Goff Septotomy Is a Safe and Effective Salvage Biliary Access Technique Following Failed Cannulation at ERCP.

BACKGROUND: Biliary cannulation is readily achieved in > 85% of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). When standard cannulation techniques fail, salvage techniques utilized include the needle knife precut, double wire technique, and Goff septotomy. METHODS: Records of patients undergoing ERCP from 2005 to 2016 were retrospectively examined using a prospectively maintained endoscopy database. Patients requiring salvage techniques for biliary access were analyzed together with a control sample of 20 randomly selected index ERCPs per study year. Demographic and clinical variables including indications for ERCP, cannulation rates, and adverse events were collected. RESULTS: A total of 7984 patients underwent ERCP from 2005 to 2016. Biliary cannulation was successful in 94.9% of control index ERCPs, 87.2% of patients who underwent Goff septotomy (significantly higher than for all other salvage techniques, p ≤ 0.001), 74.5% of patients in the double wire group and 69.6% of patients in the needle knife precut group. Adverse event rates were similar in the Goff septotomy (4.1%) and index ERCP control sample (2.7%) groups. Adverse events were significantly higher in the needle knife group (27.2%) compared with all other groups. CONCLUSIONS: This study represents the largest study to date of Goff septotomy as a salvage biliary access technique. It confirms the efficacy of Goff septotomy and indicates a safety profile similar to standard cannulation techniques and superior to the widely employed needle knife precut sphincterotomy. Our safety and efficacy data suggest that Goff septotomy should be considered as the primary salvage approach for failed cannulation, with needle knife sphincterotomy restricted to Goff septotomy failures.

Stapler Use in Salvage Total Laryngectomy: A Useful Tool?

OBJECTIVES/HYPOTHESIS: To analyze stapler benefits in salvage total laryngectomy in terms of surgical time, hospitalization length, oral feeding time, and occurrence of pharyngocutaneous fistula, and to evaluate risk factors for its onset. STUDY DESIGN: Retrospective analysis. METHODS: One hundred fourteen patients affected by endolaryngeal squamous cell carcinoma who underwent salvage total laryngectomy following primary treatment failure were reviewed. We divided patients into two groups based on type of pharyngeal suture performed: mechanical suture with stapler (group A) and manual suture (group B). These two groups were compared for surgical time, start of oral feeding, hospitalization length, surgical margins and pharyngocutaneous fistula incidence considering its relationship with diabetes mellitus, nutritional status, primary treatment, and neck dissection. RESULTS: In group A and group B, oral feeding restarting time was 15 ± 9.33 versus 20.03 ± 13.81 days, hospitalization was 17.63 ± 10.08 versus 23.72 ± 14.29 days, and surgery lasted 268.39 ± 76.93 versus 294.26 ± 140.58 minutes, respectively (P < .05). Surgical margins resulted infiltrated in two patients (4.3%) in group A and 12 patients in group B (17.6%) (P = .03). Twenty-one patients (18.4%) presented with pharyngocutanoeus fistula. In group A and group B the incidence of fistula was 15.2% and 20.6%, respectively (P = .468). Fistula occurred in 7 of 18 diabetic patients (38.9%) and 14 of 96 (14.6%) nondiabetic patients (P = .015). Nineteen fistulas (90.5%) occurred in patients who had undergone previous radiation treatment (P = .013). CONCLUSIONS: Using a stapler shortened operative time and hospitalization, while also providing a faster restart of oral feeding. Moreover, mechanical pharyngeal suture seems to decrease fistula rate even though its prevention role in salvage laryngectomy should be confirmed by further studies. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E473-E478, 2021.

Use of longer sized screws is a salvage method for broken pedicles in osteoporotic vertebrae.

