Fluoroscopic Control Research Articles

An Unusual Complication Seen in a Six-Year-Old Girl Treated with Open Reduction and Pemberton Osteotomy for Neglected Developmental Dysplasia of the Hip: A Femoral Neck Fracture Sustained during Passive Motion under General Anesthesia.

Despite the screening programs for newborn children with hip ultrasonography, neglected developmental dysplasia of the hip (DDH) is still continuing to be a problem in the east and southeast parts of our country. The main complications are redislocation, avascular necrosis, and joint stiffness. We present an unusual complication, femoral neck fracture during passive motion under general anesthesia, of a six-year-old girl with neglected DDH treated by open reduction and Pemberton osteotomy without femoral shortening. The fracture was treated by open reduction and internal fixation combined with proximal femoral shortening. After 5 years the patient had excellent clinical results, no avascular necrosis was seen, and the radiologic appearance was type IA according to modified Severin classification. In conclusion older children with neglected DDH are more likely to have joint stiffness after open reduction. If there is even a little doubt about joint stiffness after open reduction, one should not refrain from femoral shortening. Also passive motion under general anesthesia should be applied very carefully with fluoroscopic control.

Retrieval-balloon-assisted enterography for ERCP after Billroth II gastroenterostomy and Braun anastomosis.

To describe an optimal route to the Braun anastomosis including the use of retrieval-balloon-assisted enterography. Patients who received a Billroth II gastroenterostomy (n = 109) and a Billroth II gastroenterostomy with Braun anastomosis (n = 20) between January 2009 and May 2013 were analyzed in this study. Endoscopic retrograde cholangiopancreatography (ERCP) was performed under fluoroscopic control using a total length of 120 cm oblique-viewing duodenoscope with a 3.7-mm diameter working channel. For this procedure, we used a triple-lumen retrieval balloon catheter in which a 0.035-inch guidewire could be inserted into the "open-channel" guidewire lumen while the balloon could be simultaneously injected and inflated through the other 2 lumens. For the patients with Billroth II gastroenterostomy and Braun anastomosis, successful access to the papilla was gained in 17 patients (85%) and there was therapeutic success in 16 patients (80%). One patient had afferent loop perforation, but postoperative bleeding did not occur. For Billroth II gastroenterostomy, there was failure in accessing the papilla in 15 patients (13.8%). ERCP was unsuccessful because of tumor infiltration (6 patients), a long afferent loop (9 patients), and cannulation failure (4 patients). The papilla was successfully accessed in 94 patients (86.2%), and there was therapeutic success in 90 patients (82.6%). Afferent loop perforation did not occur in any of these patients. One patient had hemorrhage 2 h after ERCP, which was successfully managed with conservative treatment. Retrieval-balloon-assisted enterography along an optimal route may improve the ERCP success rate after Billroth II gastroenterostomy and Braun anastomosis.

Intraoperative three-dimensional fluoroscopy after transpedicular positioning of Kirschner-wire versus conventional intraoperative biplanar fluoroscopic control: A retrospective study of 345 patients and 1880 pedicle screws.

Study Design:Retrospective study.Objective:The aim was to find out whether intraoperative three-dimensional imaging after transpedicular positioning of Kirschner wire (K-wire) in lumbar and thoracic posterior instrumentation procedures is of benefit to the patients and if this technique is accurately enough to make a postoperative screw position control through computer tomography (CT) dispensable.Patients and Methods:Lumbar and thoracic posterior instrumentation procedures conducted at our department between 2002 and 2012 were retrospectively reviewed. The patients were divided into two groups: group A, including patients who underwent intraoperative three-dimensional scan after transpedicular positioning of the K-wire and group B, including patients who underwent only intraoperative biplanar fluoroscopy. An early postoperative CT of the instrumented section was done in all cases to assess the screw position. The rate of immediate intraoperative correction of the K-wires in cases of mal-positioning, as well as the rate of postoperative screw revisions, was measured.Results:In general, 345 patients (1880 screws) were reviewed and divided into two groups; group A with 225 patients (1218 screws) and group B with 120 patients (662 screws). One patient (0.44%) (one screw [0.082%]) of group A underwent postoperative screw correction while screw revisions were necessary in 14 patients (11.7%) (28 screws [4.2%]) of group B. Twenty-three patients (10.2%) (28 K-wires [2.3%]) of group A underwent intraoperative correction due to primary intraoperative detected K-wire mal-position. None of the corrected K-wires resulted in a corresponding neurological deficit.Conclusion:Three-dimensional imaging after transpedicular K-wire positioning leads to solid intraoperative identification of misplaced K-wires prior to screw placement and reduces screw revision rates compared with conventional fluoroscopic control. When no clinical deterioration emerges, a postoperative CT seems to be dispensable using this intraoperative three-dimensional control method.

