Distal Fibula Pro-Tibial Screws in Salvage Fixation of Bimalleolar Ankle Fractures in Osteoporotic Bone - A Novel Technique.

Here we present a novel adaptation of the previously described fibula pro-tibial fixation in a case requiring salvage fixation of a bimalleolar ankle fracture in an osteoporotic patient. Unstable osteoporotic ankle fractures are a challenging injury to manage and typically occur in a frail and comorbid subgroup of patients. Various techniques have been described in the evolution of managing these injuries, e.g. hindfoot nailing and anatomical locking plates, however in this uniquely challenging case a novel strategy was required to mitigate bone loss in the distal fibular fracture fragment. There is some evidence to suggest fibular protibial fixation offers a lower complication profile to its alternatives. The novel use of distal fibula pro-tibial screws offers a new alternative to hindfoot nailing of bimalleolar ankle fracture in osteoporotic bone with compromised distal fibular fragment bone purchase. Further research is required to investigate the compatibility of this technique with early weightbearing.

Systematic review of ambulatory selective variceal ablation under local anesthetic technique for the treatment of symptomatic varicose veins.

OBJECTIVE: The ambulatory selective variceal ablation under local anesthesia (ASVAL) technique subscribes to the "ascending" theory of varicose vein etiology, which recommends primary ambulatory phlebectomy as a treatment for tributary varicosities and truncal vein incompetence. This systematic review explores the efficacy and safety of the ASVAL technique for the treatment of symptomatic varicose veins. METHODS: A comprehensive search of the Medline and Embase databases and the Cochrane Register of Controlled Trials in May 2019 revealed 11 original articles that were qualitatively reviewed. The primary outcome was the absence from recurrent varicose veins at 1-year follow-up. Secondary outcomes were resolution of great saphenous vein (GSV) reflux on duplex ultrasound, change in GSV diameter, objective and subjective clinical improvement in chronic venous disease, and patient-reported outcome measures. RESULTS: A total of 2106 limbs underwent intervention in 1734 patients reported in two randomized controlled trials, one case control study, three cohort studies, and five case series. Varicosity recurrence at 1 year ranged from 0.5% to 13.5% in patients. Of 1622 limbs with diagnosed GSV incompetence before intervention, 1114 were competent at 1 year (mean, 68.2% [±12.62%]). All studies measuring GSV diameter reported statistically significant reductions in vein size. CONCLUSIONS: ASVAL may be considered as a minimally invasive treatment for early stages of chronic venous disease in the presence of truncal reflux. The evidence base should be strengthened by prospective randomized controlled trials that follow standardized procedures and report according to recognized measures of quality of life alongside clinical and hemodynamic data.

A methodologic assessment of lymphedema clinical practice guidelines.

OBJECTIVE: The objective of this review was to determine the methodologic quality of current lymphedema clinical practice guidelines (CPGs) to assist health care professionals in selecting accessible, high-quality guidance and to identify areas for improvement in future CPGs. METHODS: MEDLINE, Embase, online CPG databases, and reference lists of included guidelines were searched up to January 31, 2020. Full-text CPGs reporting on evidence-based recommendations in lymphedema diagnosis or management in English were included. CPGs based on expert consensus, CPG summaries, or CPGs that were not freely available were excluded. Two reviewers identified eligible CPGs, extracted data, and assessed their quality independently using the Appraisal of Guidelines for Research and Evaluation II instrument. Significant scoring discrepancies were discussed with a third reviewer. An overall scaled quality score of ≥80% was the threshold to recommend guideline use. RESULTS: Six relevant CPGs were identified. One was subsequently excluded as its full text could not be obtained. Overall, there was very good inter-reviewer reliability of scores with intraclass correlation coefficient of 0.952 (95% confidence interval, 0.921-0.974). No single CPG scored highest in all domains, with methodologic heterogeneity observed. Poor performance was noted in domain 5 (mean scaled score, 23.8% ± 17.1%) and domain 6 (22.9% ± 26.7%). No CPG achieved an overall scaled quality score of ≥80%, with the top CPG scoring 79.2%. CONCLUSIONS: According to the defined threshold, no lymphedema CPG was considered adequate for use in clinical practice. All current lymphedema CPGs have areas for improvement with elements of methodologic quality lacking, particularly with respect to rigor of development. A structured approach, guided by the use of CPG creation tools and checklists such as the Appraisal of Guidelines for Research and Evaluation II instrument, should help CPG development groups in improving the quality of future CPGs. This is of particular importance in a complex, multidisciplinary condition such as lymphedema.

In Vitro Benchmarking Study of Ventricular Assist Devices in Current Clinical Use.

BACKGROUND: Left ventricular assist devices (LVADs) offer live-saving therapy to transplant-ineligible heart failure patients. A major limitation of the technology includes pump thrombosis, bleeding, and recurrent infection that prove difficult to predict from in vivo animal testing. Shear stress introduced by the LVAD affects more than just hemolysis because platelets, leukocytes, and plasma proteins all contribute to the propensity for complications. It is important to assess overall damage by a new device against a baseline as early as possible in the development process so that design iterations can be made if required. METHODS: Explanted VADs currently in clinical use (HeartMate 2 and HVAD) were carefully cleaned, inspected, and run at 5 L/min and pressure at 100 mmHg in a standard 500 mL mock circulatory loop using bovine blood. The CentriMag was used as a control pump because of its low blood damage profile. Samples were collected at regular intervals and the following were analyzed: complete cell counts, hemolysis, platelet activation, leukocyte-derived microparticles (LMPs), and von Willebrand factor (vWF) degradation. RESULTS: The HeartMate 2 had the highest levels of hemolysis and platelet activation after 6 hours compared with the HVAD and CentriMag. A decreased granulocyte count, high numbers of LMPs and CD11bBrightHLADR- LMPs, and decreased vWF collagen binding activity was most evident in the HVAD. CONCLUSIONS: The results indicate that it is possible to observe differences between different pump designs during in vitro testing that might translate to clinical performance. This study demonstrates the importance of developing standard in vitro total blood damage methods against which device developers could use to modify design to reduce complication risk long before implantation.