Recent Clinical Follow-up Research Articles

Long-term Outcomes of Triple Arthrodesis in Cerebral Palsy Patients.

Triple arthrodesis in the appropriately indicated cerebral palsy patient with a painful and/or rigid foot deformity can significantly alleviate pain and improve function. Limited data on long-term outcomes of triple arthrodesis in this patient population exist. In addition, there have been concerns about the long-term consequences of altered biomechanics in these patients on the tibiotalar (ankle) joint. We retrospectively reviewed 21 cerebral palsy patients who had undergone triple arthrodesis for a painful and/or rigid foot deformity at our institution with at least 10 years of clinical or radiographic follow-up. Preoperative, and the most recent, clinical evaluations and radiographs were reviewed. In addition, all 21 patients and/or caretakers responded to a questionnaire at the time of this study by means of telephone to assess subjective pain, analgesia use, walking aid necessity, walking distance, and satisfaction with the procedure. In this series of 21 cerebral palsy patients, 5 patients had bilateral surgery, resulting in 26 operative feet. The mean age at the time of surgery was 19.4 years and most recent clinical or radiographic follow-up was 22.1 years postoperatively. Preoperative foot deformity was characterized by hindfoot valgus in 66.7% (14/21) and varus in 33.3% (7/21) of patients. Postoperatively, fusion was achieved in 96.2% (25/26) of feet. At final follow-up, 3 feet (11.5%) demonstrated tibiotalar joint arthritis, 1 (3.8%) had midfoot arthritis, and 10 (38.5%) had residual deformity. Of the total patients, 95.2% (20/21) were satisfied with the outcome and 61.9% (13/21) reported pain-free ambulation. There was no association between eventual functional outcome and preoperative diagnosis, preoperative foot deformity, postoperative tibiotalar joint arthritis, or postoperative residual deformity. Triple arthrodesis is a surgical option in cerebral palsy patients with painful and/or rigid foot deformities. From this series, successful outcomes can be expected as long as bony union is achieved. The incidence of tibiotalar arthritis is relatively low and not associated with long-term functional outcome. In addition, preoperative and residual postoperative foot deformity is not associated with long-term outcome.

Low Risk of Physeal Damage from a Medial Patellofemoral Ligament (MPFL) Reconstruction Technique that Uses an Epiphyseal Socket in Children

Objectives:The purpose of this study was to assess short-term distal femoral growth plate safety associated with femoral sockets for hamstring autograft fixation in pediatric MPFL reconstruction.Methods:We retrospectively reviewed a consecutive series of 31 patients (22 females, 9 males) that underwent MPFL reconstruction by one surgeon at a tertiary care academic medical center between 2008 and 2014. Study inclusion criteria consisted of patients who were skeletally immature at the time of surgery, who had greater than 1 year radiographic follow-up and who had a femoral socket introduced during their procedure. Femoral socket location was verified by intraoperative fluoroscopy. All patients received a post-operative x-ray and a clinical follow-up. For the 12 patients that obtained post-operative MRI, growth plate safety was assessed by examining the location of the femoral socket relative to the physis to rule out growth plate injury (Figure 1). Development of lower limb angular deformities or limb length discrepancies was evaluated by examining post-operative standing hip-to-ankle anteroposterior radiographs, patient records, and clinical assessments.Results:The average age at surgery of 13.0 years. The average length of radiographic follow-up was 1.5 years and the average length of clinical follow-up was 1.78 years. At most recent clinical follow-up, 90% (28/31) of patients reported no subsequent patellar dislocations in the treated knee. No patients showed evidence of an angular deformity or limb length discrepancy. Of the 12 patients with postoperative MRI, all showed femoral sockets positioned distal to the physis without growth plate disturbance.Conclusion:The use of an epiphyseal femoral socket for graft fixation presents minimal risk of physeal violation and ensures patellar stability in the majority of pediatric patients. We have demonstrated that using fluoroscopic assistance to place the femoral socket distal to the distal femoral physis is a reliable and safe method for avoiding physeal injury in children with patellar instability.

Use of Extracorporeal Membrane Oxygenation to Stabilize a Polytrauma Patient During Intramedullary Nailing of a Femoral Fracture: A Case Report.

An eighteen-year-old polytrauma patient sustained multiple nonorthopaedic and orthopaedic injuries, including a closed femoral shaft fracture. She was started on extracorporeal membrane oxygenation (ECMO) for respiratory failure. After added resuscitation and stabilization, she underwent intramedullary nailing of the femoral fracture while on ECMO on the third day after the injury. She remained stable throughout the case and recovered after a prolonged hospital course. At the most recent clinical follow-up, she was walking without assistance and had union of the fracture. ECMO successfully stabilized and mitigated any potential pulmonary complications during intramedullary nailing of a femoral shaft fracture in an unstable patient with polytrauma.

