Risk of vascular injury when screw drilling for tibial tuberosity transfer.

PURPOSE: During tibial tubercle transfer, popliteal vessels are at risk from drills and screws. The risk is around 0.11%, as described in the literature. We reviewed knee injected CT scan for analysis of the location of arteries, identified landmarks allowing minimizing risks, and defined a safe zone. MATERIAL AND METHOD: Distances between the posterior cortex and arteries were measured on CT scans from 30 adults (60 knees) at three levels (proximal part of the tibial tuberosity, 20 mm and 40 mm distally). Data were used to create a "risk map" with different angular sectors where the frequency of the presence of arteries was analyzed in each area. We also analyzed the position of 68 screws of 47 patients who underwent a medial tibial tuberosity transfer. RESULTS: The nearest distance between artery and the posterior tibial cortex was found at the level corresponding to the top of the tuberosity with less than 1 mm, while the largest distance was found at the distal level. We were able to define a safe zone for drilling through the posterior tibial cortex which allows a safe fixation for the screws. This zone corresponds to the medial third of the posterior cortex. When the safe zone is not respected, screws that overtake the posterior cortex may be close to arteries as observed for 37 of the 68 screws analyzed. CONCLUSION: We described new landmarks and recommendations to avoid this complication during tibial tuberosity transfer.

Acute peripheral arterial occlusion: prospective study evaluating intra-arterial thrombolysis with a micro-porous balloon catheter.

PURPOSE: To assess the efficacy of a new in situ thrombolysis method using a low-pressure micro-porous balloon catheter (MPBC) compared to a traditional in situ infusion (ISI) of a fibrinolytic agent in the treatment of acute limb ischemia. METHODS: Between January 2010 and December 2011, 21 patients (14 men; mean age 64.6 years, range 40-92) treated for acute lower limb ischemia were prospectively enrolled in the study. Seven patients underwent in situ thrombolysis using the ISI method and 14 patients the MPBC method to deliver urokinase. The total urokinase dose injected and the length of stay in an intermediate care unit were compared between the groups. RESULTS: Recanalization was successful in 90% of cases (6/7 patients in the ISI group; 13/14 patients in the MPBC group). The morbidity was 7% (1 pseudoaneurysm). The dose of urokinase needed was significantly lower (p<0.001) in the MPBC group (0.7±0.44 IU, range 0.15-1.6) vs. the ISI group (1.66±0.71 IU, range 0.2-2). The average length of stay in the intermediate care unit was significantly shorter in the MPBC group (1.2 vs. 3.9 days, p<0.002). The overall 6-month limb salvage rate after recanalization was 90% (83% for the ISI patients vs. 93% for the MPBC group). CONCLUSIONS: Intra-arterial thrombolysis using a balloon catheter is an effective method in the treatment of acute peripheral arterial occlusions. In the case of occlusion caused by embolism, primarily in very elderly patients, it may reduce the risk of hemorrhage. A randomized study on high-risk patients is needed to confirm these initial results.

Evaluation of balloon catheter-guided intra-arterial thrombolysis for acute peripheral arterial occlusion.

BACKGROUND: The objective of this study was to evaluate the effectiveness of a new method of in situ thrombolysis using a porous balloon with low pressure compared with traditional in situ infusion of a fibrinolytic agent in the treatment of acute limb ischemia. METHODS: Between January 2010 and December 2011, 14 patients (mean age, 67.2 years; range, 40-89 years) treated for grade II acute lower limb ischemia for fewer than 14 days were included in the study. Thromboaspiration was tried initially in all the cases. All patients benefitted from a novel method of intra-arterial thrombolysis guided with a balloon catheter (ClearWay; Atrium Medical, Hudson, NH) and using the same agent thrombolytic (Actosolv). The total amount injected, the rate of morbidity associated with the thrombolytic treatment, and the duration of hospitalization in the continuous monitoring unit were analyzed. RESULTS: Recanalization was obtained in 92% of cases (13 of 14). The rate of morbidity related to the procedure was 7%. The amount of fibrinolytic agent necessary was relatively low (82,000 units/cm of occluded artery). The rate of limb salvage 6 months after recanalization was of 92%. The mean duration of stay in the continuous monitoring unit was 1.1 day. CONCLUSIONS: Intra-arterial thrombolysis using the ClearWay balloon catheter is an effective method in the treatment of acute peripheral arterial occlusion. In the event of embolic occlusion, mainly among very old patients, it could decrease the hemorrhagic risk. A randomized study in these high-risk patients could confirm these first results.

