Good Long-term Clinical Outcomes Research Articles

Reconstructive vs Deconstructive Endovascular Approach to Intradural Vertebral Artery Aneurysms: A Multicenter Cohort Study.

Parent vessel sacrifice (PVS) has been a traditional way of treating complex aneurysms of the intradural vertebral artery (VA). Flow diversion (FD) has emerged as an alternative reconstructive option. To compare the long-term clinical and radiographic outcomes of intradural VA aneurysms following PVS or FD. We retrospectively reviewed and evaluated 43 consecutive patients between 2009 and 2018 with ruptured and unruptured intradural VA aneurysms treated by PVS or FD. Medical records including clinical and radiological details were reviewed. A total of 43 intradural VA aneurysms were treated during this period. In the 14 PVS patients, the mean follow-up was 19.5 mo, and 71.4% of cases achieved modified Rankin scale (mRS) ≤2 at the last follow-up. A total of 86.5% of cases achieved complete occlusion. There was a 14.3% (2 cases) mortality rate, 14.3% (2 cases) postoperative ischemic complication rate, and 0% postoperative hemorrhaging rate. Retreatment was required in 1 case (7.1%). In the 29 FD patients, the mean follow-up was 21.8 mo, and 89.7% of cases achieved mRS ≤2 at the final follow-up. There was a 3.2% (1 case) mortality rate, 19.4% (6 cases) of postoperative ischemic complications, and 6.5% (2 cases) of postoperative hemorrhagic complications. Complete occlusion was seen in 86.5% patients. No cases required retreatment. Mortality and complication rates were not significantly different between PVS and PED (Pipeline Embolization Device) groups. PVS was associated with comparable intraprocedural complications for VA aneurysms as compared to FD in the largest multicenter study to date. Both procedures have good long-term clinical and radiological outcomes.

Quadriceps tendon vs. patellar tendon autograft for ACL reconstruction using a hardware-free press-fit fixation technique: comparable stability, function and return-to-sport level but less donor site morbidity in athletes after 10\xa0years

IntroductionThe use of quadriceps tendon–patellar bone (QTB) autograft for anterior cruciate ligament (ACL) reconstruction is gaining momentum. Yet, long-term results that compare this procedure with established methods are lacking. The aim of this study was to report and compare long-term results of ACL reconstruction using QTB autografts versus bone–patellar tendon–bone (BPTB) autografts, both anchored using a hardware-free press-fit fixation technique.Materials and methods60 athletes (Tegner score ≥6) with primary ACL rupture were prospectively randomized into two groups. 56 patients were evaluated after a mean duration of 12.2 ± 1.9 months (range 10–14) and 43 patients after 10.3 ± 0.2 years (range 10–11).ResultsOn final follow-up, 90% of patients scored very good and good results in the functional Lysholm score (mean 99 ± 7.1, range 74–100 points). Normal or almost normal IKDC score was reported by 84% of the patients (mean 97 ± 9.5, range 60–100 points). The activity level decreased in the Tegner score from median of 7 before injury to 6 after 10 years. The KT-1000 arthrometer showed a difference in the anterior translation of less than 3 mm (mean 1.0 ± 1.2, range − 1 to 5 mm) in 91% of the patients. Significant degeneration was radiologically detected in one patient per group. No tunnel widening was seen in any patient. Up to 97% of all patients were satisfied with the operative procedure. No significant differences were found in the mentioned parameters between the two groups and also in comparison with the 1-year results. The only significant difference was in the donor site morbidity. Significantly more patients in the BPTB group had complaints during kneeling both at 1 (p < 0.001) and 10 years (p = 0.019). Squatting was also subjectively more problematic in the BPTB group than in the QTB group both after 1 (p = 0.003) and 10 years (p = 0.046).ConclusionsThis study shows equally good functional, clinical and radiological long-term results for both hardware-free methods of ACL reconstruction. These results clinically confirm the safety of press-fit anchoring after 10 years. The failure rate in this study was very low, with only one re-rupture in 10 years. The increased donor site morbidity when using the BPTB autograft compared to the QTB autograft supports already reported data. It was also seen in this study for the implant-free press-fit techniques.Study designProspective and randomized, level of evidence 2.

Fixation of the short global tissue-sparing hip stem.