Vertebroplasty Using Calcium Triglyceride Bone Cement (Kryptonite™) for Vertebral Compression Fractures. A Single-Centre Preliminary Study of Outcomes at One-Year Follow-up.

This study assessed the one-year clinical and radiographic outcomes, in terms of pain-relief, vertebral re-fracture and complications, after vertebroplasty (VP) using a new osteoconductive cement (calcium triglyceride bone cement - Kryptonite™ bone cement, Doctors Research Group Inc., Southbury, CT, USA) to treat osteoporotic vertebral compression fractures. Sixteen consecutive osteoporotic patients (12 women and four men, mean age 68+/-10.5) were treated with VP using Kryptonite™ bone cement for a total of 20 vertebral fractures. All the patients complained of a pain syndrome resistant to medical therapy and all procedures were performed under fluoroscopy control with neuroleptoanalgesia using a monopedicular approach in 12 patients and bipedicular approach in four patients. All patients were studied by MR and MDCT and were evaluated with the visual analogue scale (VAS) and the Oswestry disability index (ODI) before treatment and at one and 12 months after the procedure. A successful outcome was observed in 80% of patients, with a complete resolution of pain. Differences in pre and post treatment VAS and ODI at one-year follow-up were significant (P<0.0001). We observed a disk and venous leakage in 66% of patients but only in one case did an asymptomatic pulmonary embolism occur during cement injection. Two cases of vertebral re-fractures at distant metamers were observed during follow-up. VP using Kryptonite bone cement is a helpful procedure that allows complete and long-lasting resolution of painful vertebral symptoms. The cost of the material is very high and the rate of disk and venous leakage is too high compared to standard cement.

Orthopedic approach to foreign body injuries

Objective: Although foreign body injuries are quite common, there are an insufficient number of publications on this matter. The aim of this study was to evaluate patients with foreign body injuries, and to determine the treatment algorithm. Methods: A total of 97 patients were evaluated, including 53 men and 44 women. Ninety-one patients underwent surgery, and six patients were treated conservatively. Surgery was performed in the operating room in all cases. To ensure that the foreign body was removed, fluoroscopic control was completed during and after the procedure. Antibiotics were administered routinely to all patients, and the need for tetanus prophylaxis was evaluated in each patient. Results: The mean age of the patients was 16.5 (range: 2-58) years. Regarding the type of foreign body, there was injury due to: a needle in 65 patients, glass in 14, wood in 7, iron spit in 1, iron bar in 1, pieces of metal in 3, and other foreign bodies were found in 6 patients. There were 25 injuries of the upper extremity, and 72 of the lower extremity. The time of admission to the hospital after the injury ranged from 1 day to 3 years. Obvious signs of infection were detected in 10 patients. There were no complications after the follow-up of patients who were treated conservatively. Conclusion: Foreign body penetration is a severe injury that may cause significant problems when ignored. Treatment algorithms prepared according to the type of injury would guide the most appropriate approach to these injuries.

Medial Hip Arthroscopy Portals: An Anatomic Study

The main objective of this study was to investigate medial hip portals and evaluate their relation with anatomic structures in a cadaveric model. Placement of 3 medial arthroscopic portals was simulated in 10 fresh human paired cadaveric hip specimens by placing Steinmann pins into the joint under fluoroscopic control. Two portals were made at the groin, 1 anterior and 1 posterior to the adductor longus muscle, and the third portal was placed posterior to the adductor longus muscle, 5 cm distal to the groin. The specimens were then dissected, and the relation of the portals to the following structures was recorded: pectineus, adductor longus, gracilis, adductor brevis, adductor magnus, iliopsoas tendon, obturator nerve, femoral nerve, femoral artery, femoral vein, and profunda femoris artery. Regarding the anteromedial portal, the closest neurovascular structure was the profunda femoris artery, which was 10.4 ± 2.7 mm (range, 6 to 14 mm) distal to the portal. Regarding the posteromedial portal, the nearest neurovascular structure was the obturator nerve, which was 6.0 ± 3.6 mm (range, 2 to 13 mm) posterior to the portal. Regarding the distal posteromedial portal, the nearest neurovascular structures were the obturator nerve, which was 4.6 ± 3.0 mm (range, 1 to 9 mm) distal to the portal, and the profunda femoris artery, which was 10.5 ± 3.9 mm (range, 6 to 17 mm) distal to the portal. The use of the medial portals did not cause any damage to the neurovascular structures evaluated. Despite this, the portals are in close relation to the obturator nerve and profunda femoris, and care should be taken. This study investigated 3 medial hip portals in a cadaveric model and also defined safety parameters for this approach. Medial hip portals may be useful to directly approach medial hip pathologies.

