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Limb salvage surgery in extreme situations of prosthetic complications
No full textThe treatment of periprosthetic hip and knee infection associated with loss of bone substance, as well as the treatment of the infection of large structural allografts used in tumoral reconstructive surgery, are a major challenge to the orthopaedic surgeon. Indeed, these are chronic conditions which are submitted to multiple surgeries and prolonged antibiotic therapy in socially and professionally vulnerable patients. Many of these cases receive proposals for limb amputation/disarticulation or extraction of the prosthesis without structural reconstruction aggravating, even more, their suffering and functional disability.
The aim of this study is to show the results of a treatment of complex hip and knee periprosthetic infections and of a structural allograft, in the context of limb salvage surgery.
9 patients were treated, minimum age of 22 years and maximum of 76 years with multiple surgeries and from different national hospitals. Six of these patients had periprosthetic infection of the hip and knee (primary, revision and tumoral prostheses) and two of the patients showed an apparent allergic reaction to metal/iodine. The remaining case, an infection of a large femoral structural allograft, used in tumoral surgery. The main cause of the infection was the St. aureus multiresistant. One of the patients showed multimicrobial multiresistant flora.
Treatment consisted in 2 different operative stages. First stage (7 to 9h): Extraction of the prosthesis or allograft; debridement and extensive excision of the periprothetic infected and devitalized bone and soft tissue, a minimum thickness of 4 mm; pulsatile lavage of the bleeding “surgical bed” with betadine / H2O2 and saline; implantation of large methyl methacrylate with gentamicin spacer. Triple intravenous antibiotic therapy was made for 8 to 9 weeks, with rigorous analytical control, and some of the patients were able to walk with the support of axillary support crutches. The second surgical stage (5 to 7h) takes place after normal levels of PCR: spacer excision with prosthetic joint reconstruction in 8 cases and in one case a silver coated knee arthrodesis prosthetic implant (bactericidal effect). So, 3 silver coated total femoral prostheses and 5 silver coated total hip prostheses, with the reconstruction of the proximal half of the femur, were applied. The interventions took place between July 2014 and April 2016.
Patients were discharged after being able to walk with the help pf crutches and kept taking oral antibiotics until the normalization of PCR in 3 consecutive analytical assessments spaced by 15 days.
After a clinical/ analytical evaluation, all patients showed a normal PCR, without pain and without signs of infection and/or active fistulas. Currently 5 patients walk without external support. The oldest case has 28 months of follow-up and all have a minimum follow-up of 7 months, average of 17,5 months.
All patients expressed great satisfaction with the outcome of the surgical procedures for the preservation of their lower limbs.
Chronic relapsing, multidrug-resistant, periprosthetic infection should be treated aggressively in a combination of surgical techniques of prosthetic revision and tumoral surgery, first through an extended debridement of devitalized tissue and the extraction of the prosthesis with the appropriate antibiotic therapy; second, with the reconstruction of the bone loss with silver coated modular prostheses, which are indicated in order to prevent the mutilating surgery and provide the restoration, as much as possible, of the functional capacity.
The results obtained have been very satisfactory, although the follow-up time is insufficient to draw definitive conclusions about the infectious relapse. Such limb salvage surgery is indicated for the treatment of complex clinical situations as an alternative to the disarticulation / limb amputation, i.e. supports the hope of curing clinical and surgical situations that many surgeons designate by horrendoplasties.info:eu-repo/semantics/publishedVersio
Iliopsoas Release for Internal Snapping Hip using a Minimally Open Medial Hip Approach-Case Report
Get PDFInternal snapping hip is a recognized cause of hip pain caused by recurrent subluxation of the
iliopsoas tendon. When conservative treatment fails, surgical release of the iliopsoas tendon may be
indicated using an arthroscopic or open hip approach. Results have been better with arthroscopic
release. We report a case of a 32-year-old active female with a painful internal snapping hip. The
right hip extension from a flexed position produced a strong and audible snap. A tenotomy of the
iliopsoas in combination with a resection of the lesser trochanter was performed, using a limited
medial hip approach different than the one described by Ludloff or Ferguson. The pain and snapping
phenomenon were solved; however, a slight heterotopic ossification, as well as a weakness in the
flexion of the hip was noted after the procedure, with no functional limitation. The minimally invasive
medial hip approach appears to be a simple, reproducible and successful operation for the treatment
of an internal snapping hip caused by the iliopsoas tendon, namely in orthopaedics departments with
limited experience in hip arthroscopic approach, but it is not superior to arthroscopic release.info:eu-repo/semantics/publishedVersio
Liver MRI: From basic protocol to advanced techniques
