[Diagnostic and Treatment Strategies in Morel-Lavallee Lesions in the Spinal Column and Pelvis]

BACKGROUND

The Morel-Lavallée lesion is one of the concomitant soft tissue lesions of pelvic fractures. Its role in spine fractures and its treatment in combination with osteosynthesis of pelvic or spine fractures have not yet been determined. The aim of this study was to analyse the best diagnostic and treatment options of both spine and pelvic fractures combined with Morel-Lavallée lesions (MLL).

METHODS

An analysis of the literature was performed via PubMed and Medline. This revealed a total of 197 studies and case reports. After analysing the literature, 19 studies/case reports met our inclusion criteria.

RESULTS

There are several diagnostic options for MLL, including ultrasound, computed tomography or MRI. In spinal and pelvic lesions, ultrasound is capable of detecting MLL. Some authors tend to perform open debridement of the MLL, whereas others recommend percutanous treatment. Open debridement and vacuum-assisted closure are recommended in late diagnosed MLL, where primary suture of the soft tissue is impossible. Fracture fixation should be performed simultaneously to treatment of the MLL. Broad-spectrum cephalosporins combined with an aminoglycoside or piperacilline/tazobactam should be initiated.

CONCLUSION

Radical debridement and drainage are recommended, especially when MLL is diagnosed late. Repeated ultrasound examinations should be performed of the surrounding soft tissue of the fracture. When MLL is diagnosed within 2 days, percutanous fracture and MLL treatment should be performed. After more than 2 days, both fracture and MLL should be treated with open debridement, open fracture fixation and primary suture if possible.

IKZF1 expression is a prognostic marker in newly diagnosed standard-risk multiple myeloma treated with lenalidomide and intensive chemotherapy: a study of the German Myeloma Study Group (DSMM)

Lenalidomide is an immunomodulatory compound with high clinical activity in multiple myeloma. Lenalidomide binding to the Cereblon (CRBN) E3 ubiquitin ligase results in targeted ubiquitination and degradation of the lymphoid transcription factors Ikaros (IKZF1) and Aiolos (IKZF3) leading to growth inhibition of multiple myeloma cells. Recently, Basigin (BSG) was identified as another protein regulated by CRBN that is involved in the activity of lenalidomide. Here, we analyzed the prognostic value of IKZF1, IKZF3, CRBN and BSG mRNA expression levels in pretreatment plasma cells from 60 patients with newly diagnosed multiple myeloma uniformly treated with lenalidomide in combination with intensive chemotherapy within a clinical trial. We found that IKZF1 mRNA expression levels are significantly associated with progression-free survival (PFS). Patients in the lowest quartile (Q1) of IKZF1 expression had a superior PFS compared with patients in the remaining quartiles (Q2-Q4; 3-year PFS of 86 vs 51%, P=0.01). This translated into a significant better overall survival (100 vs 74%, P=0.03). Subgroup analysis revealed a significant impact of IKZF1, IKZF3 and BSG expression levels on PFS in cytogenetically defined standard-risk but not high-risk patients. Our data suggest a prognostic role of IKZF1, IKZF3 and BSG expression levels in lenalidomide-treated multiple myeloma.

Bio-based polycarbonate as synthetic toolbox

Completely bio-based poly(limonene carbonate) is a thermoplastic polymer, which can be synthesized by copolymerization of limonene oxide (derived from limonene, which is found in orange peel) and CO2. Poly(limonene carbonate) has one double bond per repeating unit that can be exploited for further chemical modifications. These chemical modifications allow the tuning of the properties of the aliphatic polycarbonate in nearly any direction. Here we show synthetic routes to demonstrate that poly(limonene carbonate) is the perfect green platform polymer, from which many functional materials can be derived. The relevant examples presented in this study are the transformation from an engineering thermoplastic into a rubber, addition of permanent antibacterial activity, hydrophilization and even pH-dependent water solubility of the polycarbonate. Finally, we show a synthetic route to yield the completely saturated counterpart that exhibits improved heat processability due to lower reactivity.

Sacroiliac Coalition: First Description and Report of a Successful Resection

Study Design Case report. Objective This report describes the first case of a sacroiliac coalition, its clinical features, the diagnostic difficulties, and the surgical treatment chosen in this case. Methods A 33-year-old man presented to our outpatient clinics complaining of severe left-sided low back pain with an intermitted nondermatomal radiation into the left thigh. The only abnormality on a pelvic radiograph was a coin-size, faint hyperdensity, which was almost overlooked. Subsequent computed tomography (CT) and magnetic resonance imaging (MRI) confirmed two bridging bone spurs on the anterior surface of the left joint with a fibrous interruption at the apex. After the conservative treatment failed, a surgical treatment was offered to the patient. The coalition was resected via an anterior retroperitoneal approach and through the tissue plane between the psoas and the iliacus muscles. A histopathologic examination was performed and confirmed the diagnosis of a coalition. Results The patient's pain resolved immediately after surgery. After 8 months, a follow-up CT scan showed complete removal of the coalition without any signs of recurrence, and at 12 months' follow-up, the patient remained pain-free. Conclusions This is the first published case of a sacroiliac coalition. The only sign of this rare condition on the plain radiographs was very easy to miss. As has been discussed in the literature, CT and MRI are important in the differential diagnostics of such lesions. The histopathologic findings included that of a fibrous bar, confirming the diagnosis, which is further corroborated by the complete resolution of the symptoms.