Proksimal humerus kırıklarının osteosentezinde vida boyunun sondaj tekniği ile ölçülmesi

This study aims to investigate the efficacy of screw length measurement through drilling technique on the reduction of intraarticular screw penetration and fluoroscopy time in osteosynthesis of proximal humerus fractures. Between January 2008 and June 2012, 98 patients (34 males, 64 females; mean age 64.4 years; range 35 to 81 years) who underwent osteosynthesis using locking anatomical proximal humerus plates (PHILOS) in our clinic with the diagnosis of Neer type 2, 3 or 4 were included. Two different surgical techniques were used to measure proximal screw length in the plate and patients were divided into two groups based on the technique used. In group 1, screw length was determined by a 3 mm blunt tipped Kirschner wire without fluoroscopic control. In group 2, bilateral fluoroscopic images for each screw at least were obtained. Intraarticular screw penetration was detected in five patients (10.6%) in group 1, and in 19 patients (37.3%) in group 2. The mean fluoroscopic imaging time was 10.6 seconds in group 1 and 24.8 seconds in group 2, indicating a statistically significant difference. Screw length measurement through the drilling technique significantly reduces the intraarticular screw penetration and fluoroscopy time in osteosynthesis of proximal humerus fractures using PHILOS plates.

An Obliquely Placed Headless Compression Screw for Distal Interphalangeal Joint Arthrodesis

To assess the outcomes of our technique involving oblique headless compression screw for arthrodesis of the thumb interphalangeal joint and the distal interphalangeal joints of the other digits. A total of 28 joints (19 thumb interphalangeal and 9 distal interphalangeal) in 23 patients with a mean age of 65 years (range, 58-74 y) were retrospectively analyzed. All operations were performed with the Acutrak2 micro-screw. After the resection of synovium and joint cartilage by a dorsal approach, a 0.88-mm diameter guide wire was inserted at the ulnar side of the proximal phalanx in the thumb and radial side of the middle phalanx in the other digits from proximal to distal to fix the joint obliquely. We verified its position under fluoroscopic control and placed the cannulated screw from proximal to distal over the guide wire. Intraoperative rigid fixation was obtained except for 1 case, which required additional K-wire fixation. The overall union rate was 96%. Average time to fusion was 11 weeks (range, 8-30 wk), with 76% achieving union within 3 months. There were 2 complications, 1 nonunion and 1 late infection. Other complications such as dorsal skin necrosis, nail deformity, and paresthesia did not occur. Efforts to avoid invasion of the nailbed can be technically demanding. We believe that our proximal to distal technique with oblique placement of the headless compression screw is a straightforward and effective method with a relatively low risk of complication. Therapeutic IV.

Role of Radiographic Hysterosalpingography in Infertility in Eastern Nepal

Background: Hysterosalpingography (HSG) is the radiographic technique for evaluation of uterine cavity and fallopian tubes. It still remains the best imaging procedure for fallopian tubes despite the advent of newer modalities and is used primarily for the evaluation of female infertility.1,2 The purpose of the study was to assess the uterine and tubal abnormalities detected on radiographic HSG as causative factors of infertility and to describe their imaging features. Methods: This prospective cross sectional study was conducted at the Department of Radiodiagnosis and Imaging, BPKIHS, Dharan. Forty-four patients with infertility (both primary and secondary) referred for HSG were included. HSG was performed using non-ionic contrast medium under image intensifier fluoroscopic control during the follicular phase of menstrual cycle. Radiographic films were obtained and analyzed. Results: Out of the total 44 patient, 26 (59.0%) had primary infertility while 18 (41.0%) had secondary infertility. Tubal abnormalities were seen in 28 (63.6%) and uterine abnormalities in 2 (4.6%) patients. The most common tubal abnormality detected on HSG was tubal block (50.0%). Unilateral and bilateral tubal blocks were equally distributed (50.0% each). Proximal tubal block was observed in 8 (36.4%) and distal in 13 (59.1%) patients. Fifteen (34.1%) patients had hydrosalpinx. Conclusion: HSG is easy, safe, and cost-effective and plays vital role in the evaluation of female with infertility. The most common structural cause of female infertility found as per this study was tubal block. Nepalese Journal of Radiology / Vol.3 / No.1 / Issue 4 / Jan-June, 2013 / 59-66 DOI: http://dx.doi.org/10.3126/njr.v3i1.8810

