Radioembolization with 90Y microspheres: angiographic and technical considerations

The anatomy of the mesenteric system and the hepatic arterial bed has been demonstrated to have a high degree of variation. This is important when considering pre-surgical planning, catheterization, and trans-arterial hepatic therapies. Although anatomical variants have been well described, the characterization and understanding of regional hepatic perfusion in the context of radioembolization have not been studied with great depth. The purpose of this review is to provide a thorough discussion and detailed presentation of the angiographic and technical aspects of radioembolization. Normal vascular anatomy, commonly encountered variants, and factors involved in changes to regional perfusion in the presence of liver tumors are discussed. Furthermore, the principles described here apply to all liver-directed transarterial therapies.

Radioembolization with Yttrium-90 microspheres: review of an emerging treatment for liver tumors

Understanding the effect of radiation on tissue, the principles of dosimetry and fractionation have led to the acceptance and adoption of radiation as a standard treatment option for cancer. Delivered in staged and scheduled aliquots, radiation will break nucleic strands and cause cellular death. In general, radiation therapies are delivered using external techniques (external beam and intensity-modulated therapy). One of the limitations of such external techniques is that of nontarget radiation. That is, despite best efforts to collimate and reflect radiation beams to a small target, nontarget radiation and a dose to areas outside the tumor remains a distinct possibility. With the advent of radioembolization using Yttrium-90 microspheres (90Y), the radiation source is delivered optimally through a novel mechanism: directly into the blood vessel providing flow to the tumor. This revolutionary approach capitalizes on the basic principles of tumor hypervascularity, concentrating radiation within that tumor, while at the same time minimizing the risks of nontarget radiation. This review elaborates on this technology.

Sac Hygroma After Endovascular Abdominal Aortic Aneurysm Repair: Successful Treatment with Endograft Relining

Aneurysm sac expansion following endovascular abdominal aortic aneurysm repair (EVAR) is typically associated with endoleaks that can be readily diagnosed on computed tomographic angiography (CTA), ultrasound, or catheter-directed arteriography. Sac hygromas are a cause of sac expansion without apparent endoleak and are presumed to be a result of ultrafiltration of serum manifested by accumulation of fibrinous, gelatinous material within the aneurysm sac following EVAR. Although there are no reported associated ruptures, sac expansion is nevertheless disconcerting and intervention is presumably indicated. We report a case of an expanding aneurysm after EVAR secondary to sac hygroma that was successfully treated with relining of the existing, original endograft.

Cutaneous thermal injury after endovenous laser ablation of the great saphenous vein

Herein a case of cutaneous thermal injury in the leg of a patient who underwent endovenous laser (EVL) ablation of an incompetent great saphenous vein (GSV) is reported. Follow-up ultrasonography (US) of the site of skin burn showed that the burn was directly over thrombosed superficial tributaries originating from the GSV, but medial to the treated GSV. At the level of skin burn, the thrombosed GSV was 22 mm deep, but the tributaries were 1 mm deep. In addition, US showed echogenic fat surrounding and conforming to the superficial thrombosed tributaries. Based on the clinical scenario and follow-up US findings, it was concluded that the cutaneous thermal injury resulted from heated blood traveling from the 22-mm-deep GSV to the superficial tributaries directly beneath the site of skin burn.

Primary Failure of Uterine Artery Embolization: Use of Magnetic Resonance Imaging to Select Patients for Repeated Embolization

The purpose of this study was to determine if contrast material-enhanced magnetic resonance (MR) imaging could be used to stratify patients who have undergone failed primary uterine artery embolization (UAE) for repeated embolization. One hundred one consecutive patients who underwent UAE at a single center were followed prospectively and assessed for the presence of persistent contrast enhancement of leiomyomas on follow-up MR imaging. Among 11 of the 111 patients with primary clinical failure (10%), MR imaging showed persistent enhancement in eight. Of the eight cases of failure with continued tumor enhancement on MR imaging, six were treated with repeated embolization. All six patients showed complete symptomatic relief at 12-month follow-up. In women who have been treated with failed primary UAE, continued enhancement of leiomyomas on MR imaging can be used to identify candidates for successful repeated UAE.

Greater Energy Delivery Improves Treatment Success of Endovenous Laser Treatment of Incompetent Saphenous Veins

PURPOSE

Early and midterm results of endovenous laser treatment (EVLT) of the saphenous veins for the treatment of symptomatic insufficiency are promising. However, technical factors contributing to success or failure of saphenous vein EVLT have not been fully investigated. This study was performed to test the hypothesis that treatment success is related to achieving a critical threshold of energy delivery relative to the length of vein treated.

