Computed tomography assessment of sacroiliac screw placement relative to the first sacral neuroforamen.

The radiographic interpretation of sacroiliac screws relative to the S1 neuroforamen is difficult for orthopedic surgeons and radiologists. Computed tomography (CT) with axial images alone or combined with multiplanar reconstructions are often used to assess screw position. The reliability, reproducibility, and accuracy of orthopedist and radiologist interpretations of axial CT images with and without multiplanar reconstructions was determined using 24 cadaveric hemipelves with known sacroiliac screw position. Interobserver reliability of determining screw position was fair for orthopedists and slight for radiologists regardless of imaging modality or screw composition. Intraobserver reproducibility was moderate for orthopedists regardless of imaging modality or screw type. Reproducibility among radiologists was moderate using axial images of titanium screws and substantial with addition of multiplanar reconstructions. Overall accuracy was similar for orthopedists and radiologists. CT images with multiplanar reconstructions improve accuracy in determining sacroiliac screw position, but not significantly. Current imaging modalities are limited by large inaccuracies and by interobserver and intraobserver variation.

A few considerations regarding enhancement of arterialized skin flap survival.

An arterialized skin flap is defined as a flap harvested from the anterior and distal third of the forearm over a venous pathway. It is composed essentially of skin, subcutaneous tissue, and the subdermal plexus of the veins. The flap is perfused at the recipient side by a donor artery at one end and is connected to one or more regional veins at the opposite end. Since it depends on an atypical blood perfusion, leading to edema, epidermolysis, or even some degree of skin necrosis during the immediate postoperative procedure, this skin flap is considered to have a torpid evolution. This article includes some considerations regarding the enhancing of the arterialized skin flap survival, based on our clinical and laboratory experience after its transplantation. The design, construction of its arterial afferent phase, construction of its venous efferent phase, and monitoring are discussed.

Congenital atresia of the ostium of the left coronary artery. Diagnostic difficulty and successful surgical revascularization in two patients.

We report two cases of congenital atresia of the ostium of the left coronary artery. Case 1: a six-month-old infant presenting with serious cardiac insufficiency. A noninvasive diagnosis of dilated myocardiopathy was established and the clinical picture was pharmacologically compensated. When the patient was nine months of age, a hemodynamic study was performed that revealed congenital atresia of the ostium of the left coronary artery; the infant immediately underwent a successful anastomosis of the internal mammary artery with the left coronary artery. Case 2: an eleven-year-old asymptomatic boy with a history of heart murmur from the age of six months on, was referred for surgery with a diagnosis of anomalous origin of the left coronary artery from pulmonary trunk. A definitive diagnosis of atresia of the left coronary ostium was only established during surgery. Successful surgical revascularization with the left internal mammary artery, and left ventricular aneurysmectomy were performed.

Patellar tendon defect during the first year after anterior cruciate ligament reconstruction: appearance on serial magnetic resonance imaging.

The purpose of this study was to use magnetic resonance imaging to evaluate various parameters of the patellar tendon during the first year after harvest for anterior cruciate ligament (ACL) reconstruction. Twelve consecutive patients were serially imaged on a 1.5 Tesla GE magnet (GE Medical Systems, Milwaukee, WI) with a dedicated knee coil at 3 weeks, 3 months, 6 months, and 1 year after undergoing ACL reconstruction using a central one-third patellar tendon autograft. The tendon defect was not closed primarily, but the paratenon was approximated. The following measurements were performed: tendon width, defect width, cross-sectional area of the tendon, and tendon length. In addition, the patellar bone harvest site was evaluated for healing. The width of the tendon defect decreased by 62% over 12 months (P < .05). Only two patients showed complete closure of the defect. Tendon width was noted to decrease by 6.5% (P=.017). The ratio of defect width to overall tendon width (designated R) decreased by 58% (P < .05). Tendon length was noted to decrease during this by 8% (P=.037). The tendon cross-sectional area was noted to increase by 9% at 1 year, but this was not found to be statistically significant (P=.39). One year after ACL reconstruction using a central one-third patellar tendon, the tendon defect has begun to reconstitute itself but there is still a significant gap. This persistent defect must be taken into consideration when planning revision ACL surgery using reharvest of the central one third of the patellar tendon. The entire tendon also exhibits a reduction in width and length, while cross-sectional area increases slightly. Complete healing of the graft defect can not be assumed at 12 months post-ACL reconstruction.

