Midterm outcomes and risk stratification after endovascular therapy for patients with critical limb ischaemia due to isolated below-the-knee lesions

ObjectivesTo assess and risk stratify midterm clinical outcomes after endovascular therapy (EVT) by angioplasty only of patients with critical limb ischaemia (CLI) due to isolated below-the-knee (BTK) lesions.DesignRetrospective multicenter study.Materials and methodsBetween March 2004 and October 2010, 465 limbs (Rutherford 5 and 6: 79%) from 406 patients were studied. Overall survival, limb salvage, and re-intervention were examined out to 3 years by the Kaplan–Meier method and the log-rank test. Their independent predictors and risk stratification were analysed.ResultsPatient age was 71 ± 11 yrs, with 69% diabetics and 60% on dialysis. Mean follow-up was 18 ± 15 months. Overall survival was 76 ± 2 and 57 ± 4% at 1 and 3, years, respectively. Survival predictors were body mass index <18, non-ambulatory status and ejection fraction <45%. Two-year limb salvage rate was 80 ± 2%. Factors associated with major amputation were ulcers (Rutherford 6), diabetes mellitus, C-reactive protein>5 mg/dL, and age < 60 years. Two-year freedom from re-intervention was 66 ± 3%; age and below-the-ankle runoff number after angioplasty was negatively associated with re-intervention.ConclusionsDespite relatively high mortality and re-intervention rates, limb salvage rate was acceptable after EVT for CLI patients with isolated BTK lesions. Risk stratification allows occurrence estimation for each end point.     

Use of giant-sized flow-through venous flap for simultaneous reconstruction of dual or multiple major arteries in salvage therapy for complex upper limb traumatic injury

Background/ObjectivesSalvage repair after complex upper limb traumatic injury is surgically challenging due to underlying major arterial impairment with complicating a large-sized soft tissue defect. The purpose of this study was to evaluate the effectiveness and safety of using a giant-sized (≥100 cm²) flow-through venous flap for reconstruction of dual or multiple forearm, metacarpal, or digital arteries after complex upper limb traumatic injury.MethodsSeven patients were consecutively hospitalized for emergency salvage repair after complex upper limb traumatic injury between March 2012 and May 2014. The forearm and palmar artery defects were repaired using the calf great saphenous vein flap and the volar forearm venous flap, respectively.ResultsThe flow-through venous flap ranged from 9.5 cm × 12.0 cm to 12.0 cm × 20.0 cm (mean, 158.4 cm²) in size. The flaps and affected limbs survived uneventfully in five patients, with one patient experiencing distal flap marginal necrosis and a second patient requiring amputation of the affected limb. Computed tomography angiography showed patent vessels in all patients. The mean total active motion of the repaired fingers was 199.5° versus 258.8° for the contralateral counterpart (77.1%). The sensory return was determined to be S2 in 2 patients, S3 in 3 patients and S3+ in 1 patient. The disability scores for the arm, shoulder, and hand ranged from 4.6–18.2 (mean, 11.3), and the mean Michigan hand outcomes questionnaire score was 7.8 ± 0.9.ConclusionsThe flow-through venous flap is an effective and safe treatment alternative for salvage therapy of a ≥100-cm² complex upper limb traumatic injury with dual or multiple major arterial impairment. This technique allows simultaneous reconstruction of dual or multiple artery injuries and an extensive soft tissue defect. Serious surgical site infection remains a major safety concern and necessitates radical debridement in complicating cases.     

Calcanectomy: Avoiding major amputation in the presence of calcaneal osteomyelitis—A case series

