bluuebunny/crossref_metadata_2025 huggingface dataset:
Hip Arthroplasty up to the Age of 30 and Considerations in Relation to Subsequent Revision
Authors: Tabutin Jacques , Cambas Pier M.
Published: January 2018

We reviewed a series of 17 hip arthroplasties in 16 patients performed when the patients were 30 years old or younger who presented to us for consideration of revision. The mean age was 23.1 years (14 to 30) at the initial arthroplasty. At the time of the original procedure there were 4 sequelae of septic arthritis, 7 old traumatic hip injures, 3 cases of developmental dysplasia (DDH), 1 case of rheumatoid arthritis (RA), 1 steroid-induced avascular necrosis, and 1 old slipped upper femoral epiphysis (SUFE) The implants inculded 11 total hip arthroplasties (THA), 3 double cup arthroplasties, 1 bipolar arthroplasty,1 monopolar arthroplasty and 1 cup arthroplasty. The cause for revision lay on the acetabular side in 16 cases and on the femoral side in 6 cases (some had failure on both sides of the joint). There was one revision for recurrent dislocation. The patients had undergone a mean of 1.1 procedures (range 0–3) before the primary arthroplasty. There was a mean interval of 10.6 years (2–33) between the arthroplasty and the revision and the patients had a mean of 1.9 further revision procedures (0 to 4). Complications of revision surgery inculded 1 case of sepsis, 2 recurrent dislocations and 8 re-revisions. Postel and Merle d'Aubigne (PMA) score increased from 10.1 to 14.6 at an mean follow-up of 5.4 years (1 to 20). The typical patient was male (11/17) having had the first arthroplasty at age 23 for trauma sequelae (7/17), a revision at 34 (acetabular failure (16/17). At age 46.4, and after 1.9 secondary procedures hip scores were not exceptional. Such generally disappointing results arose from errors in implant selection or technical mistakes. Careful surgery is critical, and the way of life of the patient may need to be modified.
The Mayo Conservative hip: Experience from a District General Hospital
Authors: Gilbert Rob E. , Salehi-Bird Seema , Gallacher Peter D. , Shaylor Phillip
Published: January 2018

The Mayo Conservative Hip femoral prosthesis has been designed to optimise proximal femoral loading as well as preserving proximal femoral bone stock.

Between October 2003 and May 2006, 42 patients (49 hips) underwent total hip replacement (THR) using the Mayo Conservative Hip femoral component. The mean age at operation was 57.8 years (range 44 to 74) and the mean clinical follow up was 3.1 years (range 2.3 to 4.7 years). The aim of our study was to review the short term results of this unorthodox femoral component.

We found that 18%° of stems were malaligned ≥ 5° and the prevalence of intra-operative femoral fracture was 4%. We feel this prosthesis is difficult to implant and has an unacceptable fracture rate.
The DePuy Proxima™ Hip: A Short Stem for Total Hip Arthroplasty. Early Experience and Technical Considerations
Authors: Ghera Stefano , Pavan Laura
Published: January 2018

The rationale for short stems in cementless total hip arthroplasty (THA) is proximal load transfer and absence of distal fixation resulting in preserved femoral bone stock and avoidance of thigh pain. We report a consecutive series of 65 THAs inserted mainly for osteoarthritis with the DePuy Proxima™ hip, a short, anatomic implant with a pronounced lateral flare. Patients were assessed preoperatively and postoperatively at 3, 6 and 12 months and annually thereafter, using the Harris Hip Score (HHS), the Oxford Hip Score (OHS) and standard radiographs. No thigh pain was reported. At a mean follow-up of 1.7 years the HHS improved from a preoperative mean value of 51 to 91 and the OHS decreased from a mean value of 42.5 to 12.4. Complications included 1 intraoperative fracture, 1 superficial infection, and 3 deep vein thromboses. The proximal medial edge of the resected femoral neck appeared rounded off in 49 cases whilst in 16 cases a further loss of medial cortical density was observed. Patient selection and surgical technique are crucial factors contributing to a successful outcome. The surgical technique is different from standard THA.
Leg Length Discrepancy in Total Hip Arthroplasty with the use of Cemented and Uncemented Femoral Stems. A Prospective Radiological Study
Authors: Ahmad Riaz , Sharma Vinod , Sandhu Harvey , Bishay Michael
Published: January 2018

Leg length discrepancy may occur following total hip arthroplasty, with a potentially impaired functional outcome as a result. The aim of this study was to compare the leg length discrepancy between both cemented and uncemented femoral stems when used in total hip arthroplasty. A prospective radiological study of 200 consecutive primary total hip arthroplasties was performed between June 2005 and December 2006. Pre and post-operative radiographs were analysed. 56 (56%) of the total hip arthroplasties where an uncemented femoral stem was used had a leg length discrepancy over 1 cm. However only 23 (23%) of the total hip arthroplasties with a cemented femoral stem had a leg length discrepancy over 1 cm. The use of cemented femoral stems in total hip arthroplasty results in a lower incidence of leg length discrepancy, with a potentially better functional outcome.
Bed Exercises following Total Hip Replacement: 1 Year follow-up of a Single-Blinded Randomised Controlled Trial
Authors: Smith Toby O. , Mann Charles J.V. , Clark Allan , Donell Simon T.
Published: January 2018

