Comparative systematic review of the open dislocation, mini-open, and arthroscopic surgeries for femoroacetabular impingement.

PURPOSE: To analyze the current approaches to the surgical management of symptomatic femoroacetabular impingement (FAI). METHODS: Thirteen relevant queries were used in four search engines (PubMed, EMBASE, Ovid, and the Cochrane Review) with a resultant 5,856 articles. Eighteen peer-reviewed treatment outcome studies met the inclusion criteria with minimum 1-year follow-up of the surgical treatment of skeletal pathoanatomy and associated chondrolabral pathology in skeletally mature patients with FAI. RESULTS: There were 6 open surgical dislocation, 4 mini-open, and 8 arthroscopic studies, all with Levels of Evidence III or IV. The only prospective studies were in the arthroscopic category. Outcome data were extracted and analyzed with respect to surgical efficacy, failure rates, and complications. CONCLUSIONS: The open dislocation, mini-open, and arthroscopic methods for treating symptomatic FAI are effective in improving pain and function in short-term to midterm studies and are relatively safe procedures. The historical gold standard of open dislocation surgery had a comparatively high major complication rate primarily because of trochanteric osteotomy-related issues. The mini-open method showed comparable efficacy but a significant incidence of iatrogenic injury to the lateral femoral cutaneous nerve in some studies. The arthroscopic method had surgical outcomes equal to or better than the other methods with a lower rate of major complications when performed by experienced surgeons.

Intraoperative ultrasound-fluoroscopy fusion can enhance prostate brachytherapy quality.

PURPOSE: To evaluate a transrectal ultrasound (TRUS)-fluoroscopy fusion-based intraoperative dosimetry system. METHOD AND MATERIALS: Twenty-five patients were treated for prostate cancer with Pd-103 implantation. After the execution of the treatment plan, two sets of TRUS images were collected using the longitudinal and axial transducers of a biplanar probe. Then, three fluoroscopic images were acquired at 0, -15 and +15 degrees . The three-dimensional locations of all implanted seeds were reconstructed from fluoroscopic images. A subset of the implanted seeds was manually identified in TRUS images and used as fiducial markers to perform TRUS-fluoroscopy fusion. To improve the implant quality, additional seeds were placed if adverse isodose patterns were identified during visual inspection. If additional seeds were placed, intraoperative dosimetry was repeated. Day 0 computed tomography-based dosimetry was compared with final intraoperative dosimetry to validate dosimetry achieved in the implant suite. RESULTS: An average of additional 4.0 seeds was implanted in 16 patients after initial intraoperative dose evaluation. Based on TRUS-fluoroscopy fusion-based dosimetry, the V100 improved from 86% to 93% (p = 0.005), whereas D90 increased from 94% to 109% (p = 0.011) with the guided additional seed implantation. No statistical difference was observed in V200 and V300 values. V100 and D90 values were 95 +/- 4% and 120 +/- 24%, respectively, based on the final intraoperative dosimetry evaluation, compared with 95 +/- 4% and 122 +/- 24%, respectively, based on Day 0 computed tomography-based dosimetry. CONCLUSIONS: Implantation of extra seeds based on TRUS-fluoroscopy fusion-based intraoperative dosimetry can improve the final V100 and D90 values with minimal increase in V200 and V300 values.

A prospective randomized comparison of stranded vs. loose 125I seeds for prostate brachytherapy.

PURPOSE: To compare seed loss and dosimetric parameters between stranded and loose 125I seeds (LS) for prostate brachytherapy. METHODS AND MATERIALS: Sixty-four patients with 1997 American Joint Commission on Cancer (AJCC) clinical stage T1c or T2a prostate carcinoma were prospectively randomized to brachytherapy (144Gy) with RAPID Strand 125I seeds (RS) vs. LS (Oncura, Plymouth Meeting, PA) The treatment plan for each patient was devised before randomization, and was not modified based on the randomization. Each patient underwent magnetic resonance, computed tomography, and plain film radiographs on the day of the implant (Day 0) and 30 days later (Day 30). RESULTS: Overall, 21 of 62 patients (30%) experienced seed loss. Seed loss occurred in 15 of 32 of LS patients (47%) vs. 6 of 30 RS patients (23%; p=0.053). Mean seed loss was 1.09 in the LS patient vs. 0.43 in RS patients (p=0.062). Eight LS patients (25%) lost multiple seeds, compared to 3 stranded patients (10%). Despite the lesser degree of seed loss in patients who received stranded seeds, they had a paradoxical trend toward lower V100 and D90 values. CONCLUSION: This prospective randomized trial showed a strong trend toward a decrease in postimplant seed loss with stranded seeds. Improved seed retention may be more advantageous in a setting of less generous periprostatic coverage. The lowered risk seed migration seen with stranded seeds would presumably also decrease the likelihood of lung or cardiac seed embolization.