Psychosocial perspectives of a patient with mucopolysaccharidosis type VI

The mucopolysaccharidoses (MPS) are a group of rare inherited lysosomal storage disorders. One subtype of type VI MPS, also known asMaroteauxeLamy syndrome, is characterized by systemic clinical manifestations with symptoms related to the skeletal, cardiac, respiratory, ophthalmologic, and central and peripheral nervous systems. A 21-year-old female college student was diagnosed with MPS type VI at 3 years of age and received weekly naglazyme replacement therapy since she was 12 years old (Fig. 1). Thoracolumbar spine radiography revealed flattening of the vertebral bodies, lumbar flattening of the vertebral bodies, lumbar scoliosis with bilateral dysplastic hips, and deformity of the femoral heads (Fig. 2). Spinal stenosis of the second and third cervical vertebrae with cervical cord compression and myelomalacia were noted on head and cervical magnetic resonance imaging and at recent clinical follow-up. Integrated care has been initiated but the main focus was on the diverse spectrum of disease manifestations. In order to offer more holistic clinical care, the patient’s psychosocial status was assessed by a set of semistructured questions, mixed with open-ended and closed questions focused on selfidentity, coping strategies for school life and the disease effects, the patient’s vision of the meaning of life, and the expected roles of friends and medical personnel. A 1-hour interview was scheduled

Long-term outcome of endovascular reconstruction with the Pipeline embolization device in the management of unruptured dissecting aneurysms of the intracranial vertebral artery

Use of a flow-diverting device has shown promising short-term results in the management of vertebral artery (VA) dissecting aneurysms, but there is still uncertainty regarding its long-term efficacy and safety. The authors report their initial experience with respect to the potential utility and long-term clinical outcomes of using a flow-diverting device in the treatment of unruptured dissecting VA aneurysms. The authors conducted a retrospective review of all cases of unruptured intracranial VA dissecting aneurysms treated at their institution (Tuen Mun Hospital) with a flow-diverting device. They describe the clinical presentations and angiographic features of the cases and report the clinical outcome (with modified Rankin Scale [mRS] scores) at most recent follow-up, as well as results of the latest angiographic assessment, with particular focus on in-stent patency and side-branch occlusion. A total of 4 aneurysms were successfully obliterated by using flow-diverting devices alone. Two devices were deployed in a telescoping fashion in each of 2 aneurysms, whereas only 1 device was inserted in each of the other 2 aneurysms. No periprocedural complication was encountered. No patient showed any angiographic evidence of recurrence, in-stent thrombosis, or side-branch occlusion in angiographic reassessment at a mean of 22 months after treatment (range 18-24 months). As of the most recent clinical follow-up (mean 30 months after treatment, range 24-37 months), all patients had favorable outcomes (mRS Score 0). Reconstruction using a flow-diverting device is an attractive alternative in definitive treatment of dissecting VA aneurysms, demonstrating favorable long-term clinical and angiographic outcomes and the ability to maintain parent artery and side-branch patency. It is particularly useful in cases with eloquent side-branch or dominant VA involvement.

Oxidized low-density lipoprotein as a biomarker of in vivo oxidative stress: from atherosclerosis to periodontitis

Oxidized low-density lipoprotein is known as an important factor in the development of atherosclerosis. The introduction of a sensitive procedure for the determination of oxidized low-density lipoprotein in human circulating plasma using a monoclonal antibody recognizing oxidized phosphatidylcholines has opened new fields of research based on in vivo oxidized low-density lipoprotein. The plasma oxidized low-density lipoprotein levels are significantly elevated in patients with acute myocardial infarction, cerebral infarction or chronic renal failure accompanied by hemodialysis. It was found that the plasma oxidized low-density lipoprotein level increased prior to aortic atherosclerotic lesion enlargement in apolipoprotein E-knockout mice. Recent studies have pointed out that oxidized low-density lipoprotein is transferrable between vessel wall tissue and the circulation, so it is a reasonable hypothesis that plasma oxidized low-density lipoprotein levels reflect the oxidative status at local sites of atherogenesis. Oxidized low-density lipoprotein measurement has been applied to human gingival crevicular fluids, which can be collected easily and safely, and relatively high levels of oxidized low-density lipoprotein were shown to be present. These findings, together with recent clinical follow-up studies, suggest that oxidized low-density lipoprotein is a predictive biomarker of a variety of diseases related to oxidative stress. This review summarizes the current understanding of in vivo oxidized low-density lipoprotein and its potential significance as a biomarker of disease.

