Bundle Insertion Research Articles

Enhancing the Central Venous Catheterization Competency of Medical Students through a Specialized Team and an Interactive Response System: A pre-post study.

Central venous catheterization (CVC) is a critical clinical procedure. To avoid complications, possessing good knowledge regarding the CVC care bundle and skills for the proper insertion and maintenance of CVC are important. To evaluate the effectiveness of an educational intervention and the use of an interactive response system in enhancing the CVC bundle care and insertion skills of medical students undergoing critical care medicine training. Sixth-year medical students (equivalent to fourth-year students in the United States) engaged in didactic lessons, interactive demonstrations, and simulator training facilitated by a CVC team comprising three thoracic and two vascular surgeons (all with a minimum 5 years of experience in central venous access) during their intensive care unit (ICU) rotation. Self-reported knowledge and confidence levels were assessed using pre-and posttests administered through the Zuvio App, an interactive response system. A total of 60 students underwent the educational intervention, of which 54 completed the pretest and 40 completed the posttest. In the posttest, significant improvement was found in the CVC bundle care competency and understanding (P = 0.002), preprocedural preparation (P = 0.002), insertion procedures (P = 0.004), complications (P = 0.003), and insertion depth decisions (P = 0.001). Staff and students reported that assessment and interaction via the Zuvio App were valuable, practical, and feasible in a clinical setting, providing trainees with an individual competency portfolio of receiving precise medical education. Integrating the training provided by a specialized team with an interactive response system enhanced the knowledge and competency level in CVC insertion among medical students in this study.

The Distal Oblique Bundle in the Distal Forearm: From Anatomical Features to Clinical Implementation.

Background and objective The distal oblique bundle (DOB) is nowadays recognized as thethickest component of the distal interosseous membrane (DIOM). It is neither thought to be a clear-cut ligament, and nor does it follow the typical configuration of the rest of the DIOM. It is not always present and some studies have raised disputes about its prevalence and a few anatomical features. In this study, we aimed to provide data on the prevalence and anatomical features of the DOB, which are of great importance at this early stage of research into the topic. Our findings have been correlated with current knowledge and are expected to contribute to clinical implementation. Materials and methods Twenty-eightfresh-frozen forearms were utilized for measurements. Specifically, mean length, width, distance from the middle of the bundle's insertion to the ulna to the tip of the styloid process of the ulna, as well as the distance from the midpoint of its insertion to the radius to the tip of the radiuses' styloid process were calculated. The prevalence was described with a cutoff thickness point of 0.5 mm. Early results based on three cases of DOB reconstruction with the "Riggenbach" technique due to distal radioulnar joint (DRUJ) instability were documented. Results Eleven DOBs were reported out of the 28 specimens, suggesting a prevalence of 39.3%. The mean thickness was 0.88 mm (range: 0.6-1.3 mm), the mean width was 5.22 mm (range: 2.2-8.4 mm), and the mean length was 25.68 mm (range: 22.7-29.2 mm). Proximally, the mean distance from the bundle's ulnar insertion to the tip of the styloid process of the ulna was 51.02 mm (range: 45.5-55.6 mm) while distally, the mean distance from the bundle's insertion to the radius to the tip of the styloid process of the radius was 34.5 mm (range: 31.3-37.7 mm). After a follow-up of at least six months, improvement was evident in all measured areas in the three patients who underwent surgery. Additionally, they reported satisfaction and accomplishment of their preoperative goals. Conclusions Discrepancies in measurements in some anatomic features between studies are probably due to variations in specimen types, measurement methods, and sites. Efforts must continue to be made on a more extensive scale and in a more standardized manner for more factual results and conclusions. "Reconstruction-recreation" or "original construction-creation" procedures yield promising results in a fast, simple, and less invasive manner than traditional methods of DRUJ stabilization.

