Subacute Rupture Research Articles

Early Functional Outcomes and Complications of Tibial and/or Peroneal Sesamoidectomy Utilizing a Burr Through a Medial Approach.

Sesamoid pathology can lead to significant pain and disability both with activities of daily living and high-impact athletic movements. Sesamoidectomy is a widely used procedure for patients who fail conservative treatment measures. Traditional dorsal or plantar approaches for sesamoidectomy have shown to successfully alleviate pain, but complications were reported. A proposed alternative medial approach using a burr may provide many advantages compared with traditional approaches. This study presents patient outcomes and complications for this technique. This was a retrospective chart review of patients undergoing sesamoidectomy (tibial, peroneal, or both) using a burr through a medial approach to the sesamoid metatarsal articulation. Data collected included patient demographics, radiographic analysis, and outcomes: Veterans Rand 12 Item Health Survey (VR-12), Foot and Ankle Ability Measure (FAAM), visual analog scale (VAS), patient satisfaction, and complications. Twenty-seven patients (29 feet) were included. The mean age was 38.4 years followed up for a mean of 30.9 months. VR-12 physical component improved from 35.98 ± 7.86 to 51.34 ± 8.01 (P < .001), FAAM ADL and sport improved from 58.33 ± 16.61 to 83.27 ± 18.28 (P < .001) and 26.37 ± 20.31 to 63.75 ± 29.74 (P < .001), respectively. Patient satisfaction with the treatment was 80.59% ± 27.06%. The overall complication rate was 11 (37.9%) whereas the overall reoperation rate was 4 (13.7%) of 29 feet. Complications included 1 arthrofibrosis, 1 flexor hallucis longus subacute rupture, and 1 asymptomatic hallux valgus. There were no sesamoid excision revisions. Sesamoidectomy using a medial approach with a burr provided significantly improved short-term functional outcomes, 80% patient satisfaction rate, with a relatively acceptable complications rate including 20% persistent pain. The medial approach is familiar to orthopaedic foot and ankle surgeons, provides adequate exposure, and eliminates the possibility of a painful plantar scar while avoiding disruption of the plantar plate, flexor hallucis brevis tendon, and ligamentous structures attached to the sesamoids. Larger studies with long-term follow-up from other centers are needed.

Patients’ Radiation Exposure During Endovascular Abdominal Aortic Aneurysm Repair

To investigate associations between patient characteristics, intraprocedural complexity factors, and radiation exposure to patients during endovascular abdominal aortic aneurysm repair (EVAR). Elective standard EVAR procedures between January 2015 and December 2020 were retrospectively analyzed. Patient characteristics and intraprocedural data (i.e., type of device, endograft configuration, additional procedures, and contralateral gate cannulation time [CGCT]) were collected. Dose area product (DAP) and fluoroscopy time were considered as measurements of radiation exposure. Furthermore, effective dose (ED) and doses to internal organs were calculated using PCXMC 2.0 software. Descriptive statistics, univariable, and multivariable linear regression were applied to investigate predictors of increased radiation exposure. The 99 patients were mostly male (90.9%) with a mean age of 74±7years. EVAR indications were most frequently abdominal aortic aneurysm (93.9%), penetrating aortic ulceration (2.0%), focal dissection (2.0%), or subacute rupture of infrarenal abdominal aortic aneurysm (2.0%). Median fluoroscopy time was 19.6minutes (interquartile range [IQR], 14.1-29.4) and median DAP was 86,311 mGycm2 (IQR, 60,160-130,385). Median ED was 23.2 mSv (IQR, 17.0-34.8) for 93 patients (93.9%). DAP and ED were positively correlated with body mass index (BMI) and CGCT. Kidneys, small intestine, active bone marrow, colon, and stomach were the organs that received the highest equivalent doses during EVAR. Higher DAP and ED values were observed using the Excluder endograft, other bi- and tri-modular endografts, and EVAR with ≥2 additional procedures. Multivariable linear regression analysis revealed that BMI, ≥2 additional procedures during EVAR, and CGCT were independent positive predictors of DAP and ED levels after accounting for endograft type. Patient-related and procedure-related factors such as BMI, ≥2 additional procedures during EVAR, and CGCT resulted predictors of radiation exposure for patients undergoing EVAR, as quantified by higher DAP and ED levels. The main intraprocedural factor that increased radiation exposure was CGCT. These data can be of importance for better managing radiation exposure during EVAR.

