[Intraoperative virtual implant planning for volar plate osteosynthesis of distal radius fractures]

BACKGROUND

Digital planning of implants is in most cases conducted prior to surgery. The virtual implant planning system (VIPS) is an application developed for mobile C-arms, which assists the virtual planning of screws close to the joint line during surgery for treatment of distal radius fractures with volar plate osteosynthesis. The aim of this prospective randomized study was to acquire initial clinical experiences and to compare the VIPS method with the conventional technique.

METHOD

The study included 10 patients for primary testing and 30 patients with distal radius fractures of types A3, C1 and C2, divided in 2 groups. In the VIPS group, after placement of the plate and fracture reduction, a virtual 3D model of the plate was matched with the image of the plate from the fluoroscopic acquisition. Next, the length and position of the screws close to the joint line were planned on the virtual plate. The control group was treated with the same implant in the conventional way. Data were collected regarding screw replacement, fluoroscopy and operating room (OR) times.

RESULTS

The VIPS group included six A3, one C1 and eight C2 fractures, while the control group consisted of six A3 and nine C2 fractures. Three screws were replaced in the VIPS group and two in the control group (p = 0.24). The mean intraoperative fluoroscopy time of the VIPS group amounted to 2.58 ± 1.38 min, whereas it was 2.12 ± 0.73 min in the control group (p = 0.26). The mean OR time in the VIPS group was 53.3 ± 34.5 minutes and 42.3 ± 8.8 min (p = 0.23) in the control group.

CONCLUSION

The VIPS enables a precise positioning of screws close to joint line in the treatment of distal radius fractures; however, for routine use, further development of the system is necessary.

A Quick Guide to Paravalvular Leak Closure

Paravalvular leak (PVL) is a seldomly covered aspect of structural heart disease. However, this is a condition that frequently presents after valvular replacement. This article will cover the diagnosising and treating PVL (i.e. imaging, access, and device selection). In addition, specific aspects of aortic and mitral PVL closure will be covered in this review.

High complication rate after septic orthopaedic implant removal of the lower leg

INTRODUCTION

The aim of the study was to determine predictive risk factors for revision surgery in patients with septic orthopaedic implant removal of the lower leg.

MATERIALS AND METHODS

A total of 196 patients with septic removal of orthopaedic implants after primary trauma of the lower leg between 2008 and 2012 were evaluated. Patients with endoprosthesis infection were excluded from this study.

RESULTS

Thirteen patients (22.4 %) had infectious complications with revision surgery. We found 14 patients with soft tissue infections, 10 patients with osteomyelitis, 19 patients with wound-healing problems, 10 patients with pin track infections and two patients with fistulas. High complication rates were associated with severity of the initial trauma, localisation, and the state of union or non-union. Patients with peripheral arterial disease, anaemia and smoking showed a significantly higher risk for revision surgery; whereas patients with diabetes and arterial hypertension did not. A total of 22.6 % had open fractures as an initial trauma. In 76 %, bacteria could be detected. The complication rate was 41.2 % after initial open fractures and 19.6 % after initial closed fractures. A higher grade of soft tissue damage showed no increasing complication rate (p > 0.05).

CONCLUSIONS

In this study, complications after septic implant removal of the lower leg were evaluated and risk factors were determined. The awareness of the risks for complications after septic orthopaedic implant removal can lead to a better treatment for patients. Decision-making can be based on scientific results to prevent patients suffering from further severe disease progression.

Gender aspects in clinical presentation and prognostication of chronic heart failure according to NT-proBNP and the Heart Failure Survival Score

AIMS

We performed a prospective multi-center study to assess gender-specific differences in the predictive value of the measured level of NT-proBNP and the calculated Heart Failure Survival Score (HFSS).

METHODS

Baseline characteristics and follow-up data up to 5 years from 2,019 men and 530 women diagnosed with chronic heart failure (CHF) due to ischemic heart disease or dilated cardiomyopathy were prospectively compared. Death from any cause constituted the endpoint of the study. NT-proBNP was measured and HFSS calculated according to standard methods. Survival of men and women according to level of NT-proBNP and HFSS was analyzed in logistic regression models.

RESULTS

Median NT-proBNP level in men was 1,394 ng/l (IQR 516-3,406 ng/l) and 1,168 ng/l (IQR 444-2,830 ng/l) in women (p = n.s.). Median HFSS value was 8.4 (IQR 7.7-9.1) and 8.5 (8.0-9.1) in men and women, respectively. NT-proBNP levels and HFSS score correlated well with survival rates in both genders (p for interaction = 0.22 for NT-proBNP and 0.93 for HFSS). The all-cause death rates were similar in men and women.

CONCLUSION

Despite a number of gender-specific differences in CHF and the general predominance of men measured levels of NT-proBNP and HFSS score can be utilized for risk stratification with similar informative value in men and women.

