How the Aperture of Femoral Tunnel Affected in ACL Reconstruction Performed with AM Portal Technique?

PURPOSE OF THE STUDY The purpose of this study was to evaluate the position of tibial tunnel (TT) and femoral tunnels (FT) performed by using the anteromedial (AM) portal technique and its effect on the aperture of FT. MATERIAL AND METHODS A total 44 patients operated for anterior cruciate ligament (ACL) rupture by AM portal technique between January 2013 and July 2015, were included in this study. They were subjected to a magnetic resonance imaging of the knee to assess the FT, dimensions of the FT aperture and TT. The location of the ACL graft within the joint was compared with the intact ACL of healthy individuals. The patients were also evaluated using Lysholm and IKDC subjective scores for functional outcome. RESULTS The mean FT angle on both the coronal plane (42.88°±5.83°) and the sagittal plane (68.47°±9.57°) was significantly different from the intra-articular part of the hamstring autograft angles (74.93°±7.27° and 58.74°±4.88°, respectively) (p<0.0001). The mean distance of the FT aperture was 13.18 (±2.49) mm on vertical axis, 10.97 (±1.50) mm on the sagittal axis (p<0.0001). The difference between TT axis and the axis of the intra-articular part of autograft on both coronal (72.78°±4.67° and 74.93°±7.27°, respectively) and sagittal planes (60.12°±5.53° and 58.74°±4.88°, respectively) were not significant (p>0.05). DISCUSSION Ilingrowth et al. claimed that the FT were scattered in the very large distance and some of them were placed outside of anatomical range in the series included the cases performed with transtibial and transtibial independent techniques. In this series, in which we used a femoral guide to drill the FT at lateral femoral condyle at 2 or 10 o'clock position depended upon the site of operation, we obtained a consistent FT which is comparable with the intra-articular part of native ACL. Amano et al. found that the FT aperture enlargement was significant in the series when hamstring tendons were used as autograft, over a 6-month period. We also found a significant difference between the narrowest part of the FT (7.01 ± 1.05 mm) and its aperture (10.97 ± 1.50 mm in sagittal, 13.18 ± 2.49 mm in vertical direction). The enlargement was mainly in the vertical direction, due to the fact that the loads resulting from daily life are mostly on the horizontal plane. CONCLUSIONS The direction of intra-articular part of the ACL graft in the cases operated with the AM portal technique is significantly different from the FT direction in both the coronal and sagittal planes. The enlargement of the FT aperture is larger in the vertical axis compared to the sagittal axis. Although the long-term clinical consequences of asymmetrical enlargement of the FT aperture are not known yet, to avoid this potential risk, a technique to approximate the direction of FT to the intra-articular part of the ACL without changing the FT entry site, can be used. Key words: knee, anterior cruciate ligament reconstruction, femoral tunnel, tibial tunnel, anteromedial portal.

Doppler ultrasonography-guided surgery for high-flow hemodialysis vascular access: preliminary results.

AIM: We sought to investigate the results of flow reduction with prospective Doppler ultrasonography (USG)-guided surgery. PATIENTS AND METHODS: Thirty patients with end-stage renal failure with high-flow arterio-venous (AV) fistulae (n = 25) or AV grafts (n = 5) were included in the study. The indications for operation were as follows: cardiac failure (n = 18) or steal syndrome (n = 12). AV fistula flow >800 mL/min or AV graft >1200 mL/min was the selection criterion for definition of a high-flow vascular access. The desired postoperative flow was 400 mL/min or 800 mL/min for AV fistula or AV graft, respectively. Before the surgical intervention, a vascular clamp was used to simulate the planned intervention with evaluation by Doppler USG after the anastomosis was narrowed. RESULTS: There were 16 men and 14 women with a median age of 48 +/- 9 years (range, 39-57 years). Preoperative measurements of median AV fistula, AV graft flow, and anastomosis diameter were as follows: 2663 mL/min (range, 1856-3440 mL/min); 2751 mL/min (range, 2140-3584 mL/min); and 7.3 mm (range, 6.1- 8.5 mm), respectively. The flow was reduced to 615 mL/min (range, 552-810 mL/min) for AV fistulae and 805 mL/min (range, 745-980 mL/min) for AV grafts. The median diameter of the anastomosis was reduced to 4 mm (range, 3.5-4.3 mm). There were no reinterventions. During the median 1-year follow-up, AV fistula and AV graft patency rates were 100% and 80%, respectively and clinical complaints resolved. Cardiac output rate was reduced from 8.5 +/- 2.9 L/min to 6.1 +/- 1.9 L/min (P < .01). CONCLUSION: Cardiac failure and steal syndrome resulting from high-flow vascular access can be treated successfully with Doppler USG-guided surgery. The desired anastomotic diameter and flow are limited in cases of excessively dilated efferent veins for vascular access.