Left Knee Open Rectus Femoris Repair With Achilles Allograft Augmentation: A Case Report.

We present a case of a 48-year-old man with a subacute tear of his left rectus femoris, repaired using Achilles tendon allograft. After fixation distally to the patella using suture anchors and a Krackow suture technique, the allograft was fixed proximally to the remnant rectus femoris tendon with multiple sutures in a variety of stitch configurations. The patient recovered excellently, regaining near-normal flexion and an intact straight leg raise without an extensor lag. The literature regarding repair of subacute and chronic rectus femoris ruptures is limited. We provide an additional option for operative repair of subacute and chronic ruptures using Achilles tendon allograft.

Direct Repair of Flexor Tendons Close to Bony Insertion and Ruptured Collateral Ligaments.

Lacerated flexor tendons close to bony junction are commonly repaired using a pullout suture. However, these injuries very close to the tendon-bone junction can be repaired with robust direct suture repair of the proximal tendon stump with the short residual tendon stump and any local tissues such as periosteum and joint volar plate. Subacute or chronic traumatic rupture at the midpart of the collateral ligaments can also be repaired by "refreshing" the divided ligament ends and repairing the ligament stumps to local tissues with multiple sutures often combined with tightening the elongated joint capsule.

Traumatic spleen rupture diagnosed during postmortem dissection: A STROBE-compliant retrospective study.

Spleen is typically injured in blunt abdominal trauma. Spleen injuries make 42% of all blunt abdominal injuries. The aim of this study was to perform a retrospective assessment of the cases of acute and subacute isolated traumatic spleen ruptures.A retrospective study performed on 50 patients, whose cause of death was isolated spleen rupture and bleeding into the abdominal cavity.An acute spleen rupture was diagnosed in 47 cases, whereas the rest 3 cases demonstrated a subacute rupture. In cases of acute spleen rupture, the mean weight of spleen was 309.6 g, whereas in 3 cases of subacute rupture the mean weight of the organ achieved 710 g. The mean weight of spleen in the control group with no spleen rupture was 144.7 g.Recording of the cases of isolated acute and subacute traumatic spleen ruptures and morphological assessment of them are important in forensic pathology science and in clinical practice as well.

Unusual rupture of left ventricular pseudo-false aneurysm secondary to subacute anterolateral myocardial infarction: a case report

BackgroundLeft ventricular (LV) pseudo-false aneurysm is a rare complication secondary to myocardial infarction and is caused by intramyocardial dissecting hematoma due to fragile myocardium. Very occasionally, intramyocardial dissecting hematoma appears as a neocavitation entirely contained within the myocardial wall (so called “pseudo-false LV”) and is an unusual form of subacute cardiac rupture.Case presentationA 38-year-old male experienced chest discomfort 3 weeks ago, which improved within few days. However, after that episode, he presented at our hospital with rapidly deteriorating severe breathlessness in a preshock state with acute heart failure. Emergency coronary angiography revealed an occluded left anterior descending artery. An intra-aortic balloon catheter was inserted because of unstable hemodynamics. Enhanced computed tomography revealed extensive aneurysm formation in the LV anterior wall and contrast leakage from the inner cavity to the LV myocardium, with a moderately accumulated pericardial effusion. Emergency surgery revealed a large aneurysmal sac on the anterior wall, slightly attached to the pericardium. A 5-mm, slit-like, oozing-type, rupture site was detected in the LV after dissecting the pericardium.ConclusionsTo our knowledge, this is the first report of a pseudo-false aneurysm on the LV anterior wall. Subacute rupture of pseudo-false LV aneurysm is rare.

