EUS-guided cyanoacrylate injection into the perforating vein versus direct endoscopic injection in the treatment of gastric varices.

Background and study aims Endoscopic injection of gastric varices (GVs) using cyanoacrylate (CYA) is associated with significant adverse events (AEs). We aimed to compare the efficacy and safety of endoscopic ultrasound (EUS)-guided CYA injection into the perforating vein versus direct endoscopic injection (DEI) of CYA in treatment of high-risk GVs. Patients and methods This was a randomized controlled trial that included 52 patients with high-risk GVs. Group A underwent EUS-guided injection into the perforator vein and Group B underwent DEI of 1 mL CYA. Endoscopic examination and Doppler EUS were repeated after 3 months to confirm eradication. Obliteration by Doppler EUS was considered by absence of Doppler flow within the varix. Repeated injection was performed in the absence of obliteration. Doppler EUS examination was repeated at 3 and 6 months after each injection. Results Forty-three patients including 27 males and 16 females with mean age 57 years completed the study. Variceal obliteration was achieved during the index session after 3 months in eight of 21 (38.1 %) in group B compared to 17 of 22 (77.2 %) in group A ( P  = 0.014). There was a significant difference in the amount of CYA needed to achieve obliteration in group B compared to group A (2 vs.1 mL, P  = 0.027). There was no statistically significant difference in the overall AE rate between group A and group B (4.5 % vs. 14.3 %, P  = 0.345). Conclusions EUS-guided CYA injection into the perforating veins achieved less amount of CYA, fewer number of sessions to obliteration, and similar overall AE rates in the treatment of high-risk GVs compared to DEI.

Preoperative prediction of failure following two-stage revision for knee prosthetic joint infections.

While two-stage revision is the gold standard for treatment of knee prosthetic joint infection (PJI), it is not without risk. The purpose of this study was to develop a tool to preoperatively predict the probability that a two-stage revision would fail to eradicate knee PJI. 3,809 surgical cases were retrospectively reviewed and data were collected from 314 charts. Overall, 105 (33.4%) cases failed to eradicate PJI using this procedure. Univariate analysis identified multiple variables independently associated with reinfection. Logistic regression was used to generate a model (bootstrap-corrected concordance index of 0.773) predicting failure of infection eradication. Preoperative knowledge of a high probability of failure may improve risk assessment, lead to more aggressive management, and allow for time to consider alternative therapies.

Can TKA be avoided? Alternate strategies.

In the properly selected patient, alternative options to total knee arthroplasty exist for the surgical treatment of knee joint disease. These procedures involve reestablishing healthy cartilage (i.e., bone marrow stimulation, grafting, autologous chondrocyte implantation), mechanical axis correction (i.e., osteotomy), and/or replacing pathologic knee compartments with prosthetic devices (i.e., unicompartmental and bicompartmental knee arthroplasty). Treatment modality selection varies based on a number of factors, including but not limited to age, activity level, treatment history, and lesion size, location, severity, and etiology. Reestablishing healthy cartilage in pathologic knees is dependent on the recipient's capacity and propensity to heal and regenerate new cartilage. Therefore, this technique is typically conducted in young patients, with small- to medium-sized focal chondral or osteochondral lesions. Osteotomy, unicompartmental knee arthroplasty, and bicompartmental knee arthroplasty do not have the same restrictions and are used for patients with larger, isolated knee lesions. This article reviews indications, efficacy, and advancements of existing surgical techniques for the repair or restoration of knee lesion injuries.

The preoperative prediction of success following irrigation and debridement with polyethylene exchange for hip and knee prosthetic joint infections.

Although the criterion standard for the treatment of prosthetic joint infections (PJIs) is 2-stage revision with interim placement of an antibiotic-loaded spacer, irrigation and debridement with polyethylene exchange offer advantages such as fewer surgeries, reduced potential for intraoperative complications, and lower direct costs. The purpose of this study was to develop a tool to preoperatively predict the probability of successful infection eradication following irrigation and debridement with polyethylene exchange for hip or knee PJIs. A total of 10,411 surgical cases were retrospectively reviewed, and data were collected from 309 charts. Overall, 149 (48.2%) cases failed to eradicate the infection following irrigation and debridement with polyethylene exchange. Univariate analysis identified multiple variables independently associated with reinfection including duration of symptoms, preoperative inflammatory markers, and infecting organism. Logistic regression was used to generate a model (bootstrap-corrected concordance index of 0.645) to predict successful eradication of the infection, which was the basis for a nomogram. Using commonly obtained preoperative variables, the nomogram can be used to predict the probability of infection-free survival at 1, 2, 3, 4, and 5 years. Preoperative knowledge of the probability that a treatment strategy will eradicate a patient's PJI may improve risk assessment.

Tibiofibular synostosis procedure in the management of complex tibia fractures.

Complex tibia nonunions and defects caused by tumor, trauma, and congenital abnormality are difficult to treat. The tibiofibular synostosis procedure is a treatment option. Fifteen patients with complex diaphyseal tibia fractures (4 segmental, 11 comminuted; 10 open, 5 closed) were managed with this procedure. Mean time between injury and procedure was 20.3 weeks. Mean healing time was 16 weeks (acceptable); 14 of 15 cases showed healing by final follow-up (36 months). At final follow-up, each patient's knee range of motion (ROM) and ankle ROM were acceptable. Knee ROM varied from full extension to 150 degrees of flexion for 13 patients and from full extension to 120 degrees of flexion for 2 patients. Ankle dorsiflexion ranged from 0 degrees to 40 degrees for 10 patients, from 0 degrees to 30 degrees for 3 patients, and from 0 degrees to 20 degrees for 2 patients. There were no radiographic arthritic changes in any case. The tibiofibular synostosis procedure is effective in treating complex nonunions and defects.

Open reduction and internal fixation of 117 tibial plateau fractures.

This retrospective study evaluated the surgical management of 117 tibial plateau fractures treated between 1990 and 1998. At last patient follow-up, results were rated good to excellent in 94, fair in 13, and poor in 10 cases. Follow-up radiographs showed degenerative changes in the lateral compartment in 29 cases. Other complications included five wound infections, two deep venous thromboses, five delayed unions, and three nonunions. Operative treatment of tibial plateau fractures is recommended as it enables better alignment, meniscal access, and other soft-tissue injury repair.

Intramedullary fibular allograft and nail for treatment of femoral shaft nonunion.

We present a difficult case of hypertrophic nonunion associated with a large cavity in the lower third of the femur. The cavity had been created by a windshield-wiper effect after failure of fixation with a Schneider intramedullary rod in a patient weighing 450 pounds. Treatment consisted of exchanging the Schneider nail with a larger-diame-ter interlocking nail and using the intramedullary fibular allograft to fill the cavity. The fracture healed 4 months after the procedure. At 5-year follow-up, the patient had no complaint, and plain radiographs showed obliteration of the large cavity in the distal femur. Intramedullary fibular graft technique can be used as an adjunct to use of an intramedullary nail when the distal femur contains a large cavity or when the intramedullary rod does not provide adequate fixation stability.