Medical risk analysis of renal transplant donors.

AIM: The aim of this study was to evaluate the long-term medical risks of living-related donors in our center. PATIENTS AND METHODS: 185 living-related donors participated in the study. The factors assessed were creatinine clearance rate (CrCl), serum creatinine (SCr), BUN, hematocrit levels, proteinuria, microalbuminuria and hypertension rates, and renal parenchyma thickness and kidney dimensions predonation as well as at the last follow-up. In addition, we examined postoperative complications. A lombotomy incision was the choice for donor nephrectomy procedure routinely. RESULTS: The mean length of hospital stay after donor nephrectomy was 3.2 +/- 0.6 days (range, 2-5 days). Seven donors readmitted during the first month after operation with surgical site infection were treated successfully. Four donors were reoperated for incisional hernia repairs and discharged without complication. The mean follow-up period was 61.6 +/- 50.4 months (range, 2-180 months). Mean ages of the donors at operation and at the last follow-up were 50.9 +/- 12.7 years (range, 20-81 years) and 56.5 +/- 11.9 years (range, 29-77 years), respectively. The male-to-female ratio was 0.69. Mean SCr levels and CrCl rates predonation and at the last follow-up were 0.83 +/- 0.22 mg/dL versus 1.1 +/- 0.2 mg/dL (P < .001), and 103.9 +/- 28.8 mL/min versus 88.3 +/- 25.9 mL/min (P = .03), respectively. SCr levels were within normal limits in all donors at predonation and at the last follow-up. At the last follow-up, CrCl was also within expected normal limits in all donors. Hypertension was detected in 13 donors. Mean predonation and at the last follow-up renal parenchymal thickness, BUN, and hematocrit levels were similar. Kidney dimensions were significantly different at the last follow-up after donation (P = .001). Eleven donors displayed proteinuria and 19 had microalbuminuria at the last follow-up, which had been negative for all donors predonation. There were seven surgical site infections and 4 incisional herniae. CONCLUSION: Donor nephrectomy was performed with low surgical morbidity and comparable results of clinical and laboratory data to the age-matched general population.

A primary hydatid cyst of the gracilis: a case report.

Primary hydatid disease of the skeletal muscle without systemic involvement is rare. A 40-year-old woman presented with a painful mass in her medial left upper thigh. She was misdiagnosed as having a deep intramuscular abscess and a fine needle aspiration was performed, but the fluid came out crystal clear. Further inquiry revealed that her 16-year-old daughter had been operated on twice for liver and lung hydatid disease. Thus, a provisional diagnosis of hydatid disease was made. An echinococcal haemagglutination test was positive. Ultrasonography and magnetic resonance imaging findings were consistent with a type-2 hydatid cyst showing a 'water-lily' sign. The cystic mass within the left gracilis was resected en bloc. Adjunctive albendazole chemotherapy (400 mg/day) was prescribed for 3 months. At the 22-month follow-up, the patient remained free of symptoms.

Managing atypical and typical herpetic central nervous system infections: results of a multinational study.