This paper presents the results of a study assessing whether bed exercises after primary THR (total hip replacement) improves function or quality of life, during the first post-operative year. Sixty patients undergoing primary THR were randomised to receive either a gait re-education programme and bed exercises (Group A) or a gait re-education programme without bed exercises (Group B) post-operatively. The Iowa level of assistance Scale (ILOA) and Short Form-12 Health Survey (SF-12) were assessed at baseline, 3 days, 6 weeks and 1 year post-operatively. There was no statistically significant difference in either ILOA or SF-12 after 1 year between Group A or B. There was no evidence of a subgroup effect by either the surgical approach or prosthesis fixation in either ILOA or SF-12.
Intraosseous Myelolipoma within Proximal Femoral Metaphysis in a Patient with Previous Prostate Cancer: A Case Report
Authors: Papapietro Nicola , Martinelli Nicolò , Ippolito Massimiliano , Amato Cirino , Denaro Vincenzo
Published: January 2018

We report on a case of an osteolytic lesion of the femur in a patient with previous prostate cancer, affected by hip osteoarthritis. Computed tomography of the femur demonstrated the presence of fat in the lesion. Computed tomography-guided fine needle aspiration biopsy revealed mature adipose tissue along with hematopoietic precursor cells. Surgical management consisted of curettage and packing with allograft, followed later by total hip arthroplasty. This is the third case of intraosseous myelolipoma reported in the literature.
Two Stage one Component Revision in Infected Total hip Replacements - two Case reports and Literature Review
Authors: Faroug Radwane , Shah Yousaf , Mccarthy Michael J. H. , Halawa Maher
Published: January 2018

We present two cases of infected primary total hip replacements (THR) where only one of the two components exhibited loosening. Both were revised using a two stage, one component revision technique, replacing the loose component only. In the first case the acetabular component was revised leaving the original femoral stem in situ. In the second case, the femoral component was revised, leaving the original acetabular cup undisturbed. Both patients remained infection free at three and half and three years follow up respectively.
Custom Uncemented Revision Stems Based on a Femoral Classification
Authors: Hua Jia , Walker Peter S. , Muirhead-Allwood Sarah K. , Engelhardt Fred , Bentley George
Published: January 2018

From the outcome of 175 cases, a group of 4 types of custom-designed HA-coated hip stems, based upon an incremental scale of bone condition, was demonstrated to be sufficient for use with the variety of cavitary defects encountered in revision hip surgery. Harris Hip Score evaluation showed a significant improvement in hip pain and function. Radiographic measurements of axial migration over a 4-year period were less than 2 mm. The migration data were similar across the 4 types of revision stem. A follow-up using DEXA scans showed preservation of bone in all regions up to 4 years, which justifies the design rationale for the close fit of the stems in the proximal region in achieving initial stability and strain transfer.
Uncemented Revision Hip Arthroplasty in B2 and B3 Periprosthetic Femoral Fractures - A Prospective Analysis
Authors: Rayan Faizal , Konan Sujith , Haddad Fares S.
Published: January 2018

Periprosthetic femoral fractures are an increasingly common complication of total hip arthroplasty. If there is a fracture of the femur in the presence of an unstable prosthesis (Vancouver type B2 and B3), revision of the stem is imperative. We describe our experience of cementless femoral revision in management of twenty-six patients who sustained periprosthetic fractures of the Vancouver type B2 or B3, between February 1999 and March 2005. All patients were managed by revision arthroplasty, using cementless femoral stems. Cortical struts, cable plating systems, bone allograft and demineralised bone matrix were used to aid the reconstruction where indicated. All the fractures had clinical and radiological union. The outcome was graded, subjectively as satisfactory by all patients and this is substantiated objectively, by a post operative mean Harris hip score of 83.04. Uncemented revision appears to be an attractive option for periprosthetic fractures with unstable femoral stems.
Hip Arthroplasty in Morbidly Obese Patients - Intra-Operative and Short Term Outcomes
Authors: Bennett Damien , Gibson Dessie , O'Brien Seamus , Beverland David E.
Published: January 2018

Concerns about longer and more difficult operations, increased early post-operative complications and poorer patient outcomes may deter surgeons from performing total hip arthroplasty (THA) on morbidly obese (MO) patients. Intra-operative parameters including operation time, anaesthetic time, wound length and length of hospital stay were compared between 29 MO THA patients (Body Mass Index (BMI) > 40 kg/m2) and 29 age and gender matched THA patients with normal BMI (BMI between 20 and 25 kg/m2) in a single surgeon study. Pre and post-operative Oxford Hip scores, hip range of motion and post-operative complications were also compared.

Morbidly obese patients experienced significantly longer operation times (66 minutes) and longer wounds (14.2 cm) compared to normal THA patients (58 minutes and 12.1 cm respectively). However, intra-operative anaesthetic time and length of hospital stay were not significantly different between the MO and normal patients. Improvements in patient outcomes following THA were not significantly different between the MO and normal patients at one year follow-up. Improvements in sagittal range of motion and external rotation were significantly less for MO patients. Intraoperative complication rates were 0% for the MO and 3.5% for the normal patients. Postoperative complication rates were 3.5% for the MO and 0% for the normal patients. THA operation times for MO patients were on average only 8 minutes longer and should not represent a barrier to surgery. Hospital length of stay was not longer for MO patients suggesting they do not represent a greater burden on healthcare resources during THA.
Modified Extended Trochanteric Osteotomy with Preservation of Posterior Structures
Authors: Lakstein Dror , Kosashvili Yona , Backstein David , Safir Oleg , Gross Allan E.
Published: January 2018

