A new anterior intrapelvic approach for the surgical management of displaced acetabular fractures involving predominantly the anterior column and the quadrilateral plate is described. In order to establish five 'windows' for instrumentation, the extraperitoneal space is entered along the lateral border of the rectus abdominis muscle. This is the so-called 'Pararectus' approach. The feasibility of safe dissection and optimal instrumentation of the pelvis was assessed in five cadavers (ten hemipelves) before implementation in a series of 20 patients with a mean age of 59 years (17 to 90), of whom 17 were male. The clinical evaluation was undertaken between December 2009 and December 2010. The quality of reduction was assessed with post-operative CT scans and the occurrence of intra-operative complications was noted. In cadavers, sufficient extraperitoneal access and safe instrumentation of the pelvis were accomplished. In the patients, there was a statistically significant improvement in the reduction of the fracture (pre- versus post-operative: mean step-off 3.3 mm (sd 2.6) vs 0.1 mm (sd 0.3), p < 0.001; and mean gap 11.5 mm (sd 6.5) vs 0.8 mm (sd 1.3), p < 0.001). Lesions to the peritoneum were noted in two patients and minor vascular damage was noted in a further two patients. Multi-directional screw placement and various plate configurations were feasible in cadavers without significant retraction of soft tissues. In the treatment of acetabular fractures predominantly involving the anterior column and the quadrilateral plate, the Pararectus approach allowed anatomical restoration with minimal morbidity related to the surgical access.
Objective It is currently unknown how long GCA should be treated with tocilizumab. In the first randomized controlled trial, the biologic agent was stopped after 52 weeks. We therefore studied what proportion of patients relapsed, when relapses occurred and whether factors might predict relapse after tocilizumab treatment discontinuation. Methods All patients in the tocilizumab arm who had received a 52-week treatment were evaluated. In case of lasting remission, magnetic resonance angiography (MRA) was performed and sera were taken to search for biomarkers associated with subclinical disease activity. Results Seventeen of 20 patients randomized to the tocilizumab treatment arm were in lasting remission without any co-medication at week 52. Mean follow-up after study end was 28.1 months (range 17–44). Eight patients relapsed after a mean of 6.3 months (range 2–14) (six within the first 5 months, two patients at months 13 and 14, respectively). Relapsing patients were younger and showed more signs of mural enhancement in MRA compared with non-relapsing patients. MRA documented low-intensity vessel wall signals in all subjects. No morphological changes such as formation of aneurysm of aorta occurred. Biomarkers in sera did not indicate subclinical disease activity: levels of IL-6, MMP-3, soluble TNF receptor 2, soluble CD163, soluble intercellular adhesion molecule-1 and Pentraxin-3 did not differ from matched healthy controls. Conclusion The data show that a 52-week treatment with tocilizumab induces a lasting remission that persists in half of the patients after treatment stop. None of the clinical, serological or MRA findings qualify to predict relapse. Remarkably, MRA revealed a persisting wall enhancement of the descending aorta.
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