Microsurgical reconstruction of the Achilles tendon with a fascia lata flap.

A case of total reconstruction of the Achilles tendon is reported. A compound free musculocutaneous unit of fascia lata was used to supply the absent tendon and soft tissues, achieving excellent cosmetic and functional results. This technique is suggested as an alternative for combating infection, providing soft-tissue cover, and bridging the gap in the tendon.

Occlusion of congenital ventricular septal defects by the buttoned device. "Buttoned device" Clinical Trials International Register.

OBJECTIVES: To study the feasibility of congenital ventricular septal defect occlusion by the buttoned device and to establish guidelines for its safe and effective application. DESIGN: A descriptive study of all patients with a congenital ventricular septal defect undergoing transcatheter occlusion with the buttoned device, from March 1994 to May 1995. These patients were otherwise candidates for elective surgery at their institutions because they had persistence of a significant shunt (Qp:Qs = 1.5-2.1:1, median = 1.7), with left ventricular enlargement and/or symptoms, although their systolic pulmonary artery pressure was invariably normal (20-28 mm Hg, median = 25). The angiographic diameter of the defect ranged from 2.5 to 14 mm (median 6 mm). SETTING: A multi-institutional study. PATIENTS: Out of 25 cases attempted, 18 children and adults aged 4-35 years had devices implanted. Fifteen of these patients had membranous ventricular septal defects and three had muscular defects. All patients with a membranous ventricular septal defect had an associated aneurysm of the membranous septum. INTERVENTIONS: The buttoned device was introduced either directly or, in the last 12 cases, over a wire bridging the femoral artery and the femoral or jugular vein; the devices were delivered through 7-9 French (F) long sheaths. A membranous defect was regarded as suitable for device closure if the distance from the centre of the defect to the insertion of the right coronary aortic valve leaflet was more than 50% of the size of the required device. The device was guided by echocardiography and fluoroscopy. All muscular defects were corrected through the right jugular vein and all membranous ones through the femoral vein. RESULTS: All 18 patients underwent initial successful implantation of the device. In thirteen patients the shunts were completely occluded and in the remaining five there were trivial residual shunts. In two patients with membranous ventricular septal defects a change from the original position was noticed at two weeks; mild aortic regurgitation developed in one and the murmur recurred in the other; the devices had to be removed surgically. One patient developed transient third degree atrioventricular block during implantation; no tricuspid regurgitation was observed. CONCLUSION: Clinical occlusion of congenital ventricular septal defects was achieved in 16 out of the 18 attempted cases (13 full occlusions). Membranous ventricular septal defect occlusion can be effective and safe if patients and device sizes are carefully selected.

[Congenital isolated hypoplasia of the right ventricle]. / Hipoplasia congênita isolada do ventrículo direito.

Two cases of congenital trabecular hypoplasia of the right ventricle are reported. In the first, the neonatal diagnosis was missed and the child did well until the 13th month of life when a modified Blalock-Taussig shunt was done because of increasing cyanosis. Outcome was good until the 4th year of life when symptomatic atrioventricular block was detected in an emergency situation. A bidirectional Glenn anastomosis and pacemaker implantation were successfully carried out after clinical establization and the child is doing well up to now. The second case presents the disease with its worst features: severe cyanosis and acidosis in the first day of life. A modified Blalock-Taussig shunt was performed and death occurred soon after the operation.

[Art and anatomy of the smile]. / Arte y anatomía de la sonrisa.

In this article we approach the different types of a smile, according to its anatomic characteristics, and its relation with the pathology. At the same time we establish a parallelism between the classification of Rubin and the world of Art and Literature.

Free flap with reversed arterial flow in the leg: case report.

A case of distal-third reconstruction of a leg with bone exposure is reported. A rectus abdominis muscle free flap, based on the inferior epigastric artery, was anastomosed to the distal stump of the anterior tibial artery with reversed flow. This technique is suggested as an option for microvascular reconstruction in the distal third of the leg. Anatomic and physiologic details are discussed.