The purpose of the study was to describe the technique and the clinical results of the modified extended trochanteric osteotomy (ETO) with a lateral approach to the hip. This osteotomy differs from those previously described, as it preserves the posterior part of the greater trochanter and its attached external rotators, the aim of this modification being to minimize the rate of hip dislocation. We reviewed the results of 105 extended sliding trochanteric osteotomies performed between January 2000 to January 2008. The indication for surgery was aseptic loosening in 83 cases, periprosthetic fractures in 10 cases, stem fracture in 5 cases, infection in 5 cases and instability in 2 cases. Minimum follow up was 20 months (mean, 65; range, 20–120 months). Mean length of the osteotomy was 17.6 cm (range, 9–30 cm).

Mean Harris hip score improved from 39 points preoperatively to 73 at last follow up. Six stems (6%) needed revision for loosening. There was one case (1%) of osteotomy nonunion, and one case (1%) of greater trochanteric fragment nonunion and escape. Four patients (4%) dislocated postoperatively. In conclusion, our series of ETOs reveals a low dislocation rate achieved by preservation of the attachment of the external rotators and posterior capsule, and exhibits a union rate comparable to that of other series. We recommend the use of ETO in revision surgery of cemented stems and cementless well fixed distal ingrowth stems.
Revision total hip arthroplasty with a modular tapered stem
Authors: Lakstein Dror , Kosashvili Yona , Backstein David , Safir Oleg , Lee Paul , Gross Allan E.
Published: January 2018

Femoral stem revision surgery with proximal bone loss may be treated with modular uncemented distal fixation stems. Early results of the ZMR tapered stems with relatively fewer cases were encouraging. In this prospective study, we evaluated the 2 to 10 years survivorship, associated complications and functional outcomes of 84 cases of femoral revision using the ZMR tapered stem. The indications for revision were aseptic loosening (50), periprosthetic fracture (12), infection (17), stem fracture (4) and instability (1). The mean follow-up was 46 months (range, 25–117). The Kaplan-Meier survival with femoral re-revision for any reason as an end-point was 92.7% (95% CI: 87.7%-97.7%). The mean Harris hip score improved from 37 (10–77) points before operation to 72 (41–96) points at last follow-up. The ZMR tapered stem has shown satisfactory results in 2 to 10 years followup in various femoral stem revision conditions.
Modified Ilioinguinal Approach to the Acetabulum and Pelvis from beneath the Inguinal Ligament: A Subinguinal Approach
Authors: Hosseinzadeh Hamid Reza Seyyed , Eajazi Alireza , Yeganeh Mehrnoush Hassas , Besheli Laleh Daftari , Kazemi Seyyed Morteza , Bigdeli Mohammad Reza , Okhovvatpoor Mohammad Ali
Published: January 2018

The ilioinguinal approach is favoured for fractures of the anterior part of the pelvis, but it is associated with some technical difficulties and it is not suitable for some complex fractures. In 2008, a modified ilioinguinal approach was introduced by Farid Yr which afforded visualisation of the inside and outside of the pelvis.

The approach involves retroperitoneal access below the inguinal ligament to preserve the integrity of the inguinal canal and allows exposure of anterior and medial wall fractures as well as the anterior hip capsule. Despite the dimensions of the procedure, closure is anatomical because repair of the inguinal canal floor is not required. We report the use of this approach in 17 patients with T-type fractures of the acetabulum, transverse fractures of acetabulum, Tile C1 pelvic fractures, malunion of the pelvis and acetabular dysplasia.

The approach is recommended in complex cases of acetabular surgery (including obese or muscular patients) and complicated or old fractures in which a better exposure is required. It is useful in visualisation of the anterior wall and labrum and intra articular structures, and in viewing the internal anatomy of the pelvis and acetabulum. It may be a suitable approach for periacetabular osteotomy.
Total hip arthroplasty for fractures of the proximal femur in older patients
Authors: Rutz Erich , Leumann André , Rutz Daniela , Schäfer Dirk , Valderrabano Victor
Published: January 2018

Displaced fractures of the proximal femur are common in older patients. The optimal treatment is still under debate. We retrospectively reviewed the results of 53 consecutive total hip arthroplasties (THA) performed in 12 men and 41 women for treatment of an acute fracture of the proximal femur. Men had an average age of 75.1 years (range, 61 to 90) and women 78.2 years (range, 61 to 91). At time of fracture, 42 patients (79.3 %) had radiological signs of hip osteoarthritis. At time of surgery, 8 patients (15.1%) needed trochanteric reconstruction in addition to the implanted THA.

