Successful Coil Embolization Treatment of a Large Arterioportal Fistula: A Rare Cause of Mesenteric Ischemia.

Superior mesenteric arteriovenous fistulae (SMAVF) are a rare complication from trauma or iatrogenic surgical intervention. There are less than 50 cases reported in the literature and no clear guidelines as to the best practices for diagnosis and treatment. SMAVF are often asymptomatic but can present with nonspecific abdominal symptoms ranging from nausea and vomiting to gastrointestinal bleeding and mesenteric ischemia. Symptom onset, when present, is often delayed years after the inciting event, further complicating the diagnosis. We present a case of a 71-year-old man presenting with mesenteric ischemic symptoms secondary to a large SMAVF that was successfully treated with coil embolization. We describe our approach to treatment and describe the classical imaging findings. We, then, review the current literature and management recommendations.

Uremic Leontiasis Ossea in a Patient With End-Stage Renal Disease in Hemodialysis.

Uremic leontiasis ossea is a rare condition, reported in patients with severe renal disease. Patients present with progressive enlargement of facial bones - in particular, the maxillary and mandibular bones. Rarity of this condition leaves clinicians puzzled on initial evaluation and management. Herein, we present a 31-year-old man diagnosed with uremic leontiasis ossea. The report aims to review the pathophysiology of the condition as described in the literature, the patient presentation and imaging modalities used to investigate, and classical findings seen in patients with uremic leontiasis ossea. Finally, we briefly touch base on the reported regimens used to prevent and manage this condition.

Characterization of Pulmonary Emboli in Total Joint Arthroplasty Patients Compared to General Medical Patients.

Pulmonary emboli (PEs) occur in medical and postoperative total joint arthroplasty (TJA) patients. These are different patient populations, yet both undergo identical diagnosis and treatment regardless of PEs size and quantity. To date, there has been no analysis of the location, size, and quantity of emboli that occur postoperatively in TJA compared with general medical patients. We hypothesized TJA patients would have different size and distribution of PEs per event compared with medical patients. A retrospective chart review was conducted of patients who underwent total hip or knee arthroplasty in comparison to general medical patients at our institution from 2006 to 2011 with a PE diagnosis. Medical co-morbidities, sex, age, procedure, postoperative day, size, and location of PE using spiral computed tomography were recorded using a novel mapping scheme. Embolus size was defined based on blockage level in the pulmonary arterial tree. Of the 4,178 TJA patients reviewed, 51 were diagnosed with a PE. A total of 67% of TJA patients were women, yet women represented 90% (n = 46) of TJA PE patients (p < 0.0001). Medical patients had an equal distribution of men and women with PEs. Orthopaedic patients averaged more (4.0 vs. 2.2, p < 0.0001) and smaller PEs compared with medical patients (p < 0.0001). In conclusion, women undergoing TJA had significantly higher risk of developing PE compared with male arthroplasty or medical patients. Differences were observed in size and distribution of PEs between medical and TJA patients, which suggest a different nature of embolic phenomenon.

Pulmonary Findings on Computed Tomography in Asymptomatic Total Joint Arthroplasty Patients.

An increase in the diagnosis of pulmonary embolus (PE) in the early postoperative period has been attributed to the use of multidetector 64-slice computed tomographic (CT) scans. It was suspected that this finding was the result of marrow or fat emboli that are commonly associated with arthroplasty rather than a true venous thromboembolic phenomenon. The purpose of this study was to determine the baseline pulmonary findings in asymptomatic patients after total joint arthroplasty (TJA). Over a 1-year period, an institutional review board-approved prospective study of 20 asymptomatic patients using a multidetector 64-slice CT scanner was performed. Overall, 15 TKAs and 5 total hip arthroplasties were included for analysis. All of the CT scans were negative for PE. There were no signs of microemboli or fat emboli on any scan. No patient went on to develop a PE at 2 years postoperatively. Despite the fact that emboli are created during TJA, if emboli are seen on a CT scan postoperatively, they should be assumed to be real events with clinical sequelae. If pulmonary symptoms develop postoperatively, they should not simply be assumed to be the result of fat or marrow embolism.

Water as a contrast medium: a re-evaluation using the multidetector-row computed tomography.