Biatrial flutters: unique circuits requiring a customized ablation approach

Abstract Introduction Atrial futters are macroreentrant tachycardias that typically involve several walls of a certain atrium, being the other atrium passively activated. Biatrial flutters (BAF) are peculiar macro-reentries associated with anterior/septal scars, involving both atria and using the interatrial connections. Purpose To characterize the mechanism of BAF a cohort of patients (pts) submitted to mapping and ablation. Methods Retrospective single-center study of pts with atypical atrial flutter submitted to ablation from 2015 to 2022. High resolution electroanatomical voltage and activation mapping were collected using Carto, Ensite or Rhythmia. Whenever the arrhythmia circuit was not fully displayed in a certain atrium, of the other atrium was mapped to fully characterize the reentrant circuit and establish the critical isthmus. Biatrial circuits were classified into 4 types: type 1, involving the mitral annulus and the tricuspid annulus, escaping the septal wall in both atria; type 2 using most of the mitral annulus and the right atrium (RA) septum; type 3, using both the left atrium (LA) and RA septum; and type 4, using most of the tricuspid annulus and the LA septum. Acute and long-term success was evaluated. Results From a total of 107 pts submitted to atypical flutter ablation, 5 pts presented BAF (3 male, median age: 55-yo), 4 of them previously submitted to cardiac surgery (CABG in 1, mitral valvuloplasty in 1, mitral+tricuspid valvuloplasty in 1 and surgical correction of aortic coarctation and ostium primum atrium septal defect in 1) and 1 had been previously submitted to pulmonary vein isolation (PVI), empirical roof line and cavotricuspid isthmus (CTI) ablation. A proximal-to-distal coronary sinus activation and extensive low-voltage areas at the septum were recognized in all these pts. The BAF mechanism was single loop in all of them, with a type 2 circuit in 2 pts, and types 1, 3 and 4 in one patient each. BAF types 1 and 4 were terminated with CTI ablation. BAF types 2 and 3 were terminated with linear ablations from the mitral annulus to the right superior PV, complemented with focal applications at Bachmann bundle insertion sites in the pts with type 2 BAF. Acute success was achieved in all pts. During a mean time of follow-up of 344±91 days, 1 pt had AFl recurrence. Conclusion BAF is a rare and complex arrhythmia, which is possible to ablate successfully by applying high-density mapping tools, a comprehensive analysis of the substrate/activation maps and a mechanism-tailored ablation strategy.

PO-02-003 IDENTIFICATION OF AREAS OF ANISOTROPIC CONDUCTION USING OMNIPOLAR TECHNOLOGY TO PREDICT FIRST-PASS ISOLATION AND RECONNECTION OF THE POSTERIOR WALL

Posterior wall isolation (PWI) can be a useful adjunct to pulmonary vein isolation (PVI) for the management of persistent atrial fibrillation (AF). Successful isolation of the posterior wall is challenging, with first-pass isolation rates under 40%. Difficulties in achieving block may be due to inability to create transmural lesions due to complex posterior wall architecture from septopulmonary (SPB) and septoatrial (SAB) bundle insertion. Activation mapping using omnipolar technology (OT) may allow identification of areas of anisotropic conduction that represent atrial fiber and bundle insertion points to target for additional ablation. Correlate areas of anisotropy to first-pass isolation of the posterior wall and determine whether anisotropy can predict sites requiring additional ablation to achieve bidirectional block We retrospectively analyzed patients with persistent AF who underwent first-time PVI with PWI from November 2020 to December 2022 at a single tertiary referral center with using the EnSite X mapping system with OT (Abbott, IL). Demographic and procedural information was collected. The posterior wall was divided into 6 regions and areas of anisotropy, defined as an abrupt pivot or collision in OT vectors, along with mean and maximum bipolar voltage were recorded. Areas requiring additional ablation to achieve bidirectional block were recorded. 17 patients were included in our cohort, of which 5 had first-pass isolation (29%). Final isolation of the posterior wall was achieved in all cases. There were no significant differences in patient demographics. Total ablation times were significantly less in the first-pass group (2174 versus 1721 seconds, p = 0.035). Anisotropic areas were present in 80% of first-pass cases versus 75% of cases without first-pass. While overall PW voltage was similar in both groups, voltage at sites of anisotropy was significantly higher in patients without first-pass (6.8 vs 2.6, p = 0.024). In patients without first-pass, reconnection was at site of anisotropy in 50% of cases with mean bipolar voltage 7.4mV. Activation mapping using OT may help identify areas of anisotropic conduction that are common sites of epicardial connections. Targeting these areas with additional ablation may improve rates of first-pass isolation and reduce rates of chronic reconnection. Further investigation and a larger cohort is needed to validate the predictive utility of OT.

Effectiveness of insertion care bundle to prevent Central-line-associated bloodstream infections at Pediatric ICU

Purpose: Central-line-associated bloodstream infections are the most common healthcare- associated- associated infections in Pediatric intensive care units worldwide. The aim of this survey was to quantify the impact of central-line care bundle insertion to the prevention Central-line-associated bloodstream infections in a Greek Pediatric Intensive Care Unit. Methods: All patients with non- tunneled central venous catheter admitted to the unit between October 2012 and October 2015 were included in the cohort study. After twenty-six months of surveillance, a Central-line-associated bloodstream infections prevention insertion bundle was introduced. The insertion bundle derived from the Centers for Disease Control and Prevention recommendations. Results: One hundred fifty one patients were enrolled in the present study. The incidence rates of CLABSIs decreased from 14.0 (pre-intervention period) to 4.8 (post-intervention period) per 1000 central venous catheter-days (p = 0.041, 95% Confidence Interval: 0.7023- 17.7), whilst the central-line utilization ratio was increased from 0.51 to 0.59 (p=<0.002, 95% Confidence Interval: 0.039-0.1258). The insertion-bundle compliance was 95.3% in the post- intervention period. Conclusions: According to the results the implementation of insertion bundle has the potential to reduce the incidence of Central-line-associated bloodstream infections. A prevention strategy targeted on the insertion of vascular access can decrease the incidence rates of Central-line-associated bloodstream in pediatric intensive care units.