Clinical and radiological follow-up was available for 39 patients (73.6 %). The average follow-up time was 55.5 months. The mean Harris Hip Score was 86.3 points (range, 68–97.7). The 4 month mortality rate was 1.9 % (1 patient). Four patients (7.5%) had had early postoperative complications, including dislocation in 3 patients (5.6%) and one (1.9%) minor reoperation (wound haematoma). One patient (1.9%) had revision surgery because of aseptic stem loosening 67 months after primary implantation. In elderly patients, THA is a safe long-term solution for treatment of displaced fractures of the proximal femur, allowing early weight bearing and assisting with rehabilitation.
Complications relating to accuracy of reduction of intertrochanteric fractures treated with a compressive hip screw
Authors: Pinto Francisco Guerra , Dantas Pedro , Moreira Rodrigo , Mamede Rosa , Amaral Luís Branco
Published: January 2018

Intertrochanteric fracture is the most frequent type of fracture in the proximal femur and the compressive hip screw is one of the most popular methods of treatment. The reduction criteria for this type of fracture are ill-defined. The purpose of this study was to validate 3 reduction criteria: displacement, alignment in the anteroposterior and in the lateral plane. We reviewed a cohort of 430 intertrochanteric fractures treated with a compression hip screw. The type of fracture, quality of reduction and technical complications were noted. We observed a relationship between accuracy of reduction and the incidence of complications, even among fractures of the same severity. A displacement bigger than 4mm and failure to accomplish correct alignment (a neck-shaft angle over 125deg; and less than 20° angulation on the lateral view) was considered a poor reduction and was associated with more complications.
The orthogeriatric unit for acute patients: A new model of care that improves efficiency in the management of patients with hip fracture
Authors: González-Montalvo Juan I. , Alarcón Teresa , Mauleón Jose L. , Gil-Garay Enrique , Gotor Pilar , Martín-Vega Alberto
Published: January 2018

We performed a prospective, quasi-experimental, randomised, interventional study comparing two models of care for patients admitted with osteoporotic hip fractures between February and August 2007 in a tertiary university hospital. The usual model of care was treatment of patients admitted to the orthopaedics ward, with consultation by the geriatrician (CG model). The study model involved admission to an acute orthogeriatric unit (OGU model), with joint care provided by geriatricians and orthopaedic surgeons which included immediate geriatric assessment, coordinated daily clinical care, weekly combined ward rounds, and joint planning of the surgical schedule, initial mobilisation, discharge date and destination. No differences were found between CG patients (123) and OGU patients (101) in terms of previous characteristics, number of patients surgically treated, functional level obtained, or discharge destination. OGU patients had earlier geriatric assessment (median 1 day, P25-P75: 1–2) than CG patients (median 4 days, P25-P75: 3–8), earlier surgery (median 5 days from admission to OGU, P25-P75: 3–6, versus 6 days in the CG group, P25–P75: 5–9), and had a shorter acute hospital stay (33% reduction, median 12 days in OGU, P25-P75: 9–14, versus 18 days, P25-P75: 13–23 in the CG group) and total (acute and subacute) hospital stay (30% reduction, median 14 days in OGU, P25-P75: 10–31, versus 20 days, P25-P75: 14–30 in the CG group). All these comparisons were statistically significant (p<0.01). The organization of an OGU in a tertiary hospital allowed hip fracture patients to receive earlier geriatric assessment and surgical treatment. Acute hospital stay was reduced by 33%, and total hospital stay was reduced by 30% with no differences at discharge in clinical and functional outcomes.
Infections after primary and revision total hip replacement caused by enterobacteria producing extended spectrum β-lactamases (ESBL): A case series
Authors: Haenle Maximilian , Podbielski Andreas , Mittelmeier Wolfram , Bader Rainer , Gradinger Reiner , Gollwitzer Hans
Published: January 2018

Implant infection remains a feared complication after total hip replacement. A higher rate of infection is observed after revision surgery. An additional threat for such patients arises from the fact that bacteria resistant to a multitude of antibiotics are encountered with increasing frequency in the hospital setting.

Among them enterobacteria producing extended spectrum β-lactamases (ESBL) are the second most frequent group of multiresistant isolates. ESBLs are enzymes which hydrolyse third and fourth generation cephalosporins resulting in a distinctive resistance against these antibiotics. Even though ESBLs were first described in the early 1980's and now represent pathogens of importance in intensive care units, they have been only rarely encountered in orthopaedic and trauma surgery.

We report on three cases of ESBL-associated infections in hip arthroplasty, resulting in 1) resolution of infection after removal of the hip implant, 2) death after developing a nosocomial pulmonary infection due to ESBL-producing bacteria, and 3) resolution of infection after two-stage revision.

The infections, caused by multi-resistant ESBL-producing Escherichia coli and Klebsiella pneumoniae isolates, demonstrate the difficulties in managing implant associated infections with resistant bacteria, and emphasize the importance of recognizing ESBL-positive bacteria as increasingly important pathogens that require special precautions and treatment. Our observations suggest that ESBL-expressing bacteria in orthopaedic and trauma surgery are not a rare phenomenon any more.
Arthroscopic bullet extraction from the hip in the lateral decubitus position
Authors: Sozen Yunus V. , Polat Gokhan , Kadioglu Baris , Dikici Fatih , Ozkan Korhan , Unay Koray
Published: January 2018

Hip arthroscopy was first described in 1931 by Burman, and in recent years the applications have extended to labral surgery, osteochondroplasty, and a variety of other procedures. Hip arthroscopy may also be employed to extract loose or foreign bodies from the hip, and may be associated with more rapid recovery than an open procedure. We present a case of arthroscopic bullet removal from the hip in a 24-year-old man.
Epiphyseal reperfusion after subcapital realignement of an unstable SCFE
Authors: Schoeniger Ralf , Kain Michael S.H. , Ziebarth Kai , Ganz Reinhold
Published: January 2018