Endoscopic Ultrasonography-Guided Pancreatic Pseudocysts Drainage

Purpose: Endoscopic Ultrasonography (EUS)- Guided Pancreatic Pseudocyst (PPC)Drainage has been shown to improve safety of PPC endoscopic drainage, and increases the number of patients suitable for this procedure by avoiding percutaneous and surgical drainage, both associated with higher morbility and mortality. We have analysed on performance in EUS guided PPC drainage to evaluate its applicability in the clinical algorithm of PPC treatment. Methods: Retrospective analysis of 37 consecutive EUS guided PPC drainage in 2 years period. They were performed by 2 senior endoscopists, under fluoroscopic control, with Olympus linear GF-UCT 140 and Aloka Prosound α 5 SU, using the Echotip Ultra needles (Cook Medical). Results: There were 37 drainages of PPC with transgastric approach in 90%. The average age was 52±13 years and 53% were male. In 58% of cases PPC were located in the cephalopancreatic region, 26% in the body, 13% on the tail and 3% (1 case) in the unciform process. The average size of the lesions was 37± 22 mm. There have been 3 complications: a gastrointestinal bleeding, surgically managed, and 2 pneumoperitoneum in the immediate procedure. There were 2 patients that needed further surgical treatment for PPC recurrence, and no case of postprocedure infection. Conclusion: EUS-guided PPC drainage proved to be a feasible and safe technique for the management of a potential troublesome condition.

Transesophageal H-Type TEF Evaluation and Cannulation Using a Side-Viewing Flexible Endoscope: A Novel Technique for Guidewire Placement and Repair

Introduction: Congenital tracheoesophageal fistula without esophageal atresia (H-type TEF) is an unusual entity that typically presents in the first months of life with clinical signs of aspiration. Surgical repair is usually facilitated by placement of a catheter or wire through the fistula during rigid bronchoscopy.1,2 This cannulation allows the surgeon to identify the fistula during dissection of the neck.3 We describe a case of H-type TEF in which, the fistula could not be identified on rigid bronchoscopy, but was only visible on esophagoscopy. Cannulation of the fistula was therefore achieved using video esophagoscopy. The video depicts the placement of the guidewire under a video esophagoscope using an ultraslim (pediatric) side-viewing duodenoscope. Fluoroscopic images confirming fistula cannulation are also shown. The video runtime is 1:44. Materials and Methods: The patient is a male born prematurely at 34 weeks, birth weight 2.0 kg. Respiratory distress was noted on the first day of life and a contrast study revealed the H-type TEF. Rigid bronchoscopy failed to identify the fistula. The fistula was noted on rigid esophagoscopy, but could not be cannulated given the acute angle of the fistulous opening on the esophageal side. A repeat procedure was undertaken with video esophagoscopy. The forward-view endoscope, Olympus N180 (Olympus Medical), was used for initial examination and determination of the fistula position within the esophagus. Once the exact measurement was obtained, an Olympus PGF160 (Olympus Medical) was introduced transorally and advanced to the predetermined depth within the esophagus. The H-type fistula opening was identified and cannulated using a slim (5F) tapered ERCP cannula (Mini-Tome; Wilson-Cook). A 0.018-inch soft GI guidewire (Pathfinder wire) (Boston Scientific) was then placed through the ERCP cannula. The wire placement was done under video and fluoroscopic control. The tip of the guidewire crumpled on the bronchial side of the fistula and was felt to be too flexible and soft, so it was exchanged for a 0.021-inch guidewire (Wilson-Cook). The surgical repair was then performed with the guidewire in place. Results and Conclusions: Primary repair of an H-type TEF is usually aided by placing a cannula or guidewire through the fistula under bronchoscopy. In this case, failure to place a wire was due to high takeoff of the fistula within the hypopharynx and difficulty visualizing the opening from the tracheal side. Transesophageal evaluation and guidewire placement using a side-viewing duodenoscope was undertaken and was successful. Placement was relatively smooth and atraumatic when compared with rigid bronchoscopy. This index case validates the use of this technique. Expanded experience with this technique would be needed to clarify questions regarding safety and reproducibility. In complex cases with difficult fistula cannulation during bronchoscopy, this technique offers another option for TEF guidewire placement before repair. No competing financial interests exist. Runtime of video: 1 min and 44 secs