Short, bone-conserving femoral components are increasingly used in total hip arthroplasty (THA). They are expected to allow tissue-conserving implantation and to render future revision surgery more straightforward but the long-term data on such components is limited. One such component is the global tissue-sparing (GTS) stem. Following the model for stepwise introduction of new orthopaedic implants, we evaluated early implant fixation and clinical outcome of this novel short-stem THA and compared it to that of a component with established good long-term clinical outcome. In total, 50 consecutive patients ≤ 70 years old with end-stage symptomatic osteo-arthritis were randomized to receive THA with the GTS stem or the conventional Taperloc stem using the anterior supine intermuscular approach by two experienced hip surgeons in two hospitals in the Netherlands. Primary outcome was implant migration. Patients were followed using routine clinical examination, patient reported outcome using Harris Hip Score (HHS), Hip Disability And Osteoarthritis Outcome Score (HOOS), EuroQol five-dimension questionnaire (EQ5D), and Roentgen Stereophotogrammetric Analysis (RSA) at three, six, 12, and 24 months. This study evaluated the two-year follow-up results. In addition to the initial migration pattern of distal migration (subsidence, Y-translation) and retroversion (Y-rotation) also exhibited by the Taperloc stem, the GTS stem showed an initial migration pattern of varization (X-translation combined with Z-rotation) and posterior translation (Z-translation). However, all components stabilized aside from one Taperloc stem which became loose secondary to malposition and was later revised. Clinical outcomes and complications were not statistically significantly different with the numbers available. A substantially different and more extensive initial migration pattern was seen for the GTS stem compared to the Taperloc stem. Although implant stabilization was achieved, excellent long-term survival similar to that of the Taperloc stem should not be inferred. Especially in the absence of clinically proven relevant improvement, widespread usage should be postponed until long-term safety has been established. Cite this article: Bone Joint J 2020;102-B(6):699-708.

Long-term Results of Arthroscopic Rotator Cuff Repair: A Follow-up Study Comparing Single-Row Versus Double-Row Fixation Techniques

Background: Arthroscopic rotator cuff repair (RCR) with suture anchor–based fixation techniques has replaced former open and mini-open approaches. Nevertheless, long-term studies are scarce, and lack of knowledge exists about whether single-row (SR) or double-row (DR) methods are superior in clinical and anatomic results. Purpose: To analyze long-term results after arthroscopic RCR in patients with symptomatic rotator cuff tears and to compare functional and radiographic outcomes between SR and DR repair techniques at least 10 years after surgery. Study Design: Cohort study; Level of evidence, 3. Methods: Between 2005 and 2006, 40 patients with a symptomatic full-thickness rotator cuff tear (supraspinatus tendon tear with or without a tear of the infraspinatus tendon) underwent arthroscopic RCR with either an SR repair with a modified Mason-Allen suture–grasping technique (n = 20) or a DR repair with a suture bridge fixation technique (n = 20). All patients were enrolled in a long-term clinical evaluation, with the Constant score (CS) as the primary outcome measure. Furthermore, an ultrasound examination was performed to assess tendon integrity and conventional radiographs to evaluate secondary glenohumeral osteoarthritis. Results: A total of 27 patients, of whom 16 were treated with an SR repair and 11 with a DR repair, were followed up after a mean ± SD period of 12 ± 1 years (range, 11-14 years). Five patients underwent revision surgery on the affected shoulder during follow-up period, which led to 22 patients being included. The overall CS remained stable at final follow-up when compared with short-term follow-up (81 ± 8 vs 83 ± 19 points; P = .600). An increasing number of full-thickness retears were found: 6 of 22 (27%) at 2 years and 9 of 20 (45%) at 12 years after surgery. While repair failure negatively affected clinical results as shown by the CS (P < .05), no significant difference was found between the fixation techniques (P = .456). In general, progressive osteoarthritic changes were observed, with tendon integrity as a key determinant. Conclusion: Arthroscopic RCR with either an SR or a DR fixation technique provided good clinical long-term results. Repair failure was high, with negative effects on clinical results and the progression of secondary glenohumeral osteoarthritis. While DR repair slightly enhanced tendon integrity at long-term follow-up, no clinical superiority to SR repair was found.

