Robotic-Assisted Inferior Vena Cava Filter Retrieval.

Although anticoagulation remains the mainstay of therapy for patients with venous thromboembolism, guidelines recommend the use of inferior vena cava (IVC) filters in those who fail anticoagulation or have contraindications to its use. Short-term use of filters has proven effective in reducing the rate of pulmonary embolism. However, their extended use is associated with a variety of complications such as thrombosis, filter migration, or caval perforation, thus making a case for timely filter retrieval. This is the case of a 68-year-old female with a history of chronic oral anticoagulation use for multiple deep venous thrombi (DVT) and pulmonary emboli (PE) who required cervical and thoracic spinal intervention for spondylosis and foramina stenosis. Given her increased risk of recurrent DVT and PE perioperatively, we elected to place a Cook Celect™ IVC filter (Cook Medical, Bloomington, IN) after oral anticoagulation was stopped for the procedure. Her treatment course was prolonged due to wound-healing complications. We elected to use the Magellan Robotic Catheter System (Hansen Medical, Mountain View, CA) for filter retrieval when she presented 6 months later with caval perforation from the filter struts. With its ease of use, superior mechanical stability, and maneuverability, robot-assisted IVC filter retrieval may be a safer and more reliable substitute for traditional navigation techniques when presented with challenging filter retrievals.

Treatment of massive acetabular bone loss and pelvic discontinuity with a custom triflange component and ilio-sacral fixation based on preoperative CT templating. A report of 2 cases.

Revision rates for total hip arthroplasty are increasing and pelvic discontinuity is estimated to be present in 1% to 5% (Berry). Discontinuity is defined as a separation of the cephalad portion of the pelvis from the caudad portion (AAOS Type IV defects). This results from bone loss secondary to osteolysis, infection, fracture, or mechanical loosening. The goals of revision surgery in this setting are to obtain secure fixation of the acetabular component with or without union of the discontinuity. Many methods exist for treating this problem. Results with allograft and cage fixation have generally been poor (Berry, Hansen). More favourable outcomes have been reported using either a cup cage technique or custom triflange (Gross, Christie). The custom Triflange component is designed based on preoperative imaging with CT scan to manufacture a custom titanium implant to address the patient's specific bone loss pattern and obtain secure fixation in the ilium, pubis, and ischium. However, we have encountered cases of acetabular discontinuity with massive pelvic bone loss in which bone stock in the ilium was insufficient to provide support for proximal fixation of a conventional custom triflange component. Currently in the trauma patient population posterior pelvic ring disruptions are being treated with ilio-sacral screw fixation. The sacrum provides a source of secure bony fixation for these injuries. We report on 2 patients with pelvic discontinuity and massive bone loss using a technique to obtain proximal fixation of a custom triflange component into the sacrum.

The use of the Hansen-Street intramedullary nail in midshaft fractures of the femur.

A retrospective study was conducted on 75 consecutive femoral midshaft fractures treated with intramedullary nailing using the solid-diamond-shape Hansen-Street nail with an open technique. The average age of patients was 32.5 years. Road accidents accounted for 43 cases. The average operative time was 40 minutes. There were two systemic complications. No infection occurred. Fifty-six cases could be gathered for this study, with an average follow-up of 5 years; 19 were followed for at least 6 months. At 4 months, all the fractures were united except one. The average time to sound bony union was 4 months. There was no residual deformity in varus-valgus or in the sagittal plane. Malrotation was rare and did not exceed 5 degrees. Shortening of 2 cm was found in 3 patients where the fracture was comminuted. All followed patients returned to regular daily function. The use of the Hansen-Street nail in an open procedure is an accurate method for anatomic reduction. As opposed to closed techniques, the procedure proved in our hands to be simple and quick, without undue exposure to radiation of the surgical team, and without such other complications as nerve complications due to traction. The procedure with this device is indicated for mid-third fractures of the femoral shaft only.

Rehabilitation engineering and leprosy in Nepal: a personal view.

Green Pastures Hospital is a specialist leprosy hospital in Pokhara, Nepal. As part of its service it offers a range of appliances aimed to assist in the rehabilitation of patients. This paper outlines the different orthoses and prostheses made at the Orthopaedic Appliances Centre in the hospital, their various indications and some of the benefits and problems associated with their use. Specific reference is made to the requirements related to local conditions and customs. The terrain, communications, facilities and materials available in Nepal make the work of the few rehabilitation engineers in the country somewhat different from that of those in the West. Some of these differences are described, drawing out contrasts in technical requirements of appliances and in organizational structures in the field of rehabilitation in the UK and Nepal.

Early use of the Brooker-Wills interlocking intramedullary nail (BWIIN) for femoral shaft fractures in acute trauma patients.

During a 33-month period, 40 multiply injured patients underwent 43 Brooker-Wills interlocking intramedullary nailings (BWIIN) for femur fractures in the setting of a Level I trauma unit. There were 12 open fractures (28%), 66% of the closed fractures underwent BWIIN within the first 24 hours of injury, and 33 fractures (77%) had comminution of Winquist-Hansen Type II or greater, and either static or dynamic locking techniques were used in 38 (88%) of the cases. There were three intraoperative technical problems. The estimated blood loss and operative times were consistent with other reported series for interlocking nailing techniques. The average followup was 65 weeks. Only one fracture went on to nonunion. There were no problems with angulation or rotation. One patient had 1.5 cm of shortening. There were four major (9%) and four minor (9%) complications. Rod removal was successful in 17 of 18 cases. Mechanical failure (deformation and/or fracture) of the proximal end of the rod was found in four (22%) of the extracted nails and caused failure of removal in one. The Brooker-Wills nail is a versatile device which can be used to treat complex fractures of the entire femoral shaft in acutely injured patients.

Observations on peg-prosthesis in leprosy.

Three leprosy patients with peg-prosthesis were studied in detail. It was found that there were several disadvantages of this type of prosthesis. However, its application in a rural situation has some merits, and with some suggested modifications, it could be adopted with better results.

Aseptic loosening of the Monk hip prosthesis.

In a preliminary report concerning 104 Monk arthroplasties satisfactory results were found within an observation time of 1.6 years (Hansen & Rechnagel 1977). However an early tendency for aseptic loosening was recorded. At a follow-up of the same patients after 5 years it was found that 17 patients, with their primary prostheses in place, had died. Of the remaining 86 prostheses not less than 50% had been removed because of loosening causing symptoms. Furthermore at re-examination of 39 patients with 43 of the primary prostheses still in situ radiological and clinical evidence of progressive aseptic loosening was present. The aetiology of the loosening is discussed and it is suggested that wear of the polyethylene cap plays an important role. It is concluded that the "soft top" Monk prosthesis cannot be recommended for replacement arthroplasty of the hip.