Triceps Tendon Repair

Although triceps tendon ruptures can result from a traumatic incident, chronic overuse causing degenerative changes to the insertion and leading to a complete or partial rupture is more common. In our practice, we have found that anabolic steroid abuse by weightlifters is the most common predisposing factor. The initial diagnosis is often missed. A thorough clinical examination is imperative to avoid missing a partial or complete rupture. Ultrasound or magnetic resonance imaging can confirm the diagnosis. Early diagnosis increases the chance of a direct repair. Operative treatment with direct repair is usually indicated for full-thickness or large partial-thickness tears. Direct repair may be possible for selected chronic tears. Triceps tendon repair is performed with the following steps.Step 1: The patient is placed in lateral decubitus.Step 2: The stump is debrided, and retraction of the tendon is evaluated.Step 3: Two crossed bone tunnels are drilled, and an anchor is placed centrally in the olecranon.Step 4: The elbow is extended, and the tendon is reduced and sutured centrally to the anchor and medially and laterally with use of the sutures from the bone tunnels.Step 5: The elbow is flexed to evaluate tension. If gapping occurs, the repair should be reinforced with extra sutures. Tension-free range of motion will guide postoperative rehabilitation.Step 6: A posterior splint is applied in the operating room with the elbow extended.Step 7: A dynamic brace is applied on the first postoperative day. Extension is free but flexion is blocked at the tension-free range; 30° of extra flexion is permitted every 2 weeks. Full flexion is always allowed after 6 weeks. Strengthening starts at 3 months. Pitfalls of the procedure include difficulty in differentiating between tendon and scar in subacute and chronic ruptures. It may not be possible to directly repair the triceps back to bone, and a graft may be needed to reconstruct the tendon. It is important to know where the ulnar nerve is and to release it if needed. It is important not to debride past the cortical surface of the olecranon if an anchor is used because, if this is done, fixation may be insufficient. The anchor should be predrilled as the cortical bone of the tip of the olecranon is very dense. Reruptures occur in up to 21% of cases. A functional range of motion is usually achieved with an average loss of extension of 10° and average flexion to 136°. At 1 year, one can expect a peak strength of approximately 80% of that on the uninjured side and endurance strength of 99%1.

Left Ventricular Free Wall Rupture Following Acute Myocardial Infarction: A South Canterbury Experience

Left ventricular free wall rupture following acute myocardial infarction is a rare but significant complication in the current era of percutaneous coronary intervention. Unfortunately, the risk remains high in secondary hospitals where thrombolysis continues to be the primary management for all patients presenting with acute ST elevation myocardial infarction (STEMI). We present the case of a 69 year old lady who presented with a late presentation posterolateral STEMI who was thrombolysed and subsequently developed an early subacute rupture. This was confirmed on transthoracic echocardiography. On review of the literature, we note the potential dangers of routinely thrombolysing all apparent STEMIs who present to secondary hospitals. Careful clinical consideration should be undertaken before we potentially add to the patient's list of complications. This would be an important consideration given the current South Canterbury patient demographics and generally stoic population whose access to health care have geographical limitations.

Left Ventricular Free Wall Rupture and Contained Pseudoaneurysm Formation in a Patient with Prior Coronary Artery Bypass Graft

An 87-year-old male with prior coronary artery bypass grafts (CABG) presented to hospital with a NSTEMI and peak TnI 7.6 μg/L. A drug-eluting stent was placed in the mid left anterior descending artery beyond the anastomosis of the left internal mammary artery graft. He was discharged at day 5, his echocardiogram showing akinesis of his anterolateral wall. Three days later the patient developed sudden chest pain after heavily exerting himself lawn-mowing. On arrival, his pain had resolved spontaneously, he was haemodynamically stable with no new EKG changes but TnI was 15 μg/L. Repeat coronary angiography excluded in-stent thrombosis, no ventriculogram was performed. He remained asymptomatic but on day 3 repeat echocardiogram revealed a new cavity adjacent to the left ventricle (LV) with bi-directional doppler flow. CT coronary angiogram defined a contained free wall rupture of the LV measuring 10 × 9x4.3 cm. LV free wall rupture is an uncommon but life threatening complication of ST-elevation myocardial infarction. While there are case reports describing ‘oozing’ or sub-acute rupture, we can find no case reports detailing an asymptomatic free wall rupture with an organised cavity in the setting of recent NSTEMI and previous CABG. We hypothesise that chronic adhesions between the epicardium and parietal pericardium from prior CABG formed a pseudoaneurysm preventing haemodynamic compromise. In unstable patients, urgent surgical intervention is usually the only feasible option. Our patient had been haemodynamically stable with no further chest pain following re-presentation. Following detailed multi-disciplinary team discussions with the patient his informed decision was to decline surgery.