Hierarchy of simulation models in predicting structure and energetics of the Src SH2 domain binding to tyrosyl phosphopeptides.

Structure and energetics of the Src Src Homology 2 (SH2) domain binding with the recognition phosphopeptide pYEEI and its mutants are studied by a hierarchical computational approach. The proposed structure prediction strategy includes equilibrium sampling of the peptide conformational space by simulated tempering dynamics with the simplified, knowledge-based energy function, followed by structural clustering of the resulting conformations and binding free energy evaluation of a single representative from each cluster, a cluster center. This protocol is robust in rapid screening of low-energy conformations and recovers the crystal structure of the pYEEI peptide. Thermodynamics of the peptide-SH2 domain binding is analyzed by computing the average energy contributions over conformations from the clusters, structurally similar to the predicted peptide bound structure. Using this approach, the binding thermodynamics for a panel of studied peptides is predicted in a better agreement with the experiment than previously suggested models. However, the overall correlation between computed and experimental binding affinity remains rather modest. The results of this study show that small differences in binding free energies between the Ala and Gly mutants of the pYEEI peptide are considerably more difficult to predict than the structure of the bound peptides, indicating that accurate computational prediction of binding affinities still remains a major methodological and technical challenge.

Prostate brachytherapy in obese patients.

PURPOSE: To identify and illustrate the potential problems with brachytherapy in obese patients. METHODS AND MATERIALS: Three patients with body mass index greater than 30 were treated with prostate brachytherapy. Transrectal ultrasound (TRUS) was performed using a 6.0-MHz Siemens Sonoline Prima ultrasound machine and a Barzell-Whitmore stepper unit. The patients' weight required use of an accessory table support. RESULTS: Once set up, there was ample room to maneuver, providing that the patient's legs were abducted fully. TRUS imaging of the prostate was unaffected by patients' obesity. The amount of periprostate adipose tissue visualized on TRUS appeared to be no different than that noted in nonobese patients. Similarly, there was no increased distance between the prostate and rectal surface, either on preimplant CT or transverse TRUS. To date, our experience is that the perineal skin to prostate distance was not so great that standard 20-cm applicator needles could not be used. For the 2 sub-350-pound patients who could be imaged on our CT scanner, postimplant target coverage (V100) was 88% and 95%. CONCLUSIONS: Standard TRUS and brachytherapy needles are sufficient to implant even the largest patients.

New technology review process: the laparoscopic adjustable gastric band.

The Interregional New Technologies Committee (INTC) is one evaluation route for new medical technologies or technologies with expanded indications within Kaiser Permanente (KP). The primary focus of the INTC is to consider all available published evidence on a particular technology, surgical technique, or implantable device for a specific clinical indication and provide a recommendation on the sufficiency of the evidence for determining net medical benefit to Permanente Medical Group leaders and Kaiser Foundation Health Plan management throughout KP Regions. This iterative process provides an objective, evidence-based assessment to inform decision making by physicians and support the most appropriate care for KP members. This overview illustrates the INTC process and how it supports clinical decision making using implantation of laparoscopic adjustable gastric bands (LAGBs) as an example. In February 2011, the US Food and Drug Administration (FDA) approved lowering the acceptable body mass index for the Lap-Band from 35 to 30 kg/m(2) for patients with at least one comorbid condition. It is difficult to find published studies on medical technologies that have been recently approved by the FDA. The manufacturer often submits clinical data to the FDA, but details are frequently not publicly available at the time of approval. The LAGB example demonstrates the complex issues addressed by the INTC, particularly when there is some evidence of short-term improvement in outcomes with a medical device but little if any confirmation of long-term safety or effectiveness.