AIM: Recent studies have shown that percutaneous transluminal angioplasty (PTA) can be safely performed as a day-case procedure. Many centers consider diabetes mellitus as a contraindication to day-case PTA. In this study, the safety and efficacy of 95 day-case PTA in 66 diabetic patients with critical leg ischemia (CLI) were evaluated. METHODS: Diabetic patients with CLI were assessed in a one-stop multidisciplinary outpatient clinic. Sixty-six outpatients with CLI deemed suitable for radiological intervention by non-invasive imaging (ultrasound angiology or magnetic resonance angiography) were scheduled for day-case PTA. RESULTS: PTA was initially successful in 63 out of 66 patients (95%). In 3 patients (5%), PTA was not possible because the lesion could not be balloon dilated or crossed with a guide wire. Clinically suspected first, second and third re-stenosis confirmed by non-invasive studies occurred in 20 out of 63 (31%), 7 out of 20 (35%) and 2 out of 7 (28%) patients, respectively. Following PTA, debridement was performed in 11 patients (17%), minor amputation in 8 (13%) and major amputation in 3 (5%). Relief of the primary symptom of rest pain or healing of ulcers was achieved in 23 out of 32 (72%) and 25 out of 27 (92.5%) patients, respectively. No peri-interventional morbidity or mortality was encountered. CONCLUSION: PTA is feasible and safe as a day-case procedure in diabetic patients with CLI. Re-stenosis can be managed by repeat day-case PTA.

Abdominal aortic aneurysm (AAA) is a common degenerative condition affecting the elderly population. Rupture carries a high overall mortality. Elective endovascular stent graft repair is well described. We describe a patient with ruptured AAA and co-morbid conditions making him unfit for surgery and general or epidural anaesthesia, who was successfully treated by endovascular stent graft under local anaesthesia.

PURPOSE: To report the benefit of endoluminal repair of mycotic aortic aneurysms and highlight the need for a registry. METHODS: Nine patients (five female) were identified over 5 years (1998-2003) as having presumed mycotic aortic aneurysms (12 in total) suitable for endoluminal grafting. A total of nine thoracic and three abdominal were grafted and followed up for a median of 36 months. RESULTS: Six of the aneurysms have resolved and one was converted to an open repair. There was one early death from rupture of a second undiagnosed aneurysm and two late deaths from rupture due to persistent inflammation. Long-term antibiotics have not been mandatory to ensure survival. CONCLUSIONS: Mycotic aortic aneurysms of the thoracic and abdominal aorta do benefit from endoluminal repair, particularly when arising in previously normal aortic tissue. Endoluminal grafting also has a role in the palliation of secondarily infected aortas and so to prove its efficacy in the treatment of all these rare cases a registry is required.

BACKGROUND:: The elastinolytic cysteine proteases, including cathepsins S and K, are overexpressed at sites of arterial elastin damage. Cystatin C, an inhibitor of these enzymes, is expressed in arterial smooth muscle cells; an imbalance in cystatin C has been implicated in the aortic wall degeneration observed in abdominal aortic aneurysms (AAAs). The aim of the study was to investigate the impact of a polymorphism in the signal peptide of the cystatin C gene on the growth of small AAAs. METHODS:: Some 424 patients with a small AAA (4.0-5.5 cm) were monitored for AAA growth by ultrasonography and provided a DNA sample for analysis of the + 148 G > A polymorphism in the cystatin C signal peptide and the-82 G > C polymorphism in the gene promoter. The median length of follow-up was 2.8 years and AAA growth rates were calculated by linear regression analysis. RESULTS:: For patients of + 148 GG (n = 263), GA (n = 147) and AA (n = 20) genotypes, the mean(s.d.) AAA growth rates were 0.37(0.29), 0.37(0.23) and 0.30(0.26) cm, and initial diameters were 4.58(0.35), 4.58(0.35) and 4.62(0.36) cm, respectively. Patients of + 148 AA genotype had a slower aneurysm growth rate (unadjusted P = 0.058; after adjustment for age, sex, initial AAA diameter and smoking, P = 0.027). There also was a trend for the rare homozygotes of the-82 C allele to have slower AAA growth (adjusted P = 0.055). Smoking history had a stronger association with aneurysm growth (P = 0.003). CONCLUSION:: There was a weak association between variation in the cystatin C gene and AAA growth. Medical strategies to limit AAA growth might include the inhibition of cysteine proteases.

Flexible intramedullary nails have been indicated to treat femoral fractures in pediatric patients. The purpose of this study was to examine the stability of simulated transverse fractures after retrograde intramedullary flexible nail fixation. Various nail diameter combinations were tested using composite femurs in bending, torsion, and a combined axial/bending test where a vertical compressive force was applied to the femoral head. The cross-sectional percent area fill of the nails within the femurs was also determined. In 4 point bending, the greatest repair stiffness was 12% of the intact stiffness. In torsion, the greatest stiffness was 1% of the intact stiffness for either internal or external rotation. The greatest repair stiffness was 80% of the intact stiffness for a compressive load applied to the femoral head. Nail combinations with single nail diameters greater than 40% of the mid-shaft canal width, as measured from an AP radiograph, prevented the fracture from being reduced and left a posterior gap. Flexible intramedullary nails may be of value in the treatment of pediatric femoral fractures, but care must be taken to insert nails that are correctly sized for the canal and to protect the healing fracture from high torsional and bending loads.