MATERIALS AND METHODS

Data regarding length of treated vein and total energy delivered were collected from prospectively acquired databases at two institutions. Ultrasound (US) examinations were obtained for all treated veins. Successful EVLT was defined as US-documented absence of flow in the treated vein. EVLT failure was defined by US evidence of flow at any point in the treated vein segment at any time more than 1 week after the treatment date. A two-tailed Student t test was performed for statistical analysis and the null hypothesis was rejected at a P value less than .05.

RESULTS

One hundred eleven treated veins were followed up with US over 3-78 weeks (mean, 29.5 weeks). During this time, 85 treated veins (77.5%) remained closed. In this group of successfully treated veins, average energy delivered was 63.4 J/cm (range, 20.5-137.8 J/cm). The average energy delivered to the 26 veins (22.5%) in the failure group was 46.6 J/cm (range, 25.7-78 J/cm). This difference in delivered energy was statistically significant (P < .0001). No treatment failures were identified in patients who received doses of 80 J/cm or more.

CONCLUSION

EVLT is an effective method of incompetent saphenous vein treatment. Greater doses of energy delivered are associated with successful EVLT, particularly when doses of more than 80 J/cm are delivered.

Comparison of Pain After Uterine Artery Embolization Using Tris-Acryl Gelatin Microspheres Versus Polyvinyl Alcohol Particles

When compared in a uterine artery embolization (UAE) animal model, Embospheres (ES) (Biosphere Medical, Rockland, MA) were found to induce less uterine ischemia than polyvinyl alcohol (PVA) particles. Given this finding, we aimed to test the hypothesis that ES is associated with less pain after UAE than PVA in human patients. We performed retrospective analysis on data from 72 consecutive UAE patients, collected from a prospectively acquired database. Patient-controlled analgesia (PCA) pump-delivered morphine sulfate (MS) dosages were compared between patients who received ES versus PVA. Subjective pain scores (SPS) were also compared between the two groups. Secondary outcome measures, including embolic volume and clinical outcome data, were also collected. Linear regression and t-test statistical analyses were performed. Null hypotheses were rejected at the p < 0.05 level. Mean follow-up period in the PVA population was 178 days (range 28-426), versus 96 days (range 24-197) in the ES population. The mean MS doses used by ES and PVA patients were 37.2 (s.d. 23.5) versus 47.1 (s.d. 26.8), respectively. This difference was not significant (p > 0.15). Utilizing a standard 0-10 pain scale, the mean peak SPS for the ES and PVA groups were 5.58 (s.d. 2.77) and 5.07 (s.d. 2.99), respectively. The difference was not significant. The mean amount of embolic material used in each ES and PVA patient was 4.86 cc (s.d. 3.01) and 3.52 cc (s.d. 1.63), respectively. The difference revealed a strong trend toward statistical significance (p = 0.05). There was one treatment failure in each group of patients. Within both patient samples, no significant correlation was found when comparing the volume of embolic used and subsequent MS dose. Despite a strong trend toward a significantly higher volume of ES used per patient, there is no subjective or objective difference in pain after UAE with ES when compared to PVA.

Sonography of delayed effects of uterine artery embolization on ovarian arterial perfusion and function

OBJECTIVE

We aimed to assess the delayed effects of uterine artery embolization on ovarian arterial perfusion and function by performing ovarian sonography immediately before and after uterine artery embolization, as well as several months later.

CONCLUSION

Although persistent loss of detectable arterial perfusion after uterine artery embolization occurs in some women, most patients reestablish arterial perfusion and do not develop symptoms of ovarian failure.

The effect of pelvic MR imaging on the diagnosis and treatment of women with presumed symptomatic uterine fibroids

PURPOSE

To determine if magnetic resonance (MR) imaging significantly alters the diagnostic thinking and treatment plans of interventional radiologists during the evaluation of women for uterine fibroid embolization (UFE) for presumed uterine fibroids.

MATERIALS AND METHODS

At a single institution, interventional radiologists prospectively completed questionnaires (n = 60) before and after MR imaging was performed in their evaluation of women presenting for potential UFE. The questionnaires asked these physicians the probability (0%-100%) of their most likely diagnosis before MR imaging and after receiving the MR imaging information. They were also asked their anticipated and final treatment plans. Diagnostic confidence gains and the proportion of patients with changed initial diagnoses or anticipated management were calculated. The Wilcoxon signed-rank test was used to assess gains in diagnostic confidence.

RESULTS

MR imaging caused a mean gain in diagnostic confidence of 22% (P <.0001). MR imaging changed initial diagnoses in 11 patients (18%). Immediate clinical management changed in 13 patients (22%). UFE was not performed in 11 of 57 women (19%) who were anticipated before MR imaging to receive UFE.

CONCLUSIONS

MR imaging significantly alters the diagnoses and treatment plans of interventional radiologists evaluating women with presumed symptomatic fibroids. MR imaging should be considered in all patients before UFE.

