Transcatheter arterial embolization in hepatic tumor hemorrhage.

Objective: Spontaneous hepatic tumor hemorrhage is a rare but challenging emergency especially among cirrhotic patients with poor hepatic function. This study aimed at analyzing the safety, efficacy and feasibility of transcatheter arterial embolization (TAE) in the treatment of hepatic tumor hemorrhage. Methods: This retrospective study included all patients undergoing embolization attempt for hepatic tumor hemorrhage in the Helsinki University Hospital during 2004-2017. Electronic medical records provided the study data. Outcomes included the 30-day rebleeding, complication and mortality rates, need for blood transfusions, durations of intensive care unit and hospital admissions, estimates of overall survival, and analysis of factors associated with 30-day mortality. Results: During the study period, 49 patients underwent angiography for hepatic tumor hemorrhage. TAE was technically feasible in 45 patients (92%), and controlled the bleeding with the first attempt in 84%. The 30-day complication and mortality rates were 57 and 33%, respectively. Major complications occurred in 33% of patients. In-hospital mortality was higher among cirrhotic than non-cirrhotic patients (55 versus 7%, p < .001). Patients with bleeding hepatic metastases, but no cirrhosis, had an in-hospital mortality of 0% with no major complications. Patients with benign etiology had a good prognosis and no bleeding- or tumor-related mortality. Discussion: TAE is an effective method in controlling the bleeding in spontaneous hepatic hemorrhage. Underlying pathology determines the prognosis that is poor especially in cirrhotic patients with bleeding hepatocellular carcinoma.

Selective internal radiation therapy (SIRT) as treatment for hepatic metastases of uveal melanoma: a Finnish nation-wide retrospective experience.

BACKGROUND: In Finland, selective internal radiation therapy (SIRT) is at present the preferred first-line loco-regional therapy for uveal melanoma patients with hepatic metastases not suitable for surgery. We retrospectively evaluate the outcome and safety of SIRT in this group of patients. MATERIAL AND METHODS: Yttrium-90 microspheres were delivered via the hepatic artery into the circulation of metastases from uveal melanoma in 18 patients with a predicted life expectancy of more than three months in three Finnish tertiary referral centers between November 2010 and December 2015. Progression-free survival (PFS), toxicity and overall survival (OS) were evaluated. Patients with historical uveal melanoma without extrahepatic metastases, who had received systemic chemotherapy as first-line treatment for their hepatic metastases at the Helsinki University Hospital between January 2006 and May 2010, were used as a historical control group. RESULTS: Partial response and stable disease were observed in three (17%) and eight (44%) patients, respectively; one patient was not evaluable for response. Median PFS after SIRT was 5.6 (range, 1.3-40.8) months. Median OS after SIRT was 13.5 (range, 3.6-44.8) months compared with 10.5 (range, 3.0-16.5; p = .047) months for the historical chemotherapy group. Among patients who received SIRT as first-line treatment, the median OS was 18.7 (range, 8.2-44.8) months, significantly longer than that of the chemotherapy group (10.5 months, p = .017). There were no treatment-related deaths. Toxicity was mainly WHO grade 1-2 and self-limited. CONCLUSION: SIRT is a feasible and safe treatment for liver metastases in patients with uveal melanoma.

Catheter-Directed Thrombolysis Versus Pharmacomechanical Thrombectomy for Upper Extremity Deep Venous Thrombosis: A Cost-Effectiveness Analysis.