BackgroundCalcaneal osteomyelitis is a surgical diagnosis that may be treated by local, resection or major amputation.ObjectiveTo determine the effectiveness of calcanectomy for treating calcaneal osteomyelitis.MethodWe conducted a retrospective review of patients receiving calcanectomy between 1st April 2005 and 1st October 2011 for calcaneal osteomyelitis. We reviewed these cases to determine healing, rate, microbiological analysis, length of stay, limb salvage rate and survival rate.ResultsThere were 10 patients included in this review. There were 7 with diabetes and 3 without.Mean age of group with diabetes was 64 years, of this group 5/7 healed at a mean of 64 days. Mean length of stay for this group was 49.3 ± 39.4 days. 2 patients required a transtibial amputation. Mean age of group without diabetes was 77 years, healing at a mean of 19 days. Mean length of stay for this group was 14 ± 16.8 days and all survived over 3 years. Microbiological analysis of suspected osteomyelitic bone typically isolated >4 organisms.ConclusionsCalcanectomy is a useful procedure for limb salvage. It may reduce morbidity rates for people with calcaneal osteomyelitis, those with diabetes can expect prolonged wound healing and longer length of stay.     

Factores influyentes en la respuesta al rescate con radioterapia tras prostatectomía radical

ObjectiveTo analyze the influential factors in the response in prostatectomized patients with subsequent biochemical relapse (BCR) and treated with salvage radiotherapy (RTP).Material and methodsWe analyzed 313 patients with pT2/pT3 prostate cancer who were receiving salvage therapy due to biochemical relapse (from a series of 1,310 radical prostatectomies between 1989-2012). Of the 313 patients; 159 (50.8%) only received androgen deprivation (AD), 63 (20.1%) Radiotherapy (RTP) plus concomitant AD and 91 (29.1%) only RTP. Of these, 57 (62.6%) have maintained complete response and 34 (37.4%) had failure response with post-RTP BCR.ResultsStudy of the group treated exclusively with salvage RTP. Ninety-one patients were treated with salvage RTP. Median follow-up was 6.4 years and median to recurrence 11 months. Post-RTP biochemical relapse-free survival (PRBRFS) was 68 ± 7% and 30 ± 10% in 5 to 10 years. Median PRBRFS was 7.3 years (6.3-8.3). Initial PSA (HR: 1.08; 95% CI: 1.01-1.1 P = .02) with best PSA cut-off point PSA > 20 ng/ml (HR: 13.6; 95% CI: 2.1-86 P = .005) and PSA pre-RTP (HR: 1.9; 95% CI: 1.2-3.3; P = .009), best PSA cut-off point PSA preRTP 0.92 ng/ml (HR: 4.5; 95% CI: 1.3-15.6; P = .01) showed independent influence in the response in the multivariate study. PRBRFS at 5 years, 81 ± 9% versus 58 ± 9% with initial PSA < 20 or > 20 ng/ml (P = .03). PRBRFS at 5 years, 93 ± 5% versus 53 ± 10% according to PSA pre-RTP < 0.9 or > 0.9 ng/ml (P = .02).ConclusionsIn patients treated with salvage RTP after radical prostatectomy, the preoperative PSA > 20 ng/ml and PSA preRTP > 0.92 ng/ml shows an independent influence on the response.     

Outcomes of lower limb amputees at Cotonou

BackgroundLimb amputations are responsible for disability. We studied the outcomes of lower limb amputees in our daily practice.MethodsThis prospective analytical study over 7 years (January 2009–December 2015) included 70 amputees of lower limb. They were mainly male (73%), aged on average of 42.4 ± 18.8 years. The mean time of follow- up was 3.2 ± 1.9 years. We assessed disability on balance, walking, disability in daily life for patients with prosthesis, and the socio-economic impact of the amputation. Statistical analysis was performed with Chi² and Mann-Whitney tests; a p-value ≤ 0.05 was considered statistically significant.ResultsThe average Timed Up and Go Test was 18.5 s. Class II of Pohjolainen subjects were the most recovered (37%). The mean Houghton score in the 17 fitted patients was 6.2 ± 2.0. Socially, 90% of the patients no longer practiced leisure activities, and 4/53 patients were no longer in a couple. At the economic level, 87% of patients had a decreased monthly income. Factors that bear direct correlation to functional outcome of patients were the level of amputation, and the prosthesis fitting.ConclusionLower limbs amputations entail adverse consequences at the functional and socio-economic level. Our country must review its policy on prosthetic fittings for amputees, and vote laws that involve private firms and government in socio-economic reintegration, and empowerment of these subjects.     