There have been many studies pertaining to the management of herpetic meningoencephalitis (HME), but the majority of them have focussed on virologically unconfirmed cases or included only small sample sizes. We have conducted a multicentre study aimed at providing management strategies for HME. Overall, 501 adult patients with PCR-proven HME were included retrospectively from 35 referral centres in 10 countries; 496 patients were found to be eligible for the analysis. Cerebrospinal fluid (CSF) analysis using a PCR assay yielded herpes simplex virus (HSV)-1 DNA in 351 patients (70.8%), HSV-2 DNA in 83 patients (16.7%) and undefined HSV DNA type in 62 patients (12.5%). A total of 379 patients (76.4%) had at least one of the specified characteristics of encephalitis, and we placed these patients into the encephalitis presentation group. The remaining 117 patients (23.6%) had none of these findings, and these patients were placed in the nonencephalitis presentation group. Abnormalities suggestive of encephalitis were detected in magnetic resonance imaging (MRI) in 83.9% of the patients and in electroencephalography (EEG) in 91.0% of patients in the encephalitis presentation group. In the nonencephalitis presentation group, MRI and EEG data were suggestive of encephalitis in 33.3 and 61.9% of patients, respectively. However, the concomitant use of MRI and EEG indicated encephalitis in 96.3 and 87.5% of the cases with and without encephalitic clinical presentation, respectively. Considering the subtle nature of HME, CSF HSV PCR, EEG and MRI data should be collected for all patients with a central nervous system infection.

Successful Ultrasound-Guided Percutaneous Drainage of Multiple Splenic Abscesses in a Kidney Transplant Patient With Encapsulated Sclerosing Peritonitis: A Case Report.

Differential diagnosis of post-transplant infections should include rare/uncommon foci and pathogens. We present a rare case of life-threatening infection, a splenic abscess in a 53-year-old woman who was transplanted with a cadaveric kidney 5 months previously. The patient was admitted to our clinic with chills, shivering, and fever. She required a kidney transplant because of end-stage renal disease secondary to systemic lupus erythematosus, which had previously been treated by means of peritoneal dialysis for 7 years, until encapsulated sclerosing peritonitis developed, at which time therapy was changed to hemodialysis for 1 year. On physical examination, the patient was slightly lethargic and had tenderness in the left upper quadrant of the abdomen. Laboratory evaluation revealed leukocytosis and high acute phase reactant. Abdominal ultrasonography (US) revealed multiple abscesses in the spleen, but splenectomy was not recommended because of her history of sclerosing peritonitis. Percutaneous drainage catheters were placed under US guidance. Culture of blood and fluid drained from the abscess revealed imipenem-sensitive Escherichia coli and Klebsiella spp. Imipenem (500 mg IV q6hr) was initiated, and the drainage volume was 40 to 50 mL/day in the first week and gradually decreased through the third week. The abscess was completely drained over a period of 6 weeks, as confirmed by computed tomography; percutaneous catheters were then removed. Although splenic abscesses are life-threatening, especially for immunocompromised patients, this case suggests that percutaneous drainage guided by US or computed tomography is an efficient treatment alternative to splenectomy.

Pitfalls in the diagnosis of complicated pulmonary hydatid disease.

The aim of this study was to present the pitfalls in the diagnosis of complicated pulmonary hydatid disease and to discuss the unusual radiological presentations of this endemic disorder in Turkey. We retrospectively evaluated 34 patients (12 females) aged between 8 and 64 years, who were operated on at our centre between 1991 and 1998 and diagnosed with complicated pulmonary hydatid cyst histopathologically. Computerized tomography (CT) scans of these patients were reviewed double-blind by two radiologists. The patients were then divided into two groups: group 1: initial radiological impression is pulmonary hydatid cyst and group 2: initial radiological impression is not pulmonary hydatid disease. These two groups were evaluated in terms of symptoms, radiographical presentation and laboratory tests. The presence of cystic appearance, water-lily sign, ring enhancement concomitant with intact cysts unanimously led the radiologists to the diagnosis of complicated pulmonary hydatid cyst, whereas solid appearance and presence of bronchial obliteration made the diagnosis unlikely. In such circumstances patient history, laboratory findings and bronchoscopic evaluation helped the diagnosis. In conclusion, in endemic regions like Turkey, atypical radiological presentation of complicated pulmonary hydatid disease should be considered in the differential diagnosis of solid pulmonary lesions.