We present a case of epiphyseal reperfusion in a 12-year-old boy following subcapital realignment of a unstable slipped capital femoral epiphysis. The case demonstrates that even if delayed, anatomical surgical realignment of the femoral head can be successful in preserving or reestablishing blood flow to the femoral epiphysis.
Osteochondral allograft in a femoral head chondroblastoma: A case report
Authors: Stilli Stefano , Reggiani Leonardo Marchesini , Boriani Luca , Donzelli Onofrio
Published: January 2018

Osteoarthritis of the hip joint secondary to femoral head collapse may develop after curettage of lesions in the femoral head. We report the case of a patient with chondroblastoma of the femoral head who was treated with wide curettage of the lesion and implantation of an osteochondral allograft to prevent femoral head collapse.
Heat Generation during Cement Removal in Revision Total Hip Replacement - a Comparison of Three Methods
Authors: Nogler Michael , Mayr Eckart
Published: January 2018

High speed cutting and ultrasound devices for cement extraction from the femoral cavity in hip revision procedures are frequently used. Such devices generate heat at the cutting interface which may damage osteocytes.

One ultrasound device, a manual high-speed cutter and a robot-based high-speed cutter were tested in human cadaveric bone at body temperature. Temperature probes were placed at the cement-bone interface, and data collected from 12 sensors with a digital data-logger during cement removal from the femoral cavity. Peak temperatures from each sensor were recorded and compared by Kruskal-Wallis-H-Test for global effect and Mann-Whitney-U-Test for multiple comparisons.

All devices generated mean temperature peaks of over 50°C which is above levels considered safe. A peak temperature of 164°C was reached by the ultrasound system. Significant differences between the three devices exist, with the ultrasound generating the highest median peak temperatures of 107°C. The lowest median peak temperature of 65°C was generated by the high-speed cutting system. Major improvements of the irrigation and cooling systems of the devices seem to be necessary.
Evaluation of Dialysis Access Care by Means of Process Quality Indicators
Authors: Bonucchi D. , Ferramosca E. , Ciuffreda A. , Confessore N. , Grosoli M. , Davoli D. , Cappelli G. , Albertazzi A.
Published: January 2018

Improvement of dialysis access management depends on technical skill but also on effective choice, construction, monitoring and revision of the access. Surgical procedure is only one step of a complex course, beginning with the referral of patients to nephrologists.

Using two process quality indicators, we describe the evolution of access management at our centre, where access surgery and access-related activities are performed by nephrologist. The first process indicator is based on the prevalence of temporary access at first dialysis (TA1st) in end stage renal disease ESRD patients, the second one measures the prevalence of permanent central venous catheters (%CVC) in dialysis population.

TA1st increased to 27.1% in 1999, more than twofold compared to the previous year. There was also an increase in %CVC from 20.6 to 26.3%. Native access remained the most utilised, well above 70% of dialysis patients.

Our process monitoring suggests a rapid worsening of late referral, as indicated by the increasing use of temporary catheters at the beginning of chronic dialysis. Increasing surgical activity and diagnostic procedures were only partly effective in containing the rise in CVC.

Venous sparing, early referral, Continuous Quality Improvement and a multiprofessional access-team coordinated by a nephrologist could be the key-elements in facing the never-ending-story of dialysis vascular access.
Groshong Catheters: Technical Aspects and Clinical Features
Authors: Campisi C. , Camillucci L. , Campopiano A. , Fanizza C. , Sardonio A.
Published: January 2018

After thousands of Groshong catheter applications over more than twenty years, the cause of blood withdrawal drawbacks is not yet completely understood. This phenomenon – which is not typical of closed-tip catheters since it is also common in open-tip catheters – in the Groshong catheter is attributed to the valve (ball-valve effect).

The aim of this work is to understand the relationship between causes and effects in order to provide clinicians with practical solutions. Out of the 16 catheters examined, we observed no clear correlation among electron microscope ultrastructural analysis, valve closing pressure, intraluminal clots and clinical failures after different implantation times up to a maximum of 36 months. The ultrastructural analysis revealed an optimal no-time-related aspect for internal and external surfaces, while the closing pressure in each case was compatible with the efficiency of the working valve (range 22–36 cmH2O).

We conclude that the blood withdrawal drawbacks cannot be attributed to a single cause and certainly not to the silicone biostability or directly to the valve. Different studies are suggesting that clinical failures can be the result of several different causes such as slime or clots in the internal catheter surfaces and fibrin sleeve in the external catheter surfaces. These are common causes in open-tip catheters and we believe that the presence of valves on the tip of the Groshong may encourage inferences. Our suggestion is to place the tip of the Groshong catheter in atrium one centimetre after the junction with the vena cava. After the implant, it is possible to remove the causes of drawbacks by strong flushing using a 5-ml syringe and/or postural manoeuvres.
Hemodialysis Vascular Access Thrombosis and Lipoprotein(A)
Authors: Hojs R. , Ekart R. , Dvoršak B. , Gorenjak M.
Published: January 2018

Background

Vascular access remains the Achilles's heel of successful hemodialysis and thrombosis is the leading cause of vascular access failure. Elevated lipoprotein(a) (Lp(a)) levels in hemodialysis patients were reported, and in some studies were also associated with hemodialysis vascular access thrombosis.

Patients and Methods

In our study 84 hemodialysis patients with native arteriovenous fistula were included. Two groups of patients were defined: group A including 61 patients with their vascular access either never or only once thrombosed, and group B including 23 patients with two or more thromboses of their vascular access. We determined serum concentrations of Lp(a) in all our patients.

