Testicular Dislocation After Unstable Pelvic Ring Injury.

Reproductive and genitourinary complications following pelvic ring injuries have been described; however, testicular dislocation is rare and can cause significant morbidity if not managed appropriately. We describe a case of testicular dislocation after pelvic ring injury and outline the subsequent management and outcome, and seek to identify areas of improvement to ensure expedient and appropriate care in the setting of these injuries. Our case describes a 29-year-old male who presented to a level-one trauma center following a motorcycle collision. An anteroposterior compression type II rotationally unstable pelvic ring was identified on imaging. He was hemodynamically unstable and computed tomography (CT) with angiography was ordered. Arterial extravasation was noted from the bilateral anterior internal iliac arteries, which were subsequently embolized by interventional radiology. However, no concomitant genitourinary injury was identified at the time of CT. After resuscitation, the pelvis was stabilized with an anterior symphyseal plate and bilateral sacroiliac screws. During the anterior pelvic approach, the patient's dislocated testicle was surprisingly discovered inferior to the pubis. Urology was consulted intra-operatively, and the testicle was successfully relocated. At the final follow-up, the pelvic ring was healed without any noticeable urogenital complication. While testicular dislocation has been reported in the setting of pelvic ring injury, a paucity of information exists regarding management, implications, and areas for improvement in the identification of these injuries. Therefore, in cases of pelvic ring injury with significant trauma, radiologists, traumatologists, and orthopedic surgeons should adopt a multi-disciplinary approach in diligently attempting to rule out testicular dislocation pre-operatively. Intra-operatively, examination under anesthesia and careful operative technique are important in preventing iatrogenic injury.

Extending multipoint pacing CRT battery longevity by swapping left ventricular pulse configurations.

PURPOSE: Cardiac resynchronization therapy (CRT) with left ventricular (LV) MultiPoint™ pacing (MPP) has been shown to improve CRT response by pacing two LV sites (LV1, LV2). While an additional LV pacing site reduces battery longevity, this cost can be minimized by leveraging an existing device-based capture management algorithm (LVCap™ Confirm). The purpose of this study was to evaluate the MPP battery longevity improvement achieved by configuring LV pacing sites to properly leverage LVCap Confirm. METHODS: Patients previously enrolled in the MORE-CRT MPP trial with existing MPP-enabled CRT-D devices (Abbott Quadra Assura MP™ CD3371-40QC, Quartet™ LV lead) underwent device interrogation. Device electrical characteristics and estimated battery longevities were compared for various MPP settings. RESULTS: At 2.1 ± 1.1 years post-implant, the estimated remaining battery longevity in 65 patients was 70 ± 14 months with MPP Off (LV pacing from minimum capture threshold). Enabling MPP with maximal anatomical separation between LV1 and LV2 cathodes reduced longevity by 15 ± 14%. However, swapping the LV1 and LV2 cathodes, such that the LV1 threshold was the higher of the two, allowed the device to take full advantage of the LVCap™ Confirm capture management algorithm, resulting in significantly lower longevity reduction of 9 ± 11% (p < 0.001). Ultimately, a mean MPP battery longevity improvement of 7.7 ± 10.3% (p < 0.001) was achieved by simply swapping LV1/LV2 configurations. CONCLUSIONS: By properly leveraging device-based capture management features, the impact of MPP on battery longevity can be significantly reduced.

Left ventricular endocardial pacing in the real world: Five years of experience at a single center.