Gamma Knife surgery for skull base meningiomas

Skull base meningiomas are challenging tumors owing in part to their close proximity to important neurovascular structures. Complete microsurgical resection can be associated with significant morbidity, and recurrence rates are not inconsequential. In this study, the authors evaluate the outcomes of skull base meningiomas treated with Gamma Knife surgery (GKS) both as an adjunct to microsurgery and as a primary treatment modality. The authors performed a retrospective review of a prospectively compiled database detailing the outcomes in 255 patients with skull base meningiomas treated at the University of Virginia from 1989 to 2006. All patients had a minimum follow-up of 24 months. The group comprised 54 male and 201 female patients, with a median age of 55 years (range 19-85 years). One hundred nine patients were treated with upfront radiosurgery, and 146 patients were treated with GKS following resection. Patients were assessed clinically and radiographically at routine intervals following GKS. Factors predictive of new neurological deficit following GKS were assessed via univariate and multivariate analysis, and Kaplan-Meier analysis and Cox multivariate regression analysis were used to assess factors predictive of tumor progression. Meningiomas were centered over the cerebellopontine angle in 43 patients (17%), the clivus in 40 (16%), the petroclival region in 28 (11%), the petrous region in 6 (2%), and the parasellar region in 138 (54%). The median duration of follow-up was 6.5 years (range 2-18 years). The mean preradiosurgery tumor volume was 5.0 cm(3) (range 0.3-54.8 cm(3)). At most recent follow-up, 220 patients (86%) displayed either no change or a decrease in tumor volume, and 35 (14%) displayed an increase in volume. Actuarial progression-free survival at 3, 5, and 10 years was 99%, 96%, and 79%, respectively. In Cox multivariate analysis, pre-GKS covariates associated with tumor progression included age greater then 65 years (HR 3.41, 95% CI 1.63-7.13, p = 0.001) and decreasing dose to tumor margin (HR 0.90, 95% CI 0.80-1.00, p = 0.05). At most recent clinical follow-up, 230 patients (90%) demonstrated no change or improvement in their neurological condition and the condition of 25 patients had deteriorated (10%). In multivariate analysis, the factors predictive of new or worsening symptoms were increasing duration of follow-up (OR 1.01, 95% CI 1.00-1.02, p = 0.015), tumor progression (OR 2.91, 95% CI 1.60-5.31, p < 0.001), decreasing maximum dose (OR 0.90, 95% CI 0.84-0.97, p = 0.007), and petrous or clival location versus parasellar, petroclival, and cerebellopontine angle location (OR 3.47, 95% CI 1.23-9.74, p = 0.018). Stereotactic radiosurgery offers a high rate of tumor control and neurological preservation in patients with skull base meningiomas. After radiosurgery, better outcomes were observed for those receiving an optimal radiosurgery dose and harboring tumors located in a cerebellopontine angle, parasellar, or petroclival location.

Valve-sparing aortic root repair without down-sizing of the annulus

The study was conducted to evaluate the intermediate results after patient-tailored aortic root repair with replacement of isolated sinuses adjusted to the existing aortic annulus diameter rather than annulus downsizing. Between 2000 and 2009, 236 patients with aortic root disease underwent patient-tailored restoration of the aortic root according to its anatomopathologic condition with repair of 1, 2, or all 3 sinuses in 73, 94, and 69 patients, respectively. Concomitant cusp repair was performed in 106 patients. Insufficiency grades of 0/1+, 2+, 3+, and 4+ were presented in 59, 74, 74, and 29 patients, respectively. All data were collected prospectively and intention-to-treat analysis was performed. Valve repair was successful in all but 6 patients. At the most recent clinical and echocardiographic follow-up of the remaining patients, which averaged 43 ± 24 months (range, 0.3-115 months), 216 patients showed no or slight aortic regurgitation (grade 0/1+) and 10 patients showed grade 2+. Another 4 patients had grade 3+ regurgitation and underwent aortic valve replacement. The actuarial freedom from aortic regurgitation grade 3+ or more at 8 years was 95.2%. Multivariate logistic regression analysis identified cusp repair as the independent risk factor for an aortic regurgitation grade of 2+ or more with an odds ratio of 10.9 (95% confidence interval, 2.5-47.7; P = .002). The association between aortic annulus size and functional results after repair could not be demonstrated. Aortic root repair with replacement of isolated sinuses adjusted to the existing aortic annulus leads to excellent, durable results and can be recommended. Cusp disease is a leading aspect affecting functional results of repair. Therefore, establishment of reproducible cusp repair techniques is of utmost importance for further development of reconstructive aortic valve surgery.

