Fluoroscopic Control Research Articles

Comparison of safety and efficacy of image-guided enema reduction techniques for paediatric intussusception: A review of the literature.

There is variable international practice regarding the technique used for image-guided enema reduction in paediatric intussusception. A recent meta-analysis found pneumatic reduction to be more effective than hydrostatic techniques. Clinical practice variation may impact on perforation rates, ionizing radiation exposure and requirement for surgery. The aim of this study was to review the literature regarding the efficacy and safety of fluoroscopically guided pneumatic reduction (FGPR) compared to ultrasound (US) guided intussusception reduction (USGIR) techniques for paediatric intussusception treatment. Articles were identified by searching OVID Medline on 21/02/14 and by scanning retrieved articles reference lists. The search was repeated on 30/09/15. Systematic reviews (SR) were appraised with the PRISMA critical appraisal tool. Primary studies underwent a separate critical appraisal process. Successful reductions and perforations per attempt were calculated for each study. Pooled estimates of proportions were calculated for each of these dichotomous outcomes. A SR and 42 primary studies were included in the review. No randomised control trial (RCT) study was included. Non-randomised comparative studies and non-comparative studies suggest that hydrostatic reduction under US control has a similar efficacy and safety profile to pneumatic reduction under fluoroscopic control, but USGIR data are dominated by a single large, non-comparative study performed in China. US-guided intussusception reduction should be considered an alternative to FGPR as it has similar efficacy and safety, and affords no ionised radiation exposure. However, RCT data are required to inform practice.

Swallowable Obalon Gastric Balloon for Obesity: Pilot Study

The goal of this study was to evaluate the safety and the impact on weight loss of a new swallowable gastric balloon In this prospective pilot study overweight or obese patients were included Up to two balloons were ingested under fluoroscopic control All balloons were removed by upper GI endoscopy weeks after the ingestion of the first balloon out of attempts to swallow a balloon were successful Nausea and stomach pain were the most frequent side effects Endoscopic procedures for balloon removal were uneventful Weight loss was significant at week This pilot study showed no significant side effects induced by up to two balloons and a significant weight loss

Tibial nerve neuropathy following medial opening-wedge high tibial osteotomy—case report of a rare technical complication

A 63-year-old woman developed tibial nerve injury caused by an overlong K wire and 4.5-mm cortical lag screw through the first distal hole below the osteotomy during medial opening-wedge high tibial osteotomy (HTO), leading to a lack of sensation on the sole of the foot with no disturbances in motor functions. The temporary lag screw in the first distal hole below the osteotomy is often inserted by an excessive length in order to compress the potentially fractured opposite cortex. By doing so, posterior neurovascular structures including the tibial nerve and the popliteal vessels can be injured. To avoid this type of injury during medial opening-wedge HTO, proper knee position and appropriate Hohmann retractor position in combination with meticulous insertion of the K wire or screw under fluoroscopic control are essential. In addition, our study reinforces the fact that different presentations of injury to the tibial nerve should be carefully considered in the absence of common diagnostic features, including weakness of the toe flexors and posterior tibial muscle of the leg with intractable pain.

Surgical treatment of complex proximal humeral fractures with a technique of nail and osteosuture: "NOS".

Open reduction and internal fixation of complex proximal humeral fracture represents a surgical challenge. The main objective of this procedure is to anatomically reduce the tuberosities. We propose a standardized and reproducible technique that we apply to all complex displaced 3- and 4-part fractures of patients under 50years. We use an antero-lateral trans-deltoid approach; the humeral head and the tuberosities are reduced under fluoroscopic control. The tuberosities are stabilized with an inter-tuberosity osteosuture, and we then introduce a thin and straight intra-medullary nail (Telegraph IV FH Orthopedics) at the hinge point of the humeral head. The osteosynthesis of the tuberosities is completed by 3- or 4-self-stable divergent screws in the nail. A dynamic distal locking stabilizes the humeral shaft in rotation and facilitates consolidation thanks to micro movements. The removal of the nail with an arthroscopic shoulder arthrolysis in case of stiffness is possible secondarily.