Modified Urschel Maneuver for the Surgical Management of Subacute and Chronic Traumatic Esophageal Ruptures

Modified Urschel Maneuver for the Surgical Management of Subacute and Chronic Traumatic Esophageal Ruptures

Ligamentous advancement for the treatment of subacute syndesmotic injuries. Report of a new technique in 5 cases.

Integrity and optimum functioning of the syndesmotic ligament complex is of paramount importance for stability of the ankle joint during various ankle movements. Persistent widening and chronic isolated instability of the distal tibio-fibular syndesmosis leads to poor functional outcome and the development of osteoarthritis. In subacute total ruptures the focus of treatment is to restore the normal anatomy by repair of the ruptured ligament and to protect the reconstruction for a period of time. Various techniques have been previously reported with good results but associated with donor site morbidity and multiple incisions. Ligamentous advancement allows repair of the syndesmosis when the AITFL is dysfunctional but intact. The lax AITFL was mobilised with periosteum from the tibia leaving the fibular side intact. The Syndesmosis was cleared, reduced with a clamp, and held with two syndesmotic screws inserted transversely between the distal fibular and tibial shafts. The tibial surface was roughened to receive the new attachment of AITFL. The sleeve of tissue was then secured to the roughened tibial surface under tension using suture anchors with the ankle in neutral position. The repair was protected with a two hole plate and screws. The functional outcome scores showed excellent outcome at the end of 6 months. Ligamentous advancement technique obviates the need of any bony procedure and does not involve the use of any material which will lead to any sort of foreign body reaction or donor site morbidity while providing anatomical reconstruction of the syndesmosis with excellent functional outcome.

No Differences in Prevalence of Osteoarthritis or Function After Open Versus Endoscopic Technique for Anterior Cruciate Ligament Reconstruction

Background: Although arthroscopic techniques are the most common procedures today when reconstructing the anterior cruciate ligament (ACL), many surgeons still prefer the open and/or 2-incision techniques. Hypothesis: There are no differences in knee function or prevalence of knee osteoarthritis (OA) in patients who have undergone the open versus endoscopic technique for ACL reconstruction using the patellar tendon autograft. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: Sixty-seven patients with subacute or chronic rupture of the ACL were randomly assigned to open (OPEN) (n = 33) or endoscopic (ENDO) (n = 34) reconstruction. Function was evaluated by the Cincinnati knee score, single-legged hop tests, and isokinetic muscle strength tests. The radiographs were classified according to the Kellgren and Lawrence (KL) classification system, defining grade 2 or more as the cutoff point for knee OA. The Insall-Salvati ratio and the Blackburne-Peel ratio were used to calculate the patellar position and height. Results: Mean age at inclusion and at the 12-year follow-up evaluation was 27.9 ± 8.6 and 39.8 ± 8.6 years, respectively. At 12-year follow-up, 53 patients (79%) were eligible for evaluation. There were no significant differences between the 2 surgical procedures with respect to the pain, function, muscle strength, hop tests, patellar height, or the prevalence of OA. The prevalence of OA was high in the tibiofemoral joint on the operated side, 79% and 80% in the OPEN and ENDO groups, respectively. For the uninvolved knee, the corresponding numbers were 36% and 21%. Conclusion: This study suggests that the open procedure does not produce more functional problems or osteoarthritis compared with the endoscopic technique up to 12 years postoperatively.