Long-Term Results of a Second-Generation, Small-Diameter, Metal-On-Metal Bearing in Primary Total Hip Arthroplasty at 14-year Follow-Up.

(1) Background: The objective of the present study was to review the clinical and radiological results of a small-head, MoM bearing in primary THA and to determine blood metal ion levels at long-term follow-up. (2) Methods: We retrospectively evaluated the clinical and radiological results of 284 small-diameter, MoM 28-mm Metasul THA at a mean follow-up of 14.5 years, and measured blood metal ion concentrations in 174 of these patients. (3) Results: After 14 years, survival free for revision due to any reason was 94%. Proximal femoral osteolysis was seen in 23% of hips, and MRI demonstrated ARMD in 27 of the 66 investigated hips (41%). Mean cobalt, chromium, and titanium ion concentrations were 0.82 µg/L (range 0.22–4.45), 1.51 µg/L (0.04–22.69), and 2.68 µg/L (0.26–19.56) in patients with unilateral THA, and 2.59 µg/L (0.43–24.75), 2.50 µg/L (0.26–16.75), and 3.76 µg/L (0.67–19.77), respectively in patients with bilateral THA. Twenty-nine percent of patients showed cobalt or chromium ion levels > 2 µg/L. (4) Conclusions: Despite good clinical long-term results, increased blood metal ion levels (cobalt or chromium > 2 µg/L) were found in approximately one-third of asymptomatic patients, and proximal femoral osteolysis and ARMD were frequently seen in this cohort. Blood metal ion analysis appears helpful in the long-term follow-up of these patients in order to identify individuals at risk. In accordance with contemporary consensus statements, symptomatic patients with elevated metal ion levels and/or progressive osteolysis should be considered for additional CT or MARS MRI to determine the extent of soft tissue affection prior to revision surgery. Further studies are necessary to investigate the clinical relevance of ARMD in asymptomatic patients with small-head, MoM THA.

Progression criteria in loading exercise programmes in lower limb tendinopathy: a protocol for a systematic review and meta-analysis

IntroductionLower limb tendinopathies have high rates of incidence and prevalence. Their symptomatology affects the functional capacity of people to exercise and work, being an important cause of economic and social...

L’échec de la réparation de la coiffe augmente le risque de développer une arthrose gléno-humérale secondaire : suivi à long terme après réparation ouverte des lésions sévères du tendon du sous-scapulaire

BackgroundThe subscapularis musculotendinous unit provides a stabilizing effect on the glenohumeral joint and thus, enables normal active range of motion. As pathologies of the subscapularis tendon (SSC) are diagnosed with increased regularity, treatment strategies and their long-term consequences are of relevant interest. Therefore, the primary objective of this retrospective case series was to evaluate clinical and radiological long-term results after open repair of large SSC tears. HypothesisRepair failure negatively influences clinical outcomes and the progression of secondary glenohumeral osteoarthritis (OA). MethodsBetween 1998 and 2007, 24 patients with traumatic large (Lafosse III and IV) SSC tears were treated with an open transosseous repair technique. Of those, 20 patients (83%) with a mean age of 55±8 years (range, from 31 to 68 years) at the time of surgery were subjected to a long-term follow-up after a mean of 14±3 years (range, from 10 to 18 years). The Subjective Shoulder Value (SSV), the Constant Score (CS), the University of California at Los Angeles (UCLA) Shoulder Score, and the American Society for Shoulder and Elbow Surgeons (ASES) Score were obtained. Magnetic resonance imaging (MRI) was performed to evaluate tendon integrity. The progression of secondary glenohumeral OA from pre- to postoperative was analyzed using the collective instability arthropathy (CIA) score. ResultsOne patient (5%) had to undergo revision surgery due to a symptomatic re-tear of the SSC tendon. Besides that, the mean SSV of the affected shoulder was 83%±12, the CS 78±10, the UCLA 32±2, and the ASES 89±14 points, respectively. MRI revealed a re-tear of the SSC tendon in 4 patients (29%). On the affected shoulder, glenohumeral OA progressed significantly from pre- (CIA, 0.3±0.5) to postoperative (CIA, 1.7±0.9; p=0.003) and was significantly associated with repair failure (p=0.040). ConclusionOpen repair of large SSC tears yielded good clinical long-term results. Nevertheless, repair failure was common and, in the further course, negatively affected clinical outcomes and the progression of secondary glenohumeral OA. Level of evidenceIV; retrospective case series.