Robotic radical cystectomy: Medium-term oncologic follow-up.

288 Background: We report our experience with robot assisted radical cystectomy (RARC) with regard to medium-term (at least 2 year) oncologic outcomes. Methods: A total of 275 patients have undergone RARC and urinary diversion at two institutions for invasive bladder cancer between 2005-present. We performed a retrospective analysis of the 139 patients who underwent RARC with a minimum of 2 years follow-up. Medium term oncologic outcomes including recurrence rates, time to recurrence, recurrence free survival (RFS), disease specific survival (DSS) were analyzed. Follow-up was measured from time of surgery to time of most recent clinical follow-up. Results: This cohort of patients consisted of 108 men (78%) and 31 women (22%) at a mean age of 67.3 years (range 45-86 years). Sixty-one (44%) patients had ≤ pT2 disease, 38 (27%) pT3/T4 disease, and 40 (29%) N+ disease. The mean number of lymph nodes removed was 18 (range 3-41). The average clinical follow up in this case series was nearly 3 years with a mean of 35.9 months (range 24-64 months). At this follow-up, 39 patients have recurred, 27 patients died of disease, and 5 patients died of other causes giving an overall RFS, DSS, and OS rates of 80%, 71%, and 68%, respectively. The mean (median) time to recurrence was 12.3 months (10 months). These findings are consistent with prior reports of the oncologic outcomes for open radical cystectomy. Conclusions: The oncologic follow-up of patients undergoing RARC appears to be favorable with acceptable outcomes in the medium-term (mean – 3 years). As our follow-up increases, we should expect to truly define the long-term clinical appropriateness and oncologic success of this procedure. No significant financial relationships to disclose.

Temporary Screw Epiphyseodesis of the Distal Tibia

Ankle valgus in multiple hereditary exostoses (HME) is frequently seen and may result in activity related pain, deformity, or even early degenerative arthritis. Standard treatment protocols do not exist. The effect of medial screw hemiepiphysedesis of the distal tibia to correct ankle valgus is evaluated in this patient population. A retrospective review of 9 patients with HME and ankle valgus deformity (15 affected extremities) who were treated by a screw hemiepiphyseodesis of the medial physis of the distal tibia is presented. Mean age at time of operation was 11.8 ± 1.6 years (range: 9.6 to 14.7 y). All patients underwent clinical and radiological evaluation. To define the magnitude of ankle valgus we evaluated tibial tilt angle and Malhotra stations preoperatively, at time of screw removal and/or at time of the most recent clinical follow-up. In 11 extremities the screws were removed after an average time of 22.6 ± 8.0 months (range: 12 to 35 mo) and all patients were examined after a mean time of 36.7 ± 18.7 months after hemiepiphyseodesis (range: 13 to 69 mo). The mean preoperative tibiotalar tilt was 14.3 ± 4.4 degrees (range: 9 to 22 degrees). At time of screw removal the tibiotalar tilt was normalized to 0.4 ± 1.7 degrees (range: -2 to 4 degrees), according to a mean rate of correction of 0.58 ± 0.23 degrees by the month (range: 0.23 ± 0.92 degrees). With follow up 4 ankles demonstrated a change in the fibular station. None of the patients overcorrected into a severe varus, one patient developed a recurrent ankle valgus. The temporary screw hemiepiphyseodesis of the distal tibial physis is an effective, technically simple, and minimally invasive technique to correct ankle valgus deformity in children with HME. IV.

Survival and radiographic analysis of a glenoid component with a cementless fluted central peg

Aseptic loosening of glenoid components is a common problem associated with total shoulder arthroplasty and one cause for failure. A new cementless fluted glenoid component was developed and has shown excellent bony ingrowth in a canine model. Clinical utilization of this cementless fluted pegged glenoid component in total shoulder arthroplasty would lower rates of radiolucent lines and aseptic loosening. Between January 2005 and December 2007, 83 primary shoulder arthroplasties with a minimum of 2 years' follow-up were performed with the uncemented fluted pegged glenoid component. Radiographs and records were reviewed to determine stability and survival of the glenoid component. All cementless fluted pegged glenoid components had survived at the most recent clinical follow-up. Radiographs showed no evidence of component loosening or radiolucent lines. Evidence of fingerlike projections of bone between the flanges of the implant was found in 24 cases (29%). A cementless fluted pegged glenoid component showed excellent initial clinical survival and integration. Further studies regarding continued durability of this component appear warranted.

