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BACKGROUND: Computed tomographic mesenteric angiography (CTMA) is integral in the management of patients with acute lower gastrointestinal tract bleeding (LGIB). An invasive mesenteric angiography (MA) with a view to embolize the site of bleeding is usually performed if active contrast extravasation was seen on the CTMA scans. However, the bleeding may have ceased by the time the invasive MA is performed. This study aims to identify predictors for active extravasation in invasive MA following a positive CTMA in patients with massive LGIB. METHODOLOGY: A single-center retrospective study of all patients who underwent an invasive MA following a positive CTMA for LGIB from August 2007 to October 2013 was performed. Comparison was performed between patients who had positive and negative invasive MA after a positive CTMA. RESULTS: Forty-eight invasive MA scans were performed in patients with LGIB following a positive CTMA scan. Twenty-three (47.9%) were due to diverticular disease while 20 (41.7%) bled from the small bowel. The median delay from a positive CTMA to invasive MA was 144 (32-587) min. Of the 48 invasive MA, 25 demonstrated active extravasation. Invasive MA scans that was performed within 90 min after a positive CTMA scan were 8.56 (95% CI 0.96-76.1, p = 0.05) times more likely to detect a positive extravasation. CONCLUSION: Invasive MA should be executed promptly after a positive CTMA to increase the probability of detecting the site of bleed to allow superselective embolization.
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Angiografía/métodos , Hemorragia Gastrointestinal/diagnóstico por imagen , Mesenterio/diagnóstico por imagen , Tomografía Computarizada Multidetector , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Embolización Terapéutica , Femenino , Hemorragia Gastrointestinal/terapia , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Tiempo , Adulto JovenRESUMEN
Background & aims: Knee osteoarthritis (KOA) is a progressive degenerative disease of chronic nature. The mainstay of surgical management for KOA would be total knee arthroplasty. Joint preserving options like High Tibial Osteotomy (HTO) and Proximal Fibular Osteotomy (PFO) have been offered as an inexpensive option by knee preservation surgeons. Current literature on PFO outcomes lack of clarity for specific indications for offering PFO based on degree of severity of KOA. Therefore, this systematic review aims to critically evaluate clinical and radiological outcomes of PFO stratified by severity of KOA. Methods: PubMed, Scopus, CINAHL and Google Scholar databases were searched. Eligible studies included those published up till August 2023, with 271 studies obtained. After duplicate removal, title-abstract screening, and a full text screen based on inclusion and exclusion criteria, 11 papers were included. 46 papers were further identified from snowballing of 7 existing systematic reviews, with 2 additional papers subsequently included. Results: 13 included articles analysed 788 knees. Our study found that indications based on KL grading of KOA do not seem to differ in terms of post-operative clinical outcomes (VAS score) and radiological measures also found that hip knee alignment was improved regardless of KL grading of KOA. Additionally, the most common post-operative complication reported was deep peroneal nerve palsy. Conclusion: PFO is a viable knee joint preserving surgery for medial compartment KOA, however given the high risk for complications reported in the literature, surgeons should pay close attention to the neuroanatomical landmarks and techniques to avoid neurovascular injury.
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BACKGROUND: Isolated knee medial compartmental osteoarthritis(MOA) can be treated with High Tibial Osteotomy (HTO) or Unicompartmental Knee Arthroplasty (UKA). This study aims to describe and compare outcomes of HTO and UKA in patients with isolated severe MOA. The authors hypothesized that similar outcomes can be achieved. METHODS: Data was collected prospectively of HTOs and UKAs performed between January-2016 and April-2021 by a knee surgeon. Oxford Knee Score (OKS), Knee Society Knee Score (KSKS) and Function Score (KSFS) were collected pre-operatively, six-months and two-years post-surgery. OA severity was graded on pre-operative radiograph. Medial Proximal Tibia Angle (MPTA), Lateral Distal Femoral Angle (LDFA), Joint Line Convergence Angle (JLCA) and Hip-Knee-Ankle Angle (HKAA), were measured on full-length radiograph. 47 HTO and 74 UKA were included. Propensity score matching was performed, accounting for preoperative scores, age, gender and body mass index (BMI), before statistical analysis. Level of significance was set at 0.05. RESULTS: Both groups were similar in age(56.42 vs 58.57, p = 0.067), BMI(29.82 vs 29.09, p = 0.484), gender distribution (p = 0.663) and laterality (p = 0.836). Pre-operatively, both groups were similar in clinical scores and lower limb alignment. On follow-up, both groups achieved similar improvements in clinical scores. However, the HTO group reported poorer extension at 6-months (7.91° vs 4.80°, p = 0.013) and 2-years (5.57° vs 3.24°, p = 0.018). Three cases of hinge fracture and six cases of implant removal occurred in the HTO group. One case of tibial fracture occurred in the UKA group. CONCLUSIONS: In severe MOA, similar outcomes were achieved with HTO and UKA at two years.