BACKGROUND: Upper extremity deep vein thrombosis represents (UEDVT) 2-3% of all deep vein thrombosis. Catheter directed thrombolysis (CDT) was replaced largely by pharmacomechanical thrombolysis (PMT) in our institution. In this study we compared the immediate and 1-year results as well as the total hospital costs between CDT and PMT in the treatment of UEDVT. METHODS: From 2006 to 2013, 55 patients with UEDVT were treated with either CDT or PMT at Helsinki University Hospital. Of them, 43 underwent thoracoscopic rib resection later to relieve phlebography-confirmed vein compression. This patient cohort was prospectively followed up with repeated phlebographies. CDT was performed to 24 patients, and 19 had PMT with a Trellis™ device. Clinical evaluation and vein patency assessment were performed with either phlebography or ultrasound 1 year after the thrombolysis. Primary outcomes were immediate technical success, 1-year vein patency, and costs of the initial treatment. RESULTS: The immediate overall technical success rate, defined as recanalization of the occluded vein and removal of the fresh thrombus, was 91.7% in the CDT group and 100% in the PMT group (n.s.). The median thrombolytic time was significantly longer in CDT patients than that in PMT patients (21.1 vs. 0.33 hr, P < 0.00001). There were no procedure-related complications. The 1-year primary assisted patency rate was similar in both the groups (91.7% and 94.7%). There were no recurrences of clinical DVT. The hospital costs for the acute period were significantly lower in the PMT group than those in the CDT group (medians: 11,476 € and 5,975 € in the CDT and PMT groups, respectively [P < 0.00001]). CONCLUSIONS: The clinical results of the treatment of UEDVT with CDT or PMT were similar. However, PMT required shorter hospital stay and less intensive surveillance, leading to lower total costs.

Bleeding gastric and duodenal ulcers: case-control study comparing angioembolization and surgery.

OBJECTIVES: To compare the safety, efficacy and feasibility of transcatheter arterial embolization (TAE) and surgery in the treatment of bleeding gastric and duodenal ulcers (BGDUs). MATERIALS AND METHODS: The study group comprised patients receiving TAE or surgery for BGDUs after failed endoscopic hemostasis in Helsinki University Hospital (HUH) during 2000-2015. Hospital medical records provided study data. 30-d mortality and rebleeding rates were the primary outcomes. Postoperative complications, blood transfusion rate, and the durations of intensive care and hospital admissions were the secondary outcomes. RESULTS: During the study period, BGDUs lead to 1583 hospital admissions. TAE or surgery was necessary on 85 (5.4%) patients, 43 receiving surgery and 42 TAE. Out of 42, 16 received prophylactic TAE. Two underwent angiography and TAE to localize the bleeding. The remaining 24 received TAE for active or recurrent bleeding after endoscopy. The comparison of TAE (n = 24) and surgery (n = 43) included only patients with active or recurrent bleeding. Mortality rate was 12.5% after TAE and 25.6% after surgery (p = 0.347). Rebleeding rate was 25% after TAE and 16.3% after surgery (p = 0.641). Postprocedural complications were less frequent after TAE than surgery (37.5 vs. 67.4%, p = 0.018). Other secondary outcomes did not differ. Out of 85 procedures, 14 (16.5%) took place between midnight and 8 a.m., all nighttime interventions being surgeries. CONCLUSIONS: Mortality and rebleeding rates did not differ between TAE and surgery. With less postoperative complications, TAE should be the preferred hemostatic method when endoscopy fails.

Bleeding pancreatic pseudoaneurysms: management by angioembolization combined with therapeutic endoscopy.

BACKGROUND: Bleeding pancreatic pseudocysts (PPCs) are a rare but lethal complication of pancreatitis. Transcatheter arterial embolization (TAE) is the first-line treatment of acute hemorrhage, but consensus on the definitive management of bleeding PPCs is lacking. The aim of this study was to evaluate the safety and efficacy of the combination of TAE and therapeutic endoscopy in the treatment of bleeding PPCs. METHODS: Patients with acute or chronic pancreatitis treated for bleeding PPCs in Helsinki University Hospital during 2004-2014 comprised the study group. Inpatients with acute necrotizing pancreatitis were excluded. Patients underwent TAE as the primary treatment to control the bleeding. Therapeutic endoscopy performed on an outpatient visit after TAE allowed the definitive treatment of PPCs. RESULTS: A total of 58 patients underwent TAE. Re-bleeding rate (<30 days) was 15.5 %, necessitating re-embolization on seven and surgical intervention on two patients. Overall, TAE success rate was 96.6 %. Mortality rate (<30 days) was 3.4 %. Of the 58, 47 patients were followed up for their PPCs in our unit. PPCs resolved spontaneously in 13 (27.1 %). The remaining 34 had an endoscopic treatment attempt with endoscopic draining performed on 32 and unsuccessful cannulation on two (5.9 %). Of the 32 patients with initially successful endoscopy, 7 (21.9 %) needed an additional drainage procedure (six non-surgical and one surgical). Overall success rate of non-surgical management was 91.5 %. Post-endoscopy mortality rate (<30 days) was 2.9 %. Our follow-up continued for 15 (1-75) months. By the time of data retrieval, 35 of 58 patients had died with alcohol liver disease being the most common cause of death. Five-year survival estimate was 63 %. CONCLUSIONS: Bleeding pancreatic pseudoaneurysms require non-surgical management. We need more data on the optimal timing of therapeutic endoscopy and on the role of empirical embolizations.