Screw loosening due to broken pedicles is a common complication resulting from the insertion of screws either with inadequate diameters or into an osteoporotic pedicle. In this novel in vitro study, we tried to clarify the contribution of the pedicle to screw fixation and subsequent salvage strategies using longer or larger-diameter screws in broken pedicles. Sixty L4 fresh-frozen lumbar vertebrae harvested from mature pigs were designed as the normal-density group (n = 30) and decalcified as the osteoporosis group (n = 30). Three modalities were randomly assigned as intact pedicle (n = 30), semi-pedicle (n = 15), and non-pedicle (n = 15) in each group. Three sizes of polyaxial screws (diameter × length of 6.0 mm × 45 mm, 6.0 mm × 50 mm, and 6.5 mm × 45 mm) over five trials were used in each modality. The associations between bone density, pedicle modality and screw pullout strength were analyzed. After decalcification for 4 weeks, the area bone mineral density decreased to approximately 56% (p < 0.05) of the normal-density group, which was assigned as the osteoporosis group. An appropriate screw trajectory and insertional depth were confirmed using X-ray imaging prior to pullout testing in both groups. The pullout forces of larger-diameter screws (6.5 mm × 45 mm) and longer screws (6.0 mm × 50 mm) were significantly higher (p < 0.05) in the semi- and non-pedicle modalities in the normal-density group, whereas only longer screws (6.0 mm × 50 mm) had a significantly higher (p < 0.05) pullout force in the non-pedicle modalities in the osteoporosis group. The pedicle plays an important role in both the normal bone density group and the osteoporosis group, as revealed by analyzing the pullout force percentage contributed by the pedicle. Use of a longer screw would be a way to salvage a broken pedicle of osteoporotic vertebra.

Chemosaturation with percutaneous hepatic perfusion is effective in patients with ocular melanoma and cholangiocarcinoma.

BACKGROUND: Chemosaturation with percutaneous hepatic perfusion (CS-PHP; Hepatic CHEMOSAT® Delivery System; Delcath Systems Inc, USA) is a novel interventional procedure, which delivers high doses of melphalan directly to the liver in patients with liver tumors while limiting systemic toxicity through hemofiltration of the hepatic venous blood. We have previously shown promising efficacy for patients with ocular melanoma (OM) and cholangiocarcinoma (CCA) within our single-center and multi-center experiences. The aim of this study was to analyze the safety and efficacy of CS-PHP after 141 treatments at Hannover Medical School, Germany. METHODS: Overall response rates (ORR) were assessed according to Response Evaluation Criteria In Solid Tumors (RECIST1.1). Median Overall survival (mOS), median progression-free survival (mPFS), and median hepatic PFS (mhPFS) were analyzed using the Kaplan-Meier estimation. RESULTS: Overall, 60 patients were treated with CS-PHP in the salvage setting from October 2014 until January 2019 at Hannover Medical School with a total of 141 procedures. Half of the patients were patients with hepatic metastases of ocular melanoma (OM) (n = 30), 14 patients had CCA (23.3%), 6 patients had hepatocellular carcinoma (10%), and 10 patients were treated for other secondary liver malignancies (16.7%). In total, ORR and disease stabilization rate were 33.3% and 70.3% (n = 25), respectively. ORR was highest for patients with OM (42.3%), followed by patients with CCA (30.8%). Independent response-associated factors were normal levels of lactate dehydrogenase (odds ratio (OR) 13.7; p = 0.015) and diagnosis with OM (OR 9.3; p = 0.028). Overall, mOS was 9 months, mPFS was 4 months, and mhPFS was 5 months. Patients with OM had the longest mOS, mPFS, and mhPFS with 12, 6, and 6 months, respectively. Adverse events included most frequently significant, but transient, hematologic toxicities (80% of grade 3/4 thrombopenia), less frequently hepatic injury up to liver failure (3.3%) and cardiovascular events including two cases of ischemic insults (5%). CONCLUSION: Salvage treatment with CS-PHP is safe and effective particularly in patients OM and CCA. Careful attention should be paid to possible, serious hepatic, and cardiovascular complications.

Secondary Salvage of the Unsatisfactory Microtia Reconstruction.

BACKGROUND: Because auricular reconstruction is a complex and relatively uncommon procedure, there are many patients that have had disappointing reconstructions. This study describes the authors' large experience with secondary procedures in patients with unsatisfactory or failed initial ear reconstruction. METHODS: A prospectively maintained database of all consecutive patients who underwent secondary total ear reconstruction from March of 1991 to December of 2017 was reviewed. Demographic data and outcomes were assessed. Patients with acquired absence of the ear were not included. RESULTS: There were 144 microtia patients that met the inclusion criteria. Patient age at the time of the secondary reconstruction ranged from 3 to 59 years. Follow-up duration ranged from 1 to 21 years. Primary reconstruction was performed with rib cartilage in 91 patients, porous polyethylene implant in 47 patients, prosthesis in four patients, and irradiated cadaver rib cartilage in two patients. All secondary reconstructions were performed with porous polyethylene implants. The alloplastic framework was covered with a temporoparietal fascia flap in 76 patients, an occipital fascia flap in 64 patients, and a free fascia flap in four patients (two radial forearm flaps in the same patient, one contralateral temporoparietal fascia flap, and one lateral arm flap). Fourteen patients (10 percent) had complications requiring revision surgery. Secondary surgery was successful in all but one patient. CONCLUSIONS: These data represent the largest series of secondary total ear reconstructions. The use of a porous polyethylene implant is an ideal method for these patients because of its minimal morbidity and relatively low complication rate. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Follow-Up Study: One-Step Salvage of Infected Prosthetic Breast Reconstructions Using Antibiotic-Impregnated Polymethylmethacrylate Plates and Concurrent Tissue Expander Exchange.

