Outcomes of Mini-Invasive Arthroscopic Arthrolysis Combined with Locking Screw and/or Intramedullary Nail Extraction after Osteosynthesis of the Proximal Humerus Fracture

Data on the effectiveness of arthroscopic arthrolysis and extraction of osteosynthetic material after osteosynthesis of the proximal humerus in patients with persisting problems are rare and insufficient. In this study, we performed arthroscopic arthrolysis and extraction of fixation screws, and, where protruding, extraction of the nail in 34 patients with problems persisting 12 months after osteosynthesis of the proximal humerus using an intramedullary nail. The effectiveness of the treatment was assessed using the Constant–Murley shoulder score and forward flexion difference between the treated arm and the contralateral one. A median increase of 16 points in CMS score and 30 degrees reduction in the arm forward flexion difference was recorded 12 months after the arthroscopy. The improvement was significantly higher in the patient group with intramedullary nail extraction (however, this group had worse pre-operative values and the screw was only extracted where likely to cause problems). The median time to heal was 11 weeks; no serious peri- or post-procedural complications occurred. Mini-invasive arthroscopic arthrolysis combined with extraction of osteosynthetic material proved to be a safe and effective method for treatment of patients after osteosynthesis of the proximal humerus using an intramedullary nail with persisting pain and/or mobility limitation.

Indirect Flow Diversion for Off-Centered Bifurcation Aneurysms and Distant Small-Vessel Aneurysms, a Retrospective Proof of Concept Study From Five Neurovascular Centers

Background: Treatment of cerebral aneurysms using hemodynamic implants such as endosaccular flow disruptors and endoluminal flow diverters has gained significant momentum during recent years. The intended target zone of those devices is the immediate interface between aneurysm and parent vessel. The therapeutic success is based on the reduction of aneurysmal perfusion and the subsequent formation of a neointima along the surface of the implant. However, a subset of aneurysms–off-centered bifurcation aneurysms involving the origin of efferent branches and aneurysms arising from peripheral segments of small cerebral vessels–oftentimes cannot be treated via coiling or implanting a hemodynamic implant at the neck level for technical reasons. In those cases, indirect flow diversion–a flow diverter deployed in the main artery proximal to the parent vessel of the aneurysm–can be a viable treatment strategy, but clinical evidence is lacking in this regard.Materials and Methods: Five neurovascular centers contributed to this retrospective analysis of patients who were treated with indirect flow diversion. Clinical data, aneurysm characteristics, anti-platelet medication, and follow-up results, including procedural and post-procedural complications, were recorded.Results: Seventeen patients (mean age: 60.5 years, range: 35–77 years) with 17 target aneurysms (vertebrobasilar: n = 9) were treated with indirect flow diversion. The average distance between the flow-diverting stent and the aneurysm was 1.65 mm (range: 0.4–2.4 mm). In 15/17 patients (88.2%), perfusion of the aneurysm was reduced immediately after implantation. Follow-ups were available for 12 cases. Delayed opacification (OKM A3: 11.8%), reduction in size (OKM B1-3: 29.4%) and occlusion (D1: 47.1%) were observable at the latest investigation. Clinically relevant procedural complications and adverse events in the early phase and in the late subacute phase were not observed in any case.Conclusion: Our preliminary data suggest that indirect flow diversion is a safe, feasible, and effective approach to off-centered bifurcation aneurysms and distant small-vessel aneurysms. However, validation with larger studies, including long-term outcomes and optimized imaging, is warranted.

Prevention and management of peri-procedural TAVR complications

Transcatheter aortic valve replacement (TAVR) is a safe and effective treatment strategy for severe aortic stenosis. However, peri-procedural complications can have a significant impact on acute and longer-term morbidity and mortality. Therefore, this review article provides a practical overview on how to prevent and manage the common and also rare but life-threatening peri-procedural TAVR complications.

Diagnostic Accuracy and Post-Procedural Complications Associated with Ultrasound-Guided Core Needle Biopsy in the Preoperative Evaluation of Parotid Tumors

Correct diagnosis of a parotid neoplasm based on histology preoperatively is of utmost importance in order to guide patient management. The aim of this study was to evaluate the diagnostic accuracy of an ultrasound-guided core needle biopsy of a parotid lesion and to describe associated post-procedural complications. A retrospective study was conducted between January 2015 and March 2021 of all patients who were referred to a tertiary care center for evaluation of a parotid lesion and who underwent core needle biopsy due to high-risk features or when malignancy was suspected on clinical examination or ultrasonography. Patient characteristics, histological findings, and post-procedural complications were recorded and evaluated. Among 890 patients referred for evaluation of a parotid lesion, in 138 patients a core needle biopsy was undertaken. On the basis of core needle biopsy findings, 11 lymphomas and 82 non-lymphoma malignancies were diagnosed in the parotid gland. The sensitivity of the core needle biopsy predicting the accurate tumor type was 97.56% (95% CI 91.47–99.70%) and the specificity 94.64% (95% CI 85.13–98.88%). The accuracy for the correct histopathological diagnosis was 93.48% (95% CI 87.98–96.97%). Post-procedural minor complications occurred in 19 patients (13.8%). In conclusion, a core needle biopsy can identify malignancy in the parotid gland with high sensitivity and specificity in a safe manner and therefore guide surgical treatment.

