THE ROLE OF CORE DECOMPRESSION FOR THE TREATMENT OF FEMORAL HEAD AVASCULAR NECROSIS IN RENAL TRANSPLANT RECIPIENTS

Aseptična nekroza kosti je relativno rijetka komplikacija u primatelja bubrežnog transplantata. Ona može biti posljedica djelovanja brojnih uzročnih čimbenika, ali se najviše povezuje s liječenjem kortikosteroidima. Prikazat ćemo 62-godišnju bolesnicu s terminalnim bubrežnim zatajenjem, uzrokovanim poststreptokoknim glomerulonefritisom, koja se prije transplantacije bubrega 2,5 godine liječila peritonejskom dijalizom. Dvadeset mjeseci prije presađivanja bubrega, bolesnica je zbog akutnog poliradikuloneuritisa Guillaine Barré liječena visokim dozama kortikosteroida, uz primjenu imunoglobulina i plazmafereze. Kod transplantacije bubrega primijenjen je standardni imunosupresivni protokol, koji uključuje takrolimus, mikofenolat mofetil i kortikosteroid uz indukciju baziliksimabom. Četiri mjeseca nakon transplantacije, bolesnica počinje osjećati bolove u desnom kuku kod dužeg stajanja. Na radiogramu kuka ustanovljena su subhondralna prosvjetljenja u području lateralnog dijela cirkumferencije glavice, koja su se širila u proksimalni dio vrata desnog femura, dok pregled magnetskom rezonancom (MR) nije pokazao promjene u smislu aseptične nekroze kosti. Bolesnica je zbog progresije bolova i pozitivnog radiografskog nalaza, a unatoč negativnom nalazu MR-a, podvrgnuta kirurškom zahvatu dekompresije glavice bedrene kosti. Nakon zahvata bolovi su prestali i bolesnica se zadovoljavajuće oporavila. Kod primatelja bubrežnog transplantata treba rano posumnjati i utvrditi aseptičnu nekrozu kosti, jer pravodobno liječenje dekompresijom kosti može otkloniti bol te spriječiti ili odgoditi destrukciju kosti koja bi zahtijevala aloartroplastikuA vascular bone necrosis is a relatively rare but significant complication in renal transplant recipients because it causes progressive pain and invalidity. it can be the consequence of the action of numerous causative factors, but it is mostly connected to corticosteroid treatment.the underlying pathophysiologic mechanism is a diminished blood flow to the bone leading to necrosis and bone destruction. during the past 25-years period, 570 renal transplantations and five combined kidney and pancreas transplantations were performed in our centre. a part of the patients was lost to follow-up due to the separation of croatia from the former republic of Yugoslavia. After transplantation, we revealed aseptic necrosis of the femoral head in five female patients. all patients had a history of treatment with pulse doses of corticosteroids. at transplantation the average age of the patients was 52.2 yrs (range 46 to 62 yrs), and dialytic treatment before transplantation lasted in average 9.2 yrs (range 2.5 to 21.2 yrs). the period between renal transplantation and the development of clinical signs of avascular bone necrosis lasted in average 1.2 yrs (range 0.3 to 2.3 yrs). We will demonstrate our 62-year old female patient with terminal renal failure caused by post-streptococcal glomerulonephritis, who was treated with peritoneal dialysis 2.5 years before renal transplantation. twenty months before renal transplantation the patient received pulse doses of corticosteroids, together with immunoglobulins and plasmapheresis, for the treatment of an acute polyradiculoneuritis Guillaine barré. after transplantation a standard immunosuppressive protocol was applied which included tacrolimus, mycophenolate mofetil, corticosteroids and induction with basiliximab. four months after transplantation the patient started to feel pain in the right hip after longer standing, in addition to the earlier long-lasting problems caused by bilateral coxarthrosis. the pelvic radiograph showed subchondral radiolucencies in the lateral part of the head circumference spreading into the proximal part of the neck of the right femur, which indicated the presence of aseptic necrosis, but these changes could have also been caused by coxarthrosis. unexpectedly, magnetic resonance imaging (mri) did not reveal changes characteristic for avascular bone necrosis. due to the progressively worsening of pain and the radiographic finding, the patient was submitted to decompression surgery of the femoral head. the surgical procedure was performed under diascopic guidance (c-arm) which allowed the correct positioning of a kuerschner wire. a cannulated drill (diameter 4.0 mm) was placed over the wire and we performed two drillings of the spongiosis of the femoral head through to the subchondral area. Postoperatively, the patient was soon verticalized and advised to walk with crooks during a period of six weeks. this time is necessary to allow the mineralisation and strengthening of the bone which is now better vascularised. the patient recovered well and had no more pain. in renal transplant recipients it is most important to raise suspicion and verify the presence of avascular bone necrosis early, because timely bone decompression surgery can eliminate pain and cure the patient or it can prevent or delay bone destruction. When clinical signs of avascular bone necrosis arise and radiographic or standard mri findings are negative, additional investigations (i.e. sPect or mri with contrast) should be performed to confirm or exclude the diagnosis. in latter phases of the disease, surgical decompression of the femoral head cannot lead to permanent amelioration, and it is inevitable to perform more invasive surgical procedures like “resurfacing” or bone grafting in younger patients, or the implantation of total hip ndoprotheses

