Hyperbaric oxygen therapy in stage III C Kienböck disease: Time is bone.

Kienböck disease, also known as lunatomalacia, is a rare condition which can lead to progressive wrist pain and abnormal carpal motion. We present the case of a 30-year-old patient with Down syndrome who came to our observation for treatment of stage III C Kienböck disease. In September 2019, the patient reported wrist pain with limitation in movements and initially underwent conservative treatment without benefit. In October 2020, pain symptoms and difficult movements with reduced strength worsened and surgical treatment was proposed, but the patient and his family declined. Thereby the patient underwent conservative treatment with hyperbaric oxygen therapy (HBOT) 60 sessions, 100% oxygen at 2.5 absolute atmospheres (ATA), oxygen total time 60 min, once daily, five times per week. After 6 months, a positive clinical and radiological evolution were observed, with an improvement in the patterns of pain, motion, and strength and an almost complete involution of the process of aseptic necrosis of the semilunar. To the best of our knowledge, this is the first report of stage III C Kienböck's disease in Down's syndrome patient treated with HBOT.

Modified Danielson Technique for Prosthetic Aortic Valve Endocarditis and Aortoventricular Discontinuity.

Endocarditis is a devastating complication of prosthetic aortic valve replacement. The infective process can destroy aortic annulus tissue, making conventional surgical valve replacement difficult or impossible and causing aortoventricular discontinuity. Several treatment techniques have been proposed. One of these, the Danielson technique, involves translocating the aortic valve to the native ascending aorta, débriding the abscess cavity, closing the coronary ostia, and bypassing the coronary arteries with a Y anastomosis between 2 vein grafts. We describe our use of a modified Danielson technique in a 68-year-old man with advanced prosthetic valve endocarditis that was associated with aortic annulus destruction and aortoventricular discontinuity. This modified technique enables safer, more secure anchoring of a replacement valve, reduces the risks and concerns associated with bypass grafts, and successfully treats aortoventricular discontinuity.

An interrupted technique for difficult distal anastomosis during arch surgery.

During aortic arch replacement, construction of the distal anastomosis represents the crucial step because of the time limit of circulatory arrest. If the aneurysmal neck is located at the level of the 5(th) thoracic vertebra, it becomes difficult to carry out through a sternotomy approach. We describe a case in which an interrupted suture technique, similar to that used for valve replacement, was employed to maximize the limited exposure and achieve a water-tight anastomosis.

Endovascular graft deployment in the false lumen of type B dissection.

OBJECTIVES: Thoracic endovascular aortic repair (TEVAR) is particularly indicated in a patient with complicated type B dissection. The object of this communication is to report a case of deployment of the endograft in the false lumen, to propose a protocol in order to prevent it and discuss the possible surgical options when this complication has occurred. METHODS: A case of complicated acute type B dissection is described where the endovascular prosthesis was positioned in the false lumen. The literature on the subject is briefly reviewed for the insertion techniques and conversion to surgery. RESULTS: The occurrence was recognized and treated with replacement of the entire aorta from the sinotubular junction to a level of the eighth thoracic vertebra under deep circulatory arrest with selective antegrade cerebral perfusion. CONCLUSIONS: TEVAR for complicated type B dissection should be carried out according to a precise and stepwise protocol in institutions familiar with all the different options of conversion to open repair.

The role of MRI in traumatic rupture of the diaphragm. Our experience in three cases and review of the literature.

PURPOSE: To evaluate the role and effectiveness of Magnetic Resonance Imaging (MRI) in blunt diaphragmatic injuries by reviewing the literature and our experience in three cases. MATERIALS AND METHODS: We reviewed the medical records and MRI findings of three patients with diaphragmatic injury due to blunt abdominal trauma. All patients were previously examined with chest X-ray and CT and later with MRI at our institution. Coronal and sagittal SE TI-w and fast SE T2-w sequence images were acquired. All patients underwent surgery. RESULTS: MRI showed a 5.5 cm tear in the left hemidiaphragmatic dome with herniation of the stomach and colon into the thoracic cavity in the first case; a 1 cm tear in the diaphragmatic dome with herniation of the stomach and posterior abscess in the second case; and an 8 cm breach in the left diaphragm with visceral herniation in the third case. CONCLUSIONS: The major advantage of MRI lies in its capability of directly acquiring coronal and sagittal images allowing evaluation of the entire diaphragm, both in normal and in pathological conditions. In our experience, MRI showed the exact site and size of the diaphragmatic rupture in all cases. However, this technique cannot be performed in emergency situations or in multitrauma patients. Therefore, in agreement with the literature, helical CT remains the modality of choice in traumatic patients. MR imaging is useful only in doubtful cases and in haemodynamically stable patients.