[The Compression Syndrome of Lumbar Arteries - Case Report of a Rare Disease Pattern]

STUDY DESIGN

We present a monocentric analysis of the lumbar artery compression syndrome (LACS) in the form of a case report.

OBJECTIVES

Literature information was collected about the symptoms, diagnosis and treatment of this rare disorder in the context of the existing data.

METHODS

The current medical literature includes only one report about three cases of LACS, collected over 20 years in France and Germany. We compared these cases with the experience of the European Vascular Center Aachen-Maastricht.

RESULTS

The symptoms of this rare disorder are dominated by reversible, motion-dependent paralysis of the legs. Compression of the right lumbar arteries by muscular fibres or connective tissue is a fundamental cause.

CONCLUSION

Surgical treatment, which means decompression of the lumbar arteries via a thoracolaparotomy, is an appropriate therapy with few complications and good long-term results.

CT-guided sacroiliac percutaneous screw placement in unstable posterior pelvic ring injuries: accuracy of screw position, injury reduction and complications in 71 patients with 136 screws

BACKGROUND

Sacroiliac-percutaneous-screw-placement (SPSP) for unstable-posterior-pelvic-ring-injuries (UPPRI) might be associated with severe neurovascular complications because of screw-mal-position. The aim of the present study was to analysis the effectivity of computer-tomography-guided (CTG)-SPSP including accuracy of screw-placement, quality of injury-reduction and documentation of perioperative-complications. Additionally, procedure-dependent radiation-dose and outcome should be analysed.

METHODS

A consecutive cohort of 71 patients with UPPRI was operated by CTG-SPSP at a single trauma level 1 hospital. 136 sacroiliac screws were inserted to S1 and S2. Postoperatively, by the use of a computerised-radiologic-work-station all screws were visualised three-dimensionally. Their distancesmin to the sacral-borders in anterior-posterior and cranio-caudal direction as well as to the neuroforamen S1/S2 were determined. After CTG-SPSP, injury-dislocation in anterior-posterior and cranio-caudal direction was quantified. Local and general complications were documented during the 30-day-period. In 55 patients (77.5%) a follow-up-investigation (29.1±19.1 months) was performed.

RESULTS

132 screws (97.1%) were placed completely intraosseous, 3 screws (2.2%) perforated up to 1.0 mm (n(S1)=one screw; n(S2)=two screws), and one screw (0.7%) extended 2.2 mm into the S2-neuroforamen without contact to neural structures. Postoperative dislocationanterior-posterior was 1.3±0.9 mm and dislocationcranio-caudal 1.5±0.9 mm. No procedure-associated-complication was observed. Operation time showed a significant "learning curve" during the six-year study period (initially: 88.6±60.3 min; finally: 44.3±24.6 min). Perioperative effective-radiation-dose for patientsmale was 5.9±3.1 mSv and for patientsfemale 8.7±4.5 mSv. All injuries healed and 33 patients (46.5%) had metal removal after 11.0 (±4.9) months. Only two (5.0%) out of 40 patients complained persistent UPPRI-related pain so they were not able to restart work.

CONCLUSIONS

The CTG-SPSP is a safe procedure for UPPRI-stabilisation especially in S1 but also in S2. Injury reduction was excellent and no procedure associated complications were observed.

What predicts outcome after recanalization of chronic venous obstruction: hemodynamic factors, stent geometry, patient selection, anticoagulation or other factors?

In this review we evaluated the effect of different suggested factors associate with the outcome after recanalization of chronic venous obstruction (CVO).

Hemodynamic factors:

Based upon literature no clear suggestions can be made to identify the risk of stent occlusion in association with the hemodynamic effects. However it is evident that ensuring optimal in- and outflow of the stented tract is key in maintaining the patency.

Patient selection:

Noninvasive imaging modalities are used to divide patients in three subgroups based on the place and extension of post-thrombotic changes. Moreover it should be noted that AV fistula in selected patients can reduce the risk of thrombosis or re-occlusion.

Geometry:

Excessive oversizing of the stent and stent compression from outside are considered to be associated with stent occlusion. Additionally, overlapping rigid stents, unnatural angel between stents and in-stent kinking are other geometrical factors related to worse outcome after venous recanalization.