Validation of injection parameters for catheter-directed intraarterial gadolinium-enhanced MR angiography

RATIONALE AND OBJECTIVES

Catheter-directed intraarterial (IA) injections of gadolinium contrast agents may be used during endovascular interventions with magnetic resonance (MR) imaging guidance. Injection protocols require further validation. Using a flow phantom and swine, the authors aimed to (a) measure the optimal arterial gadolinium concentration ([Gd]) required for MR angiography and (b) validate a proposed IA injection protocol for gadolinium-enhanced MR angiography.

MATERIALS AND METHODS

For in vitro experiments, the authors placed a catheter in the aorta of an aorto-renal-iliac flow phantom. Injected [Gd], injection rates, and aortic blood flow rates were varied independently for 36 separate IA gadolinium injections. The authors performed 2D and 3D MR angiography with a fast spoiled gradient-recalled echo sequence. For subsequent in vivo experiments, they selectively placed catheters within the aorta, renal artery, or common iliac artery of three pigs. Injection rate and injected [Gd] were varied. The authors performed 32 separate IA gadolinium injections for 2D MR angiography. Signal-to-noise ratios (SNRs) were compared for the various combinations of injection rate and injected [Gd].

RESULTS

In vitro, an arterial [Gd] of 2%-4% produced an optimal SNR for 2D MR angiography, and 3%-5% was best for 3D MR angiography. In swine, an arterial [Gd] of 1%-4% produced an optimal SNR. In the phantom and swine experiments, SNR was maintained at higher injection rates by inversely varying the injected [Gd].

CONCLUSION

Dilute arterial [Gd] is required for optimal IA gadolinium-enhanced MR angiography. To maintain an optimal SNR, injection rates and injected [Gd] should be varied inversely. The postulated injection protocol was validated.

The vascular impact of uterine artery embolization: prospective sonographic assessment of ovarian arterial circulation

PURPOSE

The etiology of premature ovarian failure after uterine artery embolization (UAE) is unknown. The authors prospectively assessed ovarian arterial circulation before and after UAE with use of ultrasonography (US). The authors hypothesize that nontarget embolization of the ovary occurs during routine UAE.

MATERIALS AND METHODS

Twenty-three women (mean age of 42.6 years; range, 35-51 y) participated in the study. Grayscale, color, and pulsed-wave Doppler US studies were performed immediately before and after UAE. Resistive index (RI) and pulsatility index (PI) were calculated. The proportion of women who developed increased vascular impedance after UAE was statistically assessed with use of the Yates-corrected chi(2) test.

RESULTS

Seventeen of 23 patients (74%) completed the study. Nine of 17 (54%) showed complete loss of ovarian arterial perfusion after UAE. Six of 17 (35%) had increases in RI and PI, whereas two of 17 (11%) had decreases in RI and PI. The increase in vascular impedance after UAE in 15 of 17 patients was significant (P <.0001).

CONCLUSION

Loss of detectable ovarian arterial perfusion occurs in the majority of patients undergoing UAE. Ovarian vascular impedance increases in nearly all patients as a result of UAE. The authors conclude that inadvertent nontarget embolization of the ovarian arterial bed occurs during routine UAE.

Identification and implications of transgraft microleaks after endovascular repair of aortic aneurysms

PURPOSE

The purpose of this report is to describe an interesting cause of endoleak and detail-specific techniques for identifying small transgraft defects, which we have termed microleaks.

METHODS

Four patients underwent endovascular repair of abdominal aortic aneurysms with modular nitinol/polyester endoprostheses and were studied after 6 to 30 months. All patients were enrolled in standard follow-up radiographic surveillance protocols.

RESULTS

Three of the four abdominal aortic aneurysms continued to expand after endograft repair. Standard computed tomography imaging with precontrast, dynamic contrast, and delayed imaging frequently identifies endoleak, although it fails to precisely identify microleaks as the source. Color flow duplex ultrasound scan was performed on three patients and perigraft "jets," small areas of color flow adjacent to the endograft, were identified in all. Microleaks were identified in one patient who underwent digital subtraction arteriography with directed efforts to completely opacify the prosthesis lumen and multiple oblique projections. In another patient, contrast arteriography with balloon occlusion of the distal endograft clearly depicted midgraft microleaks that might otherwise be mistaken for graft porosity or cuff junction endoleaks. No microleaks were diagnosed on angiograms when these directed efforts were not performed. Aneurysm exploration before aortic clamping provided conclusive determination of the presence of blood flow through the wall of the endoprosthesis in two patients.