Get PDFLiver MR is a well-established modality with multiparametric capabilities. However, to take advantage of its full capacity, it is mandatory to master the technique and optimize imaging protocols, apply advanced imaging concepts and understand the use of different contrast media. Physiologic artefacts although inherent to upper abdominal studies can be minimized using triggering techniques and new strategies for motion control. For standardization, the liver MR protocol should include motion-resistant T2-w sequences, in-op phase GRE T1 and T2-w fast spin echo sequences with fat suppression. Diffusion-weighted imaging (DWI) is mandatory, especially for detection of sub-centimetre metastases. Contrast-enhanced MR is the cornerstone of liver MR, especially for lesion characterization. Although extracellular agents are the most extensively used contrast agents, hepatobiliary contrast media can provide an extra-layer of functional diagnostic information adding to the diagnostic value of liver MR. The use of high field strength (3T) increases SNR but is more challenging especially concerning artefact control. Quantitative MR belongs to the new and evolving field of radiomics where the use of emerging biomarkers such as perfusion or DWI can derive new information regarding disease detection, prognostication and evaluation of tumour response. This information can overcome some of the limitations of current tests, especially when using vascular disruptive agents for oncologic treatment assessment. MR is, today, a robust, mature, multiparametric imaging modality where clinical applications have greatly expanded from morphology to advanced imaging. This new concept should be acknowledged by all those involved in producing high quality, high-end liver MR studies.info:eu-repo/semantics/publishedVersio
Enzalutamida vs quimioterapia como primeira opção no carcinoma da próstata resistente à castração
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Intra-articular calcaneus fractures. Classification and treatment
No full textDisplaced, intra-articular fractures of the calcaneus represent a surgical challenge and the ideal choice of treatment remains a subject of continued debate. The posterior facet of the subtalar joint is involved in almost 90% of all intra-articular calcaneal fractures. Several studies have shown that only anatomic reconstruction of the calcaneal anatomy and meticulous restoration of joint geometry will lead to acceptable functional results.
Sanders classification is based on the amount of displaced fracture lines in the posterior facet of the subtalar joint in the coronal CT scans which has been shown to be of prognostic relevance.
Open reduction and stable internal fixation has been established as the standard treatment for most of these fractures. Good to excellent results in more than two thirds of patients in larger clinical series. Prognostic factors that can be influenced by the surgeon are anatomical reduction of the overall shape of the calcaneus and congruity of the subtalar joint
Systemic contraindications to open reduction and internal fixation include severe neurovascular insufficiency, poorly controlled insulin-dependent diabetes mellitus, non-compliance and severe systemic disorders with immunodeficiency and/or a poor overall prognosis.info:eu-repo/semantics/publishedVersio
Polyomavirus Nephropathy: Ten-Year Experience
Get PDFBACKGROUND:
Polyomavirus nephropathy (BKVN) is an important cause of chronic allograft dysfunction (CAD). Recipient determinants (male sex, white race, and older age), deceased donation, high-dose immunosuppression, diabetes, delayed graft function (DGF), cytomegalovirus infection, and acute rejection (AR) are risk factors. Reducing immunosuppression is the best strategy in BKVN. The objective of our study was to evaluate CAD progression after therapeutic strategies in BKVN and risk factors for graft loss (GL).
METHODS:
Retrospective analysis of 23 biopsies, from patients with CAD and histological evidence of BKVN, conducted over a period of 10 years. Glomerular filtration rate was <30 mL/min in 16 patients at the time of the BKVN diagnosis.
RESULTS:
BKVN was histologically diagnosed in 23 recipients (19 men, 4 women). All patients were white, with age of 51.2 ± 12.1 years (6 patients, age >60 years), and 22 had a deceased donor. Diabetes affected 4 patients, DGF occurred in 3, cytomegalovirus infection in 2, and AR in 15. All patients were medicated with calcineurin inhibitors (CNI) (95.7% tacrolimus) and corticoids, and 16 also received an antimetabolite. One year after antimetabolite reduction/discontinuation and/or CNI reduction/switching and/or antiviral agents, graft function was decreased in 11 patients, increased/stabilized in 10, and unknown in 2. GL occurred in 9 patients. Older age (hazard ratio, 1.76; 95% confidence interval, 0.94-3.28) and DGF (hazard ratio, 2.60; 95% confidence interval, 0.54-12.64) were the main risk factors for GL. The lower GFR at the time of the BKVN diagnosis was associated with an increased risk of initiation of dialysis.
CONCLUSIONS:
GL occurred in 39.1% of patients with BKVN and DGF; older age and lower GFR at the time of diagnosis were important risk factors. Early diagnosis of BKVN is essential to prevent GL.info:eu-repo/semantics/publishedVersio
Nephrotic Range Proteinuria in Renal Transplantation: Clinical and Histologic Correlates in a 10-year Retrospective Study
Get PDFINTRODUCTION:
There is a high incidence of nephrotic proteinuria in renal transplant recipients, which is an accurate predictor of graft loss. Despite this, its histologic correlates and prognostic implications are still not well characterized. We assessed the clinical and histological correlates of kidney transplantation patients with nephrotic range proteinuria.
