure, the suture hook loaded with NO. 0 absorbable Maxon is introduced through the anteromedial portal for the role of shuttle relay. The suture hook pierces the ACL just above the superior border of the avulsion fragment, the Maxon is now advanced out through the hook and the end is brought out to the anterolateral portal. Subsequently, the suture hook is removed and a suture retriever is introduced through the anterolateral portal. PDS and Maxon are held together and retrieved out of the anterolateral portal by the suture retriever at the same time. Our technique has advantages in small comminuted fractures and skeletally immature patients.     

Delayed presentation of arteriovenous fistula and pseudoaneurysms in a renal transplant patient 10 years after percutaneous allograft biopsy

A 51-year-old man was admitted with microscopic hematuria at 10 years after living donor renal transplantation. In order to distinguish between acute tubular necrosis and acute rejection, a graft biopsy was performed under ultrasound guidance at 1 month posttransplantation. Doppler sonography revealed 3 pulsatile cystic masses and an arteriovenous fistula (AVF) in the lower kidney pole. Selective transplant renal angiography revealed 3 pseudoaneurysms with an AVF supplied by a lobular artery in the lower pole. The diagnosis was AVF with pseudoaneurysm, which developed secondary to percutaneous renal allograft biopsy. Interventional treatment was performed because of the high risk for pseudoaneurysm rupture. The AVF and pseudoaneurysms were treated successfully by percutaneous transluminal embolization; renal function remained stable after embolization.     

The clinical relevance of sex hormone levels and sexual activity in the ageing male

OBJECTIVES: To assess the changes in sex hormone levels with age and the relationship of sexual functioning to testosterone levels, evaluating serum testosterone levels and erectile function in men with lower urinary tract symptoms (LUTS). PATIENTS AND METHODS: The study included 213 men with LUTS (age range 31-78 years) who had no confirmed erectile dysfunction. Their serum total and free testosterone, and sex-hormone binding globulin (SHBG) levels were measured, and they completed the International Index of Erectile Function (IIEF) questionnaire. RESULTS: The total and free testosterone levels decreased and SHBG increased with age, but only the change in free testosterone and SHBG were statistically significant. The correlation with age was closer for free testosterone (r = - 0.356, P < 0.001) than for SHBG (r = 0.177, P = 0.010). Regression analysis of the five domain scores of the IIEF and three hormonal levels, after correcting for age, showed that free testosterone level was significantly correlated with erectile function (r = 0.2136, P = 0.005) and orgasmic function (r = 0.179, P = 0.020), but SHBG levels were significantly correlated only with orgasmic function (r = - 0.154, P = 0.046). Total testosterone levels showed no significant correlation with any of the five domains of the IIEF. CONCLUSIONS: Of the sex hormone levels, the change in free testosterone correlated most closely with ageing and had the closest correlation with sexual activity. Contrary to previous reports, free testosterone and SHBG levels were significantly correlated with orgasmic function and/or erectile function rather than sexual desire. A complete study of sex hormone levels is needed to evaluate patients with erectile dysfunction.     

Myocardial Depressant Effects of Desflurane: Mechanical and Electrophysiologic Actions In Vitro

Background: The authors determined whether desflurane altered myocardial excitation-contraction coupling and electrophysiologic behavior in the same manner as isoflurane and sevoflurane.

Methods: The effects of desflurane on isometric force in guinea pig ventricular papillary muscles were studied in modified standard and in 26 mm K+ Tyrode solution with 0.1 [mu]m isoproterenol. Desflurane effects on sarcoplasmic reticulum Ca2+ release were also determined by examining its actions on rat papillary muscles, guinea pig papillary muscles in low-Na+ Tyrode solution, and rapid cooling contractures. Normal and slow action potentials were recorded using a conventional microelectrode technique. Ca2+ and K+ currents of guinea pig ventricular myocytes were examined.

Results: Desflurane (5.3% and 11.6%) decreased peak force to approximately 70% and 40% of the baseline, respectively, similar to the effects of equianesthetic isoflurane concentrations. With isoproterenol in 26 mm K+ Tyrode solution, desflurane markedly depressed late peaking force and modestly depressed early peak force. The rested state contractions of rat myocardium or guinea pig myocardium in low-Na+ Tyrode solution were modestly depressed, whereas rapid cooling contractures were virtually abolished after desflurane administration. Desflurane significantly prolonged the action potential duration. Desflurane reduced L-type Ca2+ current and the delayed outward K+ current but did not alter the inward rectifier K+ current.     

