A Contained Ruptured Abdominal Aortic Aneurysm Presenting with Vertebral Erosion.

Chronic contained rupture (CCR) of abdominal aortic aneurysm (AAA) with vertebral erosion is a rare condition. Although it has been reported previously, it is still liable to be misdiagnosed. We present a case of CCR of AAA with vertebral erosion. A brief analysis of similar cases reported in the last 5 years is presented. A 71-year-old male was admitted to our hospital because of severe prickling pain in his left thigh. Computerized tomography angiography revealed an AAA which had caused erosion of L3 vertebral body and the left psoas muscle. An aortotomy was performed, and the excised aortic aneurysm replaced with a Dacron graft. Postoperative computed tomography (CT) angiography indicated a normal aortic graft. The patient was discharged 13 days after the surgery. In conclusion, pain in lower back and leg could be associated with vertebral erosion caused by CCR of AAA. Ultrasonography, CT, or magnetic resonance imaging of abdomen should be routinely performed in cases of lumbago that have associated risk factors for AAA.

Tropomyosin is in a reduced state in rabbit psoas muscle.

Tropomyosin (Tm) purified from skeletal and cardiac muscle often contains disulfide bonds due to oxidation of cysteine groups that are in close proximity in the coiled-coil structure. Are these disulfide crosslinks present in the muscle or produced by oxidation during preparation? To answer this question we reacted one part of freshly dissected rabbit psoas muscle fibers, which was permeabilized with Triton X-100, with N-ethyl maleimide (NEM) to block cysteine groups and another part with 5,5'-dithiobis(2-nitro benzoate) (DTNB) to facilitate disulfide bond formation by interchain sulfhydryl-disulfide exchange. We found, by high resolution gradient SDS polyacrylamide gels, that the NEM-treated muscle was only composed of uncrosslinked Tm and the DTNB treated muscle was composed of disulfide-crosslinked Tm. This work indicates that Tm exists in a reduced state in rabbit psoas muscle.

Patient-reported distress and age-related stress biomarkers among colorectal cancer patients.

OBJECTIVE: Distress among cancer patients has been broadly accepted as an important indicator of well-being but has not been well studied. We investigated patient characteristics associated with high distress levels as well as correlations among measures of patient-reported distress and "objective" stress-related biomarkers among colorectal cancer patients. METHODS: In total, 238 patients with colon or rectal cancer completed surveys including the Distress Thermometer, Problem List, and the Hospital Anxiety and Depression Scale. We abstracted demographic and clinical information from patient charts and determined salivary cortisol level and imaging-based sarcopenia. We evaluated associations between patient characteristics (demographics, clinical factors, and psychosocial and physical measures) and three outcomes (patient-reported distress, cortisol, and sarcopenia) with Spearman's rank correlations and multivariable linear regression. The potential moderating effect of age was separately investigated by including an interaction term in the regression models. RESULTS: Patient-reported distress was associated with gender (median: women 5.0, men 3.0, p < 0.001), partnered status (single 5.0, partnered 4.0, p = 0.018), and cancer type (rectal 5.0, colon 4.0, p = 0.026); these effects varied with patient age. Cortisol level was associated with "emotional problems" (ρ = 0.34, p = 0.030), anxiety (ρ = 0.46, p = 0.006), and depression (ρ = 0.54, p = 0.001) among younger patients. We found no significant associations between patient-reported distress, salivary cortisol, and sarcopenia. CONCLUSIONS: We found that young, single patients reported high levels of distress compared to other patient groups. Salivary cortisol may have limited value as a cancer-related stress biomarker among younger patients, based on association with some psychosocial measures. Stress biomarkers may not be more clinically useful than patient-reported measures in assessing distress among colorectal cancer patients.

A Comparison of Barbed Suture Versus Traditional Techniques for Muscle Belly Repair.