B-PO05-093 VALIDATION OF A NEW ABLATION INDEX PROTOCOL FOR LEFT ATRIAL LINEAR ABLATION

Standardized contiguous and optimized radiofrequency ablation encircling ipsilateral pulmonary veins (PV) with high incidence of first-pass isolation has been established with the CLOSE protocol. In this study, we evaluated the acute outcome of a specific ablation index protocol for left atrial (LA) linear ablation. This prospective study comprised 81 patients (age: 67±14 y, male: 52 %) undergoing de-novo ablation for persistent atrial fibrillation (AF) or patients requiring substrate ablation beyond PV isolation. We hypothesized that point-by-point ablation with an ablation index of 600 for the anterior line and 500 for the roof line and an interlesion distance <6mm will result in a high rate of first-pass block. Touch-up ablation was performed in case of incomplete line block. Line integrity was evaluated with a high-density mapping catheter (Pentaray) and the coherent activation mapping tool (CARTO3 V7) during LAA pacing and differential pacing maneuver. First-pass block of the roof line was achieved in 70 (92 %) patients, while another 5 (7 %) patients required additional touch-up ablation to complete the line, resulting in a total of 75 (99 %) blocked roof lines. A first-pass anterior line block was observed in 47 (69 %) patients. An additional 17 (25 %) patients required touch-up ablation for block achievement, resulting in a total of 64 (94 %) blocked anterior lines. For the anterior line, the Bachmann bundle insertion was identified as the predominant location of gaps. The mean ablation index of roof line ablation was 512±14 and 610±13 in anterior line ablation. The mean overall procedure and fluoroscopy time was 136±30 min and 7.2±3.8 min, respectively. The mean RF ablation time for roof line was 8±5.4 min and for anterior line 14±5.9 min. Baseline rhythm was AF in 46 patients, which terminated by linear ablation in 19 (41%) patients. This new standardized Ablation Index protocol accomplishes first-pass block of left atrial linear lesions in the vast majority of patients. Furthermore, with additional touch-up ablation at gap sites, line block was achieved in almost all patients.

CT Scan Assessment of Femoral Tunnel Location in ACL Reconstruction Performed During Initial Phase of the Learning Curve

Introduction:During anterior cruciate ligament (ACL) reconstruction, femoral tunnelling is one of the most imperative stage. The success of surgical reconstructions of the ACL depends on the accurate restoration of its anatomy. The significance of the location of the hole drilled in femur has been repeatedly highlighted in ACL reconstruction. Incorrect tunnel placement is not infrequent, and even with diligent training, and aids, surgeons may still have difficulty in correctly positioning tunnels intra-operatively. Usually susceptible are surgeons in initial phase of the learning curve.Objective:To determine the susceptibility of surgeons in initial phase of learning curve while drilling femoral tunnel.Methods:All patients diagnosed with ACL rupture at a single institution between August 2018 and September 2019 were considered for the study. The surgeons who were relatively new out of their fellowship and training programmes (average of less than one years of independent practice) performed all surgical reconstructions, the number of reconstructions done independently was also taken into consideration (average of less than five independent procedures done before commencement of this study). We used anatomic free hand technique using bony and anatomic indicators as our markers, assisted by ruler, to drill femoral tunnel. Every subject had an 128 slice 3D CT-Scan done in immediate post-op period. High resolution 3-Dimensional view was created of the knee to evaluate the tunnel location. The position of the femoral tunnel was evaluated using the Bernard and Hertel quadrant method. The Femoral tunnel location was expressed in terms of its distance from the notch and posterior wall of condyle, the results were expressed in terms of percentage.Results:A net total of 32 patients were included who underwent single bundle ACL reconstruction. In our study, measurement of femoral tunnel placement was - depth 37.1% and height 24.6%, represented as percentage depth (deep to shallow (t)) and height (high to low (h)). Our results were compared with other established studies. The value of height was near to that mentioned in literature; whereas the value of depth was shallower (or distal) when compared to established literature with average location being 10.7% shallower (or distal) to anteromedial bundle insertion mentioned in study by Colombet et al and 4.8% shallower when compared to study by Zantop et al. When compared to study by Bernard and Hertel the location is 12.3% shallower. The reason for comparison with anteromedial bundle is that in single bundle anatomical reconstruction Pearle et al , Segawa et al and Simmons et al advocate it to be anteromedial.Conclusion:The surgeons in initial phase of their learning curve may be more prone to shallow (non anatomic) location of femoral tunnel during single bundle ACL reconstruction. We infer that this discrepancy in proximal (deep) to distal (shallow) orientation is due to fear of posterior wall blow out, that is the violation of the posterior femoral cortex, a known intraoperative complication in ACL reconstruction.

