Migration of trochanteric cerclage cable debris to the knee joint.

Migrating orthopedic hardware has widely been reported in the literature. Most reported cases of migrating hardware involve smooth Kirschner wires or loosening/fracture of hardware involved with joint stabilization/fixation. It is unusual for hardware to migrate within the soft tissues. In some cases, smooth Kirschner wires have migrated within the thoracic cage-a proposed mechanism for this phenomenon is the negative intrathoracic pressure. While wires have also been reported to gain access to circulation, transporting them over larger distances, the majority of broken or retained wires remain local. We report a case of a 34-year-old man in whom numerous fragments of braided cable migrated from the hip to the knee.

Update on talar fracture patterns: a large level I trauma center study.

OBJECTIVE: Prior studies of talar fracture patterns are dated and based on radiography only. The purpose of our study was to describe talar fracture patterns and associated injuries in a modern large level 1 trauma center setting using both radiography and CT. MATERIALS AND METHODS: The radiolog and clinical data of patients with acute talar fractures diagnosed over an 18-month period were retrospectively reviewed. Data analysis included descriptive statistics for injury mechanisms and associated injuries. RESULTS: Over the study period, a total of 132 talar fractures were detected in 122 patients. The most common talar fracture location was the body (61%). The most common body fractures were dome compression (26%), lateral process (24%), and posterior tubercle (21%). Of the 132 fractures, 62% were comminuted and 21 (16%) were vertical neck fractures compatible with the Hawkins-Canale classification. Both radiography and CT were used in 91% of cases, with CT providing additional information in 112 (93%) cases. By use of CT as the reference standard, the sensitivity of radiography for detecting talar fractures was 74%. The most common fracture missed by radiography was talar dome compression (31% not seen on radiography) Talar fractures were associated with adjacent joint subluxation or dislocation in more than 66% of the cases and adjacent fracture in more than 72% of the cases. CONCLUSION: In our study, the most common site of talar fracture was the body. Current classification systems do not apply to most talar fractures. Talar fracture patterns cannot be characterized with radiography alone. CT is a critical tool for the detection and characterization of talar fractures. There is a high incidence of adjacent fracture and dislocation with acute traumatic talar fractures.

Quality initiative: Quantifying and reducing dose in multiphase liver CT: Eliminating the nonenhanced study and using conscientious Z-creep.

The use of computed tomography (CT) for evaluation of liver disease has increased dramatically at our tertiary care center due to increased hepatology referrals. We sought to decrease the radiation dose associated with multiphase liver CT studies while maintaining a high degree of diagnostic accuracy. We found that by eliminating the nonenhanced acquisition and adjusting the imaging field of view to include the liver-containing abdomen only-simply by manipulation of patient-specific imaging parameters-we achieved a 30% reduction in dose.

Expanded polytetrafluoroethylene-covered stent treatment of angioplasty-related extravasation during hemodialysis access intervention: technical and 180-day patency.

PURPOSE: To review technical and patency results with expanded polytetrafluoroethylene (ePTFE)-covered stents for treatment of venous rupture encountered during percutaneous hemodialysis intervention. MATERIALS AND METHODS: The Fluency covered stent is a tracheobronchial device that was used in an off-label manner to treat percutaneous transluminal angioplasty (PTA)-induced rupture in hemodialysis circuits. Data were retrospectively reviewed for all patients treated with the stent in 2004-2005 at two medical centers for PTA-related rupture. RESULTS: From a database of 106 procedures, 21 patients (21 procedures) were treated with the ePTFE-covered stent for PTA-related extravasation. Nine patients had arteriovenous (AV) grafts and 12 had AV fistulas. Five extravasations followed angioplasty as part of an AV graft declotting procedure. Location of extravasation was the outflow or cannulation venous segment (n = 11), cephalic arch (n = 3), AV graft venous anastomosis (n = 6), and intragraft (n = 1). All procedures were technically successful at halting extravasation and preserving vascular access. There were no known complications, and all patients underwent a successful first dialysis session. Twenty of the 21 circuits remained patent beyond the first week after intervention. The 180-day primary circuit patency rate was 20% and the 180-day cumulative circuit patency rate was 65%. CONCLUSIONS: In 21 patients, the ePTFE-covered stent successfully treated PTA-induced rupture with no need for acute secondary procedures such as thrombolysis or surgery. There was no instance of pseudoaneurysm formation or delayed bleeding. The ePTFE-covered stent offers advantages compared to prolonged PTA or bare stents when attempting to preserve hemodialysis access after PTA-induced rupture.

