The posterolateral approach for fluoroscopy-guided tibiotalar joint injection.

OBJECTIVE: To report a novel technique for tibiotalar joint injection that utilizes a posterolateral approach, including indications and technical considerations. METHODS: The posterolateral approach for tibiotalar injection is similar to that used in posterior subtalar joint injections. Using this technique, the tibiotalar joint space is accessed by directing the needle anterosuperiorly beneath the fibula until the posterior aspect of the talar dome has been reached. A retrospective review was conducted of all posterolateral approach tibiotalar joint injections at our institution. RESULTS: Eight patients underwent 12 technically successful therapeutic anesthetic/steroid tibiotalar joint injections using the posterolateral approach under fluoroscopic guidance. All eight patients had anterior predominant arthrosis with large osteophytes and tibiotalar joint space narrowing. The injections were well tolerated without evidence of complications. CONCLUSION: Posterolateral tibiotalar joint injection offers an alternative to the more commonly used anterior approach, particularly in cases of severe anterior predominant arthrosis. An additional advantage of this technique is that the ankle stays in the same position between the initial planning of the needle trajectory and the visualization of contrast flowing into the joint.

Incidentally discovered uterine sarcoma in a premenopausal patient after hysterectomy for postembolization endometritis.

Uterine leiomyomas (fibroids) are the most common benign tumor of the female reproductive system. Fibroids can become symptomatic with symptoms such as menorrhagia and menometrorrhagia, pelvic pain, and reproductive dysfunction. Hysterectomy, myomectomy, and the less invasive uterine artery embolization are now commonly performed if conservative management of symptomatic fibroids fails. Moreover, uterine artery embolization (UAE) is the preferred minimally invasive procedure for the treatment of symptomatic fibroids. Major complications of UAE are extremely rare but well known. Additionally, there is a risk of undiagnosed uterine sarcoma found post embolization, which has been reported in literature during the past 12 years. Herein, we describe a case of an incidentally discovered uterine sarcoma in a premenopausal female after hysterectomy for post uterine artery embolization endometritis and sepsis.

Treatment delay in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction: a key process analysis of patient and program factors.

BACKGROUND: Most hospitals that perform primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) in the United States exceed the recommended door-to-balloon time. There is heightened interest in identifying and eliminating factors that introduce delay. METHODS: We performed a key process analysis of our primary PCI program, assessed the relative contribution of individual time intervals on total ischemic time, and identified predictors of delay. RESULTS: Median times and predictors of delay within each time interval were determined for the entire STEMI cohort ("real world") and after exclusion of patients with atypical symptoms and/or presentations of STEMI that resulted in inherent delay in diagnosis and treatment ("ideal world"). Delays in therapy were symptom onset to presentation (120 minutes [interquartile range, IQR, 60-310 minutes, ideal world] and 150 minutes [IQR 60-360 minutes, real world]; predictors of delay were peripheral vascular disease, self-transportation, daytime and weekend presentation); door-to-balloon time (118.5 minutes [IQR 96-141 minutes, ideal world] and 125 minutes [IQR 100-170 minutes, real world]; predictors of delay were female sex, previous stroke, nighttime and weekend presentation, and cardiogenic shock); and symptom onset to first balloon inflation (272 minutes [IQR 187-465 minutes, ideal world] and 297 minutes [IQR 198-560 minutes, real world]; predictors of delay were peripheral vascular disease, weekend presentation, and self-transportation). CONCLUSIONS: Key process analysis of a primary PCI program identifies treatment delays unique to the hospital and the patient population it serves.