Magnetic resonance imaging findings in patients with severe neonatal indirect hyperbilirubinemia.

The aim of this study was to document the magnetic resonance imaging (MRI) findings of cases with a history of severe neonatal indirect hyperbilirubinemia. Ten cases (eight cases with neurologic findings, two normal cases) with a history of severe neonatal indirect hyperbilirubinemia were studied. Neurologic findings and MRI results were described and correlated. Seven of eight cases with neurologic findings demonstrated symmetric and uniform increased T2 signal changes limited to globus pallidi. MRI scans of two cases without neurologic findings showed no abnormality. Severe neonatal indirect hyperbilirubinemia should be considered in the differential diagnosis of bilateral symmetric hyperintense signal changes in the globus pallidus on MRI. However, high levels of unconjugated bilirubin concentrations in the neonatal period may not always cause such lesions of globus pallidus on MRI despite the presence of neurologic findings.

Avoiding abdominal flank bulge after lumbotomy incision: cadaveric study and ultrasonographic investigation.

OBJECTIVE: The object of this study was to better define the relevant anatomy and innervation of the anterolateral abdominal wall musculature seeking to avoid abdominal wall complication after open donor nephrectomy. We dissected four cadavers and retrospectively assessed donor ultrasonographic imaging of anterolateral abdominal muscle atrophy after donor nephrectomy with a lumbotomy incision. METHODS: Anatomic study was performed on four cadavers using bilateral dissections. The 8th, 9th, 10th, 11th, and 12th (subcostal) intercostal nerves were dissected from the intercostal space to the rectus sheath. With the experience gained from anatomic study, we performed 40 living donor incisions 1.5 to 2 cm medial to the tip of 12th rib, toward the lateral border of the rectus muscle and the umbilicus. Donors were invited to the hospital at 1 year postoperative to examine abdominal wall complications. Ultrasonography (USG) was performed to assess the thickness of the abdominal wall muscles bilaterally to ascertain whether there was atrophy. RESULTS: All distal intercostal nerves ran as multiple mixed segmental nerves, communicating with each other widely within the neurovascular plane. The thick 12th nerve was located at 1.5 to 2 cm medial and under the tip of the 12th rib, running to the suprapubic area. Postoperative USG confirmed that the mean percent thickness of the abdominal muscles of the operative side was not significantly different from the other side (P < .05). CONCLUSION: Most significant intercostal nerve contributions to the anterolateral abdominal wall arise from T12. Damage to the intercostal nerves will be minimal if the lombotomy incision is performed above the safe line between the tip of the 12th rib and the umbilicus.

Rare coincidence of congenital short and annular pancreas with gallbladder agenesis and splenic malrotation.

We present an adult patient with anomalies of congenital short and annular pancreas, gallbladder agenesis and splenic malrotation. The patient presented with symptoms typical of the two pancreatic malformations and is the only reported case with these malformations reported in the English imaging literature.

Alveolar hydatid disease of the liver: brief review and spectrum of adjacent organ invasion.

The purpose of this study is to show the spectrum of adjacent organ invasion and to make a brief review of hepatic alveolar hydatid disease (AHD), using CT and MR imaging. We retrospectively reviewed CT and MR images of three patients with various adjacent organ invasions surgically and histologically proven to be AHD. Local invasion to right kidney and adrenal, right hemidiaphragm and lung were detected in one patient, right adrenal in another patient and gall bladder, duodenum, gastric wall and pancreas invasion in the other. AHD may rarely extend to the gall bladder, stomach, duodenum, pancreas, right adrenal and kidney, diaphragm, pleura and lung. The extension of the disease outside the liver is usually encountered in patients with large, peripherally located masses in the advanced stage of the disease.