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Artroplastia de Reemplazo de Rodilla , Osteoartritis de la Rodilla , Osteotomía , Puntaje de Propensión , Tibia , Humanos , Osteoartritis de la Rodilla/cirugía , Osteoartritis de la Rodilla/diagnóstico por imagen , Osteotomía/métodos , Artroplastia de Reemplazo de Rodilla/métodos , Femenino , Masculino , Tibia/cirugía , Tibia/diagnóstico por imagen , Persona de Mediana Edad , Anciano , Articulación de la Rodilla/cirugía , Articulación de la Rodilla/diagnóstico por imagen , Articulación de la Rodilla/fisiopatología , Resultado del Tratamiento , Estudios Prospectivos , Rango del Movimiento ArticularRESUMEN
OBJECTIVE: The use of synthetic bone substitute material (BSM) as osteotomy gap fillers have been reported to improve outcomes in medial opening wedge high tibial osteotomy (MOWHTO). This study aims to evaluate the early radiological outcomes (bone union) and complication rates of the novel patient-specific 3D-printed honeycomb-structured polycaprolactone and tricalcium phosphate (PCL-TCP) synthetic graft compared to allogeneic bone grafts as an osteotomy gap filler in MOWHTO. METHODS: A retrospective matched-pair analysis of patients who underwent MOWHTO with either PCL-TCP synthetic graft or allogenic femoral head allograft as osteotomy gap filler was performed. The osteotomy gap was split into equal zones (Zone 1-5), and bone union was evaluated on anteroposterior radiographs based on the van Hemert classification at 1, 3, 6, and 12 months postoperatively. Postoperative complications including infection, lateral hinge fractures, and persistent pain was measured. The study and control group were matched for age, smoking status, diabetes mellitus, and osteotomy gap size. RESULTS: Significantly greater bone union progression was observed in the PCL-TCP group than in the allograft group at 1 month (Zones 1-3), 3 months (Zones 1-4), 6 months (Zones 1-2, 4), and 12 months (Zones 2-3, 5) postoperatively (P < 0.05). No significant difference in complications rates was noted between the two groups at 1 year. CONCLUSIONS: Bone union rates observed in patients who underwent MOWHTO with the PCL-TCP synthetic graft osteotomy gap filler were superior to those in the allograft group at 1 year postoperatively, with no significant difference in complication rates (postoperative infection, lateral hinge fractures, and persistent pain).
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BACKGROUND: The incidence of lateral hinge fractures (LHFs) during medial opening wedge high tibial osteotomy (MOW-HTO) is unacceptably high, especially with distractions >10 mm. LHFs result in malunion, loss of correction, and recurrence of symptoms adversely affecting clinical outcomes. PURPOSE: (1) To investigate the incidence of LHF when a protective guide wire is utilized during MOW-HTO in small and large corrections and (2) to study the effect of correction size on early clinical outcomes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective analysis was performed of 96 knees that underwent MOW-HTO between 2019 and 2020. A protective wire applied intraoperatively across the lateral hinge point before opening wedge distraction was performed for all patients. Patients were divided into 2 groups based on opening wedge sizes: group A (opening distraction <10 mm) and group B (opening distraction ≥10 mm). LHF and wound complications were recorded. Prospective Knee Score and Function Score (Knee Society), Oxford Knee Score, and Physical and Mental Component Summaries of the 36-Item Short Form Health Survey questionnaire were recorded preoperatively and at 6 months and 2 years after surgery. RESULTS: Incidence of LHF was low in group A (n = 2; 6.1%) and group B (n = 3; 9.1%). A single case of intraoperative LHF was noted in each group, with each case resulting in a type 1 fracture. The incidence of postoperative fractures was comparable between groups (groups A vs B, n = 1 vs 2). At 6 months, clinical outcomes in group A were superior to those of group B (Knee Score, 85.7 ± 14.7 vs 73.1 ± 20.3, P = 0.028; Function Score, 73.5 ± 16.5 vs 63.1 ± 19.5, P = 0.047; Oxford Knee Score, 20.2 ± 4.7 vs 25.6 ± 8.5, P = 0.008; Physical Component Summary, 46.8 ± 8.1 vs 40.2 ± 10.9, P = 0.018). However, clinical outcomes were comparable at 2 years (P > .05). CONCLUSION: A protective wire was associated with a low incidence of LHF, even in larger MOW-HTO corrections. Large corrections had poorer clinical outcomes as compared with small corrections at 6 months. However, clinical outcomes between groups were comparable at 2 years.
