Treatment of sacroiliac joint laxity-induced coronal imbalance with the kickstand rod technique.

BACKGROUND: Considerations of the sacroiliac joint (SIJ) and its role in causing lower back and limb pain have taken a secondary role ever since Mixter and Barr's hallmark article in 1934 on the herniated nucleus pulposus. However, recent literature has highlighted the contribution of sacroiliac joint degeneration in the development of failed back surgery syndrome (FBSS), especially in patients undergoing lumbar or lumbosacral spinal fusion surgeries. Many reports have studied the anatomy, physiology, and clinical significance of the sacroiliac joint, but none have linked its dysfunction with other spinal deformities. CASE DESCRIPTION: A 63-year-old female with a history of multiple complex instrumented spinal fusions presented to our institution with progressive leftward coronal imbalance despite successful arthrodesis from T3 through S1. She was initially treated with decompression and reimplantation, but adjacent segment disease at the SIJ led to laxity, distal failure, and a worsening coronal deformity. A mechanical fall after her decompression surgery led to a dramatically increased coronal imbalance, which was ultimately treated using Lenke's kickstand rod technique. At 3.5 years follow up, the patient's coronal balance remains stable. CONCLUSION: Few studies have related SIJ degeneration and laxity with spinal deformity. Our case describes SIJ degeneration that evolved to joint laxity, which ultimately produced a leftward coronal imbalance according to the adjacent segment disease mechanism. Additionally, we describe the use of a kickstand rod to effectively correct the coronal imbalance, reduce pain levels, promote SIJ arthrodesis, and prevent further SIJ-related issues without significant complications over 3 years post-operation.

A Fenestrated Balloon Expandable Stent System for the Treatment of Aortoiliac Occlusive Disease.

In aortoiliac occlusive disease, atherosclerotic plaques can occlude the distal aortic bifurcation and proximal bilateral iliac artery and thus cause ischemia in the lower extremity. This is typically treated by restoring patency with balloon expandable stents. Stents are typically deployed in a "kissing stent" configuration into the bilateral iliac arteries and into the distal aortic bifurcation lumen to restore antegrade arterial flow. However, these stents typically become re-occluded by plaques. To understand the reasons for this and look for solutions, we simulated flow dynamics in the aortic bifurcation in the presence and absence of stents using computational fluid dynamics. Results demonstrated that the kissing stent configuration was associated with high levels of vorticity and flow constriction. These prothrombotic variables were alleviated in an alternative, aortoiliac fenestrated (AIFEN), tapered, and balloon-expandable stent design. Our findings suggest that stent design can be tailored to improve flow fields for aortoiliac stenting.

Multimodal thrombectomy device for treatment of acute deep venous thrombosis.

Deep vein thrombosis (DVT) is a potentially deadly medical condition that is costly to treat and impacts thousands of Americans every year. DVT is characterized by the formation of blood clots within the deep venous system of the body. If a DVT dislodges it can lead to venous thromboembolism (VTE) and pulmonary embolism (PE), both of which can lead to significant morbidity or death. Current treatment options for DVT are limited in both effectiveness and safety, in part because the treatment of the DVT cannot be confined to a defined sequestered treatment zone. We therefore developed and tested a novel thrombectomy device that enables the sequesteration of a DVT to a defined treatment zone during fragmentation and evacuation. We observed that, compared to a predicate thrombectomy device, the sequestered approach reduced distal DVT embolization during ex vivo thrombectomy. The sequestered approach also facilitated isovolumetric infusion and suction that enabled clearance of the sequestered treatment zone without significantly impacting vein wall diameter. Results suggest that our novel device using sequestered therapy holds promise for the treatment of high risk large-volume DVTs.

Impact of N-Acetyl-Cysteine on Ischemic Stumps Following Major Lower Extremity Amputation: A Pilot Randomized Clinical Trial.