Tibial Spine Location Influences Tibial Tunnel Placement in Anatomical Single-Bundle Anterior Cruciate Ligament Reconstruction.

The purpose of this study was to assess the influence of tibial spine location on tibial tunnel placement in anatomical single-bundle anterior cruciate ligament (ACL) reconstruction using three-dimensional computed tomography (3D-CT). A total of 39 patients undergoing anatomical single-bundle ACL reconstruction were included in this study (30 females and 9 males; average age: 29 ± 15.2 years). In anatomical single-bundle ACL reconstruction, the tibial and femoral tunnels were created close to the anteromedial bundle insertion site using a transportal technique. Using postoperative 3D-CT, accurate axial views of the tibia plateau were evaluated. By assuming the medial and anterior borders of the tibia plateau as 0% and the lateral and posterior borders as 100%, the location of the medial and lateral tibial spine, and the center of the tibial tunnel were calculated. Statistical analysis was performed to assess the correlation between tibial spine location and tibial tunnel placement. The medial tibial spine was located at 54.7 ± 4.5% from the anterior border and 41.3 ± 3% from the medial border. The lateral tibial spine was located at 58.7 ± 5.1% from the anterior border and 55.3 ± 2.8% from the medial border. The ACL tibial tunnel was located at 34.8 ± 7.7% from the anterior border and 48.2 ± 3.4% from the medial border. Mediolateral tunnel placement was significantly correlated with medial and lateral tibial spine location. However, for anteroposterior tunnel placement, no significant correlation was found. A significant correlation was observed between mediolateral ACL tibial tunnel placement and medial and lateral tibial spine location. For clinical relevance, tibial ACL tunnel placement might be unintentionally influenced by tibial spine location. Confirmation of the ACL footprint is required to create accurate anatomical tunnels during surgery. This is a Level III; case-control study.

308 Comparison of Occupational Dose Levels during Traditional Right Ventricular, His Bundle and Biventricular Pacemaker Insertion

Background Pacemakers are implantable devices to sense and correct bradyarrhythmias. Recently there has been a move towards His bundle pacing(HBP) due to the potential improvement of clinical outcomes. There is a lack of literature examining the occupational dose implications of different pacing sites. Methods Radiation dose to the head of the operator, scrub, and scout nurse was measured in a prospective single-centre, observational study including PPM, HBP, and ICD (including CRT-D). Quantitative variables were compared using nonparametric tests (Friedman’s test and Wilcoxon’s test). Results Dose to staff and patients were highest during ICD implantations, and reached statistical significance when compared to other procedures for the scout(p=0.046), but demonstrated practical relevance to the cardiologist and scrub nurse. HBP resulted in a non-significant lower dose to the operator and scout nurse compared to RV pacing, but increased dose to the scrub nurse(p=0.063) and patient DAP(p=0.039).When the entire sample was considered, there was a statistically significant effect demonstrated for staff role(p=0.002) with the dose levels in descending order dr>scrub>scout. Pt BMI was shown to influence levels of dose (DAP and AK) to the patient(p=0.000) as well as to scrub and scout nurses(p=0.000) more so than operators.PtdoseDAP(Gy.cm2)AK(Gy/min)PPM 3.8 0.0415HBP 14 0.01ICD 28.62 0.198. Conclusion ICD insertion results in higher levels of staff and patient dose when compared to traditional PPM and HBP. Patient BMI influences occupational dose to nurses more than cardiologists. Staff role was significantly associated with occupational dose (p=0.002) with the dose levels in order dr>scrub>scout.

Determinants of Entheseal Anatomy: Body Size, Activity Level, or Developmental Vestige?