Virtual Colonography Detects Unsuspected Extraclonic Cancers

A study of >10,000 adults found that >1 in every 200 asymptomatic people screened with computed tomographic (CT) colonography, or virtual colonoscopy, had clinically unsuspected malignant cancer and more than half of cancers were extracolonic. The findings were published in the April issue of the journal Radiology. “We are finding that virtual colonoscopy screening actually identifies more unsuspected cancers outside of the colon than within it,” says lead author Perry J. Pickhardt, MD, professor of radiology and chief of GI Imaging, at the University of Wisconsin School of Medicine & Public Health. “As with asymptomatic colorectal cancers identified by virtual colonoscopy screening, these cancers are often detected at an early, curable stage.” In addition to the intended colorectal evaluation, CT colonography also provides for limited assessment of extracolonic structures, including the abdomen, pelvis, and lungs. Additional diagnostic imaging work-up for unsuspected extracolonic findings is performed in approximately 6% of cases, nearly half of which ultimately prove to be clinically relevant, the authors note. The researchers retrospectively determined the detection rates, clinical stages, and short-term patient survival for all unsuspected malignancies in an asymptomatic screening population. They reviewed the medical records of 10,286 adults (5,388 men and 4,898 women) with a mean age of 59.8 years who were evaluated at either the University of Wisconsin or the National Naval Medical Center. All of the adults had undergone colorectal cancer screening with virtual colonoscopy at the two centers between April 2004 and March 2008. The mean time for follow-up was 30.2 months. Unsuspected cancer was confirmed in 58 patients, including 33 women and 25 men. Invasive colorectal cancer was found in 22 patients, and extracolonic cancer was found in 36 patients. Cancers in 31 patients (53.4%) were stage 1 or localized cancers. Extracolonic malignancies included renal cell carcinoma (n = 11), lung cancer (n = 8), non-Hodgkin lymphoma (n = 6), or a variety of other tumors (n = 11). At the most recent clinical follow-up (mean, 30.0 months; range, 12–56), 3 patients (5.2%) had died of their cancer. “To our knowledge, none of the patients who presented with stage 1, stage 2 or localized disease at diagnosis has progressed to a higher stage,” Pickhardt says. “The fact that so many of the cancers in our study were localized or detected at an early stage appears to have positively affected survival.” See: Radiology 2010;255:1 orhttp://radiology.rsna.org/content/255/1/83.full.

Colorectal and Extracolonic Cancers Detected at Screening CT Colonography in 10 286 Asymptomatic Adults

To retrospectively determine the detection rates, clinical stages, and short-term patient survival for all unsuspected cancers identified at screening computed tomographic (CT) colonography, including both colorectal carcinoma (CRC) and extracolonic malignancies. From April 2004 through March 2008, prospective colorectal and extracolonic interpretation was performed in 10,286 outpatient adults (5388 men, 4898 women; mean age, 59.8 years) undergoing screening CT colonography at two centers in this institutional review board-approved, HIPAA-compliant study. For all histologically proved, clinically unsuspected cancers detected at CT colonography that were identified at retrospective review of the medical records, the stage of disease, treatment, and clinical outcome were analyzed. Benign neoplasms (including advanced colorectal adenomas), symptomatic lesions, and tumors without pathologic proof were excluded. Statistical analysis was performed with Fisher exact test and two-sample z test. Unsuspected cancer was confirmed in 58 (0.56%) patients (33 women, 25 men; mean age, 60.8 years), which included invasive CRC in 22 patients (0.21%) and extracolonic cancer in 36 patients (0.35%). Extracolonic malignancies included renal cell carcinoma (n = 11), lung cancer (n = 8), non-Hodgkin lymphoma (n = 6), and a variety of other tumors (n = 11). Cancers in 31 patients (53.4%) were stage I or localized. At the most recent clinical follow-up (mean, 30.0 months +/- 11.8 [standard deviation]; range, 12-56 months), three patients (5.2%) had died of their cancer. The overall detection rate of unsuspected cancer is approximately one per 200 asymptomatic adults undergoing routine screening CT colonography, including about one invasive CRC per 500 cases and one extracolonic cancer per 300 cases. Detection and treatment at an early presymptomatic stage may have contributed to the favorable outcome.

