ABSTRACT
In-stent stenosis is a feared complication of flow diversion treatment for cerebral aneurysms. We present 2 cases of patients treated with pipeline flow diversion for unruptured cerebral aneurysms. Initial perioperative dual antiplatelet therapy (DAPT) consisted of standard aspirin plus clopidogrel. At 6-month follow-up cerebral angiography, the patients were noted to have developed significant in-stent stenosis (63% and 53%). The patients were treated with cilostazol and clopidogrel for at least 6 months. Subsequent angiography at 1-year post-treatment showed significant improvement of the in-stent stenosis from 63% to 34% and 53% to 21%. The role of cilostazol as treatment of intracranial in-stent stenosis has not been previously described. Cilostazol’s vasodilatory effect and suppression of vascular smooth muscle proliferation provides ideal benefits in this setting. Cilostazol plus clopidogrel may be a safe and effective alternative to standard DAPT for treatment of in-stent stenosis following flow diversion and warrants further consideration and investigation.
ABSTRACT
Purpose@#Failed femoral neck fracture (FNF) fixation with in situ pinning presents a surgical challenge. Osteoporotic bone, retained hardware, and a typically elderly population magnify the risks of surgery. Here, outcomes of conversion total hip arthroplasty (THA) using two separate incisions in these high-risk patients were examined. @*Materials and Methods@#Medical records for 42 patients with a prior history of FNF fixation who underwent conversion THA with hardware removal between 2009 and 2019 were retrospectively reviewed. Surgery was performed by a single surgeon at a single institution. All patients underwent hardware removal followed by direct anterior approach (DAA) THA using two separate incisions. Clinical outcomes, radiographic findings, and perioperative morbidity and mortality are reported. @*Results@#Clinically, there were no postoperative dislocations, periprosthetic fractures, or infections at follow-up.After a mean follow-up of 4 years, the mean hip disability and osteoarthritis outcome score, junior (HOOS, Jr) was 91. Radiographically, the mean postoperative cup abduction was 44 degrees and the mean cup anteversion was 21 degrees with an improvement in preoperative leg length discrepancy. Perioperative complications included one case of immediate foot drop and two readmissions for medical issues. One patient died one month after conversion THA. @*Conclusion@#Salvage of failed FNF treatment may be managed with conversion THA and DAA with a separate incision for hardware removal. Preservation of posterior soft tissues using a DAA and intraoperative fluoroscopy may mitigate well-known complications related to fracture and dislocation. While favorable clinical outcomes are possible, salvage surgery is still not without substantial surgical and medical risks.
ABSTRACT
Purpose@#Failed femoral neck fracture (FNF) fixation with in situ pinning presents a surgical challenge. Osteoporotic bone, retained hardware, and a typically elderly population magnify the risks of surgery. Here, outcomes of conversion total hip arthroplasty (THA) using two separate incisions in these high-risk patients were examined. @*Materials and Methods@#Medical records for 42 patients with a prior history of FNF fixation who underwent conversion THA with hardware removal between 2009 and 2019 were retrospectively reviewed. Surgery was performed by a single surgeon at a single institution. All patients underwent hardware removal followed by direct anterior approach (DAA) THA using two separate incisions. Clinical outcomes, radiographic findings, and perioperative morbidity and mortality are reported. @*Results@#Clinically, there were no postoperative dislocations, periprosthetic fractures, or infections at follow-up.After a mean follow-up of 4 years, the mean hip disability and osteoarthritis outcome score, junior (HOOS, Jr) was 91. Radiographically, the mean postoperative cup abduction was 44 degrees and the mean cup anteversion was 21 degrees with an improvement in preoperative leg length discrepancy. Perioperative complications included one case of immediate foot drop and two readmissions for medical issues. One patient died one month after conversion THA. @*Conclusion@#Salvage of failed FNF treatment may be managed with conversion THA and DAA with a separate incision for hardware removal. Preservation of posterior soft tissues using a DAA and intraoperative fluoroscopy may mitigate well-known complications related to fracture and dislocation. While favorable clinical outcomes are possible, salvage surgery is still not without substantial surgical and medical risks.
ABSTRACT
Background@#Failure of unicompartmental knee arthroplasty (UKA) is a distressing and technically challenging complication. Conventional conversion techniques (CCT) with rods and jigs have produced varying results. A robotic-assisted conversion technique (RCT) is an unexplored, though possibly advantageous, alternative. We compare our reconstructive outcomes between conventional and robotic methods in the management of failed UKA. @*Methods@#Thirty-four patients with a failed UKA were retrospectively reviewed. Patients underwent conversion total knee arthroplasty (TKA) with either a CCT or RCT. Seventeen patients were included in each group. All procedures were done by a single surgeon at a single institution, with a mean time to follow-up of 3.6 years (range, 1 to 12).The primary outcome measures were the need for augments and polyethylene thickness. Secondary outcome measures were complications, need for revision, estimated blood loss (EBL), length of stay, and operative time. @*Results@#The mean polyethylene thickness was 12 mm (range, 9 to 15) in the CCT group and 10 mm (range, 9 to 14) in the RCT groups, with no statistical difference between the two groups (P = 0.07). A statistically significant difference, however, was present in the use of augments. In the CCT group, five out of 17 knees required augments, whereas none of the 17 knees in the RCT group required augments (P = 0.04). Procedurally, roboticassisted surgery progressed uneventfully, even with metal artifact noted on the preoperative computerized tomography (CT) scans. Computer mapping of the residual bone surface after implant removal was a helpful guide in minimizing resection depth. No further revisions or reoperations were performed in either group. @*Conclusions@#Robotic-assisted conversion TKA is technically feasible and potentially advantageous. In the absence of normal anatomic landmarks to guide conventional methods, the preoperative CT scans were unexpectedly helpful in establishing mechanical alignment and resection depth. In this limited series, RCT does not seem to be inferior to CCT. Further investigation of outcomes is warranted.