Entheses are sites of extreme mechanical stress, as soft, collagenous ligament inserts on to stiff bone. Fibrocartilaginous entheses display a four‐layered structure that progresses from ligament through unmineralized and mineralized fibrocartilage, and finally bone. This structure is hypothesized to minimize tension and compression at the insertion site by incorporating a stiffer material into the ligamentous midsubstance. Yet, little is known about the genetic (evolutionary) or environmental (plastic) entheseal responses of mineralized fibrocartilage to mechanical stimuli, including those associated with body size.We assessed differences in the microscopic anatomical structure of the anterior cruciate ligament insertion in seven species, including five primates (Gorilla, Pan, Pongo, Loris, Lemur, Leontopithecus, and Cercopiethecus) and two non‐primates (Panthera, Suricatta). We prepared decalcified histological sections at 7 micrometers and stained them using Safranin O and Fast Green. Mineralized fibrocartilage thickness was measured using scaled photomicrographs in ImageJ.Results of a standard linear regression of fibrocartilage thickness and body size indicate that there is no relationship between body size and average mineralized fibrocartilage thickness at either the femoral (R2= 0.04; F= 0.29; p= 0.61; eta2= .04) or tibial (R 2 =0.16; F = 1.283; p = 0.29; eta2= 0.16) insertion sites of the ACL. Additionally, there was no relationship between body size and maximum mineralized fibrocartilage thickness at either the femoral (R2= 0.01; F = 0.07; p = 0.8; eta2= 0.01) or tibial (R2= 0.28; F= 2.7; p = 0.14; eta2= 0.28) insertion sites.We also assessed regional differences in mineralized fibrocartilage thickness within the same insertion site, In order to compare fibrocartilage thickness between different regions of the femoral ACL enthesis, we conducted one‐way ANOVAs within each species. Significance was set at p= 0.05 The ligament was divided into anterior and posterior segments, as well as medial and lateral segments. We divided the ligament both based on a percentage of overall size (e.g., We took measurements at 0, 25%, 50%, 75%, and 100% of the antero‐posterior length of the ligament), as well as based on the division of the ligament into different anatomical portions (e.g., in the anteromedial bundle insertion vs. the posterolateral insertion). We were unable to detect differences in mineralized FC thickness in any of these areas.These data indicate that, despite the potential biomechanical advantage of substantial mineralized fibrocartilage thickness, in reality it is highly conserved relative to body size and mechanical environment. This suggests that this tissue may 1) be limited in thickness by avascularity; 2) exist in order to prevent communication between bone and ligamentous tissue; or 3) exist as a developmental consequence of unmineralized fibrocartilage at the ligament insertion site.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

A novel ablation approach in atrial fibrillation patients undergoing fibrotic-based substrate modification: Targeting the Bachmann's bundle?

Box isolation of fibrotic areas (BIFA) is a promising ablation approach for atrial fibrillation (AF) patients. However, complete isolation of fibrotic anteroseptal left atrial area, where Bachmann's bundle is blending into the left atrial myocardium, is very specific and complex. In 34 AF patients with anteroseptal fibrosis, circumferential BIFA was performed in addition to pulmonary vein isolation. In 8 of 34 patients, complete isolation of the fibrotic area was achieved with BIFA alone. In 26 of 34 patients, a decrease in voltage amplitude with or without conduction delay was observed after box ablation but no complete isolation. Activation mapping and characteristic unipolar potentials revealed earliest activation inside the box from one (73%), two (15%), or three (12%) remaining inputs, in the region of Bachmann's bundle insertion. Focal ablation inside the box (mean radiofrequency impulses: 1.7 ± 0.4, mean radiofrequency time: 70 ± 19 seconds) led to complete isolation of the fibrotic area in 25 of 26 patients. Overall, 97% of anteroseptal boxes were completely isolated with additional focal ablation in the study group compared to 21% in the control group with BIFA alone (33/34 vs. 7/34, P<0.001). Time of left atrial activation decreased significantly by 25% after complete box isolation (P<0.001). After a single procedure, 12-month arrhythmia-free survival was 82% with additional focal ablation compared to 71% in the control group (P = 0.2). Targeted and focal ablation in the region of Bachmann's bundle is a novel and feasible technique to achieve complete isolation of the left atrial anteroseptal fibrotic area.

Anterior cruciate ligament tibial insertion site is elliptical or triangular shaped in healthy young adults: high-resolution 3-T MRI analysis.

To clarify the morphology of anterior cruciate ligament (ACL) tibial insertion site in healthy young knees using high-resolution 3-T MRI. Subjects were 50 ACL-reconstructed patients with a mean age of 21.4±6.8years. The contralateral healthy knees were scanned using high-resolution 3-T MRI. The tibial insertion sites of the anteromedial (AM) and posterolateral (PL) bundle fibres, and the ACL attachment on the anterior horn of lateral meniscus (AHLM) were segmented from the MR images, and 3D models were reconstructed to evaluate the morphology. The shape of ACL footprint was qualitatively analysed, and the size of AM and PL attachments and AHLM overlapped area was measured digitally. Tibial AM and PL bundles were clearly identified in 42 of 50 knees (84.0%). Morphology of the whole ACL tibial insertion site was elliptical in 23 knees (54.8%) and triangular in 19 knees (45.2%), but not classified as C-shape in any knees. However, the AM bundle attachment was of C-shape in 29 knees (69.0%) and band-like in 13 knees (31.0%). Overlap of ACL on AHLM was found in 26 knees (61.9%), and the size of the overlapped area was 4.8±4.7% of the whole ACL insertion site. 3D morphology of the intact ACL tibial insertion site analysed by high-resolution 3-T MRI was elliptical or triangular in healthy young knees. However, the AM bundle insertion site was of C-shape or band-like. A small lateral portion of the ACL was overlapped with the AHLM. As for clinical relevance, these findings should be considered in order to reproduce the native ACL insertion site sufficiently. III.