Dual-energy computed tomography of cruciate ligament injuries in acute knee trauma.

OBJECTIVE: To examine dual-energy computed tomography (DECT) in evaluating cruciate ligament injuries. More specifically, the purpose was to assess the optimal keV level in DECT gemstone spectral imaging (GSI) images and to examine the usefulness of collagen-specific color mapping and dual-energy bone removal in the evaluation of cruciate ligaments and the popliteus tendon. MATERIALS AND METHODS: At a level 1 trauma center, a 29-month period of emergency department DECT examinations for acute knee trauma was reviewed by two radiologists for presence of cruciate ligament injuries, visualization of the popliteus tendon and the optimal keV level in GSI images. Three different evaluating protocols (GSI, bone removal and collagen-specific color mapping) were rated. Subsequent MRI served as a reference standard for intraarticular injuries. RESULTS: A total of 18 patients who had an acute knee trauma, DECT and MRI were found. On MRI, six patients had an ACL rupture. DECT's sensitivity and specificity to detect ACL rupture were 79% and 100%, respectively. The DECT vs. MRI intra- and interobserver proportions of agreement for ACL rupture were excellent or good (kappa values 0.72-0.87). Only one patient had a PCL rupture. In GSI images, the optimal keV level was 63 keV. GSI of 40-140 keV was considered to be the best evaluation protocol in the majority of cases. CONCLUSION: DECT is a usable method to evaluate ACL in acute knee trauma patients with rather good sensitivity and high specificity. GSI is generally a better evaluation protocol than bone removal or collagen-specific color mapping in the evaluation of cruciate ligaments and popliteus tendon.

The reverse Segond fracture: not associated with knee dislocation and rarely with posterior cruciate ligament tear.

The aims of this study were to assess the incidence of reverse Segond fracture, to examine the associated ligamentous injuries, and to examine how often reverse Segond fracture coexists with a knee dislocation. At a level 1 trauma center, an 11-year period of emergency department multidetector-row computed tomography (MDCT) examinations for knee trauma was evaluated for reverse Segond and Segond fractures. Surgical findings served as the reference standard for intra-articular injuries. The hospital discharge register was searched for the diagnosis of knee dislocation from August 2000 through the end of August 2011. A total of 1,553 knee MDCT examinations were evaluated. Ten patients with a reverse Segond fracture were found, comprising 0.64 % of emergency room acute knee trauma MDCT examinations. Seven patients who had a reverse Segond fracture were operated: Three had an avulsion fracture of the anterior cruciate ligament, one had an avulsion fracture of posterior cruciate ligament, two had a lateral meniscal tear, and two had a medial collateral ligament tear. The ratio of reverse Segond fractures to Segond fractures was 1:4. None of the 71 knee dislocation patients had a reverse Segond fracture. Reverse Segond fracture is a rare finding even in a level 1 trauma center. Cruciate ligament injuries appear to be associated with avulsion fracture, but every patient does not have PCL injury, as previously reported. Our results do not support the association of knee dislocation with reverse Segond fracture.

Noncontrast CT Selected Thrombectomy vs Medical Management for Late-Window Anterior Large Vessel Occlusion.

