A multi-center retrospective analysis of treatment effects and quality of life in adult patients with cranial ependymomas

Long term quality of life data of adult patients harboring intracranial ependymomas have not been reported. The role of adjuvant radiation therapy in Grade II ependymomas is unclear and differs from study to study. We therefore sought to retrospectively analyze outcome and quality of life of adult patients that were operated on intracranial ependymomas at four different surgical centers in two countries. All patients were attempted to be contacted via telephone to assess quality of life (QoL) at the time of the telephone interview. The standard EORTC QoL Questionnaire C30 (EORTC QLQ-C30) and the EORTC QLQ-Brain Cancer Module (QLQ-BN20) were used. 64 adult patients with intracranial ependymomas were included in the study. The only factor that was associated with increased survival was age <55 years (p < 0.001). Supratentorial location was correlated with shorter progression free survival than infratentorial location (PFS; p = 0.048). In WHO Grade II tumors local irradiation did not lead to increased PFS (p = 0.888) or overall survival (p = 0.801). Even for incompletely resected Grade II tumors local irradiation did not lead to a benefit in PFS (p = 0.911). In a multivariate analysis of QoL, irradiated patients had significantly worse scores in the item "fatigue" (p = 0.037) than non-irradiated patients. Here we present QoL data of adult patients with intracranial ependymomas. Our data show that local radiation therapy may have long-term effects on patients' QoL. Since in the incompletely resected Grade II tumors local irradiation did not lead to a benefit in PFS in this retrospective study, prospective randomized studies are necessary. In addition to age, supratentorial tumor location is associated with a worse prognosis in adult ependymoma patients.

Anterior Cruciate Ligament Injuries in Children and Adolescents: A Review of the Recent Literature

In contrast to the treatment of avulsion lesions of the anterior cruciate ligament (ACL) the management of intrasubstance ACL tears in the skeletally immature patient remains controversial. Prospective studies could show that conservative treatment results in severe instability with concomitant intraarticular damage and poor function of the knee. Reconstruction of a torn ACL always carries the risk of damaging the open growth plates; with consecutively affecting the longitudinal or axial growth of the lower extremity either on the femoral or the tibial side. Thus, several surgical procedures are available to prevent adverse events mentioned above. The purpose of this study is to review the recent literature regarding the treatment algorithm for ACL injuries in skeletally immature patients. This review will (1) investigate the indications for ACL surgery in children; (2) determine if a surgical procedure is clinically superior in skeletally immature patients; and (3) correlate the adverse events with the surgical technique.

A novel technique, dynamic intraligamentary stabilization creates optimal conditions for primary ACL healing: A preliminary biomechanical study

BACKGROUND Anterior cruciate ligament (ACL) rupture is a common lesion. Current treatment emphasizes arthroscopic ACL reconstruction via a graft, although this approach is associated with potential drawbacks. A new method of dynamic intraligamentary stabilization (DIS) was subjected to biomechanical analysis to determine whether it provides the necessary knee stability for optimal ACL healing. METHODS Six human knees from cadavers were harvested. The patellar tendon, joint capsule and all muscular attachments to the tibia and femur were removed, leaving the collateral and the cruciate ligaments intact. The knees were stabilized and the ACL kinematics analyzed. Anterior-posterior (AP) stability measurements evaluated the knees in the following conditions: (i) intact ACL, (ii) ACL rupture, (iii) ACL rupture with primary stabilization, (iv) primary stabilization after 50 motion cycles, (v) ACL rupture with DIS, and (vi) DIS after 50 motion cycles. RESULTS After primary suture stabilization, average AP laxity was 3.2mm, which increased to an average of 11.26mm after 50 movement cycles. With primary ACL stabilization using DIS, however, average laxity values were consistently lower than those of the intact ligament, increasing from an initial AP laxity of 3.00mm to just 3.2mm after 50 movement cycles. CONCLUSIONS Dynamic intraligamentary stabilization established and maintained close contact between the two ends of the ruptured ACL, thus ensuring optimal conditions for potential healing after primary reconstruction. The present ex vivo findings show that the DIS technique is able to restore AP stability of the knee.

