Background:Externally controlled intramedullary lengthening nails (IMNs) have reduced the soft-tissue morbidity associated with external fixation. However, these complex devices introduce specific risks related to their motorized and telescopic mechanisms. Existing literature often conflates structural fatigue fractures with internal mechanism dysfunction. This systematic review aims to analyze the incidence, etiology, and management of intrinsic mechanism failures in lengthening IMNs. Methods:A comprehensive search of PubMed, Embase, and Scopus was conducted from January 2000 to July 2025 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The review included human studies reporting mechanism-related failures (e.g., jamming, backtracking, and motor failure) in externally controlled IMNs. Studies describing only structural fatigue fractures or nonexternally controlled devices were excluded (e.g., Intramedullary Skeletal Kinetic Distractor [ISKD]). Data were stratified by implant generation and material. Results:Twenty-nine studies encompassing 2,495 nails were included. The overall reported mechanism-related failure rate was 4.3% (n = 107/2,495). Distinct failure phenotypes emerged based on the implant material. Titanium-alloy nails (PRECICE P1/P2) demonstrated a 4.2% failure rate (n = 74/1,761), predominantly characterized by mechanical jamming or gear slippage due to load-induced yield. Stainless steel nails (STRYDE) exhibited a significantly higher failure rate of 12.9% (n = 12/93), primarily driven by tribocorrosion and biological reactions at the telescopic junction. The FITBONE system had a reported failure rate of 3.3% (n = 21/641). Management required surgical intervention in 97.2% of failure cases, with exchange nailing being the primary salvage strategy (94.4%). Despite the need for reoperation, the target limb length was reportedly achieved in the majority of studies where quantitative outcomes were specified. Conclusion:Mechanism failure in externally controlled lengthening IMNs is a clinically significant complication with a reported incidence of approximately 1 in 24 cases. A material trade-off is evident: Titanium implants are susceptible to mechanical gear yield, whereas stainless steel implants are prone to tribocorrosion-induced failure. While these failures necessitate revision surgery, they typically do not preclude successful limb reconstruction if managed with timely nail exchange. Level of Evidence:Level III. See Instructions for Authors for a complete description of levels of evidence.
Phaeochromocytomas and paragangliomas (PPGLs) are catecholamine-secreting neuroendocrine tumours (NETs) of the adrenal medulla and autonomic nervous system. Early recognition and management is critical given their potential morbidity and mortality. For this reason, stand-alone screening investigations rely on a low diagnostic threshold, achieving high sensitivity at the relative cost of specificity. Following diagnosis, the only curative option is surgical removal of the tumour. Similar investigations are employed for postoperative surveillance. Persistent urinary normetanephrine elevation after curative phaeochromocytoma resection is rare and may lead to unnecessary investigations and anxiety. Our case highlights a previously underreported cause—analytical interference from sulfasalazine—and underscores the importance of considering medication effects in postoperative biochemical surveillance. We hereby present a 73-year-old Caucasian woman with a history of rheumatoid arthritis treated with sulfasalazine, hypertension, type 2 diabetes and hypothyroidism who exhibited persistently and significantly elevated urine normetanephrine, up to 15 months following successful surgical resection of a phaeochromocytoma. This was secondary to long-term sulfasalazine use, causing gross interference with laboratory urine normetanephrine analysis without interfering with the serum normetanephrine value. Discontinuation of sulfasalazine normalised the urine normetanephrine results. This case identifies sulfasalazine as a clinically relevant source of urine normetanephrine assay interference, reinforcing the need for careful interpretation of biochemical diagnostic or surveillance results.
AIMS:Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous group of clinical entities requiring further investigation to assess aetiology. The European Society of Cardiology guidelines recommend advanced tests to establish an underlying mechanism. We evaluated advanced diagnostic testing utilization and real-world adherence to the current guideline in an international MINOCA registry. METHODS AND RESULTS:DOMINO is a prospective, multicentre, non-commercial registry enrolling 365 patients with MINOCA across 17 centres in 13 countries. Advanced testing was defined as cardiac magnetic resonance (CMR), intracoronary imaging, and/or invasive coronary functional assessment. The association between advanced testing and diagnostic resolution was assessed by multivariable logistic regression, with standard, cluster-robust, and generalized estimating equation (GEE) approaches to account for clustering by centre. Guideline-directed testing was performed in 254/365 (69.6%) and varied markedly by country (0-100%, P < 0.0001). A specific etiologic diagnosis was reached in 337/365 patients (92.3%). Advanced testing was associated with diagnostic resolution in the standard and GEE models, with a directionally consistent but non-significant cluster-robust estimate [standard odds ratio (OR) 3.94, 95% confidence interval (CI) 1.59-10.06; cluster-robust OR 3.75, 95% CI 0.95-14.72, P = 0.058; GEE OR 3.69, 95% CI 1.04-13.11]. Diagnostic resolution increased progressively with the extent of testing performed, from 85.6% with no advanced testing to 97.1% with CMR plus invasive/functional assessment (trend P = 0.02). Discharge pharmacotherapy varied significantly by etiologic diagnosis (P = 0.0001). CONCLUSION:Advanced diagnostic testing was associated with a higher likelihood of a determined etiologic diagnosis in MINOCA, despite marked international variability in its use; however, this association is partly definitional, as advanced testing directly contributes to diagnostic ascertainment for several etiologic categories. These findings nonetheless support closing the guideline-practice gap in advanced testing, while underscoring the need to distinguish mechanistically confirmed diagnoses from presumptive ones.
Takotsubo syndrome (TTS), also known as stress-induced cardiomyopathy, is a form of transient left ventricular systolic dysfunction that typically mimics acute coronary syndrome (ACS). Although increasingly recognized, its diagnosis remains challenging due to heterogeneous clinical presentations, evolving pathophysiological concepts, and significant overlap with other acute cardiac conditions. Contemporary criteria, including the InterTAK diagnostic framework, aim to refine case identification, yet distinctions from myocardial infarction, myocarditis, and other cardiomyopathies often remain blurred. Advances in multimodal imaging, biomarkers, and artificial intelligence hold promise for improving diagnostic precision. This review explores current diagnostic challenges in TTS, integrating clinical presentation, mechanistic understanding, and management implications. By bridging mimics, mechanisms, and management, we highlight the need for a nuanced, multidisciplinary approach that balances clinical vigilance with emerging diagnostic tools to optimize patients’ outcomes.