BACKGROUND AND OBJECTIVES: There is uncertainty whether patients with large vessel occlusion (LVO) presenting in the late 6-hour to 24-hour time window can be selected for endovascular therapy (EVT) by noncontrast CT (NCCT) and CT angiography (CTA) for LVO detection. We evaluated the clinical outcomes of patients selected for EVT by NCCT compared with those medically managed in the extended time window. METHODS: This multinational cohort study was conducted at 66 sites across 10 countries. Consecutive patients with proximal anterior LVO stroke selected for EVT by NCCT or medically managed and presenting within 6-24 hours of time last seen well (TSLW) from January 2014 to May 2022 were included. The primary end point was the 90-day ordinal shift in the modified Rankin Scale (mRS) score. Inverse probability treatment weighting (IPTW) and multivariable methods were used. RESULTS: Of 5,098 patients screened, 839 patients were included, with a median (interquartile range) age of 75 (64-83) years; 455 (54.2%) were women. There were 616 patients selected to undergo EVT by NCCT (73.4%) and 223 (26.6%) who were medically managed. In IPTW analyses, there was a more favorable 90-day ordinal mRS shift in patients selected by NCCT to EVT vs those who were medically managed (odds ratio [OR] 1.99, 95% CI 1.53-2.59; p < 0.001). There were higher rates of 90-day functional independence (mRS 0-2) in the EVT group (40.1% vs 18.4%, OR 3.31, 95% CI 2.11-5.20; p < 0.001). sICH was nonsignificantly higher in the EVT group (8.5% vs 1.4%, OR 3.77, 95% CI 0.72-19.7, p = 0.12). Mortality at 90 days was lower in the EVT vs MM group (23.9% vs 32.3%, OR 0.61, 95% CI 0.45-0.83, p = 0.002). DISCUSSION: In patients with proximal anterior LVO in the extended time window, there was a lower rate of disability and mortality in patients selected with NCCT and CTA to EVT compared with those who were medically managed. These findings support the use of NCCT as a simpler and more inclusive approach to patient selection in the extended window. TRIAL REGISTRATION INFORMATION: This study was registered at ClinicalTrials.gov under NCT04096248. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that for patients with proximal anterior circulation occlusion presenting with ischemic stroke from 6 to 24 hours, compared with medical management, those undergoing thrombectomy based on NCCT have reduced disability and mortality at 90 days.

Endovascular Therapy in the Extended Time Window for Large Vessel Occlusion in Patients With Pre-Stroke Disability.

BACKGROUND AND PURPOSE: We compared the outcomes of endovascular therapy (EVT) in an extended time window in patients with large-vessel occlusion (LVO) between patients with and without pre-stroke disability. METHODS: In this prespecified analysis of the multinational CT for Late Endovascular Reperfusion study (66 participating sites, 10 countries between 2014 and 2022), we analyzed data from patients with acute ischemic stroke with a pre-stroke modified Rankin Scale (mRS) score of 0-4 and LVO who underwent EVT 6-24 hours from the time last seen well. The primary outcome was the composite of functional independence (FI; mRS score 0-2) or return to the pre-stroke mRS score (return of Rankin, RoR) at 90 days. Outcomes were compared between patients with pre-stroke disability (pre-stroke mRS score 2-4) and those without (mRS score 0-1). RESULTS: A total of 2,231 patients (median age, 72 years; median National Institutes of Health Stroke Scale score, 16) were included in the present analysis. Of these, 564 (25%) had pre-stroke disability. The primary outcome (FI or RoR) was observed in 30.7% of patients with pre-stroke disability (FI, 16.5%; RoR, 30.7%) compared to 44.1% of patients without (FI, 44.1%; RoR, 13.0%) (P<0.001). In multivariable logistic regression analysis with inverse probability of treatment weighting, pre-stroke disability was not associated with significantly lower odds of achieving FI or RoR (adjusted odds ratio 0.73, 95% confidence interval 0.43-1.25). Symptomatic intracranial hemorrhage occurred in 6.3% of both groups (P=0.995). CONCLUSION: A considerable proportion of patients with late-presenting LVO and pre-stroke disability regained pre-stroke mRS scores after EVT. EVT may be appropriate for patients with pre-stroke disability presenting in the extended time window.

Recanalization status and temporal evolution of early ischemic changes following stroke thrombectomy.