膝下血管成形术治疗重症肢体缺血的临床疗效

目的评价膝下经皮腔内血管成形术(PTA)治疗重症肢体缺血(CLI)的临床疗效。方法回顾性分析48例(50条患肢)接受膝下PTA治疗的下肢CLI患者,统计PTA的技术成功率、围术期并发症、PTA术后的缺血症状缓解情况、治疗血管的通畅情况和大截肢情况。结果共针对64条膝下动脉施行PTA,技术成功率为85.94%(55/64);围术期并发症发生率为12.50%(6/48)。平均随访(16.25±2.65)个月;PTA术后1、3、6、12、24、36个月的1期血管通畅率分别为92.0%、85.7%、79.0%、75.8%、59.8%、29.9%;保肢率分别为92.0%、92.0%、89.7%、86.4%、82.1%、72.9%。50条患肢中,1、3、6个月时的缺血症状缓解率分别为42.00%(21/50)、70.21%(33/47)和86.36%(38/44)。结论膝下PTA治疗CLI技术可行,安全性高,能有效缓解CLI的静息痛症状、促进肢体溃疡的愈合,避免大截肢的发生。     

Central venous occlusion in hemodialysis access: Comparison between percutaneous transluminal angioplasty alone and nitinol or stainless-steel stent placement

PurposeThe purpose of this study was to compare the primary and secondary patency rates of percutaneous transluminal angioplasty (PTA) alone with those of metallic stent placement in patients with hemodialysis access and central venous occlusion (CVO) and to compare the respective effects of nitinol and stainless-steel stents on patency.Materıals and methodsA total of 150 consecutive patients with hemodialysis access who underwent endovascular treatment for symptomatic CVO with ipsilateral functioning hemodialysis access were evaluated. There were 67 men and 83 women with a mean age of 56.2 ± 15.2 (SD) years (range: 15–86 years). The primary endovascular treatment of CVO was PTA alone. Stent placement either with nitinol or stainless-steel stents was performed as a bailout procedure. The results were analyzed on a per patient basis.ResultsTechnical success was achieved in 141/150 patients (94%). Of the 141 patients, 109 (77%) underwent PTA alone and 32 (23%) underwent stent placement. The mean number of interventions in the stent group [4.3 ± 2.5 (SD)] was significantly higher than that in the PTA alone group [2.6 ± 2.8 (SD)] (P = 0.002). The primary patency rates at 12, 24, and 60 months for the stent group (58.7%, 41.9%, and 27.9%, respectively) were significantly higher than those in the PTA alone group (42.4%, 36.3%, and 20.2%, respectively) (P = 0.036). Secondary patency rates at 12, 24, and 60 months for the stent group (87.6%, 80.7%, and 50.3%, respectively) were significantly greater than those in the PTA alone group (68.4%, 56%, and 38.6%, respectively) (P = 0.046). Furthermore, the primary patency rates at 6 and 12 months in the nitinol stent group (89% and 80.9%, respectively) were significantly greater than those in the stainless-steel stent group (78.8% and 38.4%, respectively) (P = 0.007). The secondary patency rates at 6, 12 and 24 months for the nitinol stent group (92.8%, 87.7% and 65.8%, respectively) were significantly greater than those in the stainless-steel stent group (85.7%, 76.2% and 65.3%, respectively) (P = 0.011).ConclusıonAlthough PTA alone is an effective interventional treatment strategy of CVO in short term, stent placement yields greater primary and secondary patency rates in the long-term. But the mean number of interventions per vein after stenting is significantly higher. Close follow-up and multiple re-interventions are necessary to ensure long-term patency.     