CONCLUSIONS

Microleaks occur up to 2.5 years after endovascular repair of aortic aneurysms. Although computed tomography demonstrates the presence of an endoleak in these patients, the exact site of origin usually remains obscure. Doppler ultrasound scan and directed arteriography appear to be of greater utility for identifying the presence and location of microleaks. Balloon occlusion arteriography and aneurysm exploration without arterial clamping provide definitive evidence of microleaks. Although the clinical significance of microleaks remains unclear, long-term monitoring of patients is imperative to diagnose and treat these and other modes of endograft failure before they progress to aneurysm rupture.

Treatment of stomal variceal hemorrhage with TIPS: case report and review of the literature

We report a case in which recurrent hemorrhage from stomal varices was successfully treated by placement of a TIPS in a patient with prior colectomy for inflammatory bowel disease. Although several treatment options have been reported for this entity we believe that TIPS offers minimally invasive and definitive treatment.

The impact of uterine fibroid embolization on resumption of menses and ovarian function

PURPOSE

To evaluate the effect of uterine fibroid embolization (UFE) on menstruation and ovarian function.

METHODS

The authors performed an observational study of UFE for the treatment of symptomatic fibroids. All patients had regular predictable menses before intervention and none had clinical or laboratory findings of menopause. UFE was performed with use of standard methods with 355-700-microm-diameter polyvinyl alcohol (PVA) foam particles. The incidence of ovarian failure was calculated for women younger than 45 years and for those 45 years or older, based on retrospective stratification by age. The authors assessed statistical differences in ovarian failure between the two age groups with use of the X2 test.

RESULTS

Sixty-six premenopausal women (age range, 30-55 years) underwent bilateral UFE and were followed for an average of 21 weeks (range, 12-77 weeks). In 56 of 66 (85%) patients, regular menses resumed after an average of 3.5 (range, 1-8) weeks. In 10 of 66 (15%) patients, regular menses did not resume. Clinical and biochemical findings consistent with ovarian failure and presumed menopause were seen in nine of 10 patients without resumption of menses (14% of total patients). Ovarian failure occurred in nine of 21 (43%) women older than 45 years and in none of the 45 women younger than 45 years (P < .05). There were no differences in presenting symptoms, amount of PVA used, or fibroid size between patients who did and did not resume menses.

CONCLUSION

The majority of patients undergoing UFE will have resumption of menses, but the incidence of postprocedure ovarian failure is considerably higher than reported to date. Loss of menses induced by UFE is significantly more likely to occur in women older than 45 years.

Treatment of posttraumatic internal carotid arterial pseudoaneurysms with endovascular stents

BACKGROUND

The sequelae of blunt injury to the carotid arteries are unusual, but pseudoaneurysms causing subsequent strokes are devastating. The utility of treatment of these pseudoaneurysms was examined.

METHODS

All patients at a Level I trauma center with previously documented traumatic risk factors were assessed for blunt injury to the carotid arteries and, when a pseudoaneurysm was present, a self-expanding metallic stent was placed across the lesion and the patient placed on anticoagulation. Follow-up arteriograms were obtained in 2 months and every 6 months thereafter.

RESULTS

Fourteen patients (7 men, 7 women) with an average age of 27 years, an Injury Severity Score of 38, had formed pseudoaneurysms in 16 extracranial internal carotid arteries. These were stented with metallic endoprostheses. No strokes occurred after the placement of the stents. Mean follow-up period has been 2.5 years.

CONCLUSIONS

Use of metallic endoprostheses is an effective method to treat this potentially devastating injury. However, longer follow-up and more patients studied are needed to further examine this promising treatment.

Role of TIPS as a bridge to hepatic transplantation in Budd-Chiari syndrome

PURPOSE

To investigate the role of transjugular intrahepatic portosystemic shunt (TIPS) as a bridge to transplantation for patients with Budd-Chiari syndrome (BCS).

MATERIALS AND METHODS

Eight patients (five women, three men) with a mean age of 49.8 years (range, 20-61 years) were diagnosed with BCS by means of computed tomography, hepatic venography, and liver biopsy. One patient had acute liver failure, with subacute or chronic failure in seven. TIPS placement was attempted in all eight patients. Clinical follow-up and portograms were obtained in all patients until death or transplantation.

RESULTS

TIPS placement was completed in seven of eight patients (87.5%). During the follow-up period, TIPS occlusion occurred in four patients. TIPS revision in this patient, although successful, was complicated by hemorrhage and multiorgan failure, and the patient died. Assisted patency rate, excluding the technical failure, was 100%. Mean follow-up in the six survivors with TIPS was 342 days (range, 19-660 days). All six survivors had complete resolution of their ascites. Albumin levels improved an average of 0.43 g/dL (range, 0.3-1.4 g/dL). Bilirubin levels improved in five of six patients (83%), decreasing by an average of 5.6 mg/dL (range, 3.0-15.2 mg/dL). Of the six survivors, three underwent elective liver transplantation, one is awaiting transplantation, and one has been removed from the transplantation list because of clinical improvement. One patient was a candidate for transplantation but declined to be put on the list.