[Postoperative malrotation after closed reduction and intramedullary nailing of the femur: a retrospective 5-year analysis]

BACKGROUND

Minimally invasive treatment of diaphyseal femur fractures (DFF) with closed reduction and intramedullary nailing is a well established procedure. However, a femoral malrotation after intramedullary nailing is considered to be a substantial problem. Studies have described femoral malrotation (FMR) in 17-35 % after this procedure. Computed tomography (CT) of both femora is accepted as an objective, reproducible measurement method to determine a postoperative femoral malrotation. An anatomic reposition of the centreline of the femur remains of high importance since a malrotation > 15° can lead to a significant limitation of the range of motion (ROM) and to clinical symptomatic constraints.

PATIENTS/MATERIAL AND METHODS

Between July 2007 and December 2011 patients with unilateral DFF were treated with closed reduction and intramedullary nailing. Exclusion criteria were defined as bilateral or prior treatment for femoral fractures, open epihyseal plate or pregnancy. In all cases a postoperative CT scan of the femora was conducted to analyse a femoral malrotation. The indication for a correction was posed in cases of a malrotation > 15°. The data were not randomised and evaluated retrospectively.

RESULTS AND CONCLUSION

In total 94 patients with unilateral DFF were included. 21 female and 73 male with an average age of 33.15 ± 14.04 years (range 14-94). In the postoperative CT scan an average FMR of 11.58 ± 9.41° (range 0-44°) was determined. In 15 cases (15.95 %), 10 male (13.7 %) and 5 female (23.81 %) a FMR > 15° (average: 23.66 ± 5.74°) was noticed. A subsequent surgery with a correction in average of 17.53 ± 6.83° was performed. After the correction the malrotation averaged 6.07 ± 5.61°. The results support the existing data that the treatment of DFF with closed reduction and intramedullary nailing may lead to a significant femoral malrotation despite a precise intraoperative monitoring. The data demonstrate that nearly 15 % of all patients appear after closed reduction and intramedullary nailing with a femoral malrotation greater than 15°. A routinely utilised postoperative CT scan provides additional information to discover an occult malrotation.

CONCLUSION

In spite of diligent attendance to the femoral torsion intraoperatively in DFF a significant femoral malrotation may result after closed reduction and intramedullary nailing. To prevent a limitation of ROM and clinical constraints a routinely performed postoperative CT scan with a adequate surgical correction is recommended.

Assessment of myocardial deformation with cardiac magnetic resonance strain imaging improves risk stratification in patients with dilated cardiomyopathy

AIMS

To investigate the prognostic impact of left-ventricular (LV) cardiac magnetic resonance (CMR) deformation imaging in patients with non-ischaemic dilated cardiomyopathy (DCM) compared with late-gadolinium enhancement (LGE) quantification and LV ejection fraction (EF).

METHODS AND RESULTS

A total of 210 subjects with DCM were examined prospectively with standard CMR including measurement of LGE for quantification of myocardial fibrosis and feature tracking strain imaging for assessment of LV deformation. The predefined primary endpoint, a combination of cardiac death, heart transplantation, and aborted sudden cardiac death, occurred in 26 subjects during the median follow-up period of 5.3 years. LV radial, circumferential, and longitudinal strains were significantly associated with outcome. Using separate multivariate analysis models, global longitudinal strain (average of peak negative strain values) and mean longitudinal strain (negative peak of the mean curve of all segments) were independent prognostic parameters surpassing the value of global and mean LV radial and circumferential strain, as well as NT-proBNP, EF, and LGE mass. A global longitudinal strain greater than -12.5% predicted outcome even in patients with EF < 35% (P < 0.01) and in those with presence of LGE (P < 0.001). Mean longitudinal strain was further investigated using a clinical model with predefined cut-offs (EF < 35%, presence of LGE, NYHA class, mean longitudinal strain greater than -10%). Mean longitudinal strain exhibited an independent prognostic value surpassing that provided by NYHA, EF, and LGE (HR = 5.4, P < 0.01).

CONCLUSION

LV longitudinal strain assessed with CMR is an independent predictor of survival in DCM and offers incremental information for risk stratification beyond clinical parameters, biomarker, and standard CMR.

Left atrial appendage closure using the Amulet device: an initial experience with the second generation amplatzer cardiac plug

OBJECTIVES

Aim of this study was to demonstrate the feasibility, safety, and short-term outcome of left atrial appendage (LAA) closure with a new generation LAA closure device.

BACKGROUND

The Amulet device (AGA, St Jude Medical, Minneapolis, MN) is a new generation of the amplatzer cardiac plug (ACP), specifically designed for LAA closure. This new version is designed to facilitate the implantation process and minimize procedural or device-related complications.

METHODS

The device was implanted in 17 patients with nonvalvular atrial fibrillation (AF). Clinical data were obtained at baseline, during the procedure, at discharge, at 30 and 90 days.

RESULTS

All devices were implanted successfully. Device sizes ranged from 20 mm to 31 mm. A 12 French (Fr) or 14 Fr delivery sheath was used depending on the selected device size. Full and partial recapture was performed in 1 case and 3 cases, respectively. There was 1 procedure-related pericardial effusion successfully managed with pericardiocentesis. There was no device embolization. The mean length of stay was 2.1 ± 0.3 days. At 90 days, there were no deaths, strokes, systemic thromboembolism, or bleeding complications. There was no device-related thrombus or pericardial effusion at 90-day TEE. In 2 of the 17 patients minimal peridevice flow (smaller than 2 mm) was present.