INTRODUCTION: Present-day computer tomography (CT) scanners have excellent spatial resolution and signal-to-noise ratio and are instrumental detecting early ischemic changes (EIC) in brain. We assessed the temporal changes of EIC based on the recanalization status after thrombectomy. PATIENTS AND METHODS: The cohort comprises consecutive patients with acute ischemic stroke in anterior circulation treated with thrombectomy in tertiary referral hospital. All baseline and follow-up scans were screened for any ischemic changes and further classified using Alberta Stroke Program Early CT Score (ASPECTS). Generalized linear mixed models were used to analyze the impact of recanalization status using modified Thrombolysis in Cerebral Infarction (mTICI) on temporal evolution of ischemic changes. RESULTS: We included 614 patients with ICA, M1, or M2 occlusions. Median ASPECTS score was 9 (IQR 7-10) at baseline and 7 (5-8) at approximately 24 h. mTICI 3 was achieved in 207 (33.8%), 2B 241 (39.3%), 2A in 77 (12.6%), and 0-1 in 88 (14.3%) patients. Compared to patients with mTICI 3, those with mTICI 0-1 and 2A had less favorable temporal changes of ASPECTS (p < 0.001). Effect of recanalization was noted in the cortical regions of ICA/M1 patients, but not in their deep structures or patients with M2 occlusions. All ischemic changes detected at baseline were also present at all follow-up images, regardless of the recanalization status. CONCLUSIONS: Temporal evolution of the ischemic changes and ASPECTS are related to the success of the recanalization therapy in cortical regions of ICA/M1 patients, but not in their deep brain structures or M2 patients. In none of the patients did EIC revert in any brain region after successful recanalization.

Segond fracture combined with tibial plateau fracture.

OBJECTIVE: The objective of our study was to examine the coexistence of Segond fracture in tibial plateau fractures and to assess the prevalence of anterior cruciate ligament (ACL) rupture and meniscal tear when those fractures coexist. MATERIALS AND METHODS: This retrospective study was conducted at a level 1 trauma center. A total of 1203 emergency department knee trauma MDCT examinations were evaluated. Surgical findings served as the reference standard for intraarticular injuries. RESULTS: A total of 33 patients with a Segond fracture were found. Of these patients, 10 had isolated Segond fractures (surgery, n = 7) and 23 patients (surgery, n = 20) had a Segond fracture associated with a tibial plateau fracture. Patients with both fractures had significantly fewer anterior cruciate ligament (ACL) ruptures (20% vs 71%, p = 0.023) and more avulsion fractures of the ACL (50% vs 0%, p = 0.026) than patients with isolated Segond fractures. For meniscal injuries, the corresponding numbers were 25% and 57% (p = 0.175), respectively. In approximately one of every 32 tibial plateau fractures, a Segond fracture also coexists. CONCLUSION: Patients with a Segond fracture combined with a tibial plateau fracture have a high risk of avulsion fracture of the ACL.

Multidetector computed tomography evaluation of bony fragments and donor sites in acute patellar dislocation.

BACKGROUND: Patellar dislocation is frequently associated with bony fragments that are difficult to see on radiographs. MRI or MDCT are often used to rule out or characterize these bony fragments. PURPOSE: To assess the use of MDCT for locating bony fragments and donor sites in patients with acute patellar dislocation, and to test whether sizes and quantity of bony fragments differ between first-time dislocations and recurrent dislocations. MATERIAL AND METHODS: Retrospective data from two hospitals during a 96-month period were collected, and a total of 46 patients (mean age 27 years, range 9-69 years) that had sustained an acute patellar dislocation (22 first-time, 24 recurrent) were identified. Size, location and donor site of bony fragments were evaluated on MDCT images. Surgical correlation was available for 22 of 46 patients. RESULTS: On MDCT images, the likely donor site could be identified in 62 of 71 (87%) bony fragments. Of the bony fragments that were seen on MDCT images, 40 of 68 (59%) were not seen on AP and lateral views of the conventional radiographs. There was no significant difference in size of bony fragments between first-time or recurrent dislocators (p=0.77). The average number of bony fragments were 2.1 and 1.0 in first-time and recurrent dislocators, respectively. The location and donor site of bony fragments was similar between two patients groups. CONCLUSION: MDCT is a suitable imaging method to locate bony fragments and donor sites. The number of bony fragments seems to be higher in first-time dislocators than recurrent dislocators, otherwise findings between the two patient groups were similar.

The implementation of a pathway and care bundle for the management of acute occlusive arterial mesenteric ischemia reduced mortality.