Type II DeBakey dissection with complete aortic rupture visualized by unenhanced postmortem imaging

We present postmortem computed tomography (pmCT) as well as postmortem magnetic resonance (pmMR) imaging findings in a case of type II DeBakey aortic dissection with a complete rupture of the ascending aorta compared to the findings obtained at forensic autopsy. PmCT only allowed a presumptive diagnosis of aortic dissection based on an anterior mediastinal enlargement. However, at pmMR the dissection including the aortic rupture was clearly visible. Visualization was realized in an unenhanced manner without the need for postmortem angiography.

Short-term Functional and Patient Outcome of the Bi-cruciate Stabilized Total Knee Replacement: Prospective Consecutive Case-series

Background: Total knee replacement is the gold standard treatment for patients suffering from advanced symptomatic knee osteoarthritis. The main goals of knee prosthetics are pain reduction and restoration of knee motion. The new prostheses on the market such as the bi-cruciate stabilized Journey knee implant, promise a reconstruction of total physiological function of the knee with physiological range of motion and therefore high patient satisfaction. Purpose: The aim of this study was to analyze the patient-based Knee Injury and Osteoarthritis Outcome Score (KOOS) outcome after total knee replacement with new physiological bi-cruciate stabilized Journey knee prosthesis. Study Design: Prospective, consecutive case-series. Patients: Ninety nine patients, who received bi-cruciate stabilized Journey total knee prosthesis between January 1st 2006 and May 31st 2012, were included in the study. A single surgeon operated all patients. There were 61.1% females and the overall average age was 68 years (range 41-83 years). Left knee was replaced in 55.6%. Methods: The patients filled in KOO’s questionnaire pre- and 1 year postoperative. Range of motion (ROM) was studied preoperatively and at 1-year follow-ups. The pre- and postoperative KOOS subscores and ROM were compared using the Wilcoxon signed rank test. Results: There are significant improvements of all KOOS subscores. Ninety percent of patients have reached the minimum clinically relevant 10 points in symptoms, 94.5% in pain, 94.5% in activities of daily living, 84.9% in sport and recreation, and 90% in knee related quality of life. Postoperative, the average passive ROM was 131° (range 110-145°) and the average active ROM 122° (range 105-135°). The highest correlation coefficients ROM and the KOOS were observed for the activity and pain subscores. Very low or no correlation was seen for the sport subscore. Conclusions: Bi-cruciate stabilized knee prosthetic offers a solid outcome 1 year postoperative based on the results measured with the KOOS evaluation questionnaire. The Patients showed a generalized improvement in all domains measured in the KOOS of minimally 35, and up to over 52 points, what can be described as statistically significant. Patients described the level of functionality close to double compared to the preoperative status.

Suitability of Common Collagen Scaffolds for Anterior Cruciate Ligament Repair

Introduction: Anterior cruciate ligament (ACL) injuries are very common; in Germany incidence of ACL ruptures is estimated at 32 per 100 000 in the general population and in the sports community this rate more than doubles. Current gold standard for anterior cruciate lig- ament repair is reconstruction using an autograft [1]. However, this approach has shown some limitations. A new method has been her- alded by the Knee Team at the Bern University Hospital (Inselspital) and the Sonnenhof clinic called Dynamic Intraligamentary Stabilization (DIS), which keeps ACL remnants in place in order to promote biologi- cal healing and makes use of a dynamic screw system [2]. The aim of this study was to investigate the cytocompatibility of collagen patches in combination with DIS to support regeneration of the ACL. The spe- cific hypothesis we tested was whether MSCs would differentiate towards TCs in co-culture. Materials and methods: Primary Tenocytes (TCs) and human bone marrow derived mesenchymal stem cells (MSCs) were harvested from ACL removed during knee prothesis or from bone marrow aspirations (Ethical Permit 187/10). Cells were seeded on two types of three dimensional carriers currently approved for cartilage repair, Novocart (NC, B. Brown) and Chondro-Gide (CG, Geistlich). These scaffolds comprise collagen structures with interconnecting pores originally developed for seeding of chondrocytes in the case of CG. ~40k cells were seeded on punched zylindrical cores of 8 mm in Ø and cultured on CG or NC patches for up to 7 days. The cells were either cultured as TC only, MSC only or co-cultured in a 1:1 mix on the scaffolds and on both sides of culture inserts (PET, high density pore Ø 0.4 mm, BD, Fal- con) with cell-cell contact. We monitored DNA content, GAG and HOP-content, tracked the cells using DIL and DIO fluorescent dyes (Molecular Probes, Life technologies) and confocal laser scanning and SEM microscopy as well as RT-PCR of tenocyte specific markers (i.e. col 1 and 3, TNC, TNMD, SCXA&B, and markers of dedifferentiation ACAN, col2, MMP3, MMP13). Finally, H&E stain was interpreted on cryosections and SEM images of cells on the scaffold were taken. Results: ThecLSMimagesshowedcellproliferationoverthe7dayson both matrices, however, on CG there were much fewer MSCs attached than on NC. SEM images showed a roundish chondrocyte-like pheno- type of cells on CG whereas on NC the phenotype was more teno- cyte-like (Fig. 1). Gene expression of both, MSC and TC seem to confirm a more favorable environment in 3D for both patches rather than monolayer control.