BACKGROUND: A left ventricular (LV) endocardial lead implant to achieve cardiac resynchronization therapy (CRT) is feasible when a conventional implant failed due to anatomical or technical issues or when the venous implant was performed but the patient did not respond to the therapy. METHODS: Data about the implantation procedure (age, sex, clinical characteristics, anticoagulant use, and previous devices), patient characteristics (indication, technique used, lead model, complications), and follow-up (clinical and echocardiographic outcome, LV lead electrical measurements) were analyzed for all CRT systems implanted using LV endocardial lead, due to failed conventional implant or nonresponse, between April 2011 and November 2016. RESULTS: Thirty-five patients were implanted with an active fixation LV endocardial lead during the study period, without significant complications. There were no dislodgements or severe complications related to the implant procedure in the follow-up period (36 ± 20 months) and a high percentage of patients responded to therapy, as assessed by several indicators. CONCLUSIONS: An LV endocardial lead implant was feasible when the conventional technique had previously failed or was not effective. A high rate of response was achieved without any significant complications.

Transfemoral access when superior venous approach is not feasible equals overall success of permanent pacemaker implantation. Ten-year series.

BACKGROUND: When permanent pacemaker implantation is not possible or advisable via superior venous access (i.e., axillary or subclavian veins), safe and feasible surgical alternatives are required. The femoral approach is relatively unknown and seldom studied. This single-center study analyzed 10-year outcomes of a femoral implantation approach. METHODS: Data about the implantation procedure (indication, approach, lead and pacemaker models, complications), patient characteristics (age, sex, medications, comorbidities), and follow-up were analyzed for all permanent pacemaker implantations using the femoral approach between June 2001 and June 2011. RESULTS: A permanent pacemaker was implanted with the femoral approach in 50 patients (mean age, 76 years [range: 45-96], 31 [61%] men). The most frequent indication was atrioventricular block, associated with sinus rhythm in 30 patients and with atrial fibrillation in eight patients. Overall, 20 patients (40%) were treated with oral anticoagulants postimplantation. Mean implantation time was 64 minutes (range: 20-210) and mean fluoroscopy time was 6.7 minutes (range: 0.2-50). Minimum follow-up window was 1 year (June 2012), with a mean of 50 months [range: 1-113]). No deaths, septic episodes, or severe complications were associated with the procedure, acute or long-term. Follow-up data were available for 46 patients, of who 21 (46%) died during follow-up (mean age, 87 years [range: 73-101]). No cause of death was associated with the femoral technique. CONCLUSION: Permanent pacemaker implantation through femoral access is not difficult for an experienced implant surgeon. Outcomes were comparable to systems implanted by superior venous approach, and no severe complications were observed at 10-year follow-up.

Anomalias dentomaxilofaciales en niños de 12 a 14 años con respiración bucal / Dento-maxillofacial abnormalities in children from 12 to 14 years old with breathing by mouth

Introducción: las anomalías dentomaxilofaciales, consideradas como un problema en la actualidad, se definen como una desviación del patrón de desarrollo esperado y deseado de la dentición y del macizo facial. Son provocadas por diferentes causas, dentro de las que se encuentra la respiración bucal. Objetivo: determinar las anomalías dentomaxilofaciales presentes en niños de 12 a 14 años con respiración bucal, de la Escuela Secundaria Básica Urbana Angola Libre, Santa Cruz del Norte, Mayabeque.Método: se realizó estudio analítico, observacional, casos y control, en el periodo septiembre 2012 a julio 2013. El universo fueron 469 niños as y la muestra 135 escolares con respiración bucal e igual número de respiradores nasales. Se identificaron anomalías faciales, de partes blandas, maxilares, dientes y de oclusión presentes en los niños. La información se obtuvo mediante interrogatorio y examen físico; y se realizó análisis estadístico aplicando función estadística no paramétrica Chi Cuadrado X2 de Pearson. Resultados: la anomalía facial más frecuente en los respiradores bucales fue la incompetencia bilabial; mientras que el micrognatismo transversal fue la anomalía de los maxilares que más se presentó en ellos, con diferencias significativas con los respiradores nasales. El apiñamiento fue la anomalía de los dientes predominante en los respiradores bucales, diferenciándose significativamente de los que tenían esta anomalía en los no respiradores bucales. El resalte aumentado predominó con diferencias significativas en los respiradores bucales. Conclusiones: la respiración bucal produce anomalías dentomaxilofaciales en los niños, predomina la Incompetencia bilabial, arcada superior Triangular, micrognatismo transversal, apiñamiento y resalte aumentado con significación estadística (AU)