An Unusual Presentation of Mycotic Popliteal Artery Pseudoaneurysm due to Pasteurella multocida Infection.

Pasteurella multocida , a zoonotic infectious pathogen, is a rare cause of mycotic aneurysms in human hosts. A 76-year-old man was admitted at our emergency unit for a superinfection of his right limb. The patient was initially treated for a knee arthritis. After a first-line antibiotherapy, the patient was referred to the vascular department for the management of a right acute limb ischemia. The work-up revealed a ruptured pseudoaneurysm of the popliteal artery. The ruptured artery was surgically explanted, and a femoropopliteal bypass was then performed. Pasteurella multocida was detected after bacterial analysis of the aneurysm. The postoperative course was uneventful. This case is the first reported case, to our knowledge, of a popliteal artery pseudoaneurysm due to Pasteurella multocida infection.

Long-term survival following lung surgery for cancer in high-risk patients after perioperative pulmonary rehabilitation.

OBJECTIVES: The benefits of a rehabilitation programme before lung surgical resection for cancer remain to be defined. The purpose of this observational study was to assess the efficacy of preoperative rehabilitation and postoperative rehabilitation on short- and long-term outcomes in patients who were at high operative risk. METHODS: Between January 2010 and December 2012, 20 consecutive non-operable patients (16 men and 4 women, mean age 66 years) with clinical N0 lung cancer were included. Eligibility criteria were lung function below guideline thresholds and/or associated severe comorbidities. The protocol included a cardiorespiratory perioperative rehabilitation programme. These patients were followed up at 5 years. RESULTS: The average increase in forced expiratory volume (FEV)1 and of VO2max preoperatively was 12% and 3.5 ml/kg/min, respectively. All patients underwent a pulmonary surgical resection procedure. The morbidity and mortality rates were 20% and 5%, respectively. Nineteen patients returned home upon the completion of postoperative rehabilitation. After 5-year follow-up, the Kaplan-Meier 5-year survival rate was 52%. CONCLUSIONS: Perioperative pulmonary rehabilitation seems to allow surgical management of lung cancer by lung resection in first-line, non-eligible patients. The long-term survival of operated high-risk patients is encouraging despite the high complication rate.

Complete thoracoscopic lobectomy for cancer: comparative study of three-dimensional high-definition with two-dimensional high-definition video systems †.

OBJECTIVES: Common video systems for video-assisted thoracic surgery (VATS) provide the surgeon a two-dimensional (2D) image. This study aimed to evaluate performances of a new three-dimensional high definition (3D-HD) system in comparison with a two-dimensional high definition (2D-HD) system when conducting a complete thoracoscopic lobectomy (CTL). METHODS: This multi-institutional comparative study trialled two video systems: 2D-HD and 3D-HD video systems used to conduct the same type of CTL. The inclusion criteria were T1N0M0 non-small-cell lung carcinoma (NSCLC) in the left lower lobe and suitable for thoracoscopic resection. The CTL was performed by the same surgeon using either a 3D-HD or 2D-HD system. Eighteen patients with NSCLC were included in the study between January and December 2013: 14 males, 4 females, with a median age of 65.6 years (range: 49-81). The patients were randomized before inclusion into two groups: to undergo surgery with the use of a 2D-HD or 3D-HD system. We compared operating time, the drainage duration, hospital stay and the N upstaging rate from the definitive histology. RESULTS: The use of the 3D-HD system significantly reduced the surgical time (by 17%). However, chest-tube drainage, hospital stay, the number of lymph-node stations and upstaging were similar in both groups. CONCLUSIONS: The main finding was that 3D-HD system significantly reduced the surgical time needed to complete the lobectomy. Thus, future integration of 3D-HD systems should improve thoracoscopic surgery, and enable more complex resections to be performed. It will also help advance the field of endoscopically assisted surgery.