The effect of pre-vertebroplasty tumor ablation using laser-induced thermotherapy on biomechanical stability and cement fill in the metastatic spine

A biomechanical study comparing simulated lytic vertebral metastases treated with laser-induced thermotherapy (LITT) and vertebroplasty versus vertebroplasty alone. To investigate the effect of tumor ablation using LITT prior to vertebroplasty on biomechanical stability and cement fill patterns in a standardized model of spinal metastatic disease. Vertebroplasty in the metastatic spine is aimed at reducing pain, but is associated with risk of cement extravasation in up to 10%. Six pairs of fresh-frozen cadaveric thoracolumbar spinal motion segments were tested in axial compression intact, with simulated metastases and following percutaneous vertebroplasty with or without LITT. Canal narrowing under load, pattern of cement fill, load to failure, and LITT temperature and pressure generation were collected. In all LITT specimens, cement filled the defect without extravasation. The canal extravasation rate was 33% in specimens treated without LITT. LITT and vertebroplasty yielded a trend toward improved posterior wall stability (P = 0.095) as compared to vertebroplasty alone. Moderate rises in temperature and minimal pressure generation was seen during LITT. In this model, elimination of tumor by LITT, facilitates cement fill, enhances biomechanical stability and reduces the risk of cement extravasation.     

Influence of strain and age differences on the yields of porcine islet isolation: extremely high islet yields from SPF CMS miniature pigs

BACKGROUND: Porcine pancreas is a potential source of material for islet xenotransplantation. However, the difficulty in isolating islets, because of their fragility and the variability of isolation outcome in donor age and breed, represents a major obstacle to porcine islet xenotransplantation. In this study, we compared the islet isolation yield of specific pathogen-free (SPF) Chicago Medical School (CMS) miniature pigs with that of another miniature pig breed and market pigs from a local slaughterhouse. METHODS: Nine adult CMS miniature (ACM) pigs (>12 months), six young CMS miniature (YCM) pigs (6-7 months), four adult Prestige World Genetics (PWG) miniature (APM) pigs (>12 months), and 13 adult market (AM) pigs from a local slaughterhouse were used for islet isolation. RESULTS: The islet yield per gram of pancreas from ACM pigs (9589 +/- 2823 IEQ/g) was significantly higher than that from APM pigs (1752 +/- 874 IEQ/g, P < 0.05), AM pigs (1931 +/- 947 IEQ/g, P < 0.05), or YCM pigs (3460 +/- 1985 IEQ/g, P < 0.05). Isolated islets from ACM pigs were significantly larger than those from AM pigs or YCM pigs. The in vitro and in vivo function of isolated islets showed no difference among experimental groups. The pancreases of ACM pigs contained higher mean islet volume density percentages and larger size of islets than those of AM or APM pigs. CONCLUSIONS: We isolated extremely high yields of well-functioning islets from ACM pigs bred under SPF conditions. SPF CMS miniature pigs should be one of the best porcine islet donors for clinical porcine islet xenotransplantation.     

Outcome of patients with huge hepatocellular carcinoma after primary resection and treatment of recurrent lesions

BACKGROUND: Tumour recurrence is common after hepatic resection of hepatocellular carcinomas (HCCs) greater than 10 cm in diameter. This study evaluated the outcome of patients with huge HCC after primary resection and treatment of recurrent lesions. METHODS: A retrospective review was undertaken of clinical data for 100 patients with huge HCC who underwent liver resection. RESULTS: Mean(s.d.) tumour diameter was 13.3(3.0) cm; 80 per cent were single lesions. Systematic and non-systematic resections were performed in 80 and 20 per cent of patients respectively, with R0 resection achieved in 86 per cent. Overall 1-, 3- and 5-year disease-free survival rates were 43, 26 and 20 per cent respectively. Risk factors for HCC recurrence were resection margin less than 1 cm and macrovascular invasion. Extensive tumour necrosis of 90 per cent or more after preoperative transarterial chemoembolization was not a prognostic factor. Some 85 per cent of patients with recurrence received various treatments, and these patients had a longer post-recurrence survival than those who were not treated. Overall 1-, 3- and 5-year survival rates were 66, 44 and 31 per cent respectively. CONCLUSION: In patients with huge HCC, hepatic resection combined with active treatment for recurrence resulted in longer-term survival. Frequent protocol-based follow-up appears to be beneficial for the early detection and timely treatment of recurrence.     

Therapeutic endovascular treatments for traumatic vertebral artery injuries

OBJECTIVE: Traumatic vertebral artery injuries pose difficulty in early diagnosis and management because of concomitant neurologic dysfunction and limitations in direct surgical access. The purpose of this report is to review endovascular therapy in patients with traumatic vertebral artery injuries for preservation of the parent artery, and to determine the safety and efficacy of such endovascular therapy. METHODS: Six patients with traumatic vertebral artery lesions were treated using therapeutic endovascular methods. Endovascular therapy was accomplished by stent insertion or coil embolization or both. RESULTS: Except one patient who underwent coil embolization of a transected vertebral artery, all dissections and pseudoaneurysms were successfully treated by stent placement or stent-assisted coiling with preservation of parent arteries. No additional surgical procedures for vascular lesions were required. There were no delayed neurologic or vascular complications and no lesions recurred during the follow-up period (mean, 36.7 months). CONCLUSION: The author's experience demonstrates that endovascular therapy using stents and coils is both feasible and safe in the treatment of traumatic vertebral artery injuries. Endovascular therapy selectively eliminated the vascular abnormality while maintaining the normal patency of the cerebral arteries. Long-term follow-up review of these repairs will be necessary to provide a full evaluation of the safety and efficacy of these devices.