Percutaneous Endovascular Treatment of Innominate Artery Lesions: A Single-centre Experience on 77 Lesions

PurposeTo assess primary success and safety of percutaneous transluminal angioplasty and/or stenting of innominate artery lesions and to compare its 30-day stroke/mortality level with the literature data.MethodsA total of 72 patients (77 stenoses, five recurrent, 58 symptomatic and 39 female) with seven innominate vessel occlusions, nine subocclusive lesions and 61 significant (>60%) stenoses of innominate artery treated between 2000 and 2009 were retrospectively reviewed. With the exception of seven, all procedures were performed using a transfemoral approach. A stent was implanted in 49 (63.6%) cases. Follow-up included neurological examination, carotid duplex scan and office/telephone interview.ResultsPrimary technical success was 93.5% (72/77). There was neither periprocedural (<48 h) death, nor major neurological complication. Minor periprocedural neurological complications consisted of 2/72 (2.6%) ipsilateral TIAs. Access site complications included 4 (5.2%) access site bleedings. Follow-up was achieved in 65/72 (90.3%) of all patients and 68 (88.3%) of all procedures for a mean of 42.3 months and revealed neither major neurological complication, nor additional TIA.The cumulative primary patency rate was 100% at 12 months, 98 ± 1.6% at 24 months, and 69.9 ± 8.5% at 96 months. The cumulative secondary patency rate was 100% at 12 and at 24 months, and 81.5 ± 7.7% at 96 months. Log-rank test showed no significant difference (p = 0.79) in primary cumulative patencies between PTA alone (n = 28) or PTA/stent (n = 49).ConclusionTransfemoral PTA with or without stent appears to be a safe treatment option for innominate artery lesions.     

The “Road to Union” protocol for the reconstruction of isolated complex high-energy tibial trauma

IntroductionThe purpose of this study was to describe a standardized staged approach, “The Road to Union”, for the reconstruction of isolated complex tibial trauma, both acute and chronic in nature.MethodsThis retrospective study included all patients treated for complex tibial trauma at a specialized limb reconstruction centre, including acute open fracture as well as infected and aseptic non-unions. This standardized approach includes eight specific steps, employed in sequence. The time in external fixation (EFT), the external fixation index (EFI), and the distraction consolidation index (DCI) were the primary outcome measures. The relationship between EFI and DCI was assessed using Pearson’s moment correlations.ResultsThirty-two patients with a mean age of 34.7 ± 14.2 years were included; 12 were treated for complex open tibial fractures with bone loss, 13 for infected non-unions, and 6 for aseptic non-union. The mean bone defect was 66 ± 32 mm. The total EFT was 42.5 ± 14.8 weeks; the EFI measured 51.9 ± 25.3 days/cm, and the DCI measured 48.3 ± 21.4 days/cm. Union was achieved in 29 out of 32 patients (91%), and there was a strong and significant relationship between EFI and DCI (r = 0.92, p = 0.0001) measurements. Pin site infections were observed in 11 patients, and 3 patients had persistent non-union. Three patients underwent delayed amputations when reconstructive procedures were unable to achieve union.ConclusionThe findings of this study demonstrate that a standardized staged treatment protocol of debridement, circular external fixation, soft-tissue management, distraction osteogenesis, and functional rehabilitation can result in a high rate of union in cases of complex tibial trauma, both acute and chronic in nature.Level of evidenceLevel IV; case series     

Epidemiologic data of trauma-related lower limb amputees: A single center 10-year experience

ObjectiveThe aim of this study is three fold: 1) to introduce epidemiologic data of patients with trauma-related amputations as a 10-year experience of a rehabitation center; 2) to determine comorbidities and secondary conditions of lower limb loss; 3) to determine the rehospitalization reasons for lower limb amputee patients.Materials and methodsThis retrospective study was conducted in a tertiary rehabilitation center in Turkey. Clinical and demographic data of amputees including sex, age, employment status, time since amputation, time after amputation to first hospitalization, length of hospitalization, how many times the patient was hospitalized, reason for hospitalization, stump complications, comorbid conditions, amputation level and K classifacation were documented.ResultsThree hundred ninetynine patients with a mean age of 23,48 ± 6,04 (4–74) years were included in this study. Mean duration after amputation was 119,71 ± 68,86 months. Patients were 3,43 ± 2,53 times hospitalized. Landmine explosion was the most common etiology of amputation with 370 patients (92.7%). Below knee amputation was the most common amputation level with 230 (50,77%) amputations. 399 patients were hospitalized 1369 times and the most common hospitalization reason were stump complications (356 times, 26,00%). Spur formation (202 times) was the most common stump complications. Pyscologic disorders were the most common comorbidity with 68 patient (37,56%).ConclusionPatients with traumatic limb amputations are likely to experience several complications and comorbidities. Prevention of secondary conditions affecting those living with the loss of a limb is an important part of amputee rehabilitation and may prevent rehospitalization.     