Structural Features of the Mental Foramen in a Saudi Subpopulation: A Retrospective CBCT Study

Introduction. Accurate and precise knowledge about the position, size, and shape of the mental foramen (MF) are critical in avoiding procedural complications. The MF’s anatomical features vary among different ethnic groups, and various radiographic techniques have been used to determine these variations. Aims. To evaluate the MF’s shape, vertical and horizontal positions, and distance from the border of the mandible. To evaluate the differences among genders as they pertain to the right and left sides of the mandible and research the bilateral symmetry regarding the same variables. Materials and Methods. Cone beam computer tomography (CBCT) scans of 155 Saudi patients (69 males and 86 females) who visited the college of dentistry’s clinics were obtained from the college database for this retrospective study. All the scans were analyzed by 3 calibrated examiners. The data collected was analyzed statistically, and results were obtained. Results. The MF was located under the mandibular second premolar in 56.9% of cases, whereas in 26.9% of cases, it was located between the first and second mandibular premolar. The most prevalent position was below the level of the apices of the mandibular premolar teeth (87.2%). The round shape was most frequent (44.9%) compared to the H-oval (34.7%) and V-oval (20.4%). The V-oval shape was more frequent in males, while the H-oval shape was more frequent in females. The average distance from the center of the MF to the mandibular border was 14.03 ± 1.58 mm , with males exhibiting a greater distance than females. Overall, there were no significant differences between the bilateral symmetry and the right and left sides for all parameters. Conclusion. The most common position of the MF was under the root apex of the mandibular second premolar, with an average distance of about 14 mm from the border of the mandible. The position and shape of the MF were the same bilaterally in the majority of individuals.

Transjugular Intrahepatic Portosystemic Shunt Reduction for Medically Refractory Hepatic Encephalopathy

Background: Transjugular intrahepatic portosystemic shunt (TIPS) is an established intervention for symptomatic portal hypertension. Following TIPS creation, 22-50% of patients experience hepatic encephalopathy (HE), with symptoms ranging from mild confusion to coma. While HE can be medically managed, refractory cases may require downsizing of the TIPS which can be accomplished by deploying a smaller caliber stent within the original shunt. Decreasing shunt diameter redirects blood flow back through liver parenchyma. The purpose of this study was to evaluate the efficacy of TIPS downsizing for the treatment of medically refractory post-TIPS HE. Methods: An IRB-approved, HIPAA compliant retrospective review was performed. A search of an institutional radiology database yielded 45 patients who underwent TIPS downsizing between 2011-2021. Four patients were excluded due to lack of post-TIPS HE, and a total 41 patients were included in the study. Clinical and serologic data were obtained for all 41 patients. The primary objective was to determine the efficacy of TIPS downsizing for reduction of HE as measured by the West Haven criteria. Secondary endpoints included post-downsize recurrence of ascites or gastrointestinal bleeding, procedural complications, and thirty-day mortality. Results: TIPS downsizing was performed in all 41 patients with a 9.8% thirty-day mortality rate. No deaths were attributable to the procedure itself. Of the remaining patients, twenty-seven patients (65.9%) had improvement in HE and 10 patients (24.4%) proceeded to TIPS occlusion due to refractory HE. The average pre-downsize and post-downsize West Haven grades were 2.9 ± 0.5 and 1.9 ± 1.2, respectively. One patient (2.4%) had spontaneous TIPS thrombosis after downsizing and developed gastrointestinal bleeding requiring embolization; 15 patients (36.6%) experienced recurrent ascites. Conclusion: In this population, TIPS downsizing improved medically refractory HE in 65.9% of patients with a 2.4% risk of recurrent gastrointestinal bleeding, 36.6% risk of recurrent ascites, and 9.8% thirty-day mortality.

Should the direct aspiration first pass technique be advocated over the stent-retriever technique for acute ischemic stroke? A systematic review and meta-analysis of 7692 patients

Background: The present meta-analysis aimed to synthesize evidence from all published studies with head-to-head data on the outcomes of a direct aspiration first pass technique (ADAPT) and the stent-retriever (SR) in acute ischemic stroke (AIS) patients. Methods: We searched PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials from inception to March 2021 for relevant clinical trials and observational studies. Eligible studies were identified, and all relevant outcomes were pooled in the meta-analysis random-effects model of DerSimonian-Laird. Results: Thirty studies were included in the meta-analysis with a total of 7868 patients. Compared with the SR, the ADAPT provides slightly higher rates of successful recanalization (RR 1.06, 95% CI [1.02 to 1.10]) and complete recanalization (RR 1.20, 95% CI [1.01 to 1.43]) but with more need for rescue therapy (RR 1.81, 95% CI [1.29 to 2.54]). There were no significant differences between the two techniques in terms of mortality at discharge, mortality at 90 days, change in the National Institutes of Health Stroke Scale score, the favorable outcome (modified Rankin scale (mRS) of 0-2), time to the groin puncture, or frequency of complications as intracerebral hemorrhage (ICH), symptomatic intracranial hemorrhage (sICH), embolus in a new territory (ENT), hemorrhagic infarction, parenchymal hematoma, subarachnoid hemorrhage, or procedural complications (all P > 0.05). Conclusion: Current evidence supports the use of the ADAPT technique to achieve successful and complete recanalization while considering the higher need for rescue therapy in some patients.