Insertion of distal locking screws of tibial intramedullary nails: A comparison between the free-hand technique and the SURESHOT™ Distal Targeting System

IntroductionPositioning of the distal locking screws of an intramedullary nail is often challenging and time consuming because of difficult localisation of the distal locking holes, potential screw malalignment and nail deformation during insertion. The standard free-hand technique under fluoroscopic control involves considerable radiation exposure of both the patient and the surgical team. In this study, we aimed to compare the free-hand technique with a new system that utilises electromagnetic (EM) tracking data (SURESHOT™ Distal Targeting System) to localise distal locking holes. Material and methodsPatients admitted from March 2010 to January 2013 for tibial fracture that required intramedullary nailing were analysed retrospectively. We compared intraoperative radiation exposure time and distal locking time in patients treated with the standard free-hand technique and distal locking using the EM field-generating device. Intraoperative radiation exposure time and distal locking time were used for comparison. ResultsData from a total of 50 patients were analysed. The standard free-hand technique and the EM field-generating device were used in 25 (group 1) and 25 (group 2) patients, respectively. Mean distal locking time was 1258.6 (450–2289) s in group 1 and 603.5 (360–1140)s in group 2. Mean radiation exposure time was 19.4 (6–33) s in group 1 and 4.6 (1–10) s in group 2. ConclusionThe EM field-generating device significantly reduces distal locking time and, more importantly, significantly decreases duration of exposure to ionising radiation.

Patient radiation exposure during different kyphoplasty techniques

The scope of this study was to quantify patient radiation exposure during two different techniques of kyphoplasty (KP), which differ by a cement delivery method, in order to assess whether or not one of the two used methods can reduce the patient dose. Twenty patients were examined for this investigation. One X-ray fluoroscopy unit was used for localization, navigation and monitoring of cement delivery. The patient biometric data, the setting of the fluoroscope, the exposure time and the kerma-area product (KAP) were monitored in all the procedures for anteroposterior (AP) and lateral (LL) fluoroscopic projections in order to assess the range of radiation doses imparted to the patient. Theoretical entrance skin dose (ESD) and effective dose (E) were calculated from intraoperatively measured KAP. An average ET per procedure was 1.5±0.5 min for the manual injection technique (study A) and 1.4±0.4 min for the distance delivery technique (study B) in the AP plane, while 3.2±0.7 and 5.1±0.6 min in the lateral plane, respectively. ESD was estimated as an average of 0.10±0.06 Gy for study A and 0.13±0.13 Gy for study B in the AP or/and 0.59±0.46 and 1.05±0.36 Gy in the lateral view, respectively. The cumulative mean E was 1.9±1.0 mSv procedure(-1) for study A and 3.6±0.9 mSv procedure(-1) for study B. Patient radiation exposure and associated effective dose from KP may be considerable. The technique of distance cement delivery appears to be slower than the manual injection technique and it requires a more protracted fluoroscopic control in the lateral projection, so that this system entails a higher amount of dose to the patient.