BACKGROUND: The use of barbed sutures in wound closure and tendon repair has been previously been studied with improved results over traditional suture material. We examine the use of barbed suture in muscle belly repair in a custom configuration, comparing it with traditional configurations and a control. METHODS: Twenty-five matched porcine psoas muscles were assigned to 5 different test groups: Mason-Allen with #1 Ethibond, Figure of Eight Allen with #1 Ethibond, Modified Kessler with #1 Ethibond, Custom Configuration with #2 Barbed PDS, Custom Configuration with #1 Ethibond. Repair was performed on the cut edge of muscle, with the free end of the suture anchored to a fixed base, forming a single-sided repair. An Instron 8874 tensiometer was used to linearly distract the repair to failure at 1 mm/s after 1 N preload. Five samples of each group were run, comparing load to failure and distraction at 10 N. RESULTS: Repair with barbed suture in custom configuration had statistically significantly greater load to failure than all other methods. It also showed statistically significant less displacement at 10 N of force than all other methods of repair except the Mason-Allen repair with #1 Ethibond. Mode of failure for traditional techniques was suture pull-through with tissue loss. Failure with barbed suture was through suture pullout without tissue loss. CONCLUSIONS: Custom configuration with a barbed suture increases the load to failure and decreases displacement of the repair site at 10 N of force. In addition, when the suture does pull out, it does so with minimal tissue loss.

Abdominopelvic mesh compartmentalization reduces the complications of radiotherapy in children: a preliminary report.

AIM: The aim of this report was to assess the effects of radiotherapy (RT) in children with abdominopelvic tumours in whom a biodegradable (Polyglactin 910) mesh had been inserted prior to commencement of radiotherapy. METHODS: Retrospective analysis was carried out of four patients with abdominopelvic tumours who underwent radiotherapy between 2000 and 2002 as part of their management. RESULTS: All children tolerated radiotherapy well with no evidence of acute or chronic radiation enteritis. One child developed prolonged postoperative ileus and a second child developed infective diarrhoea and fever, not related to radiation. CONCLUSION: We have highlighted a good tolerance of radiotherapy in children following the insertion of a Polyglactin 910 mesh prior to starting radiation and would recommend further larger studies with longer follow-up to support this.

A swallowed metal nail entrapped in the right psoas muscle.

Foreign body ingestion can be caused by many factors, including hallucination in patients with mental retardation. Most ingested foreign bodies are naturally discharged, though surgical intervention is necessary in some cases. Endoscopic intervention often leads to successful outcome, though open surgery may be required in certain instances. A 29-year-old mentally retarded woman presented to emergency services with a 2-day history of right lumbar pain that increased with movement. Physical examination revealed no specific sign beyond palpable tenderness in the right lumbar region. Radiological examination revealed a metal nail in the upper right quadrant, stretching obliquely toward the retroperitoneum. Endoscopy failed, and the nail was extracted via laparotomy. Foreign body ingestion may occur in patients of any age, but is more common in the pediatric population and in patients with mental retardation. Commonly ingested foreign bodies include daily objects, toys, and dentures, though they may differ in patients with mental retardation. The treatment of such cases requires a diversity of methods and experience. Foreign body ingestion should be kept in mind when a patient presents with pain in the right lumbar region, particularly in patients with mental retardation.

The vaginal-psoas suspension repair of uterovaginal prolapse.

BACKGROUND: This article introduces a novel technique for the abdominal suspension of the prolapsed vagina. A Gore-Tex (WL Gore & Associates, Flagstaff, AZ) graft interposition between the vaginal apex and the right psoas muscle is performed under direct visualization to effect the repair. STUDY DESIGN: Between June 1998 and June 2001, seven consecutive cases of uterovaginal prolapse were repaired abdominally using the vaginal-psoas technique as outlined here. Patients were followed postoperatively for recurrent prolapse, urinary incontinence, and the development of new or progressive pelvic support defects. RESULTS: The mean operative time was 134 minutes, and the mean blood loss was 160mL for all procedures. One patient was lost to followup after 2 months. The remaining six patients have a median followup of 22 months (range 4 to 36 months), and in these patients, there have been no instances of recurrent prolapse or urinary dysfunction. One patient developed a progression of her rectocele. There were no peroperative or postoperative complications directly related to the procedure. Specifically, there were no instances of hemorrhage, transfusion, small bowel obstruction, graft erosion, or genitofemoral neuropathy. CONCLUSIONS: The vaginal-psoas colposuspension appears to be a simple, efficacious technique for the repair of uterovaginal prolapse. No significant morbidity directly related to the procedure has occurred to date. Further studies with longer followup will be required in the future before definitive conclusions can be reached.