The Effect of Stem Design on the Prevalence of Squeaking Following Ceramic-on-Ceramic Bearing Total Hip Arthroplasty

The ceramic-on-ceramic bearing for total hip arthroplasty has an extremely low wear rate and demonstrates minimal inflammatory response in comparison with other bearing choices. However, acoustic emissions such as squeaking and clicking are being reported as annoying complications related to its use. The cause or causes of this phenomenon have not been determined. The purpose of the present study was to evaluate the possibility that design aspects of the femoral component may be a contributing factor to the etiology of squeaking associated with the ceramic-on-ceramic bearing total hip arthroplasty. We retrospectively reviewed 266 consecutive patients (304 hips) who had undergone total hip arthroplasty with use of ceramic-on-ceramic bearings. The first 131 consecutive patients (152 hips) (Group 1) received a hydroxyapatite-coated stem composed of titanium-aluminum-vanadium alloy with a C-taper neck geometry and robust midsection with an anteroposterior diameter of 13 mm. The second 135 consecutive patients (152 hips) (Group 2) also received a hydroxyapatite-coated stem, but in that group the stem was composed of titanium-molybdenum-zirconium-iron alloy, with a V-40 neck geometry and a midsection with an anteroposterior thickness of only 10 mm. All 304 hips received the same cup, composed of titanium-aluminum-vanadium alloy. Demographic characteristics, such as age, sex, height, weight, and body mass index, were similar in both groups. Data regarding the presence of squeaking were obtained prospectively. Patients who were seen for clinical follow-up either expressed the squeaking phenomenon themselves or were asked about it by the physician. Patients who were not seen at a recent clinical follow-up visit were contacted by telephone and were asked specifically about squeaking that might be associated with the hip replacement. Only patients with confirmed squeaking noise were included in the present study. Postoperative radiographs, the Short Form-36 health survey, the Harris hip score, and office or telephone interviews of the patient were used to determine the overall outcome of the procedure. The prevalence of squeaking was seven times higher for patients who received the titanium-molybdenum-zirconium-iron-alloy stem (twenty-seven patients, twenty-eight hips [18.4%]) than in those who received the titanium-aluminum-vanadium-alloy stem (three patients, four hips [2.6%]); this difference was significant (p < 0.0001). Our study suggests that different stem alloys, stem geometries, or neck geometries can have an impact on the frequency of squeaking following a ceramic-on-ceramic total hip arthroplasty.

Intrasinus Catheter-Directed Heparin Infusion in the Treatment of Dural Venous Sinus Thrombosis

In this small series, local intrasinus catheter-directed heparin infusion with or without balloon thrombectomy was safe in the treatment of dural venous sinus thrombosis (DVST). Although systemic anticoagulation (SAC) is the treatment of choice, there is a lack of consensus regarding the best treatment should SAC fail or be contraindicated. We present our institutional experience with 16 patients in whom failure of, or contraindication to, SAC occurred and who subsequently underwent intrasinus catheter-directed heparin infusion with or without balloon thrombectomy. A retrospective review of 16 patients ranging in age from 14 days to 77 years who had intrasinus catheter-directed heparin infusion was undertaken with 9 male and 7 female patients identified. Of these 16 patients, 4 (25%) had a contraindication to SAC and SAC failed in 12 (75%). Technically successful intrasinus infusion catheter placement was achieved in all 16 patients (100%). Mean duration of infusion was 3.3 days (range, 1-6 days). Adjunctive balloon thrombectomy was performed in 9 (56.3%) of 16 patients. No procedure-related mortality occurred. Partial and complete sinus recanalization occurred in 10 (62.5%) of 16 patients and 1 (6.3%) of 16 patients, respectively. There were 3 deaths (18.8%) attributed to disease progression. At most recent clinical follow-up (mean, 9.3 months), 11 (84.6%) of 13 surviving patients were independent, with a modified Rankin Scale (mRS) score of 1 or less. Local intrasinus catheter-directed heparin infusion with or without adjunctive balloon thrombectomy seems to be a safe and effective treatment of DVST in patients in whom SAC failed or in whom there was a contraindication to SAC. In addition, the risk for symptomatic intracranial hemorrhage may be significantly lower than intrasinus infusion of thrombolytics.