BACKGROUND: Periprosthetic infections represent major complications in breast reconstruction, frequently leading to expander-implant loss. No consensus regarding a management algorithm for attempted salvage currently exists. This study assessed outcomes of the authors' salvage protocol using an antibiotic-impregnated polymethylmethacrylate implant with expander device exchange. METHODS: A retrospective chart review identified infected implant-based breast reconstruction cases treated between 2009 and 2017. Of 626 cases initially identified, a total of 62 cases had severe prosthetic infections, and underwent either prosthetic salvage (n = 45) or immediate explantation (n = 17). All the prosthetic salvage patients received intravenous antibiotics followed by surgical débridement, insertion of polymethylmethacrylate plates, device exchange, and postoperative antibiotics. After clinical resolution of infection, tissue expansion was performed, with the polymethylmethacrylate plates remaining in situ until exchanged for permanent implants. RESULTS: The authors' study demonstrated a primary infection clearance rate of 82.2 percent (n = 37). Compared to the traditional explantation group, a significantly higher percentage of the salvage patients completed final reconstruction (84.4 percent versus 35.3 percent; p < 0.001). Fewer patients abandoned reconstruction efforts after infection clearance (2.2 percent versus 58.8 percent; p < 0.001). The majority of cases (78.8 percent) that succeeded the salvage protocol ultimately received implant-based reconstruction; 62.5 percent that failed the salvage protocol still went on to receive autologous tissue reconstruction. CONCLUSIONS: Sustained local antibiotic delivery using polymethylmethacrylate implants and expander device exchange can successfully salvage an infected breast expander/implant. Compared with the traditional explantation approach, more patients complete final reconstruction. Other benefits include preserved skin envelope integrity and possibly improved long-term aesthetic outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Long-Term Results and Reconstruction Failure in Patients Receiving Postmastectomy Radiation Therapy with a Temporary Expander or Permanent Implant in Place.

BACKGROUND: This study investigated the risk of reconstruction failure after mastectomy, immediate breast reconstruction, and radiotherapy to either a temporary tissue expander or permanent implant. METHODS: Records of women treated at a single institution between June of 1997 and December of 2011 were reviewed. Two patient groups were identified based on type of immediate breast reconstruction: tissue expander followed by exchange with a permanent implant and permanent implant. The study endpoint was rate of reconstruction failure, defined as a replacement, loss of the implant, or conversion to flap. RESULTS: The tissue expander/permanent implant and the permanent implant groups consisted of 63 and 75 patients, respectively. The groups were well balanced for clinical and treatment characteristics. With a median follow-up of 116 months, eight implant losses, 50 implant replacements, and four flap conversions were recorded. Reconstruction failure occurred in 22 of 63 patients in the expander/implant group and in 40 of 75 patients in the permanent implant group. A traditional proportional hazards model showed a higher risk of reconstruction failure for the expander/implant group (hazard ratio, 2.01) and a significantly shorter time to reconstruction failure compared with the permanent implant group (109.2 months versus 157.7 months; p = 0.03); however, according to a competing risk model, the between-groups cumulative incidences were not significantly different (hazard ratio, 1.09). CONCLUSIONS: Radiotherapy to either a tissue expander or a permanent implant presented a fairly large risk of reconstruction failure over time. The expander/implant group was not more likely to develop reconstruction failure compared to permanent implant group, but the timing of onset was shorter. More complex techniques should be investigated to lower the risk of reconstruction failure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Utility of Low-Profile Visualized Intraluminal Support Junior Stent as a Rescue Therapy for Treating Ruptured Intracranial Aneurysms During Complicated Coil Embolization.

