Arteriovenous fistula and nerve conduction velocity in patients on hemodialysis: statistical and electrographic findings

The aim of this study was to investigate the possible influence of arteriovenous fistula (AVF) on nerve conduction velocity in patients on intermittent hemodialysis and its relevance to the pathogenesis of carpal tunnel syndrome (CTS). The data on 22 patients showed no statistically significant differences in the electrographic parameters considered. This suggests that AVF by the end-to-end method plays no significant part in the alteration of nerve conduction. Possibly radial steal phenomena, which occur with other types of AVF, are at least partly responsible for the reported cases of CTS.

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Sommario Scopo di questo studio è stato indagare l'eventuale influenza della fistola arterovenosa (FAV) sulla velocità di conduzione nervosa in pazienti in trattamento emodialitico periodico, per le sue pssibili implicazioni nella patogenesi della sindrome del tunnel carpale (CTS). Vengono presentati i dati relativi a 22 pazienti. I risultati non hanno evidenziato differenze statisticamente significative dei parametri elettrografici considerati.Pertanto i nostri dati suggeriscono che la FAV (eseguita secondo la tecnica termino-terminale) non riveste un ruolo significativo nell'alterazione della conduzione nervosa. È possibile che fenomeni di furto nel territorio dell'arteria radiale, che si verificano con FAV eseguite con altra modalità, siano, almeno in parte, responsabili dei casi di CTS segnalati nella letteratura al riguardo.

     

Deltoid ligament reconstruction with autologous gracilis tendon in chronic medial ankle instability after ankle fracture surgery: A case report

IntroductionThe repair of a deltoid ligament injury, following an ankle fracture with involvement of the syndesmosis, has no univocal consensus. Also the surgical strategies in case of a subsequent chronic instability are still under debate. In this work the result of a double bundle anatomic reconstruction of deltoid ligament with ipsilateral autologous gracilis muscle tendon is presented.Case reportA 50 year old active male patient came to our attention with a catastrophic medial ankle instability, a severe pronation of the hindfoot and disabling ankle pain. He reported a Weber type B fracture of the left ankle with a lesion of the syndesmosis treated with anatomic plate and screws and a transyndesmotic screw 8 months before. The imaging showed a complete deltoid ligament lesion. Due to the impossibility of a direct repair of the ligament, we performed the reconstruction of the medial ligamentous complex with an autologous gracilis tendon graft. 10 months after the medial ligamentous complex reconstruction, the patient showed an excellent recovery of walking ability, disappearance of pain under load and resumed an active lifestyle.DiscussionThe deltoid ligament has a key role in ankle joint stability and its integrity promotes the recovery after ankle fractures. However, its lesion is often left untreated in the acute setting. The result of a chronic untreated deltoid ligament injury could be extremely disabling and the ligament reconstruction, when an optimal native deltoid ligament repair is not achievable, is the choice to restore ankle function and stability.ConclusionIn the delayed treatment of a deltoid ligament rupture the described double bundle anatomic reconstruction with autologous tendon graft can be an effective and suitable option.     

Atlantoaxial instability in a patient with neck pain and rheumatoid arthritis

Context: The purpose of this report is to describe the clinical decision-making process for a patient with rheumatoid arthritis with neck pain with underlying atlantoaxial instability.Findings: The patient was evaluated for worsening upper neck pain that began insidiously 1 year prior. The patient denied numbness or tingling in her upper or lower extremities, dizziness or lightheadedness, difficulty maintaining balance with walking, or muscle weakness. Cervical spine range of motion was limited in all planes due to pain and apprehension. The patient’s neurological examination was unremarkable. Prior flexion and extension radiographs of the cervical spine were interpreted as unremarkable with alignment preserved in flexion and extension. However, upon further inspection, the cervical spine flexion radiograph was concerning for inadequate cervical motion, which may have limited the diagnostic utility of these radiographs. Additionally, a Sharp-Purser test was performed, which was positive for excessive motion. Flexion and extension radiographs of the cervical spine were then repeated ensuring the patient adequately flexed and extended during the imaging. Severe anterior subluxation of C1 relative to C2 with cervical flexion was noted, as C1 moved as much as 8–9 mm anterior to C2 with cervical flexion. Given the degree of atlantoaxial instability, the patient subsequently underwent successful posterior fusion from the occiput to C2.Conclusion/Clinical Relevance: This case report demonstrates the importance of properly screening for upper cervical spine instability in patients with rheumatoid arthritis and neck pain and understanding the importance of obtaining adequate and appropriate diagnostic imaging.     