CONCLUSION

Hepatic synthetic dysfunction improves markedly after TIPS placement in patients with BCS. Significant improvement in ascites can also occur. TIPS can be an effective bridge to transplantation for patients with BCS.

Peripherally inserted central catheters: guidance with use of US versus venography in 2,650 patients

PURPOSE

To compare technical success and initial complication rates of peripherally inserted central catheters (PICCs) by interventional radiologists using ultrasound (US) or venographic guidance.

MATERIALS AND METHODS

With use of a computer database, the authors retrospectively reviewed 2,650 procedures, 2,126 of which were performed with US and 524 with venography. Technical success was defined as placement of a PICC. Initial complications were defined as development of a hematoma, inadvertent arterial puncture, or neuropathy. Statistical significance was assessed using the chi2 test.

RESULTS

During 33 consecutive months, 2,650 procedures were performed with a complication rate of 1.0%. The technical success rate was 95.8% for venography and 99.6% for US. The initial complication rate was 0.75% for venography and 1.08% for US. There was no statistically significant difference in immediate complication rates (P = .50); however, there is statistical significance in regard to technical success (P < .001).

CONCLUSION

There is no difference in initial complication rates when comparing US and venographic guidance for PICC insertion. The decision to use either method can be based on clinical grounds and/or physician preference, although US has a higher initial success rate.

The treatment of symptomatic os acromiale

Os acromiale is an uncommon condition of the shoulder. When symptomatic, os acromiale may cause impingement pain, rotator cuff tears, or pain through abnormal motion at the unfused apophysis. Treatment of symptomatic os acromiale is controversial. This article reports on four patients with symptomatic meso-acromions who were treated with open reduction and internal fixation. All four patients recovered full function postoperatively with UCLA shoulder rating scores improving from 19 preoperatively to 35 postoperatively. Open reduction and internal fixation of a symptomatic meso-acromion is a reliable and reproducible technique in which the deltoid attachment and lever arm are minimally affected.

Adolescent and pediatric sports injuries

With the ever increasing number of boys and girls participating in organized sports, specific injury patterns, often dependent upon sport and gender, have been identified. This article identifies the most common sports injuries, focusing on mechanisms of injury, pathoanatomy, the history and physical findings, as well as recommendations, for the primary care physician, for initial diagnostic studies and treatment.

The unrecognized epidemic of blunt carotid arterial injuries: early diagnosis improves neurologic outcome

OBJECTIVE

To determine the benefit of screening for blunt carotid arterial injuries (BCI) in patients who are asymptomatic.

SUMMARY BACKGROUND DATA

Blunt carotid arterial injuries have the potential for devastating complications. Published studies report 23% to 28% mortality rates, with 48% to 58% of survivors having permanent severe neurologic deficits. Most patients have neurologic deficits when the injury is diagnosed. The authors hypothesized that screening patients who are asymptomatic and instituting early therapy would improve neurologic outcome.

METHODS

The Trauma Registry of the author's Level I Trauma Center identified patients with BCI from 1990 through 1997. Beginning in August 1996, the authors implemented a screening for BCI. Arteriography was used for diagnosis. Patients without specific contraindications were anticoagulated. Endovascular stents were deployed in the setting of pseudoaneurysms.

RESULTS

Thirty-seven patients with BCI were identified among 15,331 blunt-trauma victims (0.24%). During the screening period, 25 patients were diagnosed with BCI among 2902 admissions (0.86%); 13 (52%) were asymptomatic. Overall, eight patients died, and seven of the survivors had permanent severe neurologic deficits. Excluding those dying of massive brain injury and patients admitted with coma and brain injury, mortality associated with BCI was 15%, with severe neurologic morbidity in 16% of survivors. The patients who were asymptomatic at diagnosis had a better neurologic outcome than those who were symptomatic. Symptomatic patients who were anticoagulated showed a trend toward greater neurologic improvement at the time of discharge than those who were not anticoagulated.

CONCLUSIONS

Screening allows the identification of asymptomatic BCI and thereby facilitates early systemic anticoagulation, which is associated with improved neurologic outcome. The role of endovascular stents in the treatment of blunt traumatic pseudoaneurysms remains to be defined.

Treatment of blunt injury to the carotid artery by using endovascular stents: an early experience

Identification of blunt carotid injury prior to the development of ischemic symptoms requires aggressive screening of patients at risk. The treatment of these lesions has centered around long-term anticoagulation therapy. However, studies have revealed that many of these lesions persist despite medical treatment, as does the risk of distal embolization. The authors present a series of six patients who were successfully treated by means of endovascular stent placement for nonpenetrating carotid injuries. In the authors' experience this treatment requires only temporary anticoagulation therapy, results in immediate reconstruction of the injured vessel, obliterates pseudoaneurysms, and prevents distal embolization.