BACKGROUND: Acute mesenteric ischemia (AMI) is a disease with high mortality and requires a multidisciplinary approach for effective management. A pathway and care bundle were developed and implemented with the objective to reduce mortality. The aim of this retrospective comparative study was to analyze the effects of the pathway on patient management and outcome. METHODS: All consecutive patients operated in a secondary and tertiary referral center because of occlusive arterial AMI were identified between 2014 and April 2020. The pathway aimed to increase overall awareness, and hasten and improve diagnostics and management. Patients treated before implementation of the pathway (pregroup, years 2014-2017) were compared with patients treated using the pathway (postgroup, May 2018 to April 2020). Univariate and multivariate analyses were used to compare the groups. RESULTS: There were 78 patients in the pregroup and 67 patients in the postgroup with comparable baseline characteristics and disease acuity. The postgroup was more often diagnosed with contrast-enhanced computed tomography (58 [74%] vs. 63 [94%], p = 0.001) and had shorter mean in-hospital delay to operating room (7 hours [interquartile range, 3.5-12.5] vs. 3 hours [interquartile range, 2-11], p = 0.023). Revascularization was done more often in the postgroup (53 [68%] vs. 56 [84%], p = 0.030) especially using endovascular treatment (26 [33%] vs. 43 [64%], p < 0.001). Thirty-day mortality was lower in the postgroup (23 [51%] vs. 17 [25%], p = 0.001). Being managed in the postgroup remained as a protective factor (odds ratio, 0.32; 95% confidence interval, 0.14-0.75; p = 0.008) for 30-day mortality in the multivariate analysis. CONCLUSION: Implementing a pathway and care bundle resulted in enhanced regional and in-hospital awareness of AMI, more appropriate computed tomography imaging, shorter in-hospital delays, increased number of revascularizations, and, hence, lower mortality. LEVEL OF EVIDENCE: Therapeutic/Care Management, level IV.

Hepatic Ultrasonography Compared With Computed Tomography and Magnetic Resonance Imaging at Diagnosis of Metastatic Uveal Melanoma.

PURPOSE: To evaluate the consistency of hepatic ultrasonography (US) with staging computed tomography (CT) and magnetic resonance imaging (MRI), to analyze why US was inconsistent with CT/MRI, and to compare CT/MRI. DESIGN: Reliability analysis. METHODS: Two hundred fifteen patients whose primary uveal melanoma was managed in the Helsinki University Hospital and who were diagnosed with hepatic metastases by US within 60 days of staging CT/MRI from January 1999 to December 2016 were included. Patients attended a real-life follow-up schedule including hepatic US, liver function tests (LFT), and a confirmatory CT/MRI. We evaluated the consistency of US with staging CT/MRI regarding the presence and number of metastases. RESULTS: The enrolled patients underwent 215 US, 167 CT, and 69 MRI examinations, and 67% of them had biopsy-confirmed metastases. Screening was regular for 98% of the patients, and 66% were asymptomatic. US was fully consistent with CT/MRI in detecting metastases in 113 (53%) patients, in 63 (29%) CT/MRI showed more metastases, and in 16 (7%) CT/MRI showed fewer metastases than US. CT/MRI was inconsistent with US in 23 (11%) patients. The sensitivity of US in detecting metastases was 96% (95% confidence interval, 92-98). US failed to suggest metastases in 10 patients. LFT were abnormal in 6 of them, and a newly detected hepatic lesion was present by US in 4. CONCLUSIONS: Hepatic US is a sensitive screening modality in detecting metastases in patients with primary uveal melanoma, if combined with LFT and, in case of any newly detected lesion, a confirmatory MRI.

Knee dislocation in overweight patients.