Repair failure increases the risk of developing secondary glenohumeral osteoarthritis: A long-term follow-up after open repair of large subscapularis tendon tears

BackgroundThe subscapularis musculotendinous unit provides a stabilizing effect on the glenohumeral joint and thus, enables normal active range of motion. As pathologies of the subscapularis tendon (SSC) are diagnosed with increased regularity, treatment strategies and their long-term consequences are of relevant interest. Therefore, the primary objective of this retrospective case series was to evaluate clinical and radiological long-term results after open repair of large SSC tears. HypothesisRepair failure negatively influences clinical outcomes and the progression of secondary glenohumeral osteoarthritis (OA). MethodsBetween 1998 and 2007, 24 patients with traumatic large (Lafosse III and IV) SSC tears were treated with an open transosseous repair technique. Of those, 20 patients (83%) with a mean age of 55±8 years (range, from 31 to 68 years) at the time of surgery were subjected to a long-term follow-up after a mean of 14±3 years (range, from 10 to 18 years). The Subjective Shoulder Value (SSV), the Constant Score (CS), the University of California at Los Angeles (UCLA) Shoulder Score, and the American Society for Shoulder and Elbow Surgeons (ASES) Score were obtained. Magnetic resonance imaging (MRI) was performed to evaluate tendon integrity. The progression of secondary glenohumeral OA from pre- to postoperative was analyzed using the collective instability arthropathy (CIA) score. ResultsOne patient (5%) had to undergo revision surgery due to a symptomatic re-tear of the SSC tendon. Besides that, the mean SSV of the affected shoulder was 83%±12, the CS 78±10, the UCLA 32±2, and the ASES 89±14 points, respectively. MRI revealed a re-tear of the SSC tendon in 4 patients (29%). On the affected shoulder, glenohumeral OA progressed significantly from pre- (CIA, 0.3±0.5) to postoperative (CIA, 1.7±0.9; p=0.003) and was significantly associated with repair failure (p=0.040). ConclusionOpen repair of large SSC tears yielded good clinical long-term results. Nevertheless, repair failure was common and, in the further course, negatively affected clinical outcomes and the progression of secondary glenohumeral OA. Level of EvidenceIV; retrospective case series.

Internal Fixation of Osteochondritis Dissecans of the Knee Leads to Good Long-Term Outcomes and High Degree of Healing without Differences between Fixation Devices.

The aim of the present study is to describe results at long-term follow-up of internal fixation of unstable Osteochondritis Dissecans (OCD) achieved with three different fixation devices in skeletally mature knees. A retrospective cohort study was performed at 5 to 19 years follow-up. Patient-reported questionnaires were collected at the final follow-up. Postoperative X-rays and MRIs were evaluated for healing of the lesion and articular degeneration. An arthroscopic second look was performed in 74.3% of the cases. Failures were reported as reintervention to address the osteochondral lesion or poor functional outcomes at the last follow-up. A total of 39 subjects with a median follow-up of 10.7 years were included. Herbert screws were used in 51.2% of the cases, bioabsorbable nails in 25.7% of the cases and cannulated screws in 23.1% of the cases. No differences were observed in terms of the clinical score (International Knee Documentation Committee (IKDC) p = 0.211; Lysholm p = 0.197), radiographic union (p = 0.102) or radiographic degeneration (p = 0.238) between the three different fixation devices. Arthroscopic second look found complete stability of the lesions in all 29 cases evaluated. The mean postoperative Lysholm score was 83 (range = 33–100) and IKDC score was 79 (range = 39–100). Radiographic union was seen in 74% of the cases. Lack of radiographic union was correlated with worst functional scores. A failure rate of 20.5% was found: four reinterventions were performed, and four patients had poor scores at last follow up. This study shows that internal fixation of condylar OCD in skeletally mature patients provides good long-term clinical results and a high degree of healing regardless of the dimensions of the lesion and type of fixation.