Pretraining on Southwestern stations decreases training time and cost for proficiency-based fundamentals of laparoscopic surgery training.

BACKGROUND: We previously reported a proficiency-based Fundamentals of Laparoscopic Surgery (FLS) curriculum that uniformly resulted in passing the technical skills certification criteria. We hypothesized that pretraining using the Southwestern (SW) videotrainer stations would decrease costs and training time and maintain benefits. STUDY DESIGN: Group I (2nd-year medical student, n = 10) underwent FLS pretesting (Pretest 1), SW station proficiency-based training, repeat FLS testing (Pretest 2), FLS proficiency-based training, and final FLS testing (Posttest). These data were compared with a historic control, group II (2nd-year medical student, n = 10), which underwent FLS pretesting (Pretest 1), proficiency-based training, and final FLS testing (Posttest). RESULTS: During training, group I achieved proficiency (85.4 + or - 26.2 repetitions) for all SW tasks. For both groups, proficiency was achieved for 96% of the FLS tasks, with substantial differences detected for group I and group II repetitions (100.5 + or - 15.9 versus 114 + or - 25.5) and training time (6.0 + or - 1.5 versus 9.2 + or - 2.2 hours), respectively. Per-person material costs were considerably different for groups I and II ($827 + or - 116 versus $1,108 + or - 393). Group I demonstrated significant improvement from Pretest 1 (149 + or - 39; 0% FLS pass rate) to Pretest 2 (293 + or - 83; p < 0.001; 60% FLS pass rate), and to Posttest (444 + or - 60; p < 0.001; 100% FLS pass rate). Group II demonstrated significant improvement from Pretest 1 (158 + or - 78; 0% FLS pass rate) to Posttest (469.7 + or - 12.0; p < 0.001; 100% FLS pass rate). CONCLUSIONS: Pretraining on SW stations decreases training time for FLS skill acquisition and maintains educational benefits. This strategy decreases costs associated with using consumable materials for training.

Purified NPC1 protein. I. Binding of cholesterol and oxysterols to a 1278-amino acid membrane protein.

The Niemann-Pick, Type C1 protein (NPC1) is required for the transport of lipoprotein-derived cholesterol from lysosomes to endoplasmic reticulum. The 1278-amino acid, polytopic membrane protein has not been purified, and its mechanism of action is unknown. Unexpectedly, we encountered NPC1 in a search for a membrane protein that binds 25-hydroxycholesterol (25-HC) and other oxysterols. A 25-HC-binding protein was purified more than 14,000-fold from rabbit liver membranes and identified as NPC1 by mass spectroscopy. We prepared recombinant human NPC1 and confirmed its ability to bind oxysterols, including those with a hydroxyl group on the 24, 25, or 27 positions. Hydroxyl groups on the 7, 19, or 20 positions failed to confer binding. Recombinant human NPC1 also bound [(3)H]cholesterol in a reaction inhibited by Nonidet P-40 above its critical micellar concentration. Low concentrations of unlabeled 25-HC abolished binding of [(3)H]cholesterol, but the converse was not true, i.e. unlabeled cholesterol, even at high concentrations, did not abolish binding of [(3)H]25-HC. NPC1 is not required for the known regulatory actions of oxysterols. Thus, in NPC1-deficient fibroblasts 25-HC blocked the processing of sterol regulatory element-binding proteins and activated acyl-CoA:cholesterol acyltransferase in a normal fashion. The availability of assays to measure NPC1 binding in vitro may further the understanding of ways in which oxysterols regulate intracellular lipid transport.