Introduction: dento-maxillofacial abnormalities, considered as a problem nowadaysare defined as a deviation of the expected and desired development pattern of dentition and face. They have different causes, among them, there is breathing by mouth. Objective: to determine the dento-maxillofacial abnormalities in children from 12 to 14 years old with breathing by mouth at Angola Libre Secondary School, Santa Cruz del Norte, Mayabeque. Method: an analytic, observational, cases and control study was performed, in the period from September 2012 to July 2013. The universe was composed by 469 children and the simple by 135 school students with breathing by mouth and the same number of nasal breathing. Facial, soft parts, maxillary, teeth and occlusion abnormalities were identified. The information was obtained by an interview and physical examination; a statistical analysis was carried out applying the non-parametric statistical function Pearsons Chi Square X2 Results: the most frequent facial abnormality in children who breathe my mouth was bilabial incompetence; the transversal micrognatism was the maxillary abnormality that they most presented, with significant differences with nasal breathers. Squeezing was the predominant abnormality of the teeth in breathers by mouth, being significantly different to the ones that had this abnormality compared with the other group. The increased enhancement prevailed with significant differences in children who breathe by mouth. Conclusiones: breathing by mouth produces dento-maxillofacial abnormalities in children, Triangular bilabial upper arcade prevails, transversal micrognatism, squeezing and increased enhancement with statistical meaning (AU)

Treatment of Bone Loss With the Induced Membrane Technique: Techniques and Outcomes.

OBJECTIVES: To critically review the outcomes and issues associated with the induced membrane technique in a trauma population. DESIGN: Retrospective case series, Level IV therapeutic study. SETTING: Urban Level I trauma center. PATIENTS: Sixty-nine patients aged 18 years or older who underwent treatment of bone loss with the induced membrane technique. INTERVENTION: All patients underwent open treatment of their traumatic bone loss with a 2-stage induced membrane technique. MAIN OUTCOME MEASUREMENT: Bony union rate, as evaluated with radiographic and clinical signs of healing. RESULTS: Patients in this series averaged 4.4 surgeries, which included initial debridement to definitive fixation. The tibia was the most common site of bone loss, encompassing 50.7% of the series, whereas femoral bone loss was next at 24.6%. Polymethylmethacrylate spacers were in place for a mean of 11.2 weeks (mode of 8 weeks) before bone grafting for an average bony defect volume of 76.6 cm. Union was obtained in 82.6% of patients at a mean of 26.6 weeks after grafting. Mean follow-up for these patients was 23.8 months. CONCLUSIONS: The induced membrane technique is an effective method to obtain bony union when used in the trauma population. However, it is not foolproof, and attention must be paid to the critical subtleties of the procedure. Further investigation is needed to help determine the optimal spacer composition and other technical aspects of the procedure such as timing of the exchange. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Retrograde Versus Antegrade Femoral Bone Graft Harvesting Using the Reamer-Irrigator-Aspirator.