CONCLUSIONS

The Amulet device, which has new novel features as compared with the first generation ACP, is a feasible option for LAA closure. From our initial experience, implantation of the Amulet is associated with high success rate and good short-term outcome.

Impact of the learning curve on outcome after transcatheter mitral valve repair: results from the German Mitral Valve Registry

AIMS

This analysis from the German Mitral Valve Registry investigates the impact of the learning curve with the MitraClip(®) technique on procedural success and complications.

METHODS AND RESULTS

Consecutive patients treated since 2009 in centers that performed more than 50 transcatheter mitral repairs were included. Results of the first half of the patients were compared to those of the second. Altogether 496 patients from 10 centers were included. Patients treated later had less common severe heart failure symptoms (patients with NYHA IV: 22.1 vs. 14.5 %, p < 0.05). The EuroSCORE I (22.0 vs. 23.0 %, p = ns) and Society of Thoracic Surgeons (STS) score (7.5 vs. 9.5 %, p = ns) did not differ between both groups. Procedural success was 95.6 % (238/249) in the first cases and 94.7 % (232/245, p = ns) subsequently. Also procedural time (104.3 vs. 119 min, p = ns) and complications did not decrease over time.

CONCLUSION

A learning curve using the MitraClip(®) device does not appear to significantly affect acute MR reduction, hospital and 30-day mortality. Most likely, the proctor system leads to already high initial procedure success and relatively short procedure time.

Percutaneous mitral valve repair with the MitraClip system according to the predicted risk by the logistic EuroSCORE: preliminary results from the German Transcatheter Mitral Valve Interventions (TRAMI) Registry

OBJECTIVE

To evaluate in-hospital and short-term outcomes of percutaneous mitral valve repair according to patients' logistic EuroSCORE (logEuroSCORE) in a multicenter registry

BACKGROUND

The logEuroSCORE is an established tool to predict the risk of mortality during cardiac surgery. In high-risk patients percutaneous mitral valve repair with the MitraClip system represents a less-invasive alternative

METHODS

Data from 1002 patients, who underwent percutaneous mitral valve repair with the MitraClip system, were analyzed in the German Transcatheter Mitral Valve Interventions (TRAMI) Registry. A logEuroSCORE (mortality risk in %) ≥ 20 was considered high risk

RESULTS

Of all patients, 557 (55.6%) had a logEuroSCORE ≥ 20. Implantation of the MitraClip was successful in 95.5 % (942/986) patients. Moderate residual mitral valve regurgitation was more often detected in patients with a logEuroSCORE ≥ 20 (23.8% vs. 17.1%, respectively, P < 0.05). In patients with a logEuroSCORE ≥ 20 the procedural complication rate was 8.9% (vs. 6.4, n.s.) and the in-hospital MACCE rate 4.9% (vs. 1.4% P < 0.01). The in-hospital mortality rate in patients with a logEuroSCORE ≥ 20 and logEuroSCORE < 20 was 4.3 and 1.1%, respectively (P ≤ 0.01) CONCLUSION: Percutaneous mitral valve repair with the MitraClip system is feasible in patients with a logEuroSCORE ≥ 20 with similar procedural results compared to patients with lower predicted risk. Although mortality was four times higher than in patients with logEuroSCORE < 20, mortality in high risk patients was lower than predicted. In those with a logEuroSCORE ≥ 20, moderate residual mitral valve regurgitation was more frequent.

[Amputation of the hand due to necrotising fasciitis: a case report]

We report the case of an 81-year-old woman who fell at home on her left hand and suffered a laceration of her forehead. Within days a fulminant necrotizing fasciitis of the hand from group A β-haemolytic streptococcus developed. Lacking an apparent local germ entry point at the hand, the infection was initially misinterpreted as compartment syndrome. The patient's life was saved by amputation of the hand.

[Fused little finger in the palm after operation for recurrent Dupuytren's contracture]

A 72-year-old woman suffered from Dupuytren's contracture of her right little finger, which was treated operatively 3 times in 4 years. However, the finger bent back into the palm. Over time she hid her little finger in the fist. In 2010, she presented with the hand in our office. Surprisingly a fused finger in the palm was observed. The woman reported that she had ignored her little finger and that it was no longer present in her conscious mind.

PFO closure: rational, procedure and devices

Patent foramen ovale (PFO) is a common anatomical variant occurring in 20-25% of the population. In most cases, a PFO remains asymptomatic. However it allows for any venous particle such as thrombus, air or vasoactive substances to bypass the lung and enter the arterial circulation. Accordingly, PFO's have been linked to cryptogenic stroke, migraine and decompression illness. While the number of device closures have been increasing the therapy remains controversial as ‑ until recently ‑ data supporting PFO closure came from non randomized studies only. In this review we will discuss the existing data on PFO closure including results of the three randomized controlled trials comparing device closure with medical therapy in patients with cryptogenic stroke. We will also focus on the implantation technique, the complications and the different devices that are used for this procedure.