Targeting the posterior subthalamic area for essential tremor: proposal for MRI-based anatomical landmarks

Deep brain stimulation (DBS) of the posterior subthalamic area (PSA) is an alternative to thalamic DBS for the treatment of essential tremor (ET). The dentato-rubro-thalamic tract (DRTT) has recently been proposed as the anatomical substrate underlying effective stimulation. For clinical purposes, depiction of the DRTT mainly depends on diffusion tensor imaging (DTI)-based tractography, which has some drawbacks. The objective of this study was to present an accurate targeting strategy for DBS of the PSA based on anatomical landmarks visible on MRI and to evaluate clinical effectiveness. The authors performed a retrospective cohort study of a prospective series of 11 ET patients undergoing bilateral DBS of the PSA. The subthalamic nucleus and red nucleus served as anatomical landmarks to define the target point within the adjacent PSA on 3-T T2-weighted MRI. Stimulating contact (SC) positions with reference to the midcommissural point were analyzed and projected onto the stereotactic atlas of Morel. Postoperative outcome assessment after 6 and 12 months was based on change in Tremor Rating Scale (TRS) scores. Actual target position corresponded to the intended target based on anatomical landmarks depicted on MRI. The total TRS score was reduced (improved) from 47.2 ± 15.7 to 21.3 ± 10.7 (p < 0.001). No severe complication occurred. The mean SC position projected onto the PSA at the margin of the cerebellothalamic fascicle and the zona incerta. Targeting of the PSA based on anatomical landmarks representable on MRI is reliable and leads to accurate lead placement as well as good long-term clinical outcome.

Long-term results of closed-wedge osteotomy of the lateral humeral condyle for osteochondritis dissecans of the capitellum

Various surgical methods are used for osteochondritis dissecans of the capitellum; however, we have consistently performed a closed-wedge osteotomy of the lateral humeral condyle since 1983. The purpose of this study is to clarify the long-term results of closed-wedge osteotomy for osteochondritis dissecans of the capitellum. Seventy-seven elbows with all lesion types of osteochondritis dissecans of the capitellum were treated with closed-wedge osteotomy. Unstable osteochondral fragments were fixed with a bone graft and bone pegs in combination with osteotomy. The mean age of the patients was 14.0 years. The patients were clinically and radiographically evaluated at a median value of 9.0 years after surgery. The range of elbow motion and standard deviation were increased significantly from 119° ± 22° preoperatively to 131° ± 18° postoperatively (P < .001). The Timmerman and Andrews score were improved significantly from 141 ± 26 points preoperatively to 184 ± 21 points postoperatively (P < .001). The Timmerman and Andrews score and the range of elbow motion at final examination in patients with preoperative osteoarthritic changes were significantly inferior to those in patients without preoperative osteoarthritic changes. Good remodeling of the capitellar lesions was radiographically observed in 53 elbows (69%). In the long-term follow-up evaluation, although 41 elbows (53%) had advanced osteoarthritic changes that were classified as grade II or III, disease progression was controlled in most of these cases. Good or excellent long-term clinical results were maintained in most of our patients. Closed-wedge osteotomy of the lateral humeral condyle is a useful method that can provide acceptable long-term clinical results.

Navigated neuroendoscopy combined with intraoperative magnetic resonance cysternography for treatment of arachnoid cysts

Endoscopic cystocysternostomy or cystoventriculostomy is the treatment of choice in patients with symptomatic intracranial arachnoid cysts. There are no objective diagnostic tests for reliable intraoperative evaluation of the effectiveness of performed stomies. The aim of this prospective open-label study is to demonstrate for the first time the usefulness of intraoperative cysternography performed with the low-field 0.15-T magnetic resonance imager Polestar N20 during endoscopic cysternostomies. The study was performed in patients operated for middle fossa arachnoid cysts (n = 10), suprasellar cysts (n = 4), paraventricular or intraventricular cysts (n = 6), and a pineal cyst (n = 1). The operations were performed with use of a navigated neuroendoscope. Intraoperative magnetic resonance (iMR) cysternography was performed before and after the cystostomy. In each case, iMR cysternography was safe and could show clearly the cyst morphology and the effectiveness of performed endoscopic cystostomies. In six cases, iMR cysternography had a significant influence of the surgical decision (p = 0.027). The rate of inconsistency between the intraoperative observations and iMR imaging–based findings was 29%. A good contrast flow through the fenestrated cyst walls correlated with a good long-term clinical outcome (ρ = 0.54, p < 0.05) and good long-term radiological outcome (ρ = 0.72, p < 0.05). Intraoperative low-field MR cysternography is a safe and reliable method for assessment of the efficacy of performed endoscopic cystostomies and has significant influence on the surgical decision. It may be reliably used for prediction of the long-term clinical and radiological outcome.