Traumatic bilateral jugular vein thrombosis: case report and review of the literature

OBJECTIVE AND IMPORTANCE

Thrombosis of the internal jugular vein (IJV) with associated elevated intracranial pressure (ICP) is a rare complication of central venous catheterization but has not been reported as a result of blunt trauma.

CLINICAL PRESENTATION

An 18-year-old male patient was observed to be obtunded after an assault. The initial examination was remarkable for somnolence, bruising of the anterior neck, and diffuse, edematous swelling of the face and scalp. The results of computed tomography of the brain were normal. An angiogram obtained on the 2nd hospital day to rule out carotid injury revealed bilateral IJV thromboses to the cranial base. An ICP monitor was placed with an opening pressure of 33 mm Hg. The central venous pressure was measured to be 9 mm Hg. A catheter was passed through the left IJV thrombus and into the sigmoid sinus, where the pressure was 17 mm Hg.

INTERVENTION

An intravascular stent was deployed in the left IJV. ICP rapidly normalized. A regimen of coumadin was administered to the patient for 6 weeks, at which time the stent remained patent.

CONCLUSION

We conclude that traumatic jugular vein thrombosis can be associated with significant elevation in ICP and that treatment with an endovascular stent can affect the rapid correction of intracranial hypertension in patients who are candidates for anticoagulation.

MRI appearance of meniscal cysts

PURPOSE

The purpose of this study was to review the MRI criteria for the distinction of meniscal cysts from other cystic lesions in the knee so that appropriate treatment may be planned.

DESIGN

A retrospective review of 62 knee MRI scans possibly showing meniscal cysts was performed. The type of meniscal tear, the appearance of the connection between the cyst and the meniscal tear, and the location, size, morphology, and signal characteristics of the meniscal cysts were recorded. Other types of fluid collections that had been mistaken for meniscal cysts were described.

PATIENTS

Sixty-two patients were studied, ages 16-79 years, 61% male, 39% female.

RESULTS AND CONCLUSIONS

Most of the meniscal cysts (91%) occurred immediately adjacent to the meniscal tear (98% horizontal cleavage tears, 49% anterolateral), with the tear leading directly into the cysts. In two cases, the cyst had dissected into the soft tissues distant from the meniscus and a connecting stalk was visualized. Fluid collections in normal bursae and recesses that had been mistaken for meniscal cysts had no direct connection to a meniscal tear. MRI can be used to distinguish meniscal cysts from other fluid collections that may mimic meniscal cysts. Pitfalls can be avoided by familiarity with the normal bursal and capsular anatomy, and by the application of specific diagnostic criteria.

Arthroscopic treatment of meniscal cysts

Historically meniscal cysts have been treated with either an open total menisectomy, isolated cyst excision, or a combination of the two procedures. The advent of arthroscopic techniques has led to innovative treatment options for meniscal cyst management. A review of meniscal cysts and the results of arthroscopic treatment form the basis of this study. From 1986 to 1991, 18 patients with meniscal cysts were treated by arthroscopic cyst decompression. Thirteen men and five women comprised the study group and had an average age of 28 years. The follow-up period ranged from 6 to 60 months (average 26). Eight of the cysts were medial and 10 were lateral. A horizontal cleavage tear was noted in all cases, and 15 partial and three subtotal menisectomies were performed in conjunction with an intraarticular cyst decompression. There have been no recurrences to date, and all patients returned to their previous level of activity. Parameniscal cysts may result from synovial fluid tracking through a horizontal cleavage tear. Successful treatment of the meniscal cyst must include appropriate management of the torn meniscus, which can be entirely arthroscopic, consisting of a partial or subtotal meniscectomy, identification of the cyst opening, and cyst decompression.

MR imaging in the evaluation of SLAP injuries of the shoulder: findings in 10 patients

OBJECTIVE

Injuries to the superior portion of the glenoid labrum, called SLAP (superior labrum, anterior and posterior) injuries, are recently recognized injuries consisting of tears of the long head of the biceps tendon anchor/superior labral complex. The purpose of this study was to determine if the MR imaging findings in patients with surgically proved SLAP injuries correspond to the abnormalities found at arthroscopy.