The use of RhBMP-2 in single-level transforaminal lumbar interbody fusion: a clinical and radiographic analysis

The "off label" use of rhBMP-2 in the transforaminal lumbar interbody fusion (TLIF) procedure has become increasingly popular. Although several studies have demonstrated the successful use of rhBMP-2 for this indication, uncertainties remain regarding its safety and efficacy. The purpose of this study is to evaluate the clinical and radiographic outcomes of the single-level TLIF procedure using rhBMP-2. Patients who underwent a single-level TLIF between January 2004 and May 2006 with rhBMP-2 were identified. A retrospective evaluation of these patients included operative report(s), pre- and postoperative medical records, and dynamic and static lumbar radiographs. Patient-reported clinical outcome measures were obtained from a telephone questionnaire and included a modification of the Odom's criteria, a patient satisfaction score, and back and leg pain numeric rating scale scores. Forty-eight patients met the study criteria and were available for follow-up (avg. radiographic and clinical follow-up of 19.4 and 27.4 months, respectively). Radiographic fusion was achieved in 95.8% of patients. Good to excellent results were achieved in 71% of patients. On most recent clinical follow-up, 83% of patients reported improvement in their symptoms and 84% reported satisfaction with their surgery. Twenty-nine patients (60.4%) reported that they still had some back pain, with an average back pain numeric rating score of 2.8. Twenty patients (41.7%) reported that they still had some leg pain, with an average leg pain numeric rating score was 2.4. Thirteen patients (27.1%) had one or more complications, including transient postoperative radiculitis (8/48), vertebral osteolysis (3/48), nonunion (2/48), and symptomatic ectopic bone formation (1/48). The use of rhBMP-2 in the TLIF procedure produces a high rate of fusion, symptomatic improvement and patient satisfaction. Although its use eliminates the risk of harvesting autograft, rhBMP-2 is associated with other complications that raise concern, including a high rate of postoperative radiculitis.

Proximal Humeral Nonunions Treated With Fixed-Angle Locked Plating and an Intramedullary Strut Allograft

To determine if the use of a fixed-angle locked plate plus an intramedullary allograft in the treatment of proximal humeral nonunions resulted in improved union. Retrospective clinical analysis of patients' medical charts and radiographs. Clinical practice of senior authors. Eighteen patients who presented to the senior authors' clinic between 2001 and 2007 with clinical and radiographic evidence of symptomatic proximal humeral nonunions that were treated with the described method were included for analysis. Patients with severe humeral head bone loss, avascular necrosis, evidence of arthrosis, and less than 12-month clinical follow-up were excluded. All patients with a symptomatic viable nonunion of the proximal humerus were treated with a fixed-angle locked plate and an intramedullary cortical allograft. Patients were followed until radiographic union was achieved, with this being the principle determinant of a successful outcome. Radiographic union was achieved in 17 of 18 patients (94%). The average follow-up was 26.5 months (range 12-49 months). The average time from surgery to radiographic union was 5.4 months (range 2.5-8.8 months). There was 1 failure of fixation, and 2 patients developed transient neurologic sequelae. Range of motion measurements obtained from the most recent clinical follow-up were 115 degrees (range 20-180 degrees) active forward elevation, 37 degrees (range 0-70 degrees) passive external rotation, and active internal rotation was to the 10th thoracic vertebrae. American Shoulder and Elbow Surgeon scores improved from a level of 40 preoperatively to 81 postoperatively, and visual analog scale scores improved from 6.7 to 1.5. Intramedullary strut allograft insertion combined with fixed-angle plating is an effective technique for treating viable nonunions of the proximal humerus and was successful in achieving union in 94% of our patients.

Radiofrequency ablation of chondroblastoma: procedure technique, clinical and MR imaging follow up of four cases

The aim of this study is to describe the procedure technique, clinical and imaging outcomes of patients treated with radiofrequency ablation for chondroblastoma. Four patients (female/male, 3:1; mean age, 13 years; age range; 9-16 years) underwent the procedure. All had pre-operative magnetic resonance imaging (MRI) and symptomatic, biopsy-proven chondroblastomas (two proximal femur, two proximal tibia). The lesion size ranged from 1.5 to 2.5 cm in maximal dimension (mean size, 1.8 cm). Bone access was gained with a Bonopty biopsy needle system (mean number of radiofrequency needle placements, 5; mean ablation time, 31 min). Clinical and MRI follow-up was available in all cases (mean, 12.25 months; range, 5-18 months). All patients reported resolution of symptoms at 2-6 weeks post ablation. At their most recent clinical follow-up, three patients remained completely asymptomatic with full return to normal activities and one patient had minor local discomfort (different pain pattern) that was not limiting activity. All four patients' follow-up MRI studies demonstrated resolution of the oedema pattern around the lesion and temporal evolution of the internal signal characteristics with fatty replacement. Radiofrequency ablation for chondroblastoma provides an alternative to surgical curettage, and we have demonstrated both a clinical improvement in symptoms and the follow-up MRI appearances.