OBJECTIVE: To evaluate the impact of N-acetyl-cysteine (NAC) on amputation stump perfusion and healing in patients with critical limb-threatening ischemia (CLTI). BACKGROUND: Patients with CLTI are at increased risk of poor amputation site healing leading to increased procedure-associated morbidity. METHODS: In a pilot, double-blind, placebo-controlled, randomized controlled trial, patients with CLTI undergoing major elective lower extremity amputation were randomized 1:1 to intravenous NAC (1200 mg twice-daily) or placebo for up to 5 days postoperatively. Primary outcomes were change in stump perfusion at postoperative day 3 (POD3) and POD5, and healing at POD30. Stumps were serially evaluated for wound healing, and tissue perfusion was evaluated using noninvasive laser-assisted fluorescent angiography. RESULTS: Thirty-three patients were randomized to NAC (n = 16) or placebo (n = 17). Thirty-one patients were eligible for intent-to-treat analysis (NAC14; placebo17). Twenty patients (NAC7; placebo13) had amputation stump perfusion defects at POD0 and were considered high-risk for poor healing. Intent-to-treat analysis revealed no significant differences between treatment groups. Subgroup analysis of high-risk patients revealed differences in stump perfusion defect size (NAC-0.53-fold, placebo +0.71-fold; 95% confidence interval -2.11 to-0.35; P < 0.05) and healing (NAC [100%], placebo [46%]; P < 0.01) between study treatments. CONCLUSIONS: Postoperative NAC administration may improve amputation stump perfusion and healing in patients with CLTI and tissue perfusion defects at the time of amputation. Intraoperative laser-assisted fluorescent angiogra-phy may help surgeons identify high-risk patients with stump perfusion defects and provide early adjunctive interventions. Future studies can further explore the therapeutic benefits of NAC in the healing and perfusion of other surgical operative sites in high-risk individuals. TRIAL REGISTRATION: clinicaltrials.gov, Identifier: NCT03253328.

Modular cervical plate system for adjacent segment disease.

BACKGROUND: Adjacent-level disease after anterior cervical discectomy and fusion (ACDF) occurs in a significant proportion of patients and frequently requires revision operation. Methods using traditional plates typically require removal of the plate with anecdotally increased operative-time and morbidity. We review our experience in treating symptomatic adjacent-segment disease using both traditional plate removal and modular-plate system which allows for add-on plate components rather than removal of the entire plate. METHODS: Authors compared 64 patients with revision surgery using modular-plate system for adjacent-segment disease compared to 2-cohorts: 1) patients with traditional plate-removal; and 2) patients with no prior plate. Clinical data included demographics, original surgery, presentation, current surgery, use of modular system, need for preoperative computed-topography, operative-time, blood loss, hospital stay, complications, length of dysphagia, neck disability index and time-until-fusion. RESULTS: Modular cervical plate system was utilized to prevent exposure and removal of the entire plate. The terminal portion of the plate was exposed and the distal module was removed. Following the discectomy/arthrodesis, a module-plate extension was added onto the previous plate for extension of the prior instrumentation. Preoperative planning computed-topography was required in 26% of plate-removal and 17% of modular-plate cases. Revision surgery with no prior plate had reduced operative-time (77.0±18.1 min) when compared with plate removal (103.8±46.2 min; P<0.01). Blood-loss was lower for modular-plate system (38.3±20.4 mL) and no prior plate (38.4±12.6 mL) versus plate removal (78.2±65.9 mL, P<0.01). Hospital stay was similar for all groups. No complications were experienced with modular-plate revision but plate removal and revision after no prior plate carried 7.7% and 10.5% complication rates, respectively. There was a trend towards lower dysphagia and neck disability index with modular-plate revision. CONCLUSIONS: Use of modular cervical plate system allows for extension of a plate and reduces morbidity when treating adjacent-segment disease.

Environmental Stability of Plasmonic Biosensors Based on Natural versus Artificial Antibody.

Plasmonic biosensors based on the refractive index sensitivity of localized surface plasmon resonance (LSPR) are considered to be highly promising for on-chip and point-of-care biodiagnostics. However, most of the current plasmonic biosensors employ natural antibodies as biorecognition elements, which can easily lose their biorecognition ability upon exposure to environmental stressors (e.g., temperature and humidity). Plasmonic biosensors relying on molecular imprints as recognition elements (artificial antibodies) are hypothesized to be an attractive alternative for applications in resource-limited settings due to their excellent thermal, chemical, and environmental stability. In this work, we provide a comprehensive comparison of the stability of plasmonic biosensors based on natural and artificial antibodies. Although the natural antibody-based plasmonic biosensors exhibit superior sensitivity, their stability (temporal, thermal, and chemical) was found to be vastly inferior to those based on artificial antibodies. Our results convincingly demonstrate that these novel classes of artificial antibody-based plasmonic biosensors are highly attractive for point-of-care and resource-limited conditions where tight control over transport, storage, and handling conditions is not possible.