Creatine kinase reaction in skinned rat psoas muscle fibers and their myofibrils.

The aim of this study was to evaluate myofibrillar creatine kinase (EC 2.7.3.2) activity on the background of the effect of substrate channeling by myosin ATPase and to compare it with creatine kinase (CK) activity of whole skinned fibers. In order to assess CK activity, skinned fibers were prepared from the rat psoas major muscles defined by light microscopy. The activity in permeabilized fibers after treatment with saponin, Triton X-100 and Ca(2+)-free medium reached 2.80, 6.97 and 3.32 micromol ATP min(-1) mg(-1) protein, respectively, when a coupled enzyme assay system with external hexokinase and glucose-6-phosphate dehydrogenase was used. Transmission electron microscopy (TEM) revealed a possible interference among activities of sarcolemmal, sarcoplasmic, myofibrillar and mitochondrial CK from persisting structures. For evaluation of the myofibrillar CK itself, a pure myofibrillar fraction was prepared. Fraction purity was confirmed by TEM and by enzymatic assays for marker enzymes. Two procedures, i.e. the coupled enzyme assay and the evaluation of phosphocreatine (PCr) concentration before and after the CK reaction, were used for measurement of CK activity in this fraction. The procedures resulted in 3.2 nmol ATP min(-1) mg(-1) protein and 7.6 nmol PCr min(-1) mg(-1) protein, respectively. These alternative approaches revealed a discrepancy between the reacting portions of PCr by more than 50 %, which provides information about the size of the effect, generally described as substrate channeling.

[Inflammatory pseudotumor of the ileopsoas muscle with femoral paralysis caused by massive metal abrasion of a hip endoprosthesis]. / Entzündlicher Pseudotumor im M. ileopsoas mit Femoralisparese durch massiven Metallabrieb einer Hüftendoprothese.

Case report of a 62-year-old patient with a presumed loosening of a hip endoprosthesis after 10 years and a planned replacement. In addition, the patient suffered pain in the thigh and had paresis of the femoral nerve. A CAT-Scan substantiated the diagnosis either of a suppurating or a neoplastic tumour in the left iliac foss. The wide excision revealed a rare inflammatory tumour in the left ileopsoas muscle due to the excessive abrasion of the metal hip endoprosthesis.

[Noncemented total hip arthroplasty: influence of extramedullary parameters on initial implant stability and on bone-implant interface stresses]. / Arthroplastie totale non cimentée de la hanche: influence des paramètres extra-médullaires sur la stabilité primaire de l'implant et sur les contraintes à l'interface os/implant.