Morphological size evaluation of the mid-substance insertion areas and the fan-like extension fibers in the femoral ACL footprint.

The purpose of this study was to evaluate the detailed anatomy of the femoral anterior cruciate ligament (ACL) insertion site, with special attention given to the morphology of the mid-substance insertion areas and the fan-like extension fibers. Twenty-three non-paired human cadaver knees were used (7 Males, 16 Females, median age 83, range 69-96). All soft tissues around the knee were resected except the ligaments. The ACL was divided into antero-medial (AM) and postero-lateral (PL) bundles according to the difference in macroscopic tension patterns. The ACL was carefully dissected and two outlines were made of the periphery of each bundle insertion site: those which included and those which excluded the fan-like extension fibers. An accurate lateral view of the femoral condyle was photographed with a digital camera, and the images were downloaded to a personal computer. The area of each bundle, including and excluding the fan-like extension fibers, was measured with Image J software (National Institution of Health). The width and length of the mid-substance insertion sites were also evaluated using same image. The femoral ACL footprint was divided into four regions (mid-substance insertion sites of the AM and PL bundles, and fan-like extensions of the AM and PL bundles). The measured areas of the mid-substance insertion sites of the AM and PL bundles were 35.5±12.5, and 32.4±13.8mm2, respectively. Whole width and length of the mid-substance insertion sites were 5.3±1.4, and 15.5±2.9mm, respectively. The measured areas of the fan-like extensions of the AM and PL bundles were 27±11.5, and 29.5±12.4mm2, respectively. The femoral ACL footprint was divided into quarters of approximately equal size (mid-substance insertion sites of the AM and PL bundles, and fan-like extensions of the AM and PL bundles). For clinical relevance, to perform highly reproducible anatomical ACL reconstruction, the presence of the fan-like extension fibers should be taken into consideration.

Three-Dimensional CT Evaluation of Tunnel Positioning in ACL Reconstruction Using the Single Anteromedial Bundle Biological Augmentation (SAMBBA) Technique.

Background:Remnant preservation may confer important advantages in the anterior cruciate ligament (ACL)–reconstructed knee. However, the presence of a large remnant may obscure visualization and impair the ability to correctly place tunnels during surgery.Purpose:To determine whether tunnel placement during anatomic ACL reconstruction using the single anteromedial bundle biological augmentation (SAMBBA) technique is consistent and precise when a large native remnant is preserved.Study Design:Case series; Level of evidence, 4.Methods:Included in this study were 99 patients undergoing an ACL reconstruction during which at least 50% of the native ACL was preserved. The femoral tunnel was created using an outside-in specific guide. The tibial tunnel was positioned in the anteromedial region of the ACL footprint, and the remnant was carefully preserved while drilling and passing the semitendinosus graft through it. Postoperatively, 3-dimensional computed tomography (3D CT) was used to evaluate tunnel placement. The mean tunnel locations were calculated and the standard deviation was used to evaluate precision of positioning. Inter- and intrareader agreement were determined to assess reliability of evaluation of tunnel position.Results:The center of the femoral tunnel was positioned at a mean 19.4% (SD, 2%) of the depth of the notch and a mean 23.1% (SD, 3.5%) of the lateral wall height. The center of the tibial tunnel was positioned at a mean 36.3% (SD, 3.8%) of the anteroposterior length of the tibial plateau and at a mean 47.0% (SD, 2.7%) of the mediolateral width. The small standard deviations demonstrate that this technique allows precise tunnel placement. The tunnel positions achieved were consistent with previous anatomic studies of femoral and tibial anteromedial bundle insertion. Intra- and interobserver reliability were high.Conclusion:Three-dimensional CT evaluation demonstrated that despite the presence of a large remnant, placement of femoral and tibial tunnels for anatomic ACL reconstruction using the SAMBBA technique is consistent and precise.

Sagittal femoral condyle morphology correlates with femoral tunnel length in anatomical single bundle ACL reconstruction.