Percutaneous Microballoon Compression for Trigeminal Neuralgia Using Dyna-CT

Percutaneous microballoon compression (PMC) is a well-established technique for treatment of trigeminal neuralgia (TN). However, direct puncture of the foramen ovale (FO) is sometimes difficult and there have been well-reported complications from cannulating the FO. We describe our experiences in using Dyna-CT for cannulating the FO and determining balloon position and volume. Dyna-CT was used to perform image reconstruction in 21 cases. The optimal working projection was generated and further fluoroscopic data were used to determine the needle's relationship to the foramen during puncture. Furthermore, the balloon position and three-dimensional shape were verified by Dyna-CT during balloon compression. The balloon volume and puncture angle were further calculated. Patients' prognosis was further discussed. Dyna-CT allowed quick, safe, and easy cannulation of the FO. It provided three-dimensional images which were more elaborate than the classic 'pear-shaped' images for determining correct positioning in 21 cases. The volume of the flattened balloon ranged from 568.2 mm(3) to 891.4 mm(3) with an average of 775.9 mm(3). The angle of introducing the cannula ranged from 15.17°-35.48° rotation to the midline with an average of 26.24° and 38.47°-51.89° angulation to the Reid line with an average of 46.09°. All the patients were pain free after PMC. Four patients had resolvable masseter weakness and fine touch loss. There was no recurrence of TN during follow-up. Dyna-CT demonstrated three advantages in assisting PMC. Firstly, the FO can be better visualized irrespective of the patient's position. Secondly, needle correction or insertion can be performed much more easily because of the direct fluoroscopic control. Thirdly, the needle position, balloon position, balloon configuration and the volume of the inflated balloon are more reliably determined. The use of dyna-CT provided an assisted method to PMC with a low incidence of complications and good prognosis.

Cement-augmented anterior screw fixation of Type II odontoid fractures in elderly patients with osteoporosis

Background contextClosed reduction and internal fixation by an anterior approach is an established option for operative treatment of displaced Type II odontoid fractures. In elderly patients, however, inadequate screw purchase in osteoporotic bone can result in severe procedure-related complications. PurposeTo improve the stability of odontoid fracture screw fixation in the elderly using a new technique that includes injection of polymethylmethacrylat (PMMA) cement into the C2 body. Study designRetrospective review of hospital and outpatient records as well as radiographs of elderly patients treated in a university hospital department of orthopedic surgery. Patient sampleTwenty-four elderly patients (8 males and 16 females; mean age, 81 years; range, 62–98 years) with Type II fractures of the dens. Outcome measuresComplications, cement leakage (symptomatic/asymptomatic), operation time, loss of reduction, pseudarthrosis and revision surgery, patient complaints, return to normal activities, and signs of neurologic complications were all documented. MethodsAfter closed reduction and anterior approach to the inferior border of C2, a guide wire is advanced to the tip of the odontoid under biplanar fluoroscopic control. Before the insertion of one cannulated, self-drilling, short thread screws, a 12 gauge Yamshidi cannula is inserted from anterior and 1 to 3 mL of high-viscosity PMMA cement is injected into the anteroinferior portion of the C2 body. During polymerization of the cement, the screws are further inserted using a lag-screw compression technique. The cervical spine then is immobilized with a soft collar for 8 weeks postoperatively. ResultsAnatomical reduction of the dens was achieved in all 24 patients. Mean operative time was 64 minutes (40–90 minutes). Early loss of reduction occurred in three patients, but revision surgery was indicated in only one patient 2 days after primary surgery. One patient died within the first eight postoperative weeks, one within 3 months after surgery. In five patients, asymptomatic cement leakage was observed (into the C1–C2 joint in three patients, into the fracture in two). Conventional radiologic follow-up at 2 and 6 months confirmed anatomical healing in 16 of the19 patients with complete follow-up. In two patients, the fractures healed in slight dorsal angulation; one patient developed a asymptomatic pseudarthrosis. All patients were able to resume their pretrauma level of activity. ConclusionsCement augmentation of the screw in Type II odontoid fractures in elderly patients is technically feasible in a clinical setting with a low complication rate. This technique may improve screw purchase, especially in the osteoporotic C2 body.

Stem Cell–based Therapy for Prevention of Delayed Fracture Union: A Randomized and Prospective Preliminary Study

Distal tibial fractures tend towards delayed- or nonunion. The purpose of this study was to evaluate the safety and efficacy of early minimally invasive intervention (MII) in the treatment of these fractures. A total 24 consecutive patients who underwent operative treatment for distal tibial fractures were randomized into a control and an intervention group. MII entailed aspirating iliac crest bone marrow and peripheral blood, yielding mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP) respectively, that were mixed with demineralized bone matrix (DBM) and injected under fluoroscopic control into the fracture site. No complications occurred in either group. The median time to union was 1.5 months in the MII group and 3 months in the control group. MII was found to be a safe and efficient procedure.

Dyna-CT-assisted percutaneous microballoon compression for trigeminal neuralgia

BackgroundPercutaneous microballoon compression (PMC) for trigeminal neuralgia (TN) is a well-established technique. However, complications from cannulating the foramen ovale (FO) have been reported because direct puncture of the FO is...