Ibrutinib suppresses alloantibody responses in a mouse model of allosensitization

BackgroundIbrutinib is a Bruton's tyrosine Kinase (BTK) antagonist that inhibits B cell receptor (BCR) signaling. Complete BTK deficiency is associated with absence of B-cells. Ibrutinb is currently approved by FDA for treatment of B-cell malignancies, including Waldenström macroglobulinaemia. We recently carried out studies to determine if ibrutinib could modify alloantibody responses.Materials and methodsA mouse model of allogenic sensitization using a C57BL/6 mouse as the recipient of a skin allograft from an HLA-A2 transgenic mouse was utilized to examine the effects of ibrutinib on alloantibody responses and B cell effector functions. Donor-specific antibody (DSA) levels were measured in a flow-cytometric antibody binding assay. Splenic T and B cell subsets and plasma cells were analyzed in flow cytometry.ResultsControl mice developed peak levels of DSA IgM at day 14 PTx while the ibrutinib treated mice had significantly lower levels of DSA IgM (p = 0.0047). Control mice developed HLA.A2-specific IgG antibodies at day 14 (230 ± 60 MFI) and reached peak levels at day 21 (426 ± 61 MFI). In contrast, mice in the treatment group had low levels of HLA.A2-specific IgG at day 14 (109 ± 59 MFI, p = 0.004) and day 21 (241 ± 86 MFI, p = 0.003). FACS analysis found a reduction of B220⁺ or CD19⁺ B cell population (p < 0.05). In addition, ibrutinib attenuated recall DSA IgG responses to re-sensitization (p < 0.05) and reduced CD38⁺ CD138⁺ plasma cells (p < 0.05) in the spleens.ConclusionsIbrutinib is effective in suppressing alloantibody responses through blocking BTK-mediated BCR signaling, leading to reduction of B cells and short-lived plasma cells in the spleens. Use of ibrutinib may provide benefits to HLA-sensitized transplant patients for alloantibody suppression.     

The use of cell salvage in women undergoing cesarean hysterectomy for abnormal placentation

BackgroundAlthough transfusion of autologous blood obtained from cell salvage has increased, its role in obstetric practice remains controversial. This case series reports the use of cell salvage in an attempt to avoid allogeneic transfusion in women undergoing cesarean hysterectomy for placenta accreta.MethodsThis prospective observational study, conducted in a large public maternity hospital, included 41 women with an antenatal diagnosis of placenta accreta, of whom 20 underwent cesarean hysterectomy and 15 received autologous blood after cell salvage. Intraoperative cell salvage was used for autologous blood transfusion, and salvaged blood was monitored for prewash and postfiltration squamous cells, fetal hemoglobin, and potassium concentration. Pre- and postoperative hemoglobin, platelet count and coagulation profile were compared.ResultsTwenty women underwent caesarean hysterectomy. Cell-salvaged blood was collected in 18 women and re infused in 15 women (83.3%). The mean volume of reinfused salvaged blood was 1476 ± 247 mL. Mean potassium concentrations (1.4 ± 1.2 versus 3.7 ± 0.42 mEq/L) and median squamous cell counts (0 [0–1] versus 8 [3–12]/high power field) were significantly lower postfiltration compared to prewash values. There were no instances of intraoperative or postoperative amniotic fluid embolism, hypotension, sepsis or coagulopathy. Of the 15 women who received autologous blood, 13 (86.7%) did not require allogeneic red blood cell transfusion.ConclusionsAutologous transfusion of salvaged blood can be used to minimize allogeneic transfusion in women undergoing cesarean hysterectomy for placenta accreta.     