Bacterial brain abscesses: prognostic value of an imaging severity index.

AIM: To assess the correlation between imaging findings [computed tomography (CT) or magnetic resonance imaging (MRI)] and neurological status before and after the treatment of bacterial brain abscesses. MATERIALS AND METHODS: CT and MRI images of 96 patients with brain abscesses were retrospectively evaluated in terms of the number, location and size of lesions, and the presence and extent of perilesional oedema and midline shift. An imaging severity index (ISI) based on these different radiological parameters was calculated. Initial Glasgow Coma Scale (GCS) scores and ISI were assessed and the prognostic value of these two indices was calculated. The Pearson correlation test, Mann-Whitney test, Chi-square test, receiver-operating characteristic (ROC) analysis, together with comparison of ROC analyses and Fisher's exact test were used. RESULTS: There was a negative correlation between ISI and the initial GCS values: ISI increased as the GCS score decreased, indicating an inverse relationship (r=-0.51, p<0.0001). There was a significant difference between the ISI and GCS scores of patients with an adverse event compared with patients with good recovery. Outcome was significantly worse in patients with initial ISI over the calculated cut-off values of 8 points or GCS scores under the cut-off value of 13 points. CONCLUSION: ISI is a useful prognostic indicator for bacterial brain abscess patients and correlates strongly with the patient outcome for all parameters studied. ISI score had a better prognostic value than GCS.

Marking of nonpalpable breast lesions using a custom carbon suspension.

PURPOSE: To review results of carbon marking in non-palpable breast lesions using a different type of a carbon suspension containing 0.5% polyoxyethylene sorbitan monooleate (PSM). MATERIAL AND METHODS: Sixteen lesions of 16 patients with indeterminate or suspicious mammographic findings underwent stereotaxic carbon marking. With the aid of tracing of the carbon stains surgery was then performed. RESULTS: Pathology revealed malignancy in 26% of the cases and the missed rate by carbon marking was 6% (1 lesion). Carbon marking is an easier application compared to hook-wire systems in localizing occult breast lesions. PSM added to a 4% carbon suspension results in a more homogeneous suspension, prevents early precipitation and eases injection. Animal studies have shown that no local or peripheral tissue reactions are elicited with either pure PSM or in a mixture with carbon. CONCLUSION: We recommend addition of PSM to carbon marking suspensions.

An unusual localization of massive portasystemic collaterals: CT angiographic demonstration.

This article presents a patient with portal hypertension in whom an unusual localization for portosystemic collaterals have incidentally been found. Upper abdominal sonography revealed tubular structures filling the whole perirenal and partially the perihepatic area, and their venous nature was demonstrated with duplex Doppler sonography. Spiral CT angiography identified the right-sided retroperitoneal location and mesenteric-lumbar route of the collaterals. Upper gastrointestinal endoscopy with antral biopsy and percutaneous liver biopsy were performed. Laboratory results and specimen evaluation revealed chronic active hepatitis due to hepatitis-B infection. Attention is drawn to the abnormal location of these vessels, together with the noninvasive nature and competence of CT angiography in demonstrating vascular pathologies.

Three-dimensional anatomy of the pelvis in bladder exstrophy: description of bone pathology by using three-dimensional computed tomography and its clinical relevance.

The alterations in pelvic structure that occur in bladder exstrophy were evaluated in six children (one girl and five boys) by using three-dimensional computed tomography (3D-CT). The length and angle of anterior and posterior segments and the slanting angle of iliac wings were measured. 3D-CT scans of the pelvis of four patients with a normal pelvis were obtained to serve as controls. Both anterior and posterior segments were abnormally rotated externally in patients with bladder exstrophy. Whereas the length of the posterior segment is normal, the length of the anterior segment is significantly shorter, and the iliac wings projected more inward than those in the age-matched control subjects.