METHODS:
We have retrospectively analyzed clinical and histological data from 50 kidney transplantation biopsy specimens from 44 renal transplant recipients with nephrotic range proteinuria between 2006 and 2015. The median follow-up time was 93 months (range, 14 months to 190 months).
RESULTS:
The mean age of the patients was 45.2 ± 13.7 years and our cohort included 86% recipients of deceased-donor grafts. The maintenance immunosuppressive regimen included calcineurin inhibitors in 68% and mammalian target of rapamycin inhibitors in 32% of patients. The average proteinuria was 6.9 ± 3.8 g/d and 52% of patients presented with nephrotic syndrome. The main histological findings were transplant glomerulopathy (22%), de novo glomerular disease (22%), and recurrence of primary disease (22%). Tubular atrophy and interstitial fibrosis was present in 78% of the biopsy specimens. Thirty-one patients (62%) lost the graft at follow-up. There was no statistically significant difference between the histologic diagnosis nor the proteinuria levels and the outcome of the graft.
CONCLUSIONS:
The main causes of nephrotic range proteinuria in patients undergoing biopsy were transplant glomerulopathy, recurrence of the underlying disease, and de novo glomerulonephritis. Nephrotic range proteinuria was related to a high rate of graft loss.info:eu-repo/semantics/publishedVersio
Comparison of diabetic retinopathy classification using fluorescein angiography and optical coherence tomography angiography
Get PDFPURPOSE:
To analyse and compare the classification of eyes with diabetic retinopathy using fluorescein angiography (FA) and optical coherence tomography angiography (OCTA) performed either with AngioPlex or AngioVue.
METHODS:
This was an observational cross-sectional study of 50 eyes from 26 diabetic subjects. Two independent graders classified the FA angiograms, to assess the presence and severity of several characteristics according to the ETDRS Report 11, and a similar evaluation was performed for each 3×3 mm OCTA image from the superficial retinal layer and for the full retina slab.
RESULTS:
Percentages of non-gradable images for the outline of foveal avascular zone (FAZ) in the central subfield (CSF) were 29.0% for FA, 12.0% for AngioVue and 3.0% for AngioPlex. For capillary loss, percentages of non-gradable images in the CSF were 25.0% for FA, 11% for AngioVue and 0.0% for AngioPlex. For the inner ring (IR), percentages of non-gradable images were 12.5% for FA, 11.5% for AngioVue and 0.5% for AngioPlex. Agreement between graders was substantial for outline of FAZ. For capillary loss, the agreement was fair for the CSF, and moderate for the IR.
CONCLUSIONS:
The OCTA allows better discrimination of the CSF and parafoveal macular microvasculature than FA, especially for FAZ disruption and capillary dropout, without the need of an intravenous injection of fluorescein. In addition, FA had also a higher number of non-gradable images. The OCTA can replace with advantage the FA, as a non-invasive and more sensitive procedure for detailed morphological evaluation of central macular vascular changes.
TRIAL REGISTRATION NUMBER:
NCT02391558, Pre-results.info:eu-repo/semantics/publishedVersio
A Nonrandomized, Open-Label, Multicenter, Phase 4 Pilot Study on the Effect and Safety of ILUVIEN® in Chronic Diabetic Macular Edema Patients Considered Insufficiently Responsive to Available Therapies (RESPOND)
Get PDFPURPOSE:
The aim of this study was to assess the effectiveness and safety of ILUVIEN® in patients with chronic diabetic macular edema (DME) who were insufficiently responsive to prior therapies.
METHODS:
This is a prospective, nonrandomized, multicenter, open-label, phase 4 pilot study assessing the effectiveness and safety of ILUVIEN® involving 12 patients insufficiently responsive to available therapies. Assessments were performed at screening, baseline, week 1, and months 1, 3, 6, 9, and 12. Demographics, medical/ophthalmic history, prior laser, anti-VEGF, and steroid treatments, and lab tests were recorded at screening. A complete ophthalmic examination and SD-OCT were performed at screening and at all follow-up visits.
RESULTS:
The patients showed improvements in best-corrected visual acuity (+3.7 letters), with greater improvement among pseudophakic patients (+6.8 letters) compared with phakic patients (-2.5 letters) 12 months after ILUVIEN®. The mean central subfield thickness decrease from baseline to month 12 was statistically significant, with a rapid reduction in the first week. Regarding safety, only 2 patients showed an intraocular pressure (IOP) increase over 25 mm Hg during the study, and the rise in IOP was well managed with eye drops only.
CONCLUSIONS:
This prospective and pilot study suggests that ILUVIEN® is safe and may be considered effective for chronic DME patients insufficiently responsive to other available therapies as it showed a rapid and sustained improvement of macular edema obtained after treatment with ILUVIEN®.info:eu-repo/semantics/publishedVersio