MATERIALS AND METHODS

Four variants of SLAP lesions have been described; they are based on the degree of compromise of the superior portion of the glenoid labrum, biceps tendon, and labral-biceps anchor. A type I lesion has superior labral fraying in the region of the biceps anchor. A type II lesion has superior labral fraying and stripping of the superior part of the glenoid labrum and attached biceps off the underlying glenoid fossa. A type III lesion has a bucket-handle tear of the superior portion of the glenoid labrum in the region of the biceps anchor. A type IV lesion has a bucket-handle tear of the superior part of the glenoid labrum with extension of the tear into the proximal biceps tendon. Standard spin-echo MR imaging studies in 10 patients with surgically proved SLAP lesions were evaluated retrospectively. Correlations were made between MR imaging findings and the SLAP injury type determined from descriptions in the surgical report. MR imaging studies in a control group of seven symptomatic patients surgically proved not to have SLAP injuries also were evaluated.

RESULTS

MR imaging examinations of two patients with type I lesions showed irregularity of the labral contour and a slight increase in signal intensity on all imaging sequences. MR imaging examinations of two patients with type II lesions showed globular high signal interposed between the superior part of the glenoid labrum and the superior portion of the glenoid fossa. One case showed high signal in the labral-biceps anchor. The other case showed paired cleavages in the superior and inferior aspects of the superior part of the glenoid labrum at the labral-biceps anchor. MR imaging examinations of two patients with type III lesions showed superior labral tears identified as high signal intensity within the superior part of the labrum separate from the normal superior part of the labral cavity. MR imaging examinations of the four patients with type IV lesions showed diffuse high signal intensity within the superior part of the glenoid labrum with marked abnormal high signal intensity extending into the proximal high signal intensity within the superior part of the labrum separate from the normal superior part of the labral cavity. MR imaging examinations of the four patients with type IV lesions showed diffuse high signal intensity within the superior part of the glenoid labrum with marked abnormal high signal intensity extending into the proximal biceps tendon. None of the MR imaging studies of patients in the control group showed findings seen on MR imaging studies of patients with surgically proved SLAP lesions.

CONCLUSION

Although prospective data are required to document accuracy, these preliminary data suggest that an MR examination can be useful in detecting SLAP abnormalities and establishing the type of SLAP lesion before surgery, thereby permitting better operative planning.

Arthroscopic subacromial decompression: a clinical review

Arthroscopic subacromial decompression has become a popular technique supplanting the open Neer acromioplasty in many instances of chronic rotator cuff disease. A review of 61 consecutive decompressions with a minimum follow-up of 12 months was undertaken to evaluate preoperative criteria and surgical outcomes. Of the 61 patients, 53 patients with an average follow-up of 23 months were available for review. Thirty-four men and 19 women with an average age of 47 years comprised the study group. Eleven (21%) had full-thickness tears, 35 (66%) had partial-thickness injuries, and 7 (13%) had normal-appearing rotator cuffs at the time of arthroscopy. The UCLA shoulder rating system was used to evaluate outcome. Eighty-one percent of the patients had an excellent (32%) or good (49%) result whereas 19% (15% fair and 4% poor) were considered unsatisfactory. Those with early impingement findings and partial rotator cuff tears were likely to experience a satisfactory outcome. Patients with full-thickness rotator cuff tears were less likely to experience a successful result (55%). Workmen's compensation cases had a satisfactory outcome in 74%, with a predominance of good over excellent results. Excluding those with full-thickness tears and work-related injuries, a satisfactory outcome was achieved in 90%. Arthroscopic subacromial decompression for mechanical impingement of the rotator cuff is a technically demanding procedure requiring appropriate skills as well as careful preoperative treatment and evaluation. For individuals in whom conservative measures fail and who meet stringent criteria, namely, a largely intact rotator cuff and a non-work-related injury, a highly reliable and satisfying outcome can be anticipated by both patient and surgeon.

An electromyographic analysis of shoulder function in tennis players

Shoulder injuries in tennis players are common because of the repetitive, high-magnitude forces generated around the shoulder during the various tennis strokes. An understanding of the complex sequences of muscle activity in this area may help reduce injury, enhance performance, and assist the rapid rehabilitation of the injured athlete. The supraspinatus, infraspinatus, subscapularis, middle deltoid, pectoralis major, latissimus dorsi, biceps brachii, and serratus anterior muscles were studied in six uninjured male Division II collegiate tennis players using dynamic electromyography (EMG) and synchronized high-speed photography. Each subject performed the tennis serve and the forehand and backhand groundstrokes, and each stroke was divided into stages. The tennis serve contains four stages. Three stages characterize the forehand and backhand groundstrokes. Our results indicate that the subscapularis, pectoralis major, and serratus anterior display the greatest activity during the serve and forehand. The middle deltoid, supraspinatus, and infraspinatus are most active in the acceleration and follow-through stages of the backhand. The biceps brachii increases its activity during cocking and follow-through in the serve with a similar pattern noted in the acceleration and follow-through stages of the forehand and backhand. The serratus anterior demonstrates intense activity in the serve and forehand, thus providing a stable platform for the humeral head and assisting in gleno-humeral-scapulothoracic synchrony. The tennis serve and forehand and backhand groundstrokes are accomplished by complex sequences of muscle activity that incorporate contributions from the lower extremities and trunk into smooth, coordinated patterns.(ABSTRACT TRUNCATED AT 250 WORDS)