BACKGROUND: Coil protrusion occasionally occurs during embolization and can lead to thromboembolic complications. We aimed to evaluate the efficacy of rescue stenting procedures with a low-profile stent system (LVIS Jr.) for treating ruptured intracranial aneurysms during complicated coil embolization. METHODS: We performed a retrospective review to identify patients who had subarachnoid hemorrhage and were treated with LVIS Jr. stent rescue therapy. We enrolled 15 patients with intracranial aneurysms and evaluated the technical success and immediate postprocedural clinical and angiographic outcomes. RESULTS: All 15 patients underwent successful rescue-stent treatment, and no thrombotic or hemorrhagic complications occurred. Immediate postprocedural angiography revealed complete aneurysm occlusion in 40% (6/15) of the patients, whereas 60% (9) of the patients had a residual neck. Among the 12 patients who underwent follow-up angiography, 10 (83.3%) patients had complete aneurysm occlusion, 1 (8.3%) had a residual neck, and 1 (8.3%) showed an increase in the filling status of the aneurysm. There were no thrombotic complications during the follow-up period. CONCLUSIONS: Our findings indicate that LVIS Jr. stent rescue therapy is clinically useful for handling coil protrusion during the embolization of ruptured intracranial aneurysms.

Short Term Success of Treatments to Salvage Thrombosed or Failing Synthetic Arteriovenous Grafts in End Stage Renal Disease: A Systematic Review and Network Meta-Analysis of Randomised Controlled Trials.

OBJECTIVE: There is currently uncertainty regarding the ideal treatment to salvage thrombosed or failing synthetic arteriovenous grafts (AVGs) in patients with end stage renal disease. Therefore, a systematic review up to December 2018 and network meta-analysis of randomised control trials (RCTs) that compared three month failure risk of available treatments was carried out. METHODS: Medline, Scopus, Embase, and the Cochrane Library were the data sources. Pairwise meta-analyses were based on random effects models. Network meta-analysis was conducted within a frequentist framework with a multivariable random effects approach to model treatment effects across studies. The metric of choice was the odds ratio (OR) along with the associated 95% confidence interval (CI). RESULTS: Sixteen two arm RCTs were included involving 2011 patients who were randomised to six different treatments (plain balloon angioplasty, open surgical repair, stents, stent grafts, drug eluting balloons (DEBs), and cutting balloons). The network of RCTs had a star like geometry with plain balloon angioplasty being the common comparator. There were no significant differences between treatments with regards to risk of failure at three months with the exception of stent graft use that significantly reduced the risk of failure compared with plain balloon angioplasty (OR 0.53, 95% CI 0.34-0.84). Based on surface under the cumulative ranking curve (SUCRA) values, the best interventions to salvage thrombosed or failing AVGs were DEB and stent grafts. CONCLUSIONS: Stent graft seems to perform better than plain balloon angioplasty in terms of saving thrombosed or failing AVGs. However, this network meta-analysis was limited by the lack of closed loops and thus unable to assess consistency between direct and indirect evidence. The efficacy of DEBs as a promising treatment deserves further investigation and new RCTs are required.

Proof of concept study using a modified Politzer inflation device as a rescue modality for treating Eustachian tube dysfunction during hyperbaric oxygen treatment in a multiplace (Class A) chamber.

Introduction: Eustachian tube dysfunction (ETD) and middle ear barotrauma (MEB) are the most common adverse effects of hyperbaric oxygen (HBO2) treatments. Patients practice equalization maneuvers to prevent ETD and MEB prior to hyperbaric exposure. Some patients are still unable to equalize middle ear pressure. This ETD results in undesirable consequences, including barotrauma, treatment with medications or surgical myringotomy with tube placement and interruption of HBO2. When additional medications and myringotomy are employed, they are associated with additional complications. Methods: A device known as the Ear Popper® has been reported to reduce complications from serous otitis media and reduce the need for surgical interventions (myringotomy). Patients unable to equalize middle ear pressure during initial compression in the hyperbaric chamber were allowed to use the device for rescue. All hyperbaric treatments were compressed using a United States Navy TT9, or a 45-fsw hyperbaric treatment schedule. Patients with persistent ETD and the inability to equalize middle ear pressure were given the Ear Popper upon consideration of terminating their treatment. Results: The Ear Popper allowed all patients to successfully equalize middle ear pressure and complete their treatments. Conclusion: This study substantiates the use of this device to assist in allowing pressurization of the middle ear space in patients otherwise unable to achieve equalization of middle ear pressure during HBO2 treatment in a multiplace chamber.