T2-weighted MR imaging of the chest: comparison of electrocardiograph-triggered conventional and turbo spin-echo and nontriggered turbo spin-echo sequences.

In 22 patients with a diverse range of thoracic abnormalities, T2-weighted magnetic resonance (MR) images of the chest were obtained with electrocardiograph (ECG)-triggered turbo spin-echo (TSE), ECG-triggered conventional spin-echo (CSE), and nontriggered TSE sequences, and the images were compared. A 5-point rating scale was used by three radiologists experienced in MR imaging of the chest to independently evaluate the images for (a) freedom from ghosting, (b) clarity of heart wall and cardiac chambers, (c) clarity of mediastinal structures, (d) conspicuity of abnormalities, and (e) overall image quality. Evaluations were analyzed with statistical methods. For freedom from ghosting, clarity of heart wall and cardiac chambers, clarity of mediastinal structures, and overall image quality, the ECG-triggered TSE images were rated higher than the TSE images, which, in turn, were rated higher than the ECG-triggered CSE images at the P = .05 level of significance. No significant differences were seen between the pulse sequences in the conspicuity of abnormalities, although some differences were observed in individual cases. Our results suggest that ECG-triggered TSE imaging provides improved, time-efficient T2-weighted images of the chest.

SVC syndrome as a late complication of ascending aortic aneurysm repair: MR diagnosis.

Imaging evaluation is important in the follow-up of patients who have undergone surgical repair of the aorta. We present a case in which MR imaging demonstrated compression of the superior vena cava (SVC) as a late complication of ascending aortic aneurysm surgery. This complication led to thrombosis and clinical SVC syndrome.

[Occlusion of patent ductus using the Rashkind system. Initial experience]. / Oclusão de canal arterial persistente mediante utilização do sistema de Rashkind. Experiência inicial.

Three patients were submitted to the Rashkind device technique for closure of a patent ductus arteriosus. The percutaneous transvenous technique was employed in every cases. A 12 mm prosthesis was utilized in one case and 17 mm prostheses in the other two cases. In the first case, after temporary occlusion of the ductus arteriosus, the prostheses was removed due to the technical impossibility of evaluation of the proximal umbrella position. In the second and third cases, the prostheses were duly liberated in the proper position, thus occluding the defects. This technique does not require general anesthesia, is indicated in patients over 6 kgs of body weight, and is a therapeutic alternative to the habitual surgical procedure.

[Mammary-coronary anastomosis: a new technique of approach through the brachial route for angiographic study and angioplasty]. / Anastomose mamária-coronária: nova técnica de abordagem por via braquial para estudo angiográfico e angioplastia.

PURPOSE: A new technique of mammary artery catheterization, by a brachial artery approach, utilizing a pre-molded conventional Sones catheter is described. METHODS: In a series of 300 patients, 308 procedures were performed. Three hundred internal mammary-coronary anastomosis were studied. In eight cases angioplasty were performed, five in the anterior descending artery and three in the internal mammary artery itself, with recanalization of one of the three cases. The approach was through the brachial artery homolateral to the anastomosed mammary artery. After the conventional coronarographic and bypass studies were performed, the catheter was withdrawn and pre-molded, forming a closed loop of approximately 10 mm in its distal extremity. The loop was introduced through the arteriotomy reaching the origin of the vertebral artery. The internal mammary artery was then catheterized utilizing rotation and traction movements. In the percutaneous transluminal coronary angioplasty (PTCA) procedures, the Sones catheter was replaced by a Myler right coronary catheter with a 260 cm metallic wire. RESULTS: In the 308 procedures, the internal mammary artery was catheterized in 305 instances (99.03%). In the remaining three cases selective catheterization of the internal mammary artery was not possible. In these three cases there was extreme tortuosity of the subclavian artery. The only complication observed in this series was thrombosis of the brachial artery in two cases (90.65%). In the eight patients submitted to PTCA the existing lesions were successfully dilated. CONCLUSION: Catheterization of the internal mammary artery through a brachial approach utilizing a pre-molded Sones catheter was an efficient procedure, with low incidence of complications. This approach could be the elective technique in the services that habitually utilize the brachial artery approach. It could be also an alternative for those utilizing the Judkins technique, whenever the internal mammary artery catheterization is impossible due to the anatomic characteristics of the patient.