New technique for posterior intra-articular arthrodesis using a single-block graft in cases of atlantoaxial instability

A new method of posterior C1-2 arthrodesis, derived from the W. V. Cone and G. Bertrand, technique (Montreal, 1970) is described with two modifications: (1) the exact measurements of the ideal graft are determined preoperatively, using CT and a sterilized pasteboard horseshoe-shaped model; (2) in the sitting postion, single occipital block graft was cut out microsurgically, using the preoperative model. After decortication of the graft, posterior arches of C1 and 2, and microsurgical excision of the cartilage of the C1-2 lateral joints, the graft was imbedded into the entire C1-2 space, fixed, and tightened using a braid of nylacap yarn. A case report of rotatory luxation and associated atlantoaxial instability in a 10-year-old girl illustrates the excellent functional results of this technique.Presented at the XVII Annual Meeting of the International Society for Pediatric Neurosurgery, Bombay 1989     

A role for genomic instability in cellular radioresistance?

Summary Inherent cellular radioresistance plays a critical role in the failure of radiotherapy. Although the consequences of radioresistance are well known, the molecular, biological, and cellular bases of radioresistance remain a mystery. We propose that genomic instability, the increased rate of acquisition of alterations in the mammalian genome, can directly modulate cells' sensitivity to radiation. In particular, destabilization of chromosomes occurring as a consequence of genomic instability may result in enhanced plasticity of the genome. This increased plasticity of the genome allows cells to better adapt to changes in local environment(s) during tumor progression, or improve cell survival following exposure to DNA damage encountered during radiotherapy protocols, thereby contributing to radioresistant cell populations found in tumors both before and after radiotherapy.     

The effect of supervised rehabilitation on strength, postural sway, position sense and re-injury risk after acute ankle ligament sprain

The effect of an early rehabilitation program, including postural training, on ankle joint function after an ankle ligament sprain was investigated prospectively. Ninety-two subjects, matched for age, sex, and level of sports activity, were randomized to a control or training group. All subject received the same standard information regarding early ankle mobilization. In addition, the training group participated in supervised physical therapy rehabilitation (1 h, twice weekly) with emphasis on balance training. Postural sway, position sense and isometric ankle strength were measured 6 weeks and 4 months after the injury, and at 12 months re-injury data were obtained. In the training group, there was a significant difference between the injured and uninjured side for plantar flexion (P < 0.01), eversion (P < 0.01) and inversion (P < 0.05), but not for dorsiflexion at 6 weeks. In the control group, there was a significant difference between the injured and uninjured side for plantar flexion (P < 0.01), eversion (P < 0.01), inversion (P < 0.01), and dorsiflexion (P < 0.05) at 6 weeks. Postural sway, but not position sense, differed between the injured and uninjured side in both groups (P < 0.01) at 6 weeks. The side-to-side percent differences were similar in both groups for all variables (P > 0.05) at 6 weeks, and there were no side-to-side differences at 4 months in either group. In the control group, 11/38 (29%) suffered a re-injury, while this number was only 2/29 (7%) in the training group (P < 0.05). These data showed that an ankle injury resulted in reduced ankle strength and postural control at 6 weeks, but that these variables had normalized at 4 months, independent of the supervised rehabilitation. However, the findings also demonstrated that supervised rehabilitation may reduce the number of re-injuries, and therefore may play a role in injury prevention.     

Clinical importance of urethral pressure variations

The cause of female urethral instability is still controversial. With the help of this retrospective analysis of 1168 continuous long-term recordings of the intraurethral pressure at the maximum point of urethral pressure, the correlation between pressure variations (UPV) and simultaneous bladder instability was investigated. It could be stated that clinically important UPV (more than 15 cmH₂O) are found more often in women who suffer from signs of bladder instability (defined as low bladder compliance combined with uninhibited detrusor contractions and/or urinary leakage) than in patients without signs of unstable bladder.     

Kluger's “Fixateur interne” for spinal instability

Kluger's Fixateur Interne proved to be an excellent tool not only in spinal trauma for repositioning of impacted fractures and transpedicular stabilization of the dorsal column but also in other forms of thoracic or lumbar instability.After spinal tumor excision from a dorsal approach and vertebral replacement with methylmethacrylate additional stability through dorsal fixation was achieved with this device.Spondylodiscitis, symptomatic spondylolisthesis, spinal instability from degenerative disc disease as well as nonunion following previous surgery could be cured using Kluger's internal fixation. Rare complications, i.e. from broken screws or rods (5%) caused no problems, but some patients required a second operation for readjustment of malpositioned screws which were causing pain or neurological deficit.