Results

Average serum Lp(a) concentration for all the patients included in the study was 0.273 ± 0.31 g/l. No relationship was found between serum Lp(a) concentrations and age, gender and duration of dialysis treatment. Serum Lp(a) concentrations were higher in group A than in group B patients (0.301 g/l versus 0.198 g/l), but the difference was not statistically significant. There was also no statistically significant difference between group A and group B regarding age, gender and duration of hemodialysis treatment. The use of a cut-off value for Lp(a) of 0.3 g/l and 0.57 g/l also failed to provide a significant difference between group A and B patients.

Conclusion

We found no significant differences in Lp(a) concentrations between group A (thrombosis-non-prone) and group B (thrombosis-prone) patients. Our results suggest that Lp(a) is not an independent risk factor for vascular access occlusion in hemodialysis patients.
Monitoring of Central Dual-Lumen Catheter Placement in Haemodialysis by Endocavitary Electrocardiography: A Simple and Safe Technique for the Clinical Nephrologist
Authors: Dionisio P. , Valenti M. , Bajardi P.
Published: January 2018

Complications in the placement of central venous catheter (CVC) may occur in up to 20% of cases. The catheter can be misplaced in the contralateral brachiocephalic vein, the ipsi or controlateral internal jugular vein, and usually a chest X-ray is necessary to evaluate its location. We believe that the best technique, first described by Serafini et al, to establish the position of a CVC is the endocavitary electrocardiography (EC-ECG) and its employment is recommended in all uraemic patients requiring haemodialysis. This technique uses the tip of the CVC as reference lead in a standard electrocardiograph. The best use of this technique has been obtained by echotomographic visualization of the internal jugular vein executed just before transcutaneous puncture of the vessel. From 1991 to December 1999 we have successfully applied this technique in CVC placement in 612 patients requiring haemodialysis. In our opinion, this method is a safe and simple technique that avoids the need for thoracic X-ray controls and time lost waiting for radiographs that prolong the start of the haemodialysis session. According to our experience, we believe that the EC-ECG technique is a method in compliance with Food and Drug Administration guidelines regarding catheter tip location in uraemic patients.
Distal Arteriovenous Fistulas in Elderly Hemodialysis Patients
Authors: Bonforte G. , Zerbi S. , Pasi A. , Sangalli L. , Rivera R. , Surian M.
Published: January 2018

Dialysis access procedures and complications are an important cause of morbidity and hospitalization for chronic hemodialysis patients. Subjects over 65 years old have a higher incidence of co-morbid factors (diabetes mellitus, atherosclerosis, neoplasms, heart failure), therefore the correct choice in terms of timing and type of permanent access is extremely important. As elbow fistulas are often complicated by heart failure and PTFE grafts have a higher risk of thrombosis, we decided to evaluate the success rate of distal fistula as primary dialysis access in elderly patients. We carried out a retrospective study to identify survival predictors and actual vascular network saving.

Between January 1991 and September 2000, 277 vascular access procedures were performed on 198 elderly patients (age 65 or older). The first anastomosis was positioned as peripherally as possible. In cases of patients with poor peripheral vasculature or three co-morbid factors, vascular access was first created at the origin of radial artery (Toledo-Pereyra fistula). Survival (Kaplan – Meyer analysis) was significantly higher for Toledo-Pereyra fistulas compared to wrist and snuff-box ones, in spite of the presence of a high incidence of co-morbid factors. We conclude that Toledo-Pereyra fistula is an efficient primary choice in elderly patients.
“Long-Term” Catheters for Haemodialysis: Malfunction and Management
Authors: Pecorari M.
Published: January 2018

The purpose of this study is to demonstrate the incidence of dysfunction due to thrombosis of the central venous catheters (tunnelized and siliconic) for haemodialysis.

We have also correlated the rate of the thrombotic events to the site of positioning and to the different protocols used in order to prevent these complications.

Femorals are more affected by thrombosis, partial or total, than jugular catheters.

The mean request of the urokinase-boluses is low: only 10% of the dialytic sessions examined (1200) requires these interventions.

A significant reduction is obtained if to the patients are administered ASA. No influence seems to result from the use of the anticoagulants.

Our study confirms in our population the advantages of central venous catheters in chronic haemodialysis, the ease of management and the absence of serious complications during the observation period (6 months).
Experience using a New Vascular Port Access Device for Hemodialysis: Preliminary Clinical Results
Authors: Zollo A. , Cavatorta F. , Galli S.
Published: January 2018

A new subcutaneous device (Dialock®, Biolink Corp, Middleboro, MA) provides vascular access to patients who require hemodialysis. The device consists of a port implanted in a subcutaneous pocket in the thoracic area 10 cm below the clavicle. Interdialytic patency is maintained using a priming antithrombotic solution. The device was implanted in 10 outpatients under local anesthesia, and immediately used for hemodialysis. The catheters have been used up to now for a total of 1,480 days (24- 248 days), the average being 4.8 months (1–8 months). Survival rate of Dialock® was 100% at 8 months. During this period, the device achieved prescription hemodialysis blood flow rates averaging 250–300 ml/min with a venous pressure of 180 ± 25 mmHg. Malpositioning of the catheters due to their excessive length was observed in the first three patients and led to the repositioning of the catheters’ distal tips under local anesthesia. Secondary and delayed hematoma surrounding the Dialock® device were observed in 2 patients one or two days after insertion. In one case, a hematoma was surgically removed under local anesthesia. Antibiotic therapy was administered for safety and prophylactic reasons. In one patient spontaneous catheter fracture and distal tip embolization occurred on the 49th day after repositioning. Percutaneous radiological retrieval of the catheter fragment was performed.