OBJECTIVE: The purpose of this study was to evaluate the incidence, cause, injury patterns, and MRI findings in knee dislocation in patients with normal and increased body mass index and to determine whether obesity interferes with knee MRI examinations. MATERIALS AND METHODS: A retrospective study of the period from 2000 to 2007 (90 months) was performed at a level 1 trauma center, finding a total of 24 patients who had sustained a knee dislocation. RESULTS: Twenty-two of the 24 patients underwent surgery and 19 patients had an MRI examination of diagnostic quality before surgery. Of the 24 patients, 11 had a body mass index greater than 25 and had knee dislocation due to low-energy trauma (nine due to a simple fall, two to a noncontact sport). Two of these 11 patients were morbidly obese (body mass index>40). These patients had no injuries to the popliteal tendon and they had no irreversible peroneal nerve injuries. Otherwise, the patients' injuries were in agreement with previous knee dislocation studies. Obesity did not interfere with knee MRI examinations. On the basis of the population served by our trauma center, the annual incidence of knee dislocation due to low-energy trauma in overweight patients is about 1.0 per million. CONCLUSION: The annual incidence in obese patients of knee dislocation due to low-energy trauma is not insignificant at a level 1 trauma center. As the prevalence of obesity increases, the injury patterns seen in emergency departments may change. The radiologist should be aware that even after a simple fall, overweight patients may have a knee dislocation.

Transcatheter Arterial Embolization in Lower Gastrointestinal Bleeding: Ischemia Remains a Concern Even with a Superselective Approach.

PURPOSE: To evaluate the safety, efficacy, and feasibility of transcatheter arterial embolization (TAE) in the treatment of lower gastrointestinal bleeding (LGIB). METHODS: Study group comprised all patients receiving angiography for LGIB in the Helsinki University Hospital during the period of 2004-2016. Hospital medical records provided the study data. Rebleeding, complication, and mortality rates (≤ 30 days) were the primary outcomes. Secondary outcomes included need for blood transfusions, durations of intensive care unit and hospital admissions, incidence of delayed rebleeding, and long-term complications, as well as overall survival. RESULTS: During the study period, angiography for LGIB was necessary on 123 patients. Out of 123, 55 (45%) underwent embolization attempts. TAE was technically successful in 53 (96%). Rebleeding occurred in 14 (26%). The complication rate was 36%, minor complications occurring in 10 (19%) and major in nine (17%). Major complications resulted in bowel resection in seven (13%). Post embolization ischemia was the most common single complication seen in nine (17%). The mortality rate was 6%. Survival estimates of 1 and 5 years were 79 and 49%. DISCUSSION: LGIB is a severe physiological insult occurring in patients who are often elderly and moribund. Although major post embolization complications occur, transcatheter arterial embolization should be the first-line approach over surgery in profuse LGIB in patients with hemodynamic instability, when colonoscopy fails or is unavailable, or when computerized tomography angiography detects small intestinal bleeding.

Femoral avulsion of the medial patellofemoral ligament after primary traumatic patellar dislocation predicts subsequent instability in men: a mean 7-year nonoperative follow-up study.

BACKGROUND: The clinical relevance of medial patellofemoral ligament (MPFL) injury location in primary patellar dislocation has not been studied. HYPOTHESIS: Prognosis after primary traumatic patellar dislocation may vary by MPFL injury location. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The initial magnetic resonance imaging (MRI) findings in 53 patients with identical nonoperative management were retrospectively analyzed for medial restraint injuries. The MPFL injury sites were classified as follows: femoral, midsubstance, and patellar. Magnetic resonance imaging was used to assess initial and control articular cartilage lesions in the patellofemoral joint. After a mean follow-up of 7 years, 42 patients were evaluated for redislocations, subjective symptoms, and functional limitations. RESULTS: Based on the initial MRIs, MPFL rupture was classified as femoral in 35 patients, midsubstance in 11, and patellar in 7. At follow-up, 15 patients reported an unstable patella (13 femoral, 1 patellar, 1 midsubstance; P = .01) and 9 reported patellar redislocations (8 femoral, 1 midsubstance; P = .05). The proportion of patients who regained their preinjury activity level was significantly smaller among those with femoral MPFL injury than among those with midsubstance or patellar MPFL injury (P = .05). The median Kujala score was as follows: 90 for femoral, 91 for patellar, and 96 for midsubstance (P = .76). Control MRI showed full-thickness patellofemoral cartilage lesions in 50% of the patients, unrelated to MPFL injury location. CONCLUSION: An MPFL avulsion at the femoral attachment in primary traumatic patellar dislocations predicts subsequent patellar instability. The authors suggest that MPFL injury location be taken into account when planning treatment of primary traumatic patellar dislocation.