Anticoagulation:

Adequate peri-and postoperative anticoagulation has a crutial role in stent patency. There is no data regarding the duration of anticoagulation therapy and recommendations vary between 6 weeks to 6 months.

Result:

impaired inflow or outflow, presence of a hypercoagulability, total number of treated segments and use of stents designed for implantation in arterial system are associated with decreased stent patency.

Anatomic changes of target vessels after fenestrated and branched aortic aneurysm repair

AIM

Objective of this study was to evaluate the anatomic changes of the stented target vessels after endovascular repair of complex aortic aneurysms.

METHODS

Between July 2011 and December 2013, 53 aortic aneurysms were treated in our department with fenestrated and branched stent-graft devices. Forty-two of these patients were pre- and postoperatively scanned with a high resolution computer tomography (CT) (Cook Zenith® fenestrated or branched, Australia Pty. Ltd., Brisbane, Australia: N.=19; AnacondaTM fenestrated, Vascutek, Glasgow, Scotland, UK: N.=23). The other 11 out of the 53 patients did not receive a CT scan, because of a pre-existing renal failure. In the CT scans we retrospectively evaluated the anatomic vessel deviation at the origin of the target vessel and the vessel shift distal to the stent. For the first measurement the CT scans were loaded into OsiriX MD®, and the pre- and postoperative angles of the target vessels were measured and subtracted. For matching, the CT-scans were normalized at vertebral body lumbar 2. The second measured angle was the maximal measured angle distal to the target vessel stent-graft.

RESULTS

Altogether, 113 target vessels were stented (celiac trunk [CT] 15, superior mesenteric arteries [SMA] 26, renal arteries [RA] 72), with 97 balloon-expandable PTFE stents: 90 Atrium V12 (Maquet Getinge group, Hudson, NH, USA), 7 BeGrafts (Bentley InnoMed, Hechingen, Germany) and 16 self-expandable fluency PTFE stents (Bard, Karlsruhe, Germany). The mean anatomic deviation at the target vessel origin was 28±17.3 and the mean vessel shift distal to the stent was 36.3±18.8. There were no significant differences between the main device and the target vessel stent types.

CONCLUSION

Fenestrated and branched stent-graft solutions for aortic aneurysm repair induce changes of the target vessel anatomy. We did not observe significant differences between the several devices.

A new shunting concept to prevent lower limb ischemia/reperfusion injury in prolonged fenestrated stent-graft procedures

AIM

Complex endovascular procedures to treat thoracoabdominal aortic aneurysms (TAAA) can be time consuming and therefore comprise the risk of lower limb ischemia with subsequent reperfusion injury and compartment syndrome. Aim of this study was to evaluate a new protective method to prevent these postoperative problems.

METHODS

In order to maintain blood perfusion to both legs during prolonged endovascular aortic procedures we developed a shunting technique with two additional 7 French (Fr) sheaths in both superficial femoral arteries. We evaluated the perfusion technique in 5 patients with fenestrated endovascular aortic aneurysms repair (FEVAR). First, we measured the flow in the 7 Fr sheaths; second, we clinically controlled the lower limb for developing compartment syndrome. Third we measured creatinine kinase (CK) as marker for postoperative muscular damage.

RESULTS

In 5 male patients (median age 77, range 59-80 years) undergoing endovascular TAAA repair, the perfusion technique was feasible. The median flow per catheter was 102 mL/min (range 61-156.5 mL/min) and monophasic with a mean arterial blood pressure of 71 mmHg (range 56-82 mmHg). No patient developed a compartment syndrome. The CK levels were only lightly elevated.

CONCLUSION

This simple perfusion technique allows adequate lower limb perfusion during prolonged complex endovascular aortic procedures.

Late rupture after EVAR: a new trend?

AIM

Endovascular aortic repair (EVAR) is an adequate therapy for abdominal aortic aneurysms (AAA). Late aortic ruptures caused by endoleaks after EVAR still remain a critical issue. The aim of this study was to assess the causes of ruptured aortic aneurysms after EVAR in a single center study.

METHODS

All patients, who were treated in our University hospital with a ruptured juxtra- or infrarenal AAA between January 2011 and October 2013, were included in this retrospective analysis.

RESULTS

Thirty patients with ruptured infra- or juxtrarenal aneurysms were treated in this time frame. Six out of these 30 patients had previous EVAR repair. The median maximal aneurysm diameter of these post-EVAR patients was 82 (75-95) mm. The median time between primary EVAR and rupture was 42.5 (14-99) months. Three patients with type Ia endoleaks were treated by stent removal and conventional aortic reconstruction. In two patients with type II endoleak the bleeding was controlled by occluding the back bleeding lumbar arteries. One type III endoleak was sealed by an additional stent-graft implantation into the right iliac artery.