No infection of the Dialock® device occurred and only one episode of bacteremia was observed. Blood cultures were positive for Staphylococcus epidermidis. Infection was cured by appropriate systemic antibiotic therapy combined with gentamicin and sodium citrate lock.

The device was well accepted by patients and staff. The Dialock® device catheter offers a new vascular alternative for dialysis that deserves further long-term study. In particular, the confidence of structural materials should be tested.
Arteriovenous Cannulation: Differences in Approach among Institutions and Nurses
Authors: Yürügen B. , Erdoğan N.
Published: January 2018

The aim of this study was to determine how hemodialysis (HD) nurses approach arteriovenous (A-V) cannulation and how a standard for this procedure could be reached. The study group was made up of 50 nurses who had been working for at least 6 months in the HD centers of the Social Insurance Company and university hospitals.

Data was collected by means of a questionnaire to ascertain the demographic characteristics of the 50 nurses, and an A-V cannulation procedure checklist in three sections with 47 questions, prepared in the light of the literature. Percentages and Pearson's χ2 tests were used to evaluate the data obtained by this means.

The results showed that there were significant differences in pre and post-application stages of A-V cannulation in the medical centers studied. However, the differences found in the application stage in the same centers did not correlate significantly.
Treatment of Pneumothorax as a Complication of Long-Term Central Venous Port Placement in Oncology Patients. An Observational Study
Authors: Biffi R. , Pozzi S. , Pace U. , Cenciarelli S. , Zambelli M. , Andreoni B.
Published: January 2018

Background and Purpose

In percutaneous placement of central venous catheters an inadvertent, direct lesion of the lung parenchyma can occur. This is a cause of iatrogenic pneumothorax, whose incidence is approximately 1 to 4%, largely dependent on the experience of the operator, the site of venipuncture and probably the technique employed. Initial treatment currently ranges from observation alone to formal tube-thoracostomy. In an attempt to define the best initial treatment, if any, we reviewed our personal series and contributions from the literature. As a result we have produced a flow-chart proposing a rational treatment of this frequent complication.

Patients and Methods

One thousand four hundred twenty-one ports were placed in patients at the Department of Surgery of the European Institute of Oncology in Milan through an infraclavicular standardized percutaneous subclavian approach. They were placed during the 60-month period from January 1, 1996 to December 31, 2000 for long-term chemotherapy treatment of solid tumours. Chest upright X-rays were obtained post-operatively in all cases to check the correct position of the catheter tip and the presence of pneumothorax.

Results

Twenty-two patients out of 1421 (1.54%) experienced a radiologically-proven pneumothorax, ranging from 5 to 70% of the affected pleural space. Sixteen patients out of 22 (72.7%) with minor portions of affected pleural space received simple observation. In these patients the most common finding was an uncomplicated tachycardia (more than 100 beats/min); 8 of them did not complain of any symptoms. Six patients (27.2%) underwent an additional procedure (3 tube-thoracostomies and 3 aspirations of the pleural space), claiming symptoms of chest pain and various degrees of dyspnea. Tube thoracostomy was mainly adopted at the beginning of our experience, and in patients with a severe degree of pleural involvement (55 to 70% of the pleural space). Aspiration, instead, was used more recently and in patients with varying degrees of pleural space involved, ranging from 40 to 60%.

Conclusions

Looking at our own series and literature data, patients with iatrogenic pneumothorax following central venous cannulation who do not have a severe underlying pulmonary disease can be reassured, at the time of diagnosis, that surgery is usually unnecessary and tube thoracostomy is rarely needed. Simple aspiration of the pleural air by means of a central venous catheter inserted percutaneously into the pleural space under local anesthesia should be considered, even if the amount of affected pleural space is more than 50%, before opting for a formal tube-thoracostomy using small-bore tubes.
Restoration of Acutely Thrombosed Arterio-Venous Fistulae by rTPA and Percutaneous Angioplasty
Authors: Sarkar R. , Ravanan R. , Birch P.A. , Williams A.J. , Banks R.A.
Published: January 2018

Acute thrombosis in native arterio-venous fistulae (AVF) results in considerable patient morbidity. Interventional radiology (IR) comprising thrombolysis and percutaneous transluminal angioplasty (PTA) is well established in the management of thrombosed polytetrafluoroethylene (PTFE) grafts. However its role in thrombosed AVF is uncertain. We looked retrospectively at the role of IR in re-establishing blood flow in acutely thrombosed AVF.

Between 1992–2000, 21 episodes of acutely thrombosed AVF in 15 patients (9 females; age range 29–80yrs) were referred for intervention. All fistulae were being used for haemodialysis at the time. Diagnosis was established by angiography and thrombolysis with recombinant tissue plasminogen activator (rTPA) was attempted in all patients. Discrete stenoses when present (n=12) were then treated with PTA and resistant or recurrent stenoses were managed by stent insertion (n=3). Patients were then heparinised for 24 hours.