Systematic review of endoluminal vacuum-assisted therapy as salvage treatment for rectal anastomotic leakage.

Background: Endoluminal vacuum-assisted therapy (EVT) has been introduced recently to treat colorectal anastomotic leakage. The aim of this study was to evaluate the safety and efficacy of EVT in the treatment of anastomotic leakage and rectal stump insufficiency after Hartmann's procedure. Methods: A systematic search of MEDLINE, Scopus and Cochrane databases was performed using search terms related to EVT and anastomotic leakage or rectal stump insufficiency in line with the PRISMA checklist. Observational studies, RCTs and case series studies published to July 2017 were included. Primary outcomes of the review were the success of EVT, defined as complete or partial healing of the anastomotic defect and associated cavity, and the rate of stoma reversal after EVT. Secondary outcomes included the duration of treatment to complete healing, complications of treatment and the need for further intervention. A meta-analysis was conducted. The potential effect of clinical confounders on the failure of EVT was investigated using the random-effects meta-regression model. Results: Of 476 articles identified, 17 studies reporting on 276 patients were ultimately included. The weighted mean rate of success was 85·3 (95 per cent c.i. 80·1 to 90·5) per cent, with a median duration from inception of EVT to complete healing of 47 (range 40-105) days. The weighted mean rate of stoma reversal across the studies was 75·9 (64·6 to 87·2) per cent. Twenty-five patients (9·1 per cent) required additional interventions after EVT. Thirty-eight patients (13·8 per cent) developed complications. The weighted mean complication rate across the studies was 11·1 (6·0 to 16·2) per cent. Variables significantly associated with failure included preoperative radiotherapy, absence of diverting stoma, complications and male sex. Conclusion: EVT is associated with a high rate of complete healing of anastomotic leakage and stoma reversal. It is an effective option in appropriately selected patients with anastomotic leakage.

Stentriever salvage after failed manual aspiration thrombectomy.

INTRODUCTION: Manual aspiration thrombectomy (MAT) and stent retriever mediated aspiration thrombectomy (SMAT) are well described reperfusion strategies for large vessel occlusions. This study aims to identify predictors of successful crossover to SMAT after failed first pass MAT. METHODS: Prospectively collected data for patients with acute large vessel occlusions undergoing thrombectomy over a 23 month period at a comprehensive stroke center were reviewed. The primary outcome was successful removal of the index clot with resultant Thrombolysis in Cerebral Infarction 2b or greater reperfusion at any point after a failed initial MAT attempt, and multivariate logistic regression analyses were performed to determine predictors of successful crossover to SMAT. RESULTS: Of 433 large vessel thrombectomies, 319 underwent first pass MAT, and 113 patients required a repeated pass for the index thrombus. Second pass MAT was performed in 77% of cases and was successful in 54%; second pass SMAT was performed in 23% of cases and was successful in 73% (P=0.11). Third pass MAT was employed in 45% of cases and was successful in 43% while SMAT was performed in 55% of cases and was successful in 77% (P=0.03). Overall, 12% of patients undergoing MAT on the first pass crossed over to successful SMAT. Predictors of successful crossover were internal carotid artery (ICA) location and higher presenting National Institutes of Health Stroke Scale (NIHSS) score. CONCLUSION: After failed first pass MAT, subsequent passes with SMAT had higher rates of successful index clot removal; patients with a higher initial NIHSS score and ICA clot location should be considered for early crossover or even initial SMAT for their clots.

Intracranial Rescue Stent Angioplasty After Stent-Retriever Thrombectomy : Multicenter Experience.