CONCLUSION

We observed a considerable number of patients with a ruptured AAA after EVAR. Surprisingly, we observed two ruptured aneurysms due to type II endoleaks.

Intentional left subclavian artery coverage without revascularization during TEVAR

At present, endovascular therapy is a well-established treatment for different types of thoracic aortic pathologies. There is growing evidence, that thoracic endovascular aortic repair (TEVAR) has advantages over open repair with regard to perioperative morbidity and mortality in the treatment of thoracic aortic aneurysms. However, in up to 50% of TEVAR procedures the proximal end of the stent-graft will (partly) cover the origin of the left subclavian artery (LSA) in order to achieve a save sealing zone. Intracranial stroke and paraplegia are feared complications and might be associated with LSA exclusion from the circulation. Unfortunately, no reliable technique is available to assess the individual risk of stroke and paraplegia in case of LSA coverage, so that the indication for LSA revascularization continues to be matter of assuming and guessing. The quality of available evidence on necessity or superfluity to revascularize the LSA is very low and studies report, to some extent, controversial outcome after intentional LSA coverage. In the light of the devastating consequences for patients in case of neurological complications due to LSA coverage the question of prophylactic LSA revascularization remains a significant problem which is elucidated and discussed in this manuscript.

Thoracoabdominal aneurysms and changes in adjacent vertebral bodies

AIM

The aim of this study was to assess if chronic intermittent pressure of a thoracoabdominal aortic aneurysm (TAAA) induces structural changes in vertebral bodies and if eroded vertebral bones can still be found after the extermination of syphilis.

METHODS

A retrospective analysis of computed tomography (CT) scans of patients with TAAA was performed. In the anatomical regions were the TAAA was in close contact with the vertebral bodies, the vertebral body alteration was distinguished into 4 categories. Category 0: no changes; 1: discrete changes, minimal asymmetry; 2: obvious asymmetry of the vertebral body with sustained cortical layer; 3: severe destruction of the vertebral body with loss of the cortical layer.

RESULTS

Eighty-six CT scans of patients (mean age 63; range 25-82 years) with TAAA pathology were examined (24 female, 62 male). The mean aneurysm diameter was 6.5 cm (4.3-14 cm). The results for scoring were: category 0: 33 patients; category 1: 46 patients; category 2: 5 patients and category 3: 2 patients. One of the category 3 patients suffered from acute spinal cord compression with complete paraplegia. In total, 62% of patients showed some degree of changes at vertebral bodies adjacent to the TAAA.

CONCLUSION

Intermittent pressure by either dissecting or non-dissecting TAAAs may induce structural changes in the vertebral bodies of the spine. Severe destruction of the bone is a rare, but existing complication.

[Aortic aneurysm 2012: open, hybrid or total endovascular repair?]

During the past two decades, minimally invasive endovascular procedures have changed therapeutic strategies. Such techniques have now become the method of choice for practically all vascular and aortic pathologies. This development is especially apparent in the treatment of aortic aneurysms. The purpose of this report is to provide a critical review about the current standard of care of abdominal and thoracic aorta based on an electronic Medline literature search. For elective infrarenal aneurysms, endovascular aneurysm repair (EVAR) has become a widely accepted alternative to open repair in cases with appropriate morphology. Currently, fenestrated (FEVAR) or branched endografts offer promising short- and mid-term results in juxtarenal aneurysms, however, these techniques are complex, technically challenging, and expensive. The alternative chimney or sandwich graft technique are becoming more common because they are feasible using standard endografts. Thoracic endovascular aortic repair (TEVAR) is already the gold standard for some descending pathologies. Complex thoracoabdominal aneurysms still require open surgery in centres of excellence, whereby, total endovascular repair or hybrid procedures have proved to be feasible in such specialist centres for selected patients.

Primary and secondary amputation in critical limb ischemia patients: different aspects

The TASC II working group reports on primary amputation incidence rates vary between 12 and 50 per 100,000 per year. The primary amputation rate does not only depend on co-morbidities like diabetes and PAD, but also on local factors like the regional availability of vascular surgeons and interventional radiologists and their case load. Further-more, several studies could show that increasing revascularisation rates have drastically reduced amputation rates in the US, with a 50% decrease in amputation rates during a 10 year study period and a corresponding increase in surgical and endovascular revascularisation rates. An analysis of national and state US databases confirmed a drop in major amputations and open surgical revascularisations, in favour of an increase in endovascular interventions. The same study observed an increase in minor amputations during the same period. However, it remains unclear whether this trend is a consequence of the increased usage of endovascular procedures in high-risk patients who are unfit for open surgery or of earlier endovascular intervention in less critical lesions. This review gives an overview of the incidence, indication, amputation-level finding and outcome of major amputations performed in critical limb ischemia (CLI) patients.