Integrated flat detector CT and live fluoroscopic-guided external ventricular drain placement within the neuroangiography suite

PurposeTo demonstrate the feasibility of the application of integrated flat detector (FD) CT and fluoroscopic guidance (iGuide) for the placement of external ventricular drains (EVD) within the neuroangiography suite.MethodsA retrospective...

Percutaneous Vertebral Augmentation Assisted by PEEK Implant in Painful Osteolytic Vertebral Metastasis Involving the Vertebral Wall: Experience on 40 Patients

Background: Vertebral metastases are associated with significant pain, disability, and morbidity. Open surgery for fracture stabilization is often inappropriate in this cancer population due to a poor risk-benefit profile, particularly if life expectancy is short. Vertebroplasty and kyphoplasty are appealing adjunctive procedures in patients with malignancy for alleviation of intractable pain. However, these patients have a higher risk of serious complications, notably cement extravasation. Study Design: We prospectively evaluated clinical results of polyetheretherketone (PEEK) implant (Kiva) assisted vertebroplasty performed in malignant painful osteolytic lesions at risk for cement extravasation due to vertebral wall involvement. Setting: Department of Interventional Radiology, Institute for Cancer Research and Treatment, Candiolo, Turin, Italy Methods: Forty patients (22 women; mean age 66.8 ± 12.4), suffering from a painful spine malignancy with vertebral wall involvement not responding to conventional therapies and without surgical indications, underwent vertebral augmentation with Kiva intravertebral implant for pain palliation. The procedure was performed with moderate sedation and local anesthesia under combined digital fluoroscopy and computed tomography guidance. After the coil-shaped PEEK implant was deployed within the vertebral lesion, bone cement was injected under continuous digital fluoroscopic control. Patients were discharged from the hospital the next procedural day. The Visual Analog Scale (VAS) for pain, Oswestry Disability Index (ODI), analgesic requirement, and use of external brace support were evaluated to determine efficacy. The primary end-point was safety and efficacy at one month after the procedure. However, all the patients were scheduled to be followed-up at month 3, 6, and every 6 months thereafter. Follow-up was prospectively evaluated in all patients after Kiva with clinical interviews. The Institution’s Internal Review Board approved this study. Results: Median pre-treatment VAS of 10 (range 6 – 10) significantly (P &lt; 0.001) dropped to one (range 0 – 3), with all patients achieving a clinically relevant benefit on pain at one month. Differences in pre- and post-treatment analgesic therapy were significant (P &lt; 0.001). All patients no longer use an external brace after Kiva. In 7 out of 43 (16.3%) treated vertebrae a bone cement leakage was detected. Limitations: This is a not randomized study. Participants were limited to 40 patients. Conclusion: The Kiva System potentially represents a novel and effective minimally invasive treatment option for patients suffering from severe pain due to osteolytic vertebral metastases. Key words: Vertebroplasty, metastases, pain palliation, Kiva, spine

Temporary Endoscopic Metallic Stent for Idiopathic Esophageal Achalasia

Idiopathic achalasia is a motor disorder of the esophagus of unknown etiology caused by loss of motor neurons determining an altered motility. It may determine severe symptoms such as progressive dysphagia, regurgitations, and pulmonary aspirations. Many therapeutic options may be offered to patients with achalasia, from surgery to endoscopic treatments such as pneumatic dilation, botulinum injection, peroral endoscopic myotomy, or endoscopic stenting. Recently, temporary placement of a stent was proposed by Cheng as therapy for achalasia disorders, whereas no Western authors have dealt with it up to date. The present study reports our preliminary experience in 7 patients with achalasia treated with a temporary stent. Partially covered self-expanding metallic stents (Micro-Tech, Nanjin, China) 80 mm long and 30 mm wide were placed under fluoroscopic control and removed after 6 days. Clinical follow-up was scheduled to check endoscopic success, symptoms release, and complications. The placement and the removal of the stents were obtained in all patients without complications. Mean clinical follow-up was 19 months. Five out of 7 patients referred total symptoms release and 2 experienced significant improvement of dysphagia. The procedure was not time consuming and was safe; no mild or severe complications were registered. In conclusion, our results may suggest a possible safe and effective endoscopic alternative treatment in patients with achalasia; however, further larger studies are necessary to confirm these promising, but very preliminary, data.