BACKGROUND: This retrospective study investigated the treatment of femoral shaft aseptic nonunions associated with broken distal locked screws and shortening. METHODS: In this study, 11 femoral shaft aseptic nonunions associated with both broken distal locked screws and shortening in 11 consecutive adult patients were treated. All nonunions were associated with at least 1.5 cm (range, 1.5-3.5 cm) shortening. These nonunions were treated by removal of locked nails, one-stage femoral lengthening, static locked nail stabilization, and corticocancellous bone graft supplementation. Postoperatively, ambulation with protected weightbearing was encouraged as early as possible. RESULTS: Ten nonunions were followed up for a median of 4.1 years (range, 1.8-5.5 years), and nine fractures healed at a median of 4 months (range, 3-6 months). The nonunion case had broken locked screws again at 5 months and was treated with exchange nailing. The fracture healed uneventfully at 4 months. No other complications occurred. CONCLUSIONS: The key to removal of broken screws is withdrawal of the nail slightly to release the incarcerated broken screw end. The screw end then is pushed out with a used Knowles' pin or a smaller screwdriver under image intensifier guidance. Concomitant one-stage femoral lengthening to treat nonunion with shortening has a high success rate.

OBJECTIVES: We evaluated clinical and radiologic results of intramedullary fixation with titanium elastic nails (TEN) in children with femoral fractures. METHODS: The study included 35 femoral fractures of 34 patients (20 boys, 14 girls; mean age 8.3 years; range 5 to 14 years) who were treated by intramedullary fixation with TEN. The results were evaluated according to the scoring system proposed by Flynn et al. Time to union and residual angulations were assessed on anteroposterior and mediolateral radiographs. Femoral anteversion angles and limb lengths were measured in comparison with the normal side by computed tomography (CT) in 14 patients and the results were compared using the Wilcoxon test. The mean follow-up period was 28 months (range 4 to 48 months). RESULTS: According to the criteria by Flynn et al., the results were excellent in 25 fractures (71.4%), successful in nine fractures (25.7%), and poor in one fracture (2.9%). The mean time to union was 7.4 weeks (range 5 to 12 weeks). Mediolateral and anteroposterior radiographs showed an angulation of 10 degrees or less in three fractures and of 8 degrees in one fracture, respectively. Limb length discrepancy of less than 2 cm was detected in seven patients (20.6%). Femoral anteversion angles measured by CT revealed significant retroversions on the fractured sides (p<0.01). CONCLUSION: Intramedullary fixation with TEN may be the preferred method for the treatment of femoral fractures in children aged 5 to 15 years. However, residual rotation detected by CT seems to be a technical challenge to be improved.

BACKGROUND: Venting during prophylactic nailing of metastatic femoral lesions may decrease intramedullary pressures and the risk of fat and tumor embolization. This study aimed to quantify maximum intramedullary pressure levels and durations, and to examine tumor displacement during prophylactic reamed intramedullary nailing of vented and nonvented metastatically involved femora. METHODS: Proximal metastatic defects were simulated in six pairs of cadaveric femora and prophylactically treated using reamed intramedullary nailing with or without proximal and distal vents. Maximum pressures, durations of pressure exceeding embolic threshold levels (25 and 200 mm Hg), and tumor displacement were recorded. RESULTS: Maximum pressures and durations of pressure exceeding embolic thresholds decreased more than 50% with venting (p < 0.05). Distal pressures surpassed the 25-mm Hg threshold even with venting. Post-test sectioning showed increased tumor disbursement in vented specimens. CONCLUSIONS: Venting reduces pressurization during prophylactic reamed intramedullary nailing of femoral metastases, but may increase the spread of tumor to extraskeletal tissue if vented tissue is not contained.

Five patients treated operatively on account of tibia and femur shaft delayed union and pseudoarthrosis were re-operated by locked intramedullary nailing. The method permits stable bone fixation. Intramedullary canal reaming stimulates bone union, as it refreshes fracture site and is a source of bone graft. Intramedullary nail covers anatomical axis of bone and, in the case of femur, is close to its mechanical axis. It diminishes the risk of implant breakage. The method permits active and efficient rehabilitation. Some fractures stabilised with external fixator or operated by Zespol or Polfix method can be re-operated by close technic. It shortens time of operation and diminishes its aggressiveness. In our opinion locked intramedullary nailing is an efficient method in treatment of tibia and femur shaft delayed union and pseudoarthrosis.

Femoral shaft fracture is very often main musculo-skeletal injury in polytrauma patient. We analysed bone union of femoral shaft fractures treated by different operative open methods--AO plate osteosynthesis, Zespol method and open intramedullary nailing and by closed intramedullary nailing, in patients with concomitant body injuries. We compared patients operated by open methods without complications with the group demanding fracture reoperation. We found out no statistical correlation between the frequency of local complications demanding reoperation and the presence of associated injuries p = 0.209 or their severity expressed in ISS p = 0.202. The highest ISS 29.5 points occurred in the group operated on by closed intramedullary nailing. Lack of complications in this group gives evidence of efficiency of this method of treatment.