Anatomical and biomechanical evaluation of an intramedullary nail for fractures of proximal humerus fractures based on tuberosity fixation.

BACKGROUND: For unstable proximal humerus fractures, both plates and nails may be recommended. We introduce an anterograde nail designed for the treatment of 3- and 4-parts proximal humerus fractures. The aim of this study is to compare the biomechanics of this nail versus a plate and then to analyze the relationships of the screws with the axillary nerve. Our working hypotheses are as follows: (1) this nail is biomechanically equal or better to the reference plate and (2) it does not endanger the axillary nerve. METHODS: Biomechanical study: using 40 sawbones, a reproducible 4-part fracture was created and fixed first with an angle-stable plate for proximal humeral fracture, then fixed with the nail using 2 posterior screws. All specimens were mounted in a custom testing apparatus. Two trails were performed needing each time 5 "normal" and 5 "osteoporotic" bones. ANATOMICAL STUDY: On 20 unpaired shoulders, a nail was inserted with all screws through a superior approach (deltoid split approach). Dissection of all shoulders was done to identify the axillary nerve. The distance between each screw and the axillary nerve or its branches was measured. FINDINGS: The proximal humerus nail demonstrated higher values than locking plate for both stiffness and load to failure. The failure mode differs in function of the type of osteosynthesis. The lowest distance between a screw and the axillary nerve was 20.13 mm. INTERPRETATIONS: We introduce a biomechanically efficient nail without increased neurological risks to improve the pullout strength of the screws to provide more secure fixation of proximal humeral fractures. LEVEL OF EVIDENCE: Basic Science Study, Anatomic Cadaver Study.

Imaging findings in a case of stand up paddle surfer's myelopathy.

Stand up paddle (SUP) surfing, a variant of ocean surfing, is becoming very popular because it can be performed at any level of difficulty and thus attracts athletes from a wide range of ages. Unlike ocean surfing, limited data exist on injuries related to SUP surfing. We report the first case of a 28-year-old athlete who developed myelopathy during his first SUP surfing session. Clinical examination revealed severe neurological deficit, which had not subsided fully at the 28-month follow-up.

Percutaneous stenting of a dissected superior mesenteric artery in a patient with previous surgical repair of Stanford type A aortic dissection.

BACKGROUND/AIM: We report a case of a 54-year-old male patient with background history of hypertension, which suffered a Stanford type A thoraco-abdominal aortic dissection with extension to the visceral arteries. DESCRIPTION OF CASE: The patient initially underwent surgical repair with replacement of the ascending aorta and of the hemiarch in the acute phase of the dissection. Postoperatively, he developed non-specific abdominal pain that was not related to meals but led to weight loss of 20 kg within the first five post-operative months. Follow-up computerized tomography scan revealed a chronic subphrenic aortic dissection extending to the celiac axis (with involvement of the left gastric and the splenic artery), the left renal artery and the superior mesenteric artery (SMA). The hepatic artery took origin from the SMA and received blood from the true lumen of the vessel, and the right renal artery was entirely supplied from the true aortic lumen. After exclusion of other causes of abdominal pain, the patient was treated with percutaneous stent placement in the dissected SMA with significant improvement of his symptoms. CONCLUSION: This case report emphasizes the role of visceral artery endovascular techniques in the management of patients with complicated chronic aortic dissection. Hippokratia 2015; 19 (3): 270-273.

Percutaneous biliary interventions through the gallbladder and the cystic duct: What radiologists need to know.

Percutaneous cholecystostomy is an established drainage procedure for the management of high-risk patients with acute cholecystitis. However, percutaneous image-guided access to the gallbladder may not be limited to the simple placement of a drain, but may also be used as an alternative approach to the biliary tree through the catheterization of the cystic duct, for a variety of other more complicated conditions. Percutaneous transcholecystic interventions may be performed in both malignant and benign disease. In the case of malignant jaundice, the transcholecystic route may be used when the liver parenchyma is occupied by metastatic lesions and transhepatic access is not possible. In benign conditions, access through the gallbladder may offer a solution if the biliary tree is not dilated. The transcholecystic access may then be route of insertion of large sheaths, internal drainage catheters, lithotripsy devices, stone retrieval baskets, and stents. The purpose of this review is to illustrate the techniques and to discuss the indications, complications, and technical difficulties of this alternative access to the biliary tree.