Combined subtalar distraction arthrodesis with peroneus brevis tenotomy for posttraumatic subtalar arthritis

BackgroundSubtalar distraction arthrodesis is advocated as a salvage procedure for isolated posttraumatic subtalar arthritis. This study aimed at evaluating combined subtalar distraction arthrodesis with peroneus brevis tenotomy for such cases.MethodsTwenty patients with isolated posttraumatic subtalar arthritis managed by combined subtalar distraction arthrodesis and peroneus brevis tenotomy were reviewed for a retrospective study. The American orthopaedic foot and ankle society [AOFAS] hindfoot scoring, talocalcaneal height [TCH], talocalcaneal angle [TCA] and heel valgus angle [HVA] were used for both pre and postoperative assessments.ResultsThe mean postoperative [TCH] [70.3 ± 1.9 mm] was statistically better than the preoperative value [64.7 ± 2.2 mm] [p < 0.001]. There was a statistically significant decrease in [HVA] [p < 0.001]. On the contrary, there was a statistically significant increase in both [AOFAS] hindfoot scoring and the [TCA] [p < 0.001].ConclusionsApplying this technique for isolated posttraumatic subtalar arthritis with peroneal tendinitis improved both lateral retromalleolar swelling and deformity correction.     

Is There a Benefit of Frequent CT Follow-up After EVAR?

ObjectiveImaging follow-up (FU) after endovascular aneurysm repair (EVAR) is usually performed by periodic contrast-enhanced computed tomography (CT) scans. This study aims to evaluate the effectiveness of CT-FU after EVAR.MethodsIn this study, 279 of 304 consecutive patients (261 male, aged 74 years (interquartile range (IQR): 70–79 years) with a median abdominal aortic aneurysm (AAA) diameter of 58 mm (IQR: 53–67 mm)) underwent at least one of the yearly CT scans and plain abdominal films after EVAR. All patients received Zenith stent-grafts for non-ruptured AAAs at a single institution. Patients were considered asymptomatic when a re-intervention was done solely due to an imaging FU finding. The data were prospectively entered in a computer database and retrospectively analysed.ResultsAs a follow-up, 1167 CT scans were performed at a median of 54 months (IQR: 34–74 months) after EVAR. Twenty-seven patients exhibited postoperative AAA expansion (a 5-year expansion-free rate of 88 ± 2%), and 57 patients underwent 78 postoperative re-interventions with a 5-year secondary success rate of 91 ± 2%. Of the 279 patients, 26 (9.3%) undergoing imaging FU benefitted from the yearly CT scans, since they had re-interventions based on asymptomatic imaging findings: AAA diameter expansion with or without endoleaks (n = 18), kink in the stent-graft limbs (n = 4), endoleak type III due to stent-graft limb separation without simultaneous AAA expansion (n = 2), isolated common iliac artery expansion (n = 1) and superior mesenteric artery malperfusion due to partial coverage by the stent-graft fabric (n = 1).ConclusionsLess than 10% of the patients benefit from the yearly CT-FU after EVAR. Only one re-intervention due to partial coverage of a branch by the stent-graft would have been delayed if routine FU had been based on simple diameter measurements and plain abdominal radiograph. This suggests that less-frequent CT is sufficient in the majority of patients, which may simplify the FU protocol, reduce radiation exposure and the total costs of EVAR. Contrast-enhanced CT scans continue, nevertheless, to be critical when re-interventions are planned.     

High plateletcrit is associated with early loss of patency after open and endovascular interventions for chronic limb ischemia