Wrist arthroscopy

Artroskopija ručnog zgloba je minimalno invazivna endoskopska metoda koja omogućuje dijagnosticiranje i liječenje pojedinih bolesti i ozljeda ručnog zgloba (RZ), mediokarpalnog zgloba (MKZ) i distalnog radioulnarnog zgloba (DRUZ). Ovu minimalno invazivnu kiruršku metodu prvi je opisao Yung-Cheng Chen 1979., no njezina šira primjena u kliničkoj praksi počinje tek nakon 1986., kada je Terry Lane Whipple preporučio distrakciju RZ-a i precizne lokalizacije ulaznih mjesta (portala), kako bi se učinila pravilna i potpuna evaluacija RZ-a prilikom izvođenja artroskopije. Iako je prvotno artroskopija RZ-a bila samo dijagnostička metoda, tijekom vremena, zahvaljujući kontinuiranom napretku tehnologije i uvođenju inovacija u instrumentaciji i operativnoj tehnici, artroskopija RZ-a postaje i terapeutska metoda. Cilj ovog rada prikazati je osnove o artroskopiji RZ-a, a one uključuju: povijesni razvoj, indikacije i kontraindikacije, evaluaciju i probir bolesnika za artroskopiju RZ-a na temelju anamneze, fizikalnog pregleda i slikovne obrade, pripremu za artroskopiju RZ-a, potrebnu opremu, poznavanje izvanzglobne anatomije, portale (ulazna mjesta), poznavanje unutarzglobne anatomije, preduvjete, tehniku artroskopije RZ-a, prednosti i nedostatke ove operativne metode, komplikacije i zaključak.Wrist arthroscopy is minimally invasive endoscopic procedure which enables the diagnosis and treatment of certain diseases and injuries of the wrist joint (WJ), midcarpal joints (MCJs) and distal radioulnar joint (DRUJ). This minimally invasive surgical procedure was first described by Yung-Cheng Chen in 1979. However, its widespread application in clinical practice began after 1986, when Terry Lane Whipple recommended wrist distraction and precise localization of portals to do proper and complete evaluation of the wrist when performing arthroscopy. Although initially wrist arthroscopy was only a diagnostic tool, during time due to the continuous advancement of technology and the introduction of innovations in instrumentation and surgical technique, wrist arthroscopy became a therapeutic method. The aim of this professional paper is to present the basics of wrist arthroscopy, which include: historical development, indications and contraindications, evaluation and selection of patients for wrist arthroscopy on the basis of history, physical examination and diagnostic imaging procedures, wrist arthroscopy setup, the necessary equipment, superficial anatomy, portals, intraarticular anatomy, preconditions, technique of wrist arthroscopy, the advantages and disadvantages of this surgical procedure, complications, and conclusion

Semi-automated detection of anterior cruciate ligament injury from MRI

Background and objectives: A radiologist’s work in detecting various injuries or pathologies from radiological scans can be tiresome, time consuming and prone to errors. The field of computer-aided diagnosis aims to reduce these factors by introducing a level of automation in the process. In this paper, we deal with the problem of detecting the presence of anterior cruciate ligament (ACL) injury in a human knee. We examine the possibility of aiding the diagnosis process by building a decision- support model for detecting the presence of milder ACL injuries (not requiring operative treatment) and complete ACL ruptures (requiring operative treatment) from sagittal plane magnetic resonance (MR) volumes of human knees. Methods: Histogram of oriented gradient (HOG) descriptors and gist descriptors are extracted from manually selected rectangular regions of interest enveloping the wider cruciate ligament area. Performance of two machine-learning models is explored, coupled with both feature extraction methods: support vector machine (SVM) and random forests model. Model generalisation properties were determined by performing multiple iterations of stratified 10-fold cross validation whilst observing the area under the curve (AUC) score. Results: Sagittal plane knee joint MR data was retrospectively gathered at the Clinical Hospital Centre Rijeka, Croatia, from 2007 until 2014. Type of ACL injury was established in a double-blind fashion by comparing the retrospectively set diagnosis against the prospective opinion of another radiologist. After clean up, the resulting dataset consisted of 917 usable labelled exam sequences of left or right knees. Experimental results suggest that a linear-kernel SVM learned from HOG descriptors has the best generalisation properties among the experimental models compared, having an area under the curve of 0.894 for the injury-detection problem and 0.943 for the complete-rupture-detection problem. Conclusions: Although the problem of performing semi-automated ACL-injury diagnosis by observing knee-joint MR volumes alone is a difficult one, experimental results suggest potential clinical application of computer- aided decision making, both for detecting milder injuries and detecting complete ruptures