The interventional radiological management of cholangiocarcinoma.

The successful management of cholangiocarcinoma requires the collaboration of several clinical disciplines. Modern imaging can demonstrate the liver and the surrounding structures in exquisite detail. Complete surgical resection offers the only potential for cure. The judgement of whether resection is feasible requires precise staging of the tumour. Unfortunately, in most cases, imaging delineates an advanced and inoperable tumour, requiring non-surgical palliative treatment, usually by means of endoscopic or percutaneous radiological techniques. The management of hilar lesions can be problematic requiring substantial experience and skill.

Sedations and analgesia in patients undergoing percutaneous transhepatic biliary drainage.

AIM: To present our experience using intravenous sedoanalgesia for percutaneous biliary drainage. MATERIALS AND METHODS: This study comprised 100 patients, all of whom were continuously monitored [electrocardiogram (ECG), blood pressure, pulse oxymetry] and received an initial dose of 2mg midazolam followed by 0.02 mg fentanyl. Before every anticipated painful procedure, a maintenance dose of 0.01 mg fentanyl was administered. If the procedure continued and the patient became aware, another 1mg midazolam was given. This was repeated if patients felt pain. A total dose of 0.08 mg fentanyl and 7 mg midazolam was never exceeded. Immediately after the procedure, the nurse was asked to evaluate patients' pain score. The patients were asked 3h later to complete a visual 10-degree pain score scale. RESULTS: The average dose of fentanyl and midazolam was 0.042 mg (0.03-0.08 mg) and 4.28 mg (2-7 mg), respectively. Only one patient recorded the procedure as painful. The scores given by the attending nurse (1-7 points, mean 2.9) correlated well with those given by the patients (1-6 points, mean 2.72). No complications were noted. CONCLUSION: According to our experience, interventional radiologists practising biliary procedures can administer low doses of midazolam and minimize the doses of fentanyl, without loss of adequate sedation and analgesia.

Intraureteral metallic endoprosthesis in the treatment of ureteral strictures.

OBJECTIVE: We report our experience on intraureteral metallic stents placement for the treatment of malignant and benign ureteral strictures. METHODS: Eight patients (six men and two women) with inoperable malignant or benign ureteral strictures, underwent insertion of metallic stents through percutaneous tracts. Six lesions (three malignant, three benign) involved ureterointestinal anastomoses after cystectomy for bladder cancer and ureteroileal urinary diversion or bladder substitution, and two malignant lesions involved the midureter. Self-expandable stents were used in seven cases and a balloon-expandable stent in the remaining one case. One stent was sufficient in seven ureters, and in one ureter, two overlapping stents were placed. RESULTS: Metallic stents were inserted without technical difficulties in all obstructed ureters and patency was achieved in all patients. Ultrasonography revealed resolution of pre-existing hydronephrosis. The duration of follow-up was 6-17 months (mean, 9 months). One ureter was occluded 8 months after stent placement because of ingrowth of tumor and granulation tissue. The other ureters showed no signs of obstruction during follow-up. No major complications directly attributable to the metallic stent occurred. CONCLUSIONS: Our results suggest that insertion of a metallic stent in the ureter is feasible and safe for the treatment of benign or malignant ureteral strictures. However, more work needs to be done to establish the use of these stents for the treatment of ureteral obstruction.

Gastric outlet obstruction caused by a giant gastroduodenal artery aneurysm: a case report.

Gastric outlet (GO) obstruction in an adult is usually caused by intrinsic gastric or duodenal lesions or pancreatic tumours. This study describes a case of a 77-year-old man who developed GO obstruction due to extrinsic compression from a large gastroduodenal artery aneurysm under rupture. This cause of GO obstruction has never previously been reported in the literature.