Bilateral High Hip Center Provides Gait Parameters Similar to Anatomical Reconstruction: A Gait Analysis Study in Hip Replacement Patients With Bilateral Developmental Dysplasia

BackgroundTotal hip arthroplasty in severe dysplasia is challenging due to diminished periacetabular bone stock and the highly placed femoral head. Although anatomical reconstruction of the hip, with required interventions such as subtrochanteric osteotomy and graft usage, is the main aim of the procedure, good long-term clinical outcomes of the high hip center technique have also been reported. Information regarding the effect of hip center placement on gait characteristics is limited; therefore, the aim of this study is to analyze the differences in gait parameters between the high hip center technique and anatomical reconstruction of the hip. MethodsTwenty patients (40 hips) with bilateral Crowe type III-IV developmental dysplasia of the hip who underwent bilateral total hip arthroplasty and completed at least 2 years of follow-up were included. Group 1 comprised 10 patients (20 hips) who underwent anatomical hip center reconstruction, while group 2 comprised 10 patients (20 hips) who underwent high hip center reconstruction. The gait characteristics of patients were examined through markers placed in certain anatomical regions, the cameras placed around, and the force plates embedded in the walking platform. ResultsThere was no significant difference in the gait characteristics according to the location of the hip rotation center. The mean temporospatial, kinematic, and kinetic values were similar between the groups. The most prominent difference was in the peak dynamic hip extension, which was lower in group 2 (−9.71° ± 7.46°) compared to group 1 (−6.80° ± 11.44°), although it was not statistically significant (P = .09). ConclusionThe bilateral high hip center technique can provide similar gait characteristics as anatomical reconstruction and may be preferred in particularly difficult cases based on the surgeon’s decision.

Salud bucal en paciente con prótesis total

Recibido: 25 de abril de 2019Aprobado: 26 de mayo de 2019El objetivo de este artículo es realizar una revisión bibliográfica a la luz de la evidencia actual de la salud bucal y el estado de los implantes orales en de pacientes con prótesis dental total. Considerando que el edentulismo es una desventaja que afecta la calidad de vida y la nutrición. La pérdida de dientes conduce a un deterioro funcional a nivel del sistema orofacial, lo que interfiere significativamente con la masticación, la deglución y el habla, así como con disfunción de la articulación temporomandibular, trastornos de la relación intermaxilar y fisionomía facial. La rehabilitación oral ideal de pacientes desdentados puede requerir la instalación de implantes endóseos para soportar una prótesis fija o removible. Se han demostrado buenos resultados clínicos a largo plazo en este grupo de pacientes, particularmente en casos en los que el tratamiento prostodóntico convencional ha fallado o es inaceptable para el paciente. Por otra parte, estudios indican que la terapia de implante oral puede considerarse como el tratamiento de elección en pacientes de edad avanzada, incluso cuando la higiene oral no es óptima.

First-stage scapholunate fusion for the treatment of a chronic lunate dislocation

Rationale:Lunate dislocation is a rare injury to the wrist caused by high-energy trauma, and poor prognosis is often associated with missed initial diagnosis. To date, there is no consensus regarding an effective treatment plan for such cases.Patient concerns:Here, we describe the case of a 36-year-old man who presented with lunate dislocation following a delay in diagnosis of over 7 weeks, and further illuminate its diagnosis and treatment.Diagnosis:The diagnosis of chronic lunate dislocation was rendered.Interventions:The patient was treated using reduction via the dorsal approach brachial plexus anesthesia. After the reduction, a headless compression screw fixation was performed for first-stage scapholunate fusion, and Kirschner wire fixation of the lunate-triquetrum-hamate was used to stabilize the distal and proximal carpal rows.Outcomes:The patient was followed up for 1 year and showed wrist function recovered well; radiographic examination showed no lunate dislocation and successful scapholunate bony fusion. A satisfactory outcome was achieved.Lessons:The case study presented here provide evidence that performing an effective first-stage scapholunate fusion is recommended to achieve better therapeutic outcomes for a chronic lunate dislocation. Furthermore, this approach led to a good long-term clinical outcome in our case.