ObjectivePlateletcrit (PCT) reflects the total platelet mass in blood and can be calculated from a complete blood count. We examined the effect of PCT on outcomes of endovascular and open interventions for chronic limb ischemia.MethodsPatients who underwent revascularization for chronic limb ischemia (Rutherford categories 3-6) between June 2001 and December 2014 were retrospectively identified. PCT on admission was recorded. Patients and limbs were divided into tertiles of low (0.046-0.211), medium (0.212-0.271), and high (0.272-0.842) PCT. Patency, limb salvage, major adverse limb events, major adverse cardiac events, and survival rates were calculated using Kaplan-Meier analysis and compared with log-rank test. Cox regression analysis was used for multivariate analysis.ResultsA total of 1431 limbs (1210 patients) were identified and divided into low PCT (477 limbs in 407 patients), medium PCT (477 limbs in 407 patients), and high PCT (477 limbs in 396 patients) groups. The patients in the high tertile were 2 years older that the patients in the other two tertiles (P = .009). Five-year primary patency was 65% ± 3% in the low-PCT group compared with 55% ± 3% and 51% ± 3% in the medium and high PCT groups, respectively (P = .004). Five-year secondary patency was 81% ± 2% in the low PCT group compared with 82% ± 2% and 72% ± 3% in the medium and high PCT groups, respectively (P = .02). Five-year limb salvage rate was 86% ± 2% in the low PCT group compared with 79% ± 3% and 74% ± 3% in the medium PCT and high PCT groups, respectively (P = .004). Multivariate regression analysis showed that low PCT was independently associated with primary patency after endovascular interventions (hazard ratio, 0.67 [0.47-0.95]; P = .02) but not after open interventions (hazard ratio, 0.72 [0.43-1.21]; P = .21).ConclusionsHigh PCT is associated with poor patency and limb salvage rates after interventions for lower extremity chronic limb ischemia. Multivariate regression analysis confirmed association of low PCT with improved primary patency after endovascular interventions but not after open interventions. High PCT may be a marker of increased platelet reactivity and could be used to identify patients at high risk for early thrombosis and failure after interventions.     

Duplex Ultrasound Scanning of Peripheral Arterial Disease of the Lower Limb

ObjectivesTo assess the reliability and applicability of duplex ultrasound scanning (DUS) of lower limb arteries, compared with digital subtraction angiography (DSA), in patients with peripheral arterial disease (PAD).DesignA prospective, blinded, comparative study.Materials and methodsA total of 169 patients were examined by DUS and DSA. Intermittent claudication (IC) was present in 42 (25%) patients and critical limb ischaemia (CLI) in 127 (75%) patients. To allow segment-to-segment comparison, the arterial tree was divided into 15 segments. In total, 2535 segments were examined using kappa (κ) statistics to test the agreement.ResultsThe agreement between DUS and DSA was very good (κ > 0.8) or good (0.8 ≥ κ > 0.6) in most segments, but moderate (0.6 ≥ κ > 0.4) in the tibio-peroneal trunk and the peroneal artery. Agreement between the two techniques was significantly better in the supragenicular (κ = 0.75 (95% confidence interval (CI): 0.70–0.80)) than in the infragenicular segments (κ = 0.63 (0.59–0.67)) (p < 0.001). Similarly, the technical success rate was significantly higher in the supragenicular segments (DUS: 100%; DSA: 99%) than in the infragenicular segments (both 93%) (p < 0.001). DUS was the best technique for imaging of the distal crural arteries (92% vs. 97%; p < 0.001) and DSA was the best technique for imaging of the proximal crural arteries (95% vs. 91%; p < 0.01). Neither the agreement nor the technical success rate was influenced by the severity of PAD, that is, IC versus CLI.ConclusionThe agreement between DUS and DSA was generally good, irrespective of the severity of ischaemia. DUS performed better in the supragenicular arteries than in the infragenicular arteries. However, DUS compared favourably with DSA in both tibial vessels, particularly in the distal part, which makes DUS a useful non-invasive alternative to DSA.     

Bloqueo axilar ecoguiado frente a bloqueo infraclavicular ecoguiado para la cirugía de miembro superior

BackgroundMost upper limb regional anaesthesia techniques are successful, and differences in efficacy should dictate the choice of technique.MethodsThis prospective, randomised study compares ultrasound-guided infraclavicular (IB) and ultrasound-guided axillary brachial plexus blocks (AB) for upper limb surgery. Anaesthesia time (performance time and onset time) was the primary outcome measure. The success rate (surgical anaesthesia), analgesia duration, postoperative pain scores, and the incidence of complications over the following 24 h were recorded.ResultsA total of 82 patients were included in the study, and received either IB (n = 42) or AB (n = 40). No differences were observed between the 2 groups in terms of total anaesthesia-related time, performance time, success rate (90-95%), or postoperative pain scores. Compared with the infraclavicular approach, ultrasound-guided AB group required a longer onset time, 10.2 min (SD ± 1.4), than IB group, 6.35 min (SD ± 2). IB was also associated with a longer analgesia duration than that of AB; 20 h (SD ± 1.36) versus 13.70 h (SD ± 2.16), respectively. The only complications we observed were uneventful vascular punctures.ConclusionsWe can conclude that compared to ultrasound-guided AB, ultrasound-guided IB provides a similar efficacy, a shorter onset time and longer lasting analgesia.     