PURPOSE: Stent-retriever thrombectomy (SRT) for acute intracranial large artery occlusion (LAO) may not result in permanent recanalization in rare cases, e.g. due to an underlying stenosis or dissection. In this specific patient group, rescue stent angioplasty (RSA) may be the only treatment option to achieve permanent vessel patency and potentially a good clinical outcome. To date, the experience with RSA is limited. METHODS: In this retrospective analysis, interventional and clinical data of patients with acute intracranial LAO of the anterior and posterior circulation who underwent RSA after SRT due to an underlying lesion between 2012-2017 in four neurovascular centers were studied. RESULTS: In this study 34 patients (mean age 67 years) were included whereby 18 patients had anterior circulation LAO and 16 patients posterior circulation LAO. The SRT maneuver count ranged between 1 and 15 (median 2). Indications for RSA were an immediate re-occlusion in 25 (74%), and a persistent high-grade stenosis in 9 patients (26%). The RSA was technically feasible in 33 patients (97%). A mTICI 2b/3 result was obtained in 26 patients (76%). Median onset-to-recanalization time was 248 min (range 80-650 min). After 3 months 10/34 patients (29%) had a good clinical outcome (modified Rankin Scale, mRS 0-2). In detail, 4/18 patients (22%) with anterior circulation LAO and 6/16 patients (38%) with posterior circulation LAO were functionally independent. CONCLUSION: The use of RSA can be considered for acute intracranial LAO in cases with immediate re-occlusion or high-grade stenosis after SRT alone.

Use of a Subtemporal Approach for a Salvage Placement of a Trigeminal Ganglion Stimulating Electrode for the Treatment of Trigeminal Neuropathic Pain.

BACKGROUND: Trigeminal ganglion stimulation can be effective for trigeminal neuralgia. For patients who respond well to neurostimulation delivered percutaneously through the foramen ovale but require extensive revision and removal of instrumentation, a subtemporal approach for stimulation of the trigeminal ganglion is an alternative option as a salvage procedure. CASE DESCRIPTION: We report on a 47-year-old woman who responded well to neurostimulation for trigeminal neuropathic pain over a 1-year period from 2008 to 2009. Her preoperative pain on the numerical rating scale (NRS) was between 7 and 8 out of 10, which decreased to 2 out of 10 postoperatively. However, she developed lead migration because of a motor vehicle accident. After revision surgeries to correct this, she continued to experience pain relief until 2011. At follow-up, signs of infection prompted removal of instrumentation and subsequent return of her pain. She continued to experience persistent and severe pain (NRS score 7 of 10), which was intractable to pharmacologic treatment over 5 years. She returned in 2016 to discuss neurosurgical options, and the original approach was ruled out because of her history of lead migration, erosion, and scarring. A subtemporal approach was pursued as a salvage option, which provided several advantages for this patient. CONCLUSIONS: The subtemporal approach for salvage placement of the trigeminal ganglion stimulating electrode was effective in this patient and minimized risks given her history of erosion and multiple operations. This suggests that the subtemporal approach is a viable salvage operation for trigeminal ganglion stimulation for trigeminal neuropathic pain.

A new technique to salvage myocardium following the failure of thrombus aspiration in acute myocardial infarction: a case report.

BACKGROUND: The failure of aspiration thrombectomy may negatively impact outcomes in patients with acute myocardial infarction (AMI), but the available options are limited. CASE PRESENTATION: A 41-year-old man with chest pain for 2 h presented with ST-segment elevation myocardial infarction. Coronary angiography revealed a large filling defect extending from the distal left main (LM) coronary artery into the proximal left circumflex (LCX) coronary artery. The whole thrombus moved and occluded the proximal left anterior descending (LAD) artery, while the guidewire crossed the lesion. Dedicated manual aspiration thrombectomy (MAT) and balloon dilation failed to reduce thrombus burden. We considered thrombus extraction as impossible when it moved forward to occlude the middle LAD. To reduce infarct size, a new balloon-pushing technique was successfully performed to move the thrombus to the terminal LAD based on the actual condition of the LAD. The final angiogram demonstrated no stenosis in the LM artery and stent deployment was not performed. A 1-week follow-up coronary angiography revealed the complete resolution of thrombus and flow restoration in the left coronary artery. Intravascular ultrasound (IVUS) showed nonsignificant residual stenosis of the LM artery. No adverse events occurred during a 12-month follow-up period. CONCLUSION: This case suggests that the new balloon-pushing technique is a useful remedy if repeated MAT fails during AMI.

The management of infected nonunion of tibia with a segmental defect using simultaneous fixation with a monorail fixator and a locked plate.