Long-term patency and clinical outcome of the transjugular intrahepatic portosystemic shunt using the expanded polytetrafluoroethylene stent-graft.

BackgroundTransjugular intrahepatic portosystemic shunt (TIPS) creation is an established treatment option to management the complications of portal hypertension. Recent data on the long-term outcomes of TIPS are scarce.Materials and methodsIn this single-institution retrospective study, 495 patients underwent TIPS with the Fluency stent-grafts between December 2011 and June 2015 were evaluated. The cumulative rates of TIPS dysfunction, hepatic encephalopathy (HE), survival, and variceal rebleeding were determined using the Kaplan–Meier method. Cox regression analysis was used to assess the parameters on TIPS patency, occurrence of HE and all-cause mortality.ResultsTechnical success was 98.2%. TIPS-related complications occurred in 67 patients (13.5%) during the index hospital stay. TIPS creation resulted in an immediate decrease in mean portosystemic pressure gradient from 23.4 ± 7.1 mmHg to 7.6 ± 3.5 mmHg. The median follow-up period was 649 days. Primary TIPS patency rates were 93%, and 75.9% at 1 and 3 years, respectively. Previous splenectomy was associated with a higher risk of TPS dysfunction. The cumulative survival rates were 93.4% and 77.2% at 1 and 3 years, respectively. The 1- and 3-year probability of remaining free of variceal bleeding rates were 94.2% and 71.4%, respectively.ConclusionsThis retrospective single-center experience with TIPS using the Fluency stent-grafts demonstrates good long-term patency and favorable good clinical results. Previous splenectomy strongly predicts shunt dysfunction.

Technique d’alignement cinématique des prothèses unicompartimentaires médiales Oxford : une étude in vitro

BackgroundMobile bearing unicompartmental knee arthroplasty (UKA) Oxford™ components are recommended to be systematically and mechanically aligned (MA) for restoring the constitutional lower-limb alignment. Good long-term clinical outcomes have been generated with the medially implanted MA Oxford™, but some sub-optimal biomechanical-related complications still remain. Kinematic Alignment (KA) is a personalised technique for anatomically and kinematically implanting components (total knee, fixed bearing partial knee, total hip) aimed at creating more physiological prosthetic joint biomechanics. Interestingly, for decades the principles for implanting fixed bearing UKA components were consistent with those promoted by the KA technique, but differently formulated. We initiated this computational study to assess the feasibility of this technique with the Oxford™ components, as we thought this more anatomical implantation may be clinically advantageous. HypothesisWe surmised that kinematically aligning the Oxford™ medial UKA would maximise the prosthesis-bone interface through maximising the implants’ size used (question 1), and alter, within an acceptable limit, the components’ orientation (question 2) compared to conventional mechanical alignment. MethodsA cohort of 40 consecutive medial osteoarthritic knee patients scheduled for UKA had a preoperative CT scan that was segmented to create 3D knee bone models. MA and KA of medial UKA Oxford® components (Zimmer-Biomet, Warsaw, Indiana, USA) were simulated. Component sizing and positioning were compared between the two techniques. ResultsWe found no difference in component size, but significantly fewer occurrences of borderline fit with the KA simulation. KA technique oriented the femoral component 3.6° more valgus (from 1° varus to 7° valgus) and the tibial component 2.9° more varus (from 8° varus to 0°) compared to the MA technique. The tibial component slope in KA simulation was 6.4° posterior (from 0° to 12°) compared to a systematic 7° posterior for MA positioning. Discussion and conclusionKinematic alignment of the medial Oxford™ generated a different, albeit still acceptable (Oxford group recommendations), implant orientation, in addition to a likely better shape-fit between components and the supportive bone cut, compared to the MA technique. The potential to improve the implants’ interaction and to restore a more physiological bone loading makes the KA of Oxford™ an attractive, potentially clinically beneficial option. Clinical investigations are needed to assess its true value. Level of evidenceI, computational study.