Pseudoaneurizma leve komore

We report a case of a 72 year-old patient with a chronic left ventricular pseudoaneurysm (PAN), discovered as an incidental finding on routine echocardiographic study. The patient had a history of inferoposterolateral (IPL) myocardial infarction (AMI) 5 years ago, and subacute left ventricular free wall rupture remained undiagnosed at the time. There was also a manyyear history of rheumatoid arthritis. The patient underwent a successful operation, pseudoaneurysm was resected and the ventricular wall defect was closed with a patch. In this paper we discuss whether it was possible to recognize a subacute myocardial rupture at the time of AMI. We also discuss the link between cardiovascular disease and rheumatoid arthritis.

Survival after Left Ventricular Free Wall Rupture in an Elderly Woman with Acute Myocardial Infarction Treated Only Medically

Pseudoaneurysm of the left ventricle is rare and may occur as a result of transmural myocardial infarction. The course of rupture after acute myocardial infarction varies from a catastrophic event, with an acute tear leading to immediate death (acute rupture), or slow and incomplete tear leading to a late rupture (subacute rupture). Incomplete rupture may occur when the thrombus and haematoma together with the pericardium seal the rupture of the left ventricle and may develop into a pseudoaneurysm. Early diagnosis and treatment is essential in this condition. Two-dimensional color Doppler echocardiography is the first-choice method for most patients with suspected left ventricular pseudoaneurysm (LVP) and suggests left ventricular rupture in 85% to 90% of patients. We report the case of an 87-year-old woman presenting with symptoms and findings of myocardial infarction and left ventricular free wall rupture with a pseudoaneurysm formation diagnosed by echocardiography and confirmed on CT, MRI, and NM. She received only intense medical treatment, because she refused surgery with a favorable outcome. After 24-month followup, she is in NYHA functional class II. The survival of this patient is due to the contained pseudoaneurysm by dense pericardial adhesions, related to her previous coronary bypass surgery.

Cardiac Rupture After Intravenous t-PA Administration in Acute Ischemic Stroke

Ventricular free wall rupture is a fatal complication of myocardial infarction (MI). Although described in MI patients who receive thrombolytic therapy, this complication is not well known in ischemic stroke patients who receive intravenous (IV) t-PA. Case report. We present a 93-year-old woman with an acute onset of a right middle cerebral artery syndrome in the setting of subacute MI. IV t-PA was administered and she subsequently developed asystolic arrest and died. Autopsy showed subacute MI, hemopericardium, and rupture of the left ventricle. This case illustrates a fatal cardiac complication of IV thrombolytic therapy for stroke. The speculated mechanism is hemorrhage into the infarcted myocardium.

Subacute rupture of intracavernous carotid artery aneurysm with cavernous sinus thrombophlebitis: Potential diagnostic and therapeutic challenges

We report on a patient with subacute ruptured intracavernous carotid artery aneurysm presenting with nonspecific features of cavernous sinus thrombophlebitis initially, leading to delayed diagnosis. It alerts our awareness of the potential causes and consequences of cavernous sinus thrombophlebitis, in particular in the presence of complicating internal carotid artery aneurysm and hence, the importance of angiographic evaluation. The increased risk of thrombogenic event from coexisting inflammation raises difficulty in endovascular coiling of aneurysm, which would be further aggravated with presence of stent due to potential risk of stent infection from local spread, as demonstrated in our case with complicated parent artery occlusion due to in-stent thrombus formation during the procedure. Adequate antithrombotic therapy at both before and after the procedure is required and regular follow-up is mandatory.