OBJECTIVES: To compare retrograde versus antegrade femoral bone graft harvesting using the reamer-irrigator-aspirator system to determine whether there was any difference in intraoperative, postoperative, or patient outcome variables. DESIGN: Retrospective cohort study. SETTING: Urban Level I Trauma Center. PATIENTS/PARTICIPANTS: Ninety-four (62 antegrade and 32 retrograde procedures) consecutive adult patients who underwent femoral autologous bone graft harvesting using the Synthes reamer-irrigator-aspirator system between April 2008 and March 2013. MAIN OUTCOME MEASUREMENTS: Amount of bone graft, perioperative fractures or other complications, and postoperative hip and/or knee pain. RESULTS: There was no significant difference between demographic or medical comorbidities between the groups. There was no significant difference in the side of the graft harvest, graft volume, hospital length of stay, or the ability to ambulate on postoperative day 1. There was a significantly increased incidence of iatrogenic fracture or prophylactic nailing with antegrade reaming (4 vs. 0, P = 0.01). Average length of follow-up was 500 (range, 20-1477) days for the antegrade group and 378 (range, 19-706) days for the retrograde group. The antegrade group had a nonsignificant increased incidence of hip pain (8.1% vs. 3.1%, P = 0.66), and the retrograde group had a significantly higher incidence of knee pain (15.6% vs. 1.6%, P = 0.02) at 6-month follow-up. Neither hip nor knee complaints were present at final follow-up. No cases of delayed femur fracture, infection, or abductor and/or antalgic gait involving the donor extremity were seen at final follow-up. CONCLUSIONS: This study provides support to the safety of femoral bone graft harvesting using both antegrade and retrograde techniques. Both techniques provide reliable, high-volume, nonstructural autologous bone graft with minimal associated morbidity. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Plating of patella fractures: techniques and outcomes.

Operative treatment of displaced patella fractures with tension band fixation remains the gold standard, but is associated with a significant rate of complications and symptomatic implants. Despite the evolution of tension band fixation to include cannulated screws, surprisingly little other development has been made to improve overall patient outcomes. In this article, we present the techniques and outcomes of patella plating for displaced patella fractures and patella nonunions.

Lower incidence of venous thrombosis with temporary active-fixation lead implantation in mobile patients.

AIMS: Temporary transfemoral cardiac pacing is widely accepted, but is associated with high incidence of asymptomatic deep vein thrombosis (DVT), which in turn is associated with restricted patient mobility. The passive-fixation lead typically used in this procedure restricts patient mobility during implantation. METHODS AND RESULTS: An active-fixation lead allowing normal ambulation was prospectively assessed in 47 consecutive patients. Prior to explantation, venous duplex ultrasound was performed to determine DVT incidence, with the contralateral leg as control. To reduce possible false negatives, ventilation/perfusion scintigraphy was also performed (n = 42). Patient mobility during implantation was classified as high (n = 29), moderate (n = 6), or low (n = 12). Anticoagulants were limited to cases meeting standard guidelines. Asymptomatic DVT was diagnosed in three patients (6.4%), compared with 25-39% reported using standard passive-fixation leads. Furthermore, all of these patients had low mobility during the implantation period. No post-implantation lung scan showed high probability of pulmonary embolism. CONCLUSION: In the 75% of patients with moderate or high mobility, there were no DVT cases. The 6.4% DVT incidence was limited to patients with low mobility and was significantly lower than the norm for this procedure. A larger, randomized study is needed to confirm the benefits of the mobility allowed by an active-fixation lead.

Permanent transfemoral pacemaker: a single-center series performed with an easier and safer surgical technique.

INTRODUCTION: When venous access via the upper venous tree is not possible, the usual approach is to proceed to epicardial lead placement. MATERIAL AND METHODS: This report presents a consecutive series of 12 permanent pacemaker systems utilizing the right femoral vein for venous access implanted between May 2001 and October 2004. RESULTS: A modification of the previously reported surgical technique was used with a mean implant time of 52 minutes. Five were dual-chamber systems and seven were VVIR. All the leads implanted were active fixation. There was a 0% dislodgment rate and a mean follow-up of 18 months. During this time, three patients required revision or treatment of a pocket complication. All systems remained in the pacing mode as originally programmed with stable low sensing and pacing thresholds. There was no clinical evidence for acute or chronic venous thrombosis and no evidence of asymptomatic venous obstruction in eight patients who underwent echo-duplex studies. CONCLUSION: We believe that the permanent femoral implant utilizing the technical modifications described in this article, offers an alternative to epicardial lead placement when the usual upper venous tree access is not available.