PURPOSE OF THE STUDY: After total hip replacement, the initial stability of the cementless femoral stem is a prerequisite for ensuring bone ingrowth and therefore long term fixation of the stem. For custom made implants, long term success of the replacement has been associated with reconstruction of the offset, antero/retro version of the neck orientation and its varus/valgus orientation angle. The goals of this study were to analyze the effects of the extra-medullary parameters on the stability of a noncemented stem after a total hip replacement, and to evaluate the change of stress transfer. MATERIAL AND METHODS: The geometry of a femur was reconstructed from CT-scanner data to obtain a three-dimensional model with distribution of bone density. The intra-medullary shape of the stem was based on the CT-scanner. Seven extra-medullary stem designs were compared: 1) Anatomical case based on the reconstruction of the femoral head position from the CT data; 2) Retroverted case of - 15 degrees with respect to the anatomical reconstruction; 3) Anteverted case with an excessive anteversion angle of + 15 degrees with respect to the anatomical case; 4) Medial case: shortened femoral neck length (- 10 mm) inducing a medial shift of the femoral head offset; 5) Lateral case: elongated femoral neck length (+ 10 mm) inducing lateral shift of the femoral head offset 6) Varus case with CCD angle 127 degrees; 7) Valgus case with CCD angle 143 degrees. The plasma sprayed stem surface was modeled with a frictional contact between bone and implant (friction coefficient: 0.6). The loading condition corresponding to the single limb stance phase during the gait cycle was used for all cases. Applied loads included major muscular forces (gluteus maximus, gluteus medius, psoas). RESULTS: Micromotions (debonding and slipping) of the stems relative to the femur and interfacial stresses (pressure and friction) were different according to the extra-medullary parameters. However, the locations of peak stresses and micromotions were not modified. The highest micromotions and stresses corresponded to the lateral situation and to the anteverted case (micro-slipping and pressure were increased up to 35 p.100). High peak pressure was observed for all designs, ranging from anatomical case (34 MPa) to anteverted case (44 MPa). The peak stresses and micromotions were minimal for the anatomical case. The maximal micro-debonding was not significantly modified by the extra-medullary design of the femoral stem. DISCUSSION: The extra-medullary stem design has been shown to affect the primary stability of implant and the stress transfer after THR. Most interfacial regions present small micro-slipping which normally allows the occurrence of bone ingrowth. The anatomical design presents the lowest micromotions and the lowest interfacial stresses. The worst cases correspond to the anteverted and lateralized cases. Probably, the anteverted situation involves higher torsion torque, which in turn may induce high torsion shear micromotions and higher stress at the interface. Moreover, the lever arm of the weight bearing force on the femoral head is augmented for the augmented neck length situation. This increases the bending moment, and therefore may increase the stresses as well as the stem shear micromotions. In summary, the present results could be taken as biomechanical arguments for the requirement of anatomical reconstruction of not only the intra-medullary shape but also the extra-medullary parameters (reconstruction of the normal hip biomechanics).

A cyanoacrylate and silastic patch to reduce the risk of opening of the tumor: technical note.

BACKGROUND: Wide surgery is the main factor influencing survival in muscular skeletal tumor. Sometimes the margin can be very thin and the contamination risk can be very high because of manipulation of the mass. MATERIALS AND METHODS: A patch of cyanoacrylate and a silastic mesh are applied on tumor surface. In order to demonstrate the tumor sealing an histologic exam was performed. DISCUSSION: The application of protective patch can decrease the risk of accidental tumor rupture and neoplastic cells spreading.

Imaging assessment of groin pain.

Groin pain is a common condition in athletes, especially those who play certain sports, for instance soccer, ice hockey, fencing which request rapid acceleration and frequent changes of movement. This condition represents a diagnostic difficulty for the radiologist due to either the anatomical pubic region complexity than the many causes that can be a source of pain, because the groin pain can be determined by conditions affecting the bony structures, cartilage and muscle tendons that are part of the proper pubis but also from those involving the hip. The approach to the groin through diagnostic imaging is multidisciplinary: The study of the patient is performed by traditional radiographs, ultrasound examination, magnetic resonance imaging or computed tomography, based on clinical suspicion, and each of these methods provides different results depending on the disease in question. The purpose of this article is to examine what are the optimal imaging techniques to investigate the various diseases affecting the patient with groin pain.

[Superficial femoral vein thrombosis due to large psoas bursitis secondary to particle disease in total hip arthroplasty]. / Trombosis de vena femoral superficial por bursitis del psoas posterior a artroplastía total de cadera.

Male, 76 year-old patient with a history of total hip arthroplasty who presents with a mass in the iliac fossa with swelling of the thigh and hip pain upon flexion and extension. Complementary ultrasound and computed tomography scan studies show a giant lobulated cystic mass in the left iliac fossa, 7 cm in diameter, near the prosthesis. Cyst formation caused by polyethylene disease after total hip arthroplasty is infrequent. We present a case of large psoas bursitis secondary to the release of polyethylene particles which caused superficial femoral vein compression and thrombosis.