Mesenchymal stem cells and collagen patches for anterior cruciate ligament repair

AIM: To investigate collagen patches seeded with mesenchymal stem cells (MSCs) and/or tenocytes (TCs) with regards to their suitability for anterior cruciate ligament (ACL) repair. METHODS: Dynamic Intraligamentary Stabilization (DIS) utilizes a dynamic screw system to keep ACL remnants in place and promote biological healing, supplemented by collagen patches. How these scaffolds interact with cells and what type of benefit they provide has not yet been investigated in detail. Primary ACL-derived TCs and human bone marrow derived MSCs were seeded onto two different types of 3D collagen scaffolds, Chondro-Gide® (CG) and Novocart® (NC). Cells were seeded onto the scaffolds and cultured for 7 days either as a pure populations or as “premix” containing a 1 : 1 ratio of TCs to MSCs. Additionally, as controls, cells were seeded in monolayers and in co-cultures on both sides of porous high-density membrane inserts (0.4µm). We analyzed the patches by real time polymerase chain reaction (RT-PCR), glycosaminoglycan (GAG), DNA and hydroxy-proline (HYP) content, was determined. To determine cell spreading and adherence in the scaffolds microscopic imaging techniques, i.e. confocal laser scanning microscopy (cLSM) and scanning electron microscopy (SEM), were applied. RESULTS: CLSM and SEM imaging analysis confirmed cell adherence onto scaffolds. The metabolic cell activity revealed that patches promote adherence and proliferation of cells. The most dramatic increase in absolute metabolic cell activity was measured for CG samples seeded with tenocytes or a 1:1 cell premix. Analysis of DNA content and cLSM imaging also indicated MSCs were not proliferating as nicely as tenocytes on CG. The HYP to GAG ratio significantly changed for the premix group, resulting from a slightly lower GAG content, demonstrating that the cells are modifying the underlying matrix. Real-time quantitative polymerase chain reaction data indicated that MSCs showed a trend of differentiation towards a more tenogenic-like phenotype after 7 days. CONCLUSION: CG and NC are both cyto-compatible with primary MSCs and TCs; TCs seemed to perform better on these collagen patches than MSCs.

Blastomycosis granuloma involving the cranial vena cava associated with chylothorax and cranial vena caval syndrome in a dog

A four-year-old, sexually intact, male dachshund was diagnosed with pulmonary blastomycosis. Itraconazole was administered for 60 days, and the dog was considered to be disease-free at three- and 12-month reevaluations. Two years following discontinuation of itraconazole, the dog developed a granuloma of the cranial vena cava resulting in chylothorax and cranial vena caval obstruction. To the authors' knowledge, this is the first case of a blastomycotic granuloma involving the vena cava reported in the dog. Blastomycosis should be considered as a differential diagnosis for both chylothorax and cranial vena caval syndrome in the dog.

ACL reconstruction with physiological graft tension by intraoperative adjustment of the anteroposterior translation to the uninjured contralateral knee.