Occupational exposure in orthopedic procedures under fluoroscopic control

In interventional radiology the highest radiation doses are usually recorded for both the medical staff and the patients. Interventional procedures with X-rays are implemented in a number of medical specializations. This paper concerns the exposure of interventional teams performing orthopedic procedures under X-rays control. Doses for interventional teams were measured in the 3 Łódź hospitals. Thermoluminescent dosemeters were applied to measure the following dose equivalents: Hp(3) for eye lens, Hp(0.07) for palm skin, Hp(10) at the level of the neck without a protective shield (i.e., collar) and Hp(10) for the whole body on the front surface of the trunk (measured under the protective apron at the level of the chest). Doses for the operator who performs surgery, assisting physicians and scrub nurse were measured during 95 procedures. The highest doses were received by the operator the dose for eyes per 1 procedure did not exceed 0.1 mSv, the highest dose for hands was 1.6 mSv and the highest recorded effective dose was 0.02 mSv. On the basis of the results of measurements and their comparison with the values reported in the literature it may be concluded that the obtained results fall within the published reference range (for non-vascular procedures). This proves the compatibility of practice in the monitored Łódź hospitals with routine methodology applied in other interventional departments. The measurement results confirm that the usage of thermoluminescent dosimetry is fully adequate for the evaluation of exposure in interventional radiology and that the usage of at least 2 dosemeters for that staff is necessary. Med Pr 2017;68(2):221-227.

Anterior Opening Wedge Osteotomy of the Tibia for the Treatment of Genu Recurvatum

Pathologic genu recurvatum is defined by knee hyperextension in excess of 15 degrees and is usually asymmetric. This is a rare disease that can be related to bony, soft tissue or a combination of both. Patients with genu recurvatum commonly present with anterior knee pain, knee instability, ambulation difficulty on uneven ground, and patellofemoral instability. Anterior opening wedge osteotomy of the tibia is indicated when deformity in the sagittal plane emanates from the tibia (reversed posterior tibial slope) or a combination of tibia and soft tissue. The aim of this study is to present a surgical technique for anterior high tibial osteotomy, with indications, limitations, and review of the literature. We explain the different steps of the surgery with radiologic preoperative planning, skin incision and approach, osteotomy and fluoroscopic control, fixation, and bone grafting. Although this surgery is uncommon and difficult, the overall results in the literature are very positive and lead to increased patient satisfaction and function.

Endoscopic rendez-vous reconstruction of complete biliary obstruction

Background and study aimsComplete biliary strictures normally require surgical intervention. We describe an alternative, minimally invasive endoscopic/percutaneous rendez-vous technique for the reconstruction of complete benign biliary strictures. Patients and methodsComplete biliary strictures were reconstructed in four patients using a rendez-vous percutaneous-endoscopic or percutaneous-percutaneous route guided by fluoroscopic and visual (transillumination) control. ResultsAll four patients were treated successfully and safely with the rendez-vous technique. Complications were caused by the preliminary creation, dilatation and maturation of the percutaneous tract. ConclusionThis technique may offer a good alternative to surgical bilio-enteric anastomosis in experienced hands. The long term course of the patients treated remains to be seen.

Acromial J-bone graft on the acromion for surgical treatment of glenohumeral instability: an anatomical study.