[Femoral superficial vein thrombosis due to a large iliopsoas bursitis secondary to polyethylene wear debris in total hip arthroplasty]. / Trombosis de la vena femoral superficial por gran bursitis en psoas secundaria a enfermedad de las partículas en artroplastia total de cadera.

A 76 year old male patient with a history of implantation of a total hip arthroplasty Perfecta (Orthomet(®)), who presented with an iliac fossa mass, increased diameter of the thigh, and pain during hip flexion and extension. CT and ultrasound show the presence of a giant cystic mass in left iliac fossa about 7 cm in diameter next to the prosthesis. A pseudo-tumour secondary to wear debris after placement of a total arthroplasty is rare. We present a case of a large iliopsoas bursitis caused by polyethylene particles, which caused compression and thrombosis of the superficial femoral vein.

Subsidence of polyetheretherketone intervertebral cages in minimally invasive lateral retroperitoneal transpsoas lumbar interbody fusion.

STUDY DESIGN: A retrospective review. OBJECTIVE: The objective is to evaluate subsidence related to minimally invasive lateral retroperitoneal lumbar interbody fusion by reviewing our experience with this procedure. SUMMARY OF BACKGROUND DATA: Polyetheretherketone intervertebral cages of different lengths, widths, and heights filled with various allograft types are commonly used as spacers in lumbar fusions. Subsidence is a potential complication. To date, there are no published reports specifically addressing subsidence, because it relates to a series of patients undergoing minimally invasive lateral retroperitoneal transpsoas lumbar interbody fusion. METHODS: An institutional review board-approved, retrospective review of a prospectively collected database was conducted. One hundred forty consecutive patients who underwent this procedure between L1 and L5 during a 2-year period were included. All patients had T scores of -2.5 or more. Postoperative radiographs during routine follow-ups were reviewed for subsidence, defined as any violation of the vertebral end plate. RESULTS: Radiographical subsidence occurred in 14.3% (20 of 140), whereas clinical subsidence occurred in 2.1%. Subsidence occurred in 8.8% (21 of 238) of levels fused. Construct length had a significant positive correlation with increasing subsidence rates. Subsidence rates decreased progressively with lower levels in the lumbar spine, but had a higher than expected rate at L4-L5. Subsidence rates of 14.1% (19 of 135) and 1.9% (2 of 103) were associated with 18-and 22-mm-wide cages, respectively. No significant trends were observed with cage lengths. Supplemental lateral plates had a higher rate of subsidence than bilateral pedicle screws. Subsidence occurred at the superior end plate 70% of the time. CONCLUSION: The use of wider intervertebral cages leads to a significantly lower rate of subsidence, but a longer cage does not necessarily offer a similar advantage. Wide cages are protective against subsidence, and the widest cages should be used whenever feasible for interbody fusion in the lumbar spine to protect indirect compression and promote arthrodesis.

Acquired haemophilia complicated with gastrointestinal bleeding and spontaneous iliopsoas muscle haematoma in a woman with chronic C hepatitis under treatment with pegylated IFN alpha 2a and ribavirin.

Acquired haemophilia A is a very rare (1-2 cases per million people) but often life-threatening haemorrhagic disorder characterized by antibodies directed against coagulation factor VIII. We report the case of a 55-year old woman under treatment with Pegylated alpha 2a interferon (IFN) and Ribavirin for chronic viral C hepatitis, who developed a progressive severe haemorrhagic syndrome diagnosed as acquired haemophilia based on supplementary laboratory data (prolonged activated partial thromboplastin time, extremely low factor VIII level - 1%, high titre of factor VIII inhibitor - 30 Bethesda U/ml).The onset was insidious, about three months before presenting to our unit. Antiviral therapy had been stopped three weeks before current admission. Emergency intensive treatment included: haemostatic agents - rFVII (Novoseven), FEIBA (Factor VIII Inhibitor Bypassing Activity), vitamin K, adrenostazin, cryoprecipitate, fresh frozen plasma, as well as immunosuppressive therapy (high dose corticotherapy and cyclophoshamide), immunoglobulins (Humaglobin), prophylactic PPI and antibiotics. The evolution was slowly favourable with the remission of the haemorrhagic syndrome and regression of the iliopsoas muscle haematoma. Clinicians should be aware that acquired forms of haemophilia do exist, representing a rare diagnosis and a therapeutic challenge. To our knowledge, this is the first reported case of acquired haemophilia in Romania, in a patient with chronic viral C hepatitis under antiviral treatment.