PURPOSE Fixation of anterior cruciate ligament (ACL) substitutes with non-physiological anteroposterior translation (APT) worsens outcome. The aim was to present a technique for physiological APT adjustment of the transplant in ACL reconstruction and its outcome at midterm. METHODS In a consecutive series of 28 patients (age 32 ± 11 years, 24 male), chronic ACL deficiency was treated by bone-patella-tendon-bone reconstruction. Transplant APT was adjusted to that of the contralateral uninjured ACL, measured 3, 6, and 12 months postoperatively using the Rolimeter. At a median follow-up of 5.3 years (3-8 years), 82% of the patients were re-evaluated with APT measurement and using IKDC-, Tegner-, Lysholm-Scores, conventional radiographs and MRI. RESULTS No differences in APT (mean ± SD) between uninjured and reconstructed knees were observed after adjustment (6 ± 1 versus 6 ± 1 mm, n.s.). Three months postoperatively, a statistically significant increase in APT (7 ± 1 mm) and a further increase at midterm (9 ± 2 mm) were observed. Patients scored "normal" or "nearly normal", respectively, in 79% (IKDC) and 4 (3-9) points (Tegner; median, range) or 89 ± 9 points (Lysholm; mean ± SD). Radiological evaluation showed no, minimal or moderate joint degeneration in 5, 20 and 75% of patients, respectively. MRI confirmed intact ACL transplants in all patients. CONCLUSION ACL reconstruction using the presented technique was considered successful, as patients did not suffer from subjective instability, radiographic analysis did not provide evidence for graft rupture at midterm. However, APT increase and occurrence of degenerative changes in reconstructed knees at the midterm might not be prevented even by restoration of a physiological APT in ACL reconstruction. The Rolimeter can be used for quick and easy intraoperative indirect control of the applied tension to the ACL transplant by measuring the APT to obtain physiological tensioning resulting in a satisfying outcome at midterm. LEVEL OF EVIDENCE IV.

Complete rupture of the popliteal artery complicating high tibial osteotomy.

We present two cases of high tibial osteotomies performed at our institution. Both cases were complicated with the immediate postoperative occurrence of an ischaemic syndrome of the lower leg. Urgent diagnostics revealed a complete rupture of the popliteal artery that required re-operation and a vascular repair. Although neurovascular complications during high tibial osteotomies are rare the awareness of this potentially catastrophic complication should be present when performing this common procedure. All precautions to minimize the harm to the neurovascular bundle should be put into practice. A summary of the surgical precautions is presented and discussed in this paper.

Intracranial Aneurysm Rupture Is Predicted by Measures of Solar Activity.

OBJECTIVE The cause precipitating intracranial aneurysm rupture remains unknown in many cases. It has been observed that aneurysm ruptures are clustered in time, but the trigger mechanism remains obscure. Because solar activity has been associated with cardiovascular mortality and morbidity, we decided to study its association to aneurysm rupture in the Swiss population. METHODS Patient data were extracted from the Swiss SOS database, at time of analysis covering 918 consecutive patients with angiography-proven aneurysmal subarachnoid hemorrhage treated at 7 Swiss neurovascular centers between January 1, 2009, and December 31, 2011. The daily rupture frequency (RF) was correlated to the absolute amount and the change in various parameters of interest representing continuous measurements of solar activity (radioflux [F10.7 index], solar proton flux, solar flare occurrence, planetary K-index/planetary A-index, Space Environment Services Center [SESC] sunspot number and sunspot area) using Poisson regression analysis. RESULTS During the period of interest, there were 517 days without recorded aneurysm rupture. There were 398, 139, 27, 12, 1, and 1 days with 1, 2, 3, 4, 5, and 6 ruptures per day. Poisson regression analysis demonstrated a significant correlation of F10.7 index and RF (incidence rate ratio [IRR] = 1.006303; standard error (SE) 0.0013201; 95% confidence interval (CI) 1.003719-1.008894; P < 0.001), according to which every 1-unit increase of the F10.7 index increased the count for an aneurysm to rupture by 0.63%. A likewise statistically significant relationship of both the SESC sunspot number (IRR 1.003413; SE 0.0007913; 95% CI 1.001864-1.004965; P < 0.001) and the sunspot area (IRR 1.000419; SE 0.0000866; 95% CI 1.000249-1.000589; P < 0.001) emerged. All other variables analyzed showed no significant correlation with RF. CONCLUSIONS We found greater radioflux, SESC sunspot number, and sunspot area to be associated with an increased count of aneurysm rupture. The clinical meaningfulness of this statistical association must be interpreted carefully and future studies are warranted to rule out a type-1 error.

Is fast track management after elective cranial surgery safe and can it replace routine early postoperative computed tomography?