Anterior glenohumeral instability is frequently associated with anteroinferior glenoid bone defects. One original technique has been described in the literature that incorporates a J-shaped graft from the iliac crest into the anterior glenoid rim. The main goal of the present study was to evaluate the feasibility of harvesting a J-shaped graft from the acromion that corresponds to previously described dimensions. The secondary goal was to determine the ideal harvesting site. Forty shoulders from 20 cadavers were included. Twenty grafts were harvested from the posterior acromion and 20 from the lateral acromion. The length, width and thickness of the grafts were measured. The incision was then enlarged to confirm the absence of an acromial fracture by fluoroscopic control. Harvesting a graft whose size was similar to a J-graft was successfully performed in all cases (100%) with a mean (SD) incision of 4.2 (0.3) cm. Mean (SD) harvesting time was 4.5 (0.5) minutes. Two acromial fractures were identified during lateral harvesting (10%) and none during posterior harvesting (p = 0.49). It is always possible to harvest a J-graft on the acromion. The posterior side of the acromion is the best site to harvest a graft that has the necessary size to treat glenoid bone defects.

Arthroscopic Technique for Treatment of Schatzker Type III Tibia Plateau Fractures Without Fluoroscopy

Accurate reduction and maintenance of the stability with correct implant positioning is critical for surgical treatment of tibial plateau fractures. Our technique includes an arthroscopic reduction and fixation of Schatzker type III tibial plateau fractures with a bulls-eye screw placement without fluoroscopy control. With the arthroscopic guidance, an anterior cruciate ligament drill guide is placed and a K-wire sent to the midpoint of the depressed fragment through the guide at a 40° angle to the coronal axis of the tibia. A tunnel is created with the drill over the K-wire. The depressed fragment is further augmented with gentle impacts over the K-wire. After arthroscopic reduction control, an appropriate-sized iliac graft is pushed until it is below the depressed fragment. The targeting device is adjusted at 130° so that it is parallel to the joint line and a K-wire sent through the device so that it would pass just below the graft. The graft is then supported with cannulated screws sent over the K-wire. This technique provides an arthroscopic reduction of the chondral surface and precise placement of the rafting screws without fluoroscopy.

Mitral implant of the Inovare transcatheter heart valve in failed surgical bioprostheses: a novel alternative for valve-in-valve procedures.

Reoperative procedure for the treatment of a failed mitral bioprosthesis is associated with considerable risk. In some cases, mortality is high and might contraindicate the benefit of the procedure. The minimally invasive valve-in-valve (ViV) transcatheter mitral valve implant offers an alternative less-invasive approach, reducing morbidity and mortality. The objective of this paper was to evaluate the mitral ViV approach using the Braile Inovare prosthesis. The transcatheter balloon-expandable Braile Inovare prosthesis was used in 12 cases. Procedures were performed in a hybrid operating room, under fluoroscopic and echocardiographic control. Through left minithoracotomy, the prostheses were implanted through the cardiac apex. Serial echocardiographic and clinical examinations were performed. Follow-up varied from 1 to 30 months. A total of 12 transapical mitral ViV procedures were performed. Patients had a mean age of 61.6 ± 9.9 years and 92% were women. Mean logistic EuroSCORE was 20.1%. Successful valve implantation was possible in all cases. In one case, a right lateral thoracotomy was performed for the removal of an embolized prosthesis. There was no operative mortality. Thirty-day mortality was 8.3%. Ejection fraction was preserved after the implant (66.7%; 64.8%; P = 0.3). The mitral gradient showed a significant reduction (11 mmHg; 6 mmHg; P < 0.001). Residual mitral regurgitation was not present. There was no left ventricular outflow tract obstruction. The mitral ViV implant in a failed bioprosthesis is an effective procedure. This possibility might alter prosthesis selection in the future initial surgical prosthesis selection, favouring bioprostheses. Further large trials should explore its safety.

The modern view of the radiodiagnostic methods applied for determining the position of the electrode array in cochlear implantation surgery

The objective of the present work was to overview the currently available literature publications dealing with the radiodiagnostic techniques applied to evaluate the position of the electrode array used for the purpose of cochlear implantation surgery including both the conventional methods and the recently proposed approaches. It is shown that the intraoperative control guarantees the timely identification of the possible complications and should meet both the safety criteria and the