The purpose of this study was to reveal the correlation between femoral tunnel length and the morphology of the femoral intercondylar notch in anatomical single bundle anterior cruciate ligament (ACL) reconstruction using three-dimensional computed tomography (3D-CT). Thirty subjects undergoing anatomical single bundle ACL reconstruction were included in this study (23 female, 7 male: average age 45.5 ± 16.7). In the anatomical single bundle ACL reconstruction, the femoral and tibial tunnels were created close to the antero-medial bundle insertion site with trans-portal technique. Using post-operative three-dimensional computed tomography (3D-CT), accurate axial and lateral views of the femoral condyle were evaluated. The correlation of femoral tunnel length, which was measured intra-operatively, with the transepicondylar length (TEL), notch width index, notch outlet length, the notch area (axial), length of Blumensaat's line, and the height and area of the lateral wall of the femoral intercondylar notch was statistically analyzed. Tunnel placement was also evaluated using a Quadrant method. The average femoral tunnel length was 35.4 ± 4.4mm. The average TEL, NWI, notch outlet length, and the axial notch area, were 76.9 ± 5.1mm, 29.1 ± 3.8%, 19.5 ± 3.9mm, and 257.4 ± 77.4mm2, respectively. The length of Blumensaat's line and the height and area of the lateral wall of the femoral intercondylar notch were 33.8 ± 3.2mm, 22.8 ± 2.3mm, and 738.7 ± 129mm2, respectively. The length of Blumensaat's line, the height, and the area of the lateral wall of the femoral intercondylar notch were significantly correlated with femoral tunnel length. Femoral tunnel placement was 23.4 ± 4.5% in a shallow-deep direction and 35.4 ± 8.8% in a high-low direction. The length of Blumensaat's line, height, and area of the lateral wall of the femoral intercondylar notch are correlated with femoral tunnel length in anatomical single bundle ACL reconstruction. For clinical relevance, these parameters are useful in predicting the length of the femoral tunnel in anatomical single bundle ACL reconstruction for the prevention of extremely short femoral tunnel creation. Case controlled study, Level III.

In vivo posterior cruciate ligament elongation in running activity after anatomic and non-anatomic anterior cruciate ligament reconstruction.

The goals of this study were to (1) investigate the in vivo elongation behaviour of the posterior cruciate ligament (PCL) during running in the uninjured knee and (2) evaluate changes in PCL elongation during running after anatomic or non-anatomic anterior cruciate ligament (ACL) reconstruction. Seventeen unilateral ACL-injured subjects were recruited after undergoing anatomic (n=9) or non-anatomic (n=8) ACL reconstruction. Bilateral high-resolution CT scans were obtained to produce 3D models. Anterolateral (AL) and posteromedial (PM) bundles insertion sites of the PCL were identified on the 3D CT scan reconstructions. Dynamic knee function was assessed during running using a dynamic stereo X-ray (DSX) system. The lengths of the AL and PM bundles were estimated from late swing through mid-stance. The contralateral knees served as normal controls. Control knees demonstrated a slight decrease in AL bundle and a significant decrease in PM bundle length following foot strike. Length and elongation patterns of the both bundles of the PCL in the anatomic ACL reconstruction group were similar to the controls. However, the change in dynamic PCL length was significantly greater in the non-anatomic group than in the anatomic reconstruction group after foot strike (p<0.05). The AL bundle length decreased slightly, and the PM bundle length significantly decreased after foot strike during running in uninjured knees. Anatomic ACL reconstruction maintained normal PCL elongation patterns more effectively than non-anatomic ACL reconstruction during high-demand, functional loading. These results support the use of anatomic ACL reconstruction to achieve normal knee function in high-demand activities. Case-control study, Level III.

The evaluation of muscle recovery after anatomical single-bundle ACL reconstruction using a quadriceps autograft.

The purpose of this study was to reveal the degree of muscle recovery and report the clinical results of anatomical single-bundle ACL reconstruction using a quadriceps autograft. Twenty subjects undergoing anatomical single-bundle ACL reconstruction using a quadriceps autograft were included in this study. A 5-mm-wide, 8-cm-long graft, involving the entire layer of the quadriceps tendon, was harvested without bone block. The average graft diameter was 8.1±1.4mm. An initial tension of 30N was applied. The femoral tunnel was created from the far-medial portal. Each femoral and tibial tunnel was created close to the antero-medial bundle insertion site. For the evaluation of muscle recovery (quadriceps and hamstring), a handheld dynamometer was used. The evaluation of muscle recovery was performed pre-operatively, and at 3, 6, 9, and 12months after surgery. Muscle recovery data were calculated as a percentage of leg strength in the non-operated leg. Anterior tibial translation (ATT), pivot shift test, and IKDC score were evaluated. The average quadriceps strength pre-operatively, and at 3, 6, 9, and 12months after ACL reconstruction was 90.5±19, 67.8±21.4, 84±17.5, and 85.1±12.6%, respectively. The average hamstring strength pre-operatively, and at 3, 6, 9, and 12months after ACL reconstruction was 99.5±13.7, 78.7±11.4, 90.5±19, and 96.7±13.8%, respectively. ATT pre-operatively and at 12months after surgery was 5.4±1.3 and 1.0±0.8mm, respectively. No subjects exhibited positive pivot shift after surgery. Within 6months following surgery, quadriceps hypotrophy was observed in all subjects. However, the hypotrophy had recovered at 12months following surgery. No subjects complained of donor site pain after surgery. Anatomical single-bundle ACL reconstruction using a quadriceps autograft resulted in equivalent level of muscle recovery and knee stability when compared with previously reported ACL reconstruction using hamstrings tendon with no donor site complications. Case controlled study, Level III.