Aims: Patient management following elective cranial surgery varies between different neurosurgical institutions. Early routine postoperative cranial computed tomography (CT) is often performed while keeping patients sedated and ventilated for several hours. We hypothesize that fast track management without routine CT scanning, i.e., early extubation within one hour allowing neurological monitoring, is safe and does not increase the rate of return to OR compared with published data. Methods: We prospectively screened 1118 patients with cranial procedures performed at our department over a period of two years. 420 patients with elective brain surgery older than 18 years with no history of prior cranial surgery were included. Routine neurosurgical practice as it is performed at our department was not altered for this observational study. Fast track management was aimed for all cases, extubated and awake patients were further monitored. CT scanning within 48 hours after surgery was not performed except for unexpected neurological deterioration. This study was registered at ClinicalTrials.gov (NCT01987648). Results: 420 elective craniotomies were performed for 310 supra- and 110 infratentorial lesions. 398 patients (94.8%) were able to be extubated within 1 hour, 21 (5%) within 6 hours, and 1 patient (0.2%) was extubated 9 hours after surgery. Emergency CT within 48 hours was performed for 36 patients (8.6%, 26 supra- and 10 infratentorial cases) due to unexpected neurological worsening. Of these 36 patients 5 had to return to the OR (hemorrhage in 3, swelling in 2 cases). Return to OR rate of all included cases was 1.2%. This rate compares favorably with 1-4% as quoted in the current literature. No patient returned to the OR without prior CT imaging. Of 398 patients extubated within one hour 2 (0.5%) returned to the OR. Patients who couldn’t be extubated within the first hour had a higher risk of returning to the OR (3 of 22, i.e., 14%). Overall 30-day mortality was 0.2% (1 patient). Conclusions: Early extubation and CT imaging performed only for patients with unexpected neurological worsening after elective craniotomy procedures is safe and does not increase patient mortality or the return to OR rate. With this fast track approach early postoperative cranial CT for detection of postoperative complications in the absence of an unexpected neurological finding is not justified. Acknowledgments The authors thank Nicole Söll, study nurse, Department of Neurosurgery, Bern University Hospital, Switzerland for crucial support in data collection and managing the database.

Is intracranial aneurysm rupture related to solar activity?

Objective: A number of intrinsic and extrinsic risk factors for the rupture of intracranial aneurysms have been identified. Still, the cause precipitating aneurysm rupture remains unknown in many cases. In addition, it has been observed that aneurysm ruptures are clustered in time but the trigger mechanism remains obscure. As solar activity has been associated with cardiovascular mortality and morbidity we decided to study ist association to aneurysm rupture in the Swiss population. Method: Patient data was extracted from the Swiss SOS database, at time of analysis covering 918 patients with angiography-proven aSAH treated at seven Swiss neurovascular centers between 01/01/2009 – 12/31/2011. The number of aneurysm rupture per day, week, month (Daily/Weekly/Monthly Rupture Frequency = RF) was measured and correlated to the absolute amount and the change in various parameters of interest representing continuous measurements of solar activity (radioflux (F10.7 index), solar proton flux, solar flare occurrence, planetary K-index/planetary A-index) using Poisson regression analysis. Results: Of a consecutive series of 918 cases of SAH, precise determination of the date of symptom onset was possible in 816 (88.9%). During the period of interest there were 517 days without recorded aneurysm rupture. There were 398, 139, 27 and 12 days with 1, 2, 3, and 4 ruptures per day. Five or 6 ruptures were only noted on a single day each. Poisson regression analysis demonstrated a significant correlation of F10.7 index and aneurysm rupture (incidence rate ratio (IRR) = 1.006303; standard error (SE) 0.0013201; 95% confidence interval (CI) 1.003719 – 1.008894; p<0.001), according to which every 1-unit increase of the F10.7 index increased the count for an aneurysm to rupture by 0.63%. As the F10.7 index is known to correlate well with the Space Environment Services Center (SESC) sunspot number, we performed additional analyses on SESC sunspot number and sunspot area. Here, a likewise statistically significant relationship of both the SESC sunspot number (IRR 1.003413; SE 0.0007913; 95%CI 1.001864 – 1.004965; p<0.001) and the sunspot area (IRR 1.000419; SE 0.0000866; 95%CI 1.000249 – 1.000589; p<0.001) emerged. All other variables analyzed showed no correlation with RF. Conclusions: Using valid methods, we found higher radioflux, sunspot number and sunspot area to be associated with an increased count of aneurysm rupture. Since we were using rupture frequencies rather than incidences and because we cannot explain the physiological basis of this statistical association, the clinical meaningfulness of this statistical association must be interpreted carefully. Future studies are warranted to rule out a type-1 error.