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Fracturas Óseas , Humanos , Estudios de Cohortes , Incidencia , Estudios Prospectivos , Estudios Retrospectivos , Osteotomía/efectos adversosRESUMEN
BackgroundPosterior stabilized (PS) total knee arthroplasty (TKA) is advocated in severe varus osteoarthritic (OA) knees as the posterior cruciate ligament posed challenges in gap balancing. However, there is scarcity in the literature to illustrate the superiority of PS TKA over cruciate retaining (CR) TKA. Our study aims to compare the outcomes between CR and PS TKAs in patients with severe varus OA knees. Methods: A retrospective review was conducted on patients who underwent primary TKA for OA knee from 2003 to 2013. Patients with OA knees of varus tibiofemoral angle ≥15 were matched into two groups (Group CR and PS) according to age, gender, and body mass index and compared in terms of clinical (tibiofemoral alignment, range of motion, and revision rate) and functional outcome (Knee Society Scoring, Oxford Knee Score, Short Form-36 Health Survey). Results: Both Group CR (n = 56) and PS (n = 56) had similar pre-operative scores. Both groups achieved correction of tibiofemoral alignment from median pre-operative varus of 17.6/17.0 (CR/PS) (p = .279) to median post-operative valgus of 4.9/4.0 (CR/PS) (p = .408). Over 24 months, both groups were comparable in achieving significant improvement in clinical and functional outcomes. No case of revision surgery was reported (median follow-up months; CR: 65, PS: 74, p = .549). Conclusion: Both CR and PS TKAs perform similarly well in severe varus OA knee up to 2 years post-operation. Further studies are warranted to assess the long-term outcome between the two implant designs.
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Artroplastia de Reemplazo de Rodilla , Prótesis de la Rodilla , Osteoartritis de la Rodilla , Osteoartritis , Ligamento Cruzado Posterior , Humanos , Articulación de la Rodilla/cirugía , Osteoartritis/cirugía , Osteoartritis de la Rodilla/cirugía , Ligamento Cruzado Posterior/cirugía , Rango del Movimiento ArticularRESUMEN
OBJECTIVES: The role of arthroscopic debridement in the painful degenerative knee is controversial. Studies have shown that arthroscopic surgery for knee osteoarthritis provides no additional benefit to optimized physical and medical therapy. There are however, limited studies on the management of the subgroup of significantly symptomatic patients who remain refractory to maximal conservative treatment and are poor candidates for knee replacement surgery.We propose that with careful patient selection, arthroscopic debridement can provide good symptomatic relief with sustained benefits in the degenerative knee. METHODS: We performed a retrospective, single-surgeon study of 180 consecutive knee arthroscopies performed in 169 patients, aged 40 years and above, who had mechanical symptoms affecting their daily lives and underwent arthroscopic debridement after failure of a minimum 2 months of optimized medical and physical therapy. Severity of the knee osteoarthritis on plain radiographs was assessed using the Kellgren-Lawrence classification.Functional and satisfaction scores were assessed using Oxford Knee Score, Koos Knee Survey, Short Form-36, Numeric Pain Rating Scale, and questions adapted from the North American Spine Society Questionnaire. RESULTS: Excellent functional outcomes and patient satisfaction were reported in the majority of patients over the follow-up timeframe of 2-8 years. The mean pre-operative Kellgren-Lawrence score was 2.02 (SD 0.580). Significant improvements compared to pre-operative scores were seen across all scoring systems tested. 90% of patients reported good to excellent results. CONCLUSION: Arthroscopic knee debridement can provide good symptomatic relief and sustained benefits in significantly symptomatic patients with early degenerative knees who have failed conservative management. This is most useful in patients with mechanical symptoms secondary to degenerative meniscal tears or chondral flaps, and those with symptomatic patellofemoral osteoarthritis.
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BACKGROUND: The optimal management of bleeding from the lower gastrointestinal tract (LGIB) remains controversial. We aim to evaluate the efficacy of mesenteric embolization for LGIB and to identify predictors for re-bleeding after the procedure. METHODS: We conducted a retrospective review of all patients who underwent mesenteric embolizations for LGIB in our institution over a 6-year period (from August 2007 to August 2013). Technical success was defined as the absence of contrast extravasation on post-embolization angiogram. Clinical success was defined as the absence of overt LGIB (clinical bleeding with >1 g/dL decrease in haemoglobin) within 30 days post-embolization. RESULTS: Mesenteric embolization was performed in 26 patients with LGIB. Technical success rate was 100%, with no occurrence of post-embolization ischaemia. Clinical success rate was 65.4%, with nine patients re-bleeding within 30 days post-embolization. Three underwent surgery, one underwent re-embolization and five were treated conservatively. Mortality rate was 19.3% (five patients), with two bleeding-associated mortalities. Site and aetiology of LGIB, platelet count and coagulation status prior to embolization, number of packed red blood cells and fresh frozen plasma transfusion were found to be predictors of clinical failure. After Bonferroni's correction (P < 0.005), platelet count of ≤140 × 10(9) /L prior to embolization was the only statistically significant factor associated with re-bleeding (odds ratio = 17.5, 95% confidence interval: 2.364-129.57; P = 0.004). CONCLUSION: Mesenteric embolization was found to be safe and effective in treating LGIB (100% technical success, no post-embolization ischaemia), with 65.4% of cases not requiring further intervention. Low platelet count prior to embolization appears to be associated with clinical failure.