Outcome of combined all-inside and outside-in arthroscopic meniscal repair: long-term study

Background The long-term unfavorable consequences of meniscectomy, either partial or total, are well documented. The purpose of the current study is to demonstrate the long-term clinical outcome after arthroscopic meniscal repair using combined all-inside and outside-in techniques.Patients and methods A retrospective study of patients who underwent meniscal repair was conducted between December 2005 and October 2013. A total of 48 patients were included (42 males and six females), with an average age of 24.3 years (range, 10–38 years) at operation. Meniscal repairs were done using combined outside-in and all-inside techniques. All meniscal tears were repaired using one Fast-Fix posterior all-inside suture and multiple outside-in sutures using the remaining Ultrabraid suture and PDS no. 2-0 nonabsorbable suture.Results Only four cases required a second procedure (partial meniscectomy). At the final follow-up of an average of 80.11 months (range, 24–121 months), the average International Knee Documentation Committee (IKDC) score of the meniscus repair group was 95.18±3.9, and the Lysholm score was 93.93±4.54.Conclusion Combined all-inside and outside-in arthroscopic meniscal repair is a safe and a cheap technique, with a good long-term clinical outcome.

Importance of Fenestration Size for Definitive Treatment of a Quadrigeminal Arachnoid Cyst: Endoscopic Inspection of the Cyst and Surrounding Anatomy: 2-Dimensional Operative Video.

Arachnoid cysts are fluid-filled sacs, located between the brain or spinal cord and the arachnoid membrane. Their prevalence in children is between 1% and 3%. Quadrigeminal arachnoid cysts represent 1% to 10% of them and are often associated with hydrocephalus, mostly by an obstructive mechanism, explained by compression of the tectum of the midbrain. When an indication for treatment is retained, 3 surgical options are available: microsurgical excision/fenestration, endoscopic fenestration, and shunt placement. Endoscopic treatment is considered the best compromise of definitive treatment with least surgical morbidity, especially because quadrigeminal cysts are located close to the midline, in intimate relationships with basal cisterns and ventricles. We here present the endoscopic treatment of a prenatally diagnosed quadrigeminal arachnoid cyst type III1 with right lateral extension into the middle cerebral fossa, and associated hydrocephalus, treated at the age of 18 mo.Step-by-step detail of surgical technique is presented in original anatomic conditions. Restoration of better cerebrospinal fluid pathways being the objective of this surgery, ventriculocystic, and cyst-cisternal fenestrations were made. Secondary obstruction of the cyst occurred a few months later, requiring further endoscopic treatment to obtain a larger fenestration that allowed good long-term clinical and radiological outcome. The key point of this video is to compare the 2 procedures, stressing the importance of the dimension of fenestrations, to ensure a long-term patency of both stomas.The patient being a child, both parents gave their consent for publication and signed a form.

Unrepaired rotator cuff tears following acromioplasty

Background: The natural history of rotator cuff tears suggests that not all tears progress and small isolated rotator cuff tears might heal. To date there have been no long-term studies assessing the MRI changes of unrepaired full thickness supraspinatus tears after acromioplasty. Methods: A database of patients from a single surgeon that have had acromioplasty without rotator cuff repair in the last five to 15 years was reviewed. The number of shoulders examined in this study was 17. Patients all completed an Oxford score, Constant score and had an MRI to assess fatty infiltration and atrophy. Results: Mean follow-up time 7.2 years (range, 5–13 years). The patients were divided into three groups depending on the size of the tear at time of surgery: C1 tears (<1 cm) n=5, C2 tears (1–1.9 cm) n=8, C3 tears (2–3 cm) n=4. In the C2 group, MRI evaluation showed there were two patients that had tears that had regressed in size (CI 1.4–36, 4). In the C3 group, MRI evaluation revealed that all (100%) of the rotator cuff tears had significant fatty infiltration and atrophy. There was no statistical difference between groups when assessing Oxford scores (p=0.75) and Constant scores (p=0.69). There was significant association between increase in tear size and fatty infiltration (p=0.028). A possible association was noted between increase in tear size and atrophy (p=0.054). Conclusion: Patients had good long-term clinical outcomes irrespective of tear size. It showed that not all tears progressed to significant fatty change and atrophy. Level of evidence: Level 3