Aims: The aims of this study were to establish whether composite fixation (rail-plate) decreases fixator time and related problems in the management of patients with infected nonunion of tibia with a segmental defect, without compromising the anatomical and functional outcomes achieved using the classical Ilizarov technique. We also wished to study the acceptability of this technique using patient-based objective criteria. Patients and Methods: Between January 2012 and January 2015, 14 consecutive patients were treated for an infected nonunion of the tibia with a gap and were included in the study. During stage one, a radical debridement of bone and soft tissue was undertaken with the introduction of an antibiotic-loaded cement spacer. At the second stage, the tibia was stabilized using a long lateral locked plate and a six-pin monorail fixator on its anteromedial surface. A corticotomy was performed at the appropriate level. During the third stage, i.e. at the end of the distraction phase, the transported fragment was aligned and fixed to the plate with two to four screws. An iliac crest autograft was added to the docking site and the fixator was removed. Functional outcome was assessed using the Association for the Study and Application of Methods of Ilizarov (ASAMI) criteria. Patient-reported outcomes were assessed using the Musculoskeletal Tumor Society (MSTS) score. Results: The mean age of patients was 38.1 years (sd 12.7). There were 13 men and one woman. The mean size of the defect was 6.4 cm (sd 1.3). the mean follow-up was 33.2 months (24 to 50). The mean external fixator index was 21.2 days/cm (sd 1.5). The complication rate was 0.5 (7/14) per patient. According to the classification of Paley, there were five problems and two obstacles but no true complications. The ASAMI bone score was excellent in all patients. The functional ASAMI scores were excellent in eight and good in six patients. The mean MSTS composite score was 83.9% (sd 7.1), with an MSTS emotional acceptance score of 4.9 (sd 0.5; maximum possible 5). Conclusion: Composite fixation (rail-plate) decreases fixator time and the associated complications, in the treatment of patients of infected nonunion tibia with a segmental defect. It also provides good anatomical and functional results with high emotional acceptance. Cite this article: Bone Joint J 2018;100-B:1094-9.

A novel use of cement as a salvage procedure in patients with complex spinal injuries with proximal junctional failure.

Long-construct fixations can be complicated by proximal junctional kyphosis. In elderly, high-risk patients with numerous comorbidities, lengthy surgical times and increased blood loss associated with revision osteotomies and extension of fusions are not often tolerated and pose serious life-threatening risks. We present a salvage technique used in a patient with proximal junctional failure and demonstrate its role in improving symptoms and functionality in those not deemed fit for major surgery. Pre- and postoperative pain scores in accordance with the visual analogue scale, walking distances and radiographs were reviewed in a patient who underwent the salvage technique to ascertain the subjective and objective difference in pain and functionality. The patient showed marked improvement in pain scores and walking distances postoperatively. Additionally, the degree of proximal junctional kyphosis was lower on postoperative radiographs. While holding risks of its own, our described technique can be performed in select cases and is a good salvage procedure in high-risk patients. It prevents their exposure to the risks that accompany large revision operations and fusion models with further potential to fail. We recommend that our technique is performed only at specialist centres.

From transplant to novel cellular therapies in multiple myeloma: European Myeloma Network guidelines and future perspectives.

Survival of myeloma patients has greatly improved with the use of autologous stem cell transplantation and novel agents, such as proteasome inhibitors, immunomodulatory drugs and monoclonal antibodies. Compared to bortezomib- and lenalidomide-based regimens alone, the addition of high-dose melphalan followed by autologous transplantation significantly improves progression-free survival, although an overall survival benefit was not observed in all trials. Moreover, follow up of recent trials is still too short to show any difference in survival. In the light of these findings, novel agent-based induction followed by autologous transplantation is considered the standard upfront treatment for eligible patients (level of evidence: 1A). Post-transplant consolidation and maintenance treatment can further improve patient outcome (1A). The availability of several novel agents has led to the development of multiple combination regimens such as salvage treatment options. In this context, the role of salvage autologous transplantation and allotransplant has not been extensively evaluated. In the case of prolonged remission after upfront autologous transplantation, another autologous transplantation at relapse can be considered (2B). Patients who experience early relapse and/or have high-risk features have a poor prognosis and may be considered as candidates for clinical trials that, in young and fit patients, may also include an allograft in combination with novel agents (2B). Ongoing studies are evaluating the role of novel cellular therapies, such as inclusion of antibody-based triplets and quadruplets, and chimeric antigen receptor-T cells. Despite encouraging preliminary results, longer follow up and larger patient numbers are needed before the clinical use of these novel therapies can be widely recommended.