Radiographic and clinical outcomes following single-level anterior cervical discectomy and allograft fusion without plate placement or cervical collar

Although the clinical outcomes following anterior cervical discectomy and fusion (ACDF) surgery are generally good, 2 major complications are graft migration and nonunion. These complications have led some to advocate rigid internal fixation and/or cervical immobilization postoperatively. This paper examines a single-surgeon experience with single-level ACDF without use of plates or hard collars in patients with degenerative spondylosis in whom allograft was used as the fusion material. The authors conducted a retrospective review of a prospective database of (Cloward-type) ACDF operations performed by the senior author (J.A.J.) between July 1996 and June 2005. Radiographic follow-up included static and flexion/extension radiographs obtained to assess fusion, focal and segmental kyphosis, and change in disc space height. At most recent follow-up, the patients' condition was evaluated by an independent physician examiner. The Odom criteria and Neck Disability Index (NDI) were used to assess outcome. One hundred seventy patients underwent single-level ACDF for degenerative pathology during the study period. Their most common presenting symptoms were pain, weakness, and radiculopathy; 88% of patients noted >or= 2 neurological complaints. The mean hospital stay was 1.76 days (range 0-36 days), and 3 patients (2%) had major immediate postoperative complications requiring reoperation. The mean duration of follow-up was 22 months (range 12-124 months). Radiographic evidence of fusion was present in 160 patients (94%). Seven patients (4%) showed radiographic evidence of pseudarthrosis, and graft migration was seen in 3 patients (2%). All patients had increases in focal kyphosis at the operated level on postoperative radiographs (mean -7.4 degrees ), although segmental alignment was preserved in 133 patients (78%). Mean change in disc space height was 36.5% (range 28-53%). At most recent clinical follow-up, 122 patients (72%) had no complaints referable to cervical disease and were able to carry out their activities of daily living without impairment. The mean postoperative NDI score was 3.2 (median 3, range 0-31). Single-level ACDF without intraoperative plate placement or the use of a postoperative collar is an effective treatment for cervical spondylosis. Although there is evidence of focal kyphosis and loss of disc space height, radiographic evidence of fusion is comparable to that attained with plate fixation, and the rate of clinical improvement is high.

Endoscopic ultrasound-guided fine-needle aspiration for diagnosis of solid pseudopapillary tumors of the pancreas: a multicenter experience

Solid pseudopapillary tumors of the pancreas are rare, low-grade, epithelial neoplasms that are usually discovered incidentally in young women. Distinguishing solid pseudopapillary tumors from other pancreatic tumors, especially pancreatic endocrine tumors, can be challenging. The role of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in this context remains unclear. The purpose of this study was to describe the endoscopic ultrasound features of solid pseudopapillary tumors and the role of EUS-FNA in the preoperative diagnosis of these tumors. Patients from five tertiary referral centers with surgically confirmed solid pseudopapillary tumors who had undergone preoperative EUS-FNA were included. The endoscopic ultrasound findings, cytologic descriptions, immunostaining results, operative records, surgical pathology, and results of the most recent clinical follow-up were reviewed. A total of 28 patients were identified (four men [14 %], 24 women [86 %], mean age +/- standard deviation [SD] 35 +/- 10 years). Solid pseudopapillary tumors had been found as incidental findings on cross-sectional imaging in 50 % of cases. The mean tumor size +/- SD was 42 +/- 19.5 mm and the majority were located in the pancreatic body and tail. The endoscopic ultrasound report described a well-defined, echo-poor mass in 86 %; the tumors were solid in 14 patients (50 %), mixed solid and cystic in 11 patients (39 %), and cystic in three patients (11 %). A preoperative diagnosis of solid pseudopapillary tumor was made in 21 patients (75 %) on the basis of EUS-FNA cytology. Surgical resection was performed in all cases. Laparoscopic resection was performed in eight of these patients (29 %). A solid pseudopapillary tumor should be included in the differential diagnosis of any well-demarcated, echo-poor, solid or mixed solid/cystic pancreatic lesion seen during endoscopic ultrasound, particularly in young women. The diagnostic accuracy of EUS-FNA for solid pseudopapillary tumors was 75 % in this study. A definitive preoperative diagnosis can guide the surgical approach in selected cases.