Contained rupture of an inflammatory abdominal aortic aneurysm into the iliopsoas muscle: report of a case.

A 72-year-old man with a history of old myocardial infarction was admitted to our hospital for surgical treatment of a ruptured abdominal aortic aneurysm. His hemodynamics was stable. He had left lumbar pain on moving his left leg and constipation for ten days without abdominal pain and high fever. Elevation of fat density around the aneurysm and ureter involvement were noted on the computed tomography. These characteristic image findings indicated inflammatory aortic aneurysm. During operation, an infrarenal abdominal aortic aneurysm with an 8 cm maximum diameter was noted. This aneurysm was firm and thick and adhered to some organs due to inflammation. An 5 × 5 cm punched-out defect was found on the lateral wall of the aneurysm. We replaced the ruptured aneurysm with a Dacron graft. Histological examination showed that the aneurysm wall had an infiltrate of inflammatory cells, lymphoid follicles and thickened adventitia. From these findings, the diagnosis was inflammatory aortic aneurysm.

Laparotomized direct puncture for embolization of a retroperitoneal arteriovenous fistula.

A 28-year-old woman was referred to our institution with hope for another child after having an abortion several months previously to avoid a potential risk of catastrophic hemorrhage from a retroperitoneal arteriovenous fistula (AVF) with enlarged and twisted draining veins in the pelvis. Multiple branches coming from the right lumbar arteries and the right iliac arteries fed fistulae converging on an enlarged venous pouch anterior to the psoas major muscle in the right retroperitoneal space. It seemed impossible to achieve complete occlusion of the lesion in a single session by either transarterial or transvenous approach. A laparotomy and direct puncture of the enlarged draining vein immediately downstream of the venous pouch was performed and embolization was done with n-butyl cyanoacrylate and the aid of coils. Complete occlusion of the retroperitoneal AVF was achieved and confirmed in control angiography 5 months later.

Percutaneous embolization of a lumbar pseudoaneurysm in a patient with type IV Ehlers-Danlos syndrome.

Ehlers-Danlos syndrome (EDS) is a rare hereditary connective tissue disorder. Patients with type IV EDS are prone to develop visceral pseudoaneurysms and aortic aneurysms. Surgical and endovascular interventions are fraught with complications and high morbidity. We present a case of a patient with type IV EDS who presented with a new psoas pseudoaneurysm arising from a hypertrophied lumbar artery which was treated with percutaneous embolization by using n-butyl cyanoacrylate glue and coils.

Hemispheric cups do not reproduce acetabular rim morphology.

BACKGROUND: Iliopsoas impingement is a recurrent complication following THA, caused by muscle friction against a protrusive prosthetic cup.This study was designed to quantify the dimensional variations in acetabular rim profiles, with particular regard to the iliopubic valley, in order to suggest means to prevent iliopsoas impingement. MATERIAL AND METHODS: 34 cadaver pelvises were analyzed using a hip navigation system. The morphometric data were processed to plot profiles of all acetabular rims with particular regard to the shape and depth of the psoas valley. RESULTS: The acetabular rim is an asymmetric succession of 3 peaks and 3 troughs. The psoas valley is a salient feature in most pelvises and there is only a weak correlation between its depth (mean 3.8 mm, SD 2.0) and acetabular diameter, anteversion, or inclination. INTERPRETATION: It would be difficult to obviate the anterior overlap of the acetabulum using a hemispheric cup, a fortiori in certain morphotypes, without compromising range of motion or risk of dislocation. The solution for prevention of iliopsoas impingement would be to adapt cup design to acetabular anatomy, which may require different implants for the right and left sides, and hence a doubled inventory.