Early results of minimally invasive,reverse-oblique,distal metaphyseal metatarsal osteotomy (R-DMMO) for arthritis of the lesser tarsometatarsal joints — A retrospective case series

BackgroundArthrodesis is the gold standard for operative management of osteoarthritis of the lesser tarsometatarsal joints (TMTJs) but is not without complications. Our early results of a minimally invasive alternative treatment – the reverse-oblique distal metaphyseal metatarsal osteotomy (R-DMMO) are described.MethodsThis is a single-centre, single-surgeon, retrospective series of patients with isolated, symptomatic lesser TMTJ arthrosis who underwent R-DMMO.ResultsSixteen feet in 15 patients were included. The mean age was 64.7 ± 9.7 years and mean duration of follow-up was 109.4 ± 27.4 weeks. There were no non-unions, infections or wound complications. Two patients developed transfer symptoms to their first metatarsal, one of these patients improved after three months. There was one delayed union which united at 12 months. Two patients developed recurrence of symptoms but felt that they were still improved compared to preoperatively and no patient has required arthrodesis thus far. The mean preoperative VAS was 8.3 ± 1.3 and the mean postoperative VAS was 2.4 ± 2.2 (P < 0.001). The mean postoperative MOxFQ-Walking was 25.2 ± 25.6, MOxFQ-Pain was 24.8 ± 20.5, MOxFQ-Social was 18.4 ± 19.1, and MOxFQ-Index was 23.4 ± 20.6. Eight patients were ‘very satisfied’ and seven were ‘satisfied’ with the procedure.ConclusionsR-DMMO is a minimally invasive and safe procedure for lesser TMTJ arthrosis which can produce good results and prevent, or at least delay, the need for arthrodesis without compromising future operative options. Good to excellent outcomes have been shown with few significant complications in the short term in selected patients.     

Salvage of upper extremities with humeral fracture and associated brachial artery injury

BackgroundHumeral fractures with brachial artery injury present a challenge for treating surgeons. Treatment practices vary, including use of vascular shunts, multispecialty teams versus an upper-extremity surgeon, and temporizing external fixation. Our objectives were to describe our treatment approach, to define “absolute ischaemia,” to determine whether to use a vascular shunt, and to identify variables that could improve limb salvage rate.MethodsWe conducted a retrospective study of 38 patients with humeral fracture and brachial artery injury from 1999 through 2012 at a level I trauma centre. Demographic and treatment characteristics were compared between blunt and penetrating injuries and between treatment by multispecialty teams and treatment by an upper-extremity surgeon. We investigated other variables of interest, including immediate internal fixation, shunt use, time to brachial artery repair, and flap coverage. This study focused on immediate limb salvage and not on eventual functional outcomes of the limb or patient satisfaction regarding the extremity. The main outcome measure was salvage versus amputation.ResultsThirty-six upper extremities were successfully salvaged, and two underwent eventual amputation. Immediate internal fixation (33 of 38 patients) did not have an adverse effect on the rate of successful limb salvage (p > .05). Shunt use and treatment by an upper-extremity surgeon were not associated with improved salvage rate (p > .05). The need for flap coverage was significantly associated with failed salvage of the extremity (p = .02).ConclusionsSalvage of the upper extremity with humeral fracture and associated brachial artery injury is not dependent on time to brachial artery repair, shunt use, or specialty of treating surgeon. Immediate internal fixation can be performed without adversely affecting the potential for successful salvage. Flap coverage, which is an indicator of severity of soft-tissue injury, correlates with amputation in these severe injuries.Type of study/level of evidenceTherapeutic III.