No Difference in Knee Function or Prevalence of Osteoarthritis after Reconstruction of the Anterior Cruciate Ligament with 4-Strand Hamstring Autograft versus Patellar Tendon—Bone Autograft

Background The choice of different graft types and surgical techniques used when reconstructing a torn anterior cruciate ligament may influence the long-term prevalence of osteoarthritis and functional outcomes. Hypothesis There are no differences in the prevalence of knee osteoarthritis or knee function in patients undergoing reconstruction of a torn anterior cruciate ligament with 4-strand hamstring autograft versus patellar tendon—bone autograft. Study Design Randomized controlled trial; Level of evidence, 1. Methods Seventy-two patients with subacute or chronic rupture of the anterior cruciate ligament were randomly assigned to autograft reconstruction with 4-strand gracilis and semitendinosus tendon (HAM) (N = 37) or with patellar tendon—bone (PTB) (N = 35) from the ipsilateral side. Outcome measurements were the Cincinnati knee score, single-legged hop tests, isokinetic muscle strength tests, pain, knee joint laxity test (KT-1000 arthrometer), and a radiologic evaluation (Kellgren and Lawrence) at 10-year follow-up. Results At 10 years, 57 patients (79%) were eligible for evaluation—29 in the HAM group and 28 in the PTB group. No differences were found between the 2 graft groups with respect to the Cincinnati knee score, the single-legged hop tests, pain, muscle strength measurements, or knee joint laxity. Fifty-five percent and 64% of the patients had osteoarthritis corresponding to Kellgren and Lawrence grade 2 or more in the HAM and the PTB groups, respectively (P = .27). For the uninvolved knee, the corresponding numbers were 28% and 22% (P = .62). Conclusion At 10 years postoperatively, no statistically significant differences in clinical outcome between the 2 graft types were found. The prevalence of osteoarthritis was significantly higher in the operated leg than in the contralateral leg, but there were no significant differences between the 2 groups. The results indicate that the choice of graft type after an anterior cruciate ligament injury has minimal influence on the prevalence of osteoarthritis 10 years after surgery.

Medium-Term Echocardiographic Follow-up of Systolic and Diastolic Left Ventricular Abnormalities After Surgical Treatment of Subacute Rupture

Subacute rupture of the left ventricular free wall is a complication that occurs during the acute phase of a myocardial infarction. The subacute presentation makes surgical management possible. However, it is not known whether either pericardial manipulation or the use of pericardial patches influences left ventricular function over the medium term. Our aim was to monitor changes in left ventricular function and the development of constrictive pericarditis over the medium term in patients who had been treated surgically for subacute rupture of the left ventricle. Eleven patients with subacute rupture underwent surgery, of whom six were followed up over the medium term. A modest improvement in left ventricular systolic function was observed and there was no evidence of constrictive pericarditis. In conclusion, the surgical approach appears to be safe over the medium term and had no influence on left ventricular function. Nor did it lead to the development of constrictive pericarditis.

Role of contrast-enhanced magnetic resonance imaging in detecting early adverse remodeling and subacute ventricular wall rupture complicating myocardial infarction

Ventricular free wall rupture is a catastrophic complication of acute myocardial infarction accounting for a significant proportion of in-patient deaths. Various imaging modalities including two-dimensional and contrast echocardiography have been applied for the early diagnosis of free wall rupture. Cardiac magnetic resonance imaging has recently gained favor as a tool providing accurate diagnosis and visualization of the site of rupture to enable planned surgery. We present a case of subacute free wall rupture where contrast enhanced myocardial resonance imaging helped to delineate the location and extent of the myocardial tear, thereby prompting appropriate surgical intervention.

A case of fracture of posterior margin of lateral tibial plateau by pivot shift mechanism in chronic ACL insufficiency

We present a case of the fracture of the posterior margin of the lateral tibial plateau, probably by pivot shift mechanism in a chronic anterior cruciate ligament (ACL) insufficient knee. Multitudes of direct and indirect signs of ACL injury were evident on MRI, including anterior translation of the lateral tibial plateau, buckling of the posterior cruciate ligament, deep sulcus sign, and the fracture of the posterior aspect of lateral tibial plateau. With careful interpretation of the history and arthroscopic findings, the main insult of the current case was identified as the fracture of the posterior margin of the lateral tibial plateau with antecedent chronic ACL insufficiency, rather than as the acute or subacute ACL rupture. This type of injury is worth due attention as a late complication of chronic ACL insufficiency, and the clinicians should be careful in constructing the clinical scenario for the temporal relationship of injury. To the best of our knowledge, this type of injury as a late complication of chronic ACL insufficiency has never been reported in the literature.