Technical success as defined by radiological patency was achieved in 86% cases. Clinical success i.e. the ability to reuse of the fistula for haemodialysis was achieved in 62% of the interventions, where patency rates at 3 and 6 months were 92% and 69% respectively. Five patients had recurrence of thrombosis >3 months after the primary procedure, 3 had successful re-intervention. Minor local bleeding was the only complication.

Our retrospective study shows rTPA and PTA is successful in the management of acutely thrombosed AVF. We advocate the routine use of IR as a valuable technique for prolonging the life of native AVF in patients on maintenance haemodialysis.
Non-Tunneled Central Venous Catheters in Adult Stem Cell Transplantation Recipients: An Effective Option
Authors: Cicconi S. , Pittiruti M. , Buononato M. , Piccirillo N. , Sorà F. , Chiusolo P. , Laurenti L. , Leone G. , Sica S.
Published: January 2018

Stem cell transplantation (SCT) recipients require central venous catheter (CVC) insertion for the administration of chemotherapy, antibiotics and total parenteral nutrition. Traditionally, tunneled CVC have been considered as the golden standard although they require surgery for both insertion and removal. We prospectively evaluated the use of a non-tunneled CVC in 182 consecutive patients who had undergone allogenic or autologous SCT. The median duration of CVC was 4 weeks (range 1–24) with a significant difference between allogenic (8 weeks, range 2–24) and autologous SCT (4 weeks, range 1–24) (p<0.0001). The life expectancy of the CVC was significantly influenced by spontaneous removal, which occurred in 26 patients (13.8%). There was a significant increase of this complication in allogenic SCT (p=0.039). The overall incidence of sepsis was 24.5%, although catheter-related sepsis was microbiologically documented by positive culture of the tip only in 17 cases (9%). Non-tunneled CVC in adult SCT recipients allowed (a) bedside insertion and removal, (b) guidewire replacement for diagnostic or therapeutic purposes (dialysis or pheresis procedures) thus reducing the need for repeated venipunctures.
The Management of Totally Implanted Venous Ports in the Ambulatory Oncologic Patient
Authors: Dal Molin A. , Guerretta L. , Mazzufero F. , Rasero L.
Published: January 2018

Totally implanted venous access devices (ports) are widely used in all oncology units, because of the many advantages that they offer if compared to external central venous catheters, particularly in terms of safety. Nonetheless, infection, lumen occlusion and venous thrombosis may still occur, and they are often caused or facilitated by inappropriate insertion or inappropriate management. Reviewing the management protocols of ports in ambulatory patients of 50 Italian oncology units, we have been able to detect the lack of common standardized behavior regarding the technical management of these devices: in addition, some aspects of management differ significantly from what suggested by international guidelines.
Pre-Operative Vessel Mapping and Early Post-Operative Surveillance Duplex Scanning of Arteriovenous Fistulae
Authors: Ives C.L. , Akoh J.A. , George J. , Vaughan-Huxley E. , Lawson H.
Published: January 2018

Purpose

To increase the proportion of dialysis patients using native arteriovenous fistulae (AVF), improved selection of the most appropriate procedure must be coupled with early access surveillance to determine which access would likely mature and when intervention might lead to access salvage. This study was aimed at auditing pre-operative vessel mapping and post-operative access surveillance against the primary outcome measure of AVF maturation.

Methods

Between January 2006 and August 2007, 113 AVF created in 101 patients were studied. Data on pre-operative vessel mapping, type of AVF, post-operative surveillance scans were analyzed against the outcome AVF.

Results

Pre-operative mapping and post-operative scanning were carried out in 86% and 91%, respectively. A maturing fistula on post-operative scan highly correlated with a satisfactory outcome (p<0.001). The sensitivity and specificity of the post-operative scan were 100% and 85%, respectively. There were 79 brachiocephalic and 34 radiocephalic fistulae with a primary failure rate of 23% and 47%, respectively, giving an overall failure rate of 30%. Nine fistulae had further intervention (angioplasty or thrombolysis) and five (56%) were salvaged. Seventy-two AVF matured satisfactorily giving a primary cumulative patency of 71% (72/102).

Conclusion

This study shows that preoperative vessel mapping provides useful information regarding the choice of AVF. Access surveillance duplex scanning at 6–8 weeks post-operatively is viable and has a high sensitivity and specificity for final outcome of fistula. Identifying AVF with potential problems early means that further intervention or surgery can be planned earlier, which will have a positive impact on patients.
Surgical Banding for Refractory Hemodialysis Access-Induced Distal Ischemia (HAIDI)
Authors: Scheltinga M.R. , Van Hoek F. , Bruyninckx C.M.A.
Published: January 2018

Hemodialysis patients may develop distal ischemia in an extremity harboring a functioning arteriovenous access (AVA). Surgery is indicated if conservative treatment including catheter-based therapies fails. The role of surgical banding for refractory hemodialysis access-induced distal ischemia (HAIDI) is systematically reviewed (n=39 articles). If banding is executed without an intraoperative monitoring tool (“blind”), or guided by finger pressures only, clinical success and access patency rates are low (<50%). In contrast, banding is clinically successful when access flow is monitored during the operative procedure, with excellent long-term patency of banded AVA's (97%, 17 ± 3 months). Banding is the method of choice in HAIDI patients with a normal or high access flow (>1.2 l/min) provided that flow and distal perfusion are closely monitored intraoperatively.