Effectiveness of insertion and maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis

Central-line-associated bloodstream infections (CLABSIs) are a major problem in intensive care units (ICUs) worldwide. We aimed to quantify the effectiveness of central-line bundles (insertion or maintenance or both) to prevent these infections. We searched Embase, MEDLINE OvidSP, Web-of-Science, and Cochrane Library to identify studies reporting the implementation of central-line bundles in adult ICU, paediatric ICU (PICU), or neonatal ICU (NICU) patients. We searched for studies published between Jan 1, 1990, and June 30, 2015. For the meta-analysis, crude estimates of infections were pooled by use of a DerSimonian and Laird random effect model. The primary outcome was the number of CLABSIs per 1000 catheter-days before and after implementation. Incidence risk ratios (IRRs) were obtained by use of random-effects models. We initially identified 4337 records, and after excluding duplicates and those ineligible, 96 studies met the eligibility criteria, 79 of which contained sufficient information for a meta-analysis. Median CLABSIs incidence were 5·7 per 1000 catheter-days (range 1·2-46·3; IQR 3·1-9·5) on adult ICUs; 5·9 per 1000 catheter-days (range 2·6-31·1; 4·8-9·4) on PICUs; and 8·4 per 1000 catheter-days (range 2·6-24·1; 3·7-16·0) on NICUs. After implementation of central-line bundles the CLABSI incidence ranged from 0 to 19·5 per 1000 catheter-days (median 2·6, IQR 1·2-4·4) in all types of ICUs. In our meta-analysis the incidence of infections decreased significantly from median 6·4 per 1000 catheter-days (IQR 3·8-10·9) to 2·5 per 1000 catheter-days (1·4-4·8) after implementation of bundles (IRR 0·44, 95% CI 0·39-0·50, p<0·0001; I(2)=89%). Implementation of central-line bundles has the potential to reduce the incidence of CLABSIs. None.

The correlation of femoral tunnel length with the height and area of the lateral wall of the femoral intercondylar notch in anatomical single-bundle ACL reconstruction.

The purpose of this study was to reveal the correlation between femoral tunnel length and the height and area of the lateral wall of the femoral intercondylar notch in anatomical single-bundle anterior cruciate ligament (ACL) reconstruction . Twenty-four subjects undergoing anatomical single-bundle ACL reconstruction were included in this study (19 females and 5 males; average age 45.5±16.7). In the anatomical single-bundle ACL reconstruction, the femoral and tibial tunnels were created close to the anteromedial bundle insertion site. Using post-operative three-dimensional computed tomography (3D-CT), an accurate lateral view of the femoral condyle was evaluated. The correlation of femoral tunnel length, which was measured intra-operatively, with the length of Blumensaat's line, and the height and area of the lateral wall of the femoral intercondylar notch was statistically analysed. Tunnel placement was also evaluated using 3D-CT (Quadrant method). The average femoral tunnel length was 35.3±4.9mm. The length of Blumensaat's line, and the height and area of the lateral wall of the femoral intercondylar notch were 33.6±3.4, 22.8±2.4, and 734.6±136mm2, respectively. Both the height and the area of the lateral wall of the femoral intercondylar notch were significantly correlated with femoral tunnel length. Femoral tunnel placement was 24.1±3.9% in a shallow-deep direction, and 33.5±7.7% in a high-low direction. The height and area of the lateral wall of the femoral intercondylar notch are correlated with femoral tunnel length in anatomical single-bundle ACL reconstruction. For clinical relevance, surgeons should be careful not to make the femoral tunnel too short in knees in which the femoral intercondylar notch is low in height or small in size. Case-controlled study, Level III.

Behavior of the multidisciplinary team about Bundle of Central Venous Catheter in Intensive Care

Objective: To analyze the behavior of nursing and medical staff related to Bundle insertion and good practices in the management of Central Venous Catheter. Methods: Analytical cross-sectional study conducted from June to September 2014. It was applied a questionnaire to 76 professionals of a sector of intensive care. Performed descriptive statistics and odds ratio to evaluate the association. Results: In the pre-catheter insertion was 1.6 higher risk of antiseptic cleaning procedures of the hands and choice of vein to be punctured be questioned, if not met the current recommendations, if accompanied by a top level professional. In the maintenance of the catheter, the assessment of daily permanence was presented 12 times greater risk of being realized through higher education professionals (p < 0.05). Conclusion: Was demonstrated need for improved assistance. New studies on infection prevention and multidisciplinary team educational programs can contribute to this.