Arthroscopic meniscal repair with two-year follow-up: a clinical review

The potential for healing of meniscal tissue has been historically underappreciated, but is currently more widely acknowledged. We have reviewed our experience with arthroscopic meniscal repair in 29 patients who had had a minimum of 2 years' follow-up. Between September 1983 and November 1986, 31 patients who had undergone arthroscopic meniscal repair with a minimum of 2-years' follow-up were identified. Of the 31 patients, 29 were available for additional follow-up. The patient population averaged 31 years of age, with 15 men and 14 women. Utilizing a closed arthroscopic cannulated technique, 16 lateral and 15 medial menisci were repaired. The majority of lesions were vertical bucket-handle tears involving the posterior horn and averaged 2.5 cm in length. Of the 31 tears, 29 were in the red-red or red-white zones. Clinical healing was present in 27 (87%) of the 31 repaired menisci. Nine patients underwent relook arthroscopy at which time healing was confirmed in eight, and a retear noted in one. Four reruptures occurred and the menisci required removal. Of the 29 patients, 16 had concomitant anterior cruciate ligament injuries ranging from partial tears to complete disruptions. Seven patients underwent immediate or delayed anterior cruciate ligament stabilization. Healing occurred in six of the seven patients whose anterior cruciate ligaments had been reconstructed. Among those patients with reruptures, chronic anterolateral rotatory instability was identified as a significant risk factor for rerupture. A complication rate of 13% was noted. Three patients underwent manipulation under anesthesia for postoperative ankylosis and one patient experienced a transient saphenous nerve neuropraxia.(ABSTRACT TRUNCATED AT 250 WORDS)

Soft tissue sarcoma associated with aluminum oxide ceramic total hip arthroplasty. A case report

Malignant tumors around fracture fixation implants have been reported sporadically for many years. Recently, however, reports of sarcomatous degeneration around a standard cemented hip arthroplasty and around cobalt-chromium-bearing hip arthroplasties raise new questions of the malignant potential of metallic ends prostheses. Sarcomatous changes around aluminum oxide ceramics seem not to have been reported in the literature. The present report may be the first documented case of an aggressive soft tissue sarcoma detected 15 months after the patient had an uncemented ceramic total hip arthroplasty. If a causal relationship exists, the incidence of this phenomenon in the United States is 250 times greater than would be expected from statistics on soft tissue sarcoma at the hip. Because of the similarity on plane roentgenograms of this tumor to lesions known to be caused by wear debris, tumors should be included in the differential diagnosis of cases of total hip loosening.

Fasciocutaneous flap coverage for periolecranon defects

Soft tissue defects in the periolecranon region are difficult to manage by standard techniques such as closure by approximation, split-thickness skin grafting, or healing by secondary intention. We employed cadaver injections and dissections to study the vascular anatomy of the periolecranon region in search of a suitable local flap for coverage of periolecranon defects. This report details our experience in 31 patients with a one-stage technique for elbow coverage employing a proximally based forearm fasciocutaneous flap. Surgical techniques and clinical applications are discussed; a satisfactory long-term outcome is documented in 30 of 31 patients. The advantages of using this model fasciocutaneous flap include enhanced vascularity, sensibility, and ease of elevation.

An unusual avulsion fracture of the proximal tibial epiphysis. Case report and proposed addition to the Watson-Jones classification

Avulsion injuries of the tibial tuberosity are uncommon fractures that are seen most frequently in adolescents. Watson-Jones classified these injuries into three types, but this classification does not account for fractures of the tibial tuberosity that extend into the posterior cortex, nor has such a fracture configuration been described in the literature. The present case of a 16-year-old boy indicates that the Watson-Jones classification should be expanded to include this fracture configuration (Type IV).

The Reel Splint: experience with a new traction splint apparatus in the prehospital setting

A new lower extremity splint apparatus was applied by paramedics to 50 patients in the prehospital setting to manage a total of 60 injuries. The Reel Splint was designed to provide stabilization with or without traction to a variety of angulated lower extremity fractures/dislocations. In 37 instances (74%), the splint was judged by the rescuers to be superior to the standard Thomas splint. In this series the splint was used successfully for extrication , to immobilize deformed limbs, and to provide traction for the restoration and maintenance of peripheral circulation, with frequent pain relief. No deleterious functional complexities or manufacturing defects were identified. The Reel Splint is a uniquely useful alternative to currently available splints.