Water as an intraluminal negative contrast medium produces improved image quality with reduced artefact. However, rapid absorption of oral water in the bowel relative to speed and timing of image capturing has limited its clinical application. These findings predate advances in multidetector-row computed tomography (CT). To re-evaluate differences in image quality, we studied image clarity and luminal distention between the same group of patients who received both a pancreas protocol CT (PPCT) that uses oral water and a conventional positive oral contrast scan. We reviewed 66 patients who had previously undergone both a PPCT and an oral contrast abdominal CT. CT images were independently reviewed by two board-certified radiologists who scored degree of hollow viscus distention and visualization of mural detail using a Likert 5-point scale. Results were evaluated by using the Wilcoxon-signed rank test. Student's t test was applied to evaluate the differences in radiation dosage and Spearman's correlational test was used to evaluate interrater correlation between the radiologists. In comparing the mean radiation dosage, there was no statistical difference between the two protocols, and there was good interrater association with ratios of 0.595 and 0.51 achieved for the PPCT and conventional oral scan, respectively. The Wilcoxon signed-rank test showed statistical differences in the stomach (P < 0.001) for both clarity (P < 0.001) and distention (P < 0.001), the duodenum for both clarity (P < 0.001) and distention (P = 0.02), and the ileum for distention (P = 0.02) with the PPCT having a better median score for organ clarity in the stomach and duodenum and better luminal distention in the stomach, equal distention in the duodenum, and slightly worse distention in the ileum. For the remainder of the bowel and organs evaluated, there was no statistically significant difference in the ratings between the two protocols. Using present CT scan technology, water can be an effective contrast medium causing better or equal distention in the bowel and better or equal clarity than routine barium contrast. This calls for a need to reconsider the use of water as a contrast medium in clinical practice.

Novel angle measurements for assessment of shoulder location using the scapular y radiograph.

Shoulder dislocation is an injury with potential long-term consequences that requires prompt diagnosis and treatment. Patient positioning and imperfect radiographic views may result in discomfort, added examination time, and problematic diagnosis. The scapular Y radiograph has been shown to be useful in diagnosing shoulder dislocation but is not considered sufficient in isolation. Using a synthetic bone shoulder model, we propose a novel technique wherein osseous landmarks are used to form angles that significantly improved diagnostic accuracy for shoulder dislocation, even in significantly rotated and otherwise indeterminate scapular Y radiographs.

The MR dimple sign in irreducible posterolateral knee dislocations.

While posterolateral knee dislocation is a rare entity, its identification has important implications. The invagination of skin seen in posterolateral knee dislocations is referred to as the "dimple sign" on physical exam. We report a case where the "dimple sign" was also demonstrated on magnetic resonance imaging. Failure to recognize this finding on imaging will render the knee irreducible, as a result of interposed tissues, until discovered by the orthopedic surgeon intraoperatively. The incarcerated medial capsule and medial collateral ligament could also be misinterpreted as torn meniscus, as occurred in our case.

Observational study on intrathecal and peridural changes after routine spinal and epidural anesthesia in patients undergoing total joint arthroplasty.

Epidural bleeding from spinal anesthetics or epidural catheter placement is concerning, especially when anticoagulants are used. Little is known of the natural changes that occur subdurally or epidurally after each of these procedures. To describe the natural history and occurrence of bleeding that may result from these anesthetics with anticoagulants, we studied 16 joint arthroplasty patients who underwent spinal magnetic resonance imaging postoperatively. Seven patients had an epidural catheter, 7 had a straight spinal injection, and 2 had a general anesthetic. All patients received 5 mg of warfarin postoperatively, with dosing to an international normalized ratio of 2.0. Magnetic resonance imaging readings were blinded. No magnetic resonance image demonstrated peridural inflammation or hemorrhage. No difference was observed between the anesthetics. Warfarin did not cause abnormal bleeding. Based on these observations, one should consider bleeding or peridural inflammation to be abnormal after spinal or epidural anesthesia.

The use of polyacrylamide gel in soft-tissue augmentation: an experimental assessment.

BACKGROUND: An increasing number of soft-tissue filler substances that lack experimental and clinical data have been introduced into plastic surgery practice outside the United States. One of these substances is polyacrylamide gel. It contains 2.5% polyacrylamide and 97.5% water. It is homogenous and stable, and has optimum viscosity and elasticity. METHODS: One milliliter of polyacrylamide gel was injected into the subcutaneous layer of the right ear in 28 rabbits. The rabbits were divided into two groups, according to when the material was harvested and evaluated. Material was harvested at 4 months in 15 rabbits and 7 months in 13 rabbits. Each group underwent volumetric ultrasound evaluation, magnetic resonance imaging, and histological evaluation with hematoxylin and eosin and CD68 staining. RESULTS: Results were easily observed because of the superficial position of the injected material. There were no systemic or local complications. The samples harvested showed a clear and jelly-like consistency similar to that of the initially injected material. The volume was constant after 6 weeks, after an initial period of acute stretching. Ultrasound volumetric analysis was also constant in all groups. At 7 months, a stable volume of 1.0 +/- 0.2 ml was observed. Magnetic resonance imaging scanning showed that the material was stable and that there was no inflammatory reaction. Histological analysis revealed a minimal foreign-body reaction, and the injected material was occasionally surrounded by a thin collagen membrane. The material remained in place. CONCLUSIONS: Polyacrylamide gel has a long-lasting effect, with minimal volume variation. It remains soft to the touch and in place.