Nitinol stents for palliative treatment of malignant obstructive jaundice: should we stent the sphincter of Oddi in every case?

PURPOSE: To evaluate the necessity of metallic stenting of the sphincter of Oddi in malignant obstructive jaundice when the tumor is more than 2 cm from the papilla of Vater. METHODS: Sixty-seven self-expandable biliary stents were used in 60 patients with extrahepatic lesions of the common hepatic or common bile duct and with the distal margin of the tumor located more than 2 cm from the papilla of Vater. Stents were placed above the papilla in 30 cases (group A) and in another 30 with their distal part protruding into the duodenum (group B). RESULTS: The 30-day mortality was 15%, due to the underlying disease. The stent occlusion rate was 17% after a mean period of 4.3 months. No major complications were noted. Average survival was 132 days for group A and 140 days for group B. In group A, 19 patients survived < or = 90 days and in eight of these, cholangitis occurred at least once. Of 11 patients in group A with survival > 90 days, only two developed cholangitis. In group B, 13 patients who survived < or = 90 days had no episodes of cholangitis and in 17 with survival > 90 days, cholangitis occurred in three. There is a statistically significant difference (p < 0.05) regarding the incidence of cholangitis in favor of group A. CONCLUSIONS: In patients with extrahepatic lesions more than 2 cm from the papilla and with a relative poor prognosis (< or = 3 months), due to more advanced disease or to a worse general condition, the sphincter of Oddi should also be stented in order to reduce the postprocedural morbidity.

Solid pseudopapillary neoplasm of the pancreas: report of a case after a 10-year follow-up and review of the literature.

A solid pseudopapillary neoplasm (SPN) is an extremely rare tumour of the pancreas that frequently occurs in young females and is mostly benign. SPN is a low-grade malignant tumour that may evolve years before symptoms start. However, the pathogenesis of this tumour remains unclear and there are no adequate reports of long-term results to evaluate the management and the long-term surgical control. We describe a new case of SPN with a 10-year follow-up, and review the world literature that accounts for approximately 322 cases. Moreover, a review of the current management and surgical tendencies in the treatment of SPN is considered. An SPN pancreatic tumour occurred in a 24-year-old female who complained of episodic mild abdominal pain sustained by a palpable epigastric mass. The tumour mass was detected by ultrasound and computer tomography and was localised at the tail of the pancreas adherent to the spleen. The preoperative diagnosis was uncertain and en-block distal pancreatectomy and splenectomy were performed. The size of the mass which weighed 300 g was 11 x 12 x 8 cm, and the tumour was strictly adherent and invaded the splenic hilum. Histologic examination confirmed a complete resection of the primary SPN that locally invaded spleen. The postoperative period was uneventful and after a 10-year follow-up the patient is free of symptoms. SPN should be considered in the differential diagnosis of large pancreatic masses, especially in young females. Radical resection, where technically feasible, should be considered the therapy of choice as it is a safe and effective control of the disease.

Late complication following percutaneous cholecystostomy: retained abdominal wall gallstone.

A case of recurrent abdominal wall abscess following percutaneous cholecystostomy (PC) is presented. Transperitoneal PC was performed in an 82-year-old female with calculous cholecystitis. Symptoms resolved and the catheter was removed 29 days later. The patient came back 5 months later with a superficial abscess that was drained and 8 months post PC with a fistula discharging clear fluid. Ultrasonography revealed the tract adjacent to an area of inflammation containing a calculus, whereas CT failed to depict the stone. Subsequent surgery confirmed US findings. To our knowledge, this is the first report of a dislodged bile stone following percutaneous cholecystostomy.

Preoperative autologous donation for total joint arthroplasty. An analysis of risk factors for allogenic transfusion.

BACKGROUND: While autologous blood is commonly predonated to provide replacement of blood lost in orthopaedic procedures, few studies of patients managed with total joint replacement have addressed the problem of which patients are likely to benefit from an autologous blood-donation program. METHODS: A retrospective analysis of 489 consecutive patients who had had a total joint arthroplasty was performed to identify the risk factors for allogenic transfusion and to further define the indications for preoperative autologous blood donation. The operations included 247 total knee replacements (157 unilateral primary, thirty-two revision, and twenty-nine one-stage bilateral primary procedures) and 271 total hip replacements (163 primary and 108 revision procedures). Fifty-four percent (264) of the 489 patients donated a total of 527 units of blood (average, 2.0 units per patient) preoperatively. RESULTS: One hundred and ninety-one patients (39 percent) required a transfusion of autologous blood or allogenic blood, or both. One hundred and thirty-one patients (27 percent) received autologous blood, and eighty-two patients (17 percent) received a transfusion of allogenic blood; twenty-two patients (4 percent) received both autologous and allogenic blood. Neither form of transfusion caused serious complications. Fifty-six percent (295) of the 527 units of autologous blood were discarded. Autologous donation significantly decreased the requirements for allogenic transfusion (relative risk, 0.1; p<0.0001). It also caused the level of hemoglobin to decrease an average of 12.2 grams per liter from the time before donation to the time before the operation (p<0.0001). Factors that increased the risk for allogenic transfusion were a revision knee or hip procedure or a one-stage bilateral primary knee replacement (relative risk, 5.7; p<0.0001), an initial hemoglobin level of less than 130 grams per liter (relative risk, 5.6; p<0.0001), and an age of sixty-five years or older (relative risk, 2.8; p = 0.02). None of the sixty-seven patients who had a primary knee or hip arthroplasty and an initial hemoglobin level of 150 grams per liter or more required an allogenic transfusion. In addition, none of the sixty-three patients who had a primary arthroplasty, an initial hemoglobin level of between 130 and less than 150 grams per liter, and an age of less than sixty-five years required an allogenic transfusion. Eighty-three percent (115) of the 138 autologous units donated by the seventy patients in these two groups were discarded. These wasted units accounted for 39 percent of the 295 discarded units for the entire study sample. CONCLUSIONS: The efficiency of collection of autologous blood can be improved by identifying patients who have a very low risk of transfusion according to the type of arthroplasty, the initial level of hemoglobin, and age. Patients who have an initial hemoglobin level of at least 150 grams per liter or an initial hemoglobin level of between 130 and 150 grams per liter and an age of less than sixty-five years have a minimal risk of needing a transfusion during or after a primary total joint replacement. These patients should be apprised of their low risk so that they can make an informed decision regarding preoperative autologous donation.

Percutaneous cholangioscopy in the management of biliary disease: experience in 25 patients.

PURPOSE: To present our experience performing percutaneous cholangioscopy in the management of 25 patients with biliary disease. METHODS: During the last 3 years, 26 percutaneous cholangioscopies were performed in 25 patients with common bile duct disease (n = 16), intrahepatic ducts disease (n = 6), and gallbladder disease (n = 4). Our patient population group included seven with common bile duct stones, three with intrahepatic lithiasis, and eight with benign strictures (six iatrogenic and two postinflammatory). In four patients malignancy was to be excluded, in two the tumor extent was to be evaluated, whereas in one case the correct placement of a metallic stent needed to be controlled. A 9.9 Fr flexible endoscope URF-P (Olympus, 1.2 mm working channel, 70-cm length) was used. RESULTS: In total, percutaneous cholangioscopy answered 30 diagnostic questions, was technically helpful in 19 cases (performing lithotripsy or biopsy or guiding a wire), and of therapeutic help in 12 (performing stone retrieval). In 24 of 26 cases the therapeutic decision and the patient management changed because of the findings or because of the help of the method. In two cases biliary intervention failed to treat the cause of the disease. No major complication due to the use of the endoscopy was noted. CONCLUSIONS: Percutaneous cholangioscopy is a very useful tool in the management of patients with biliary disease. The method can help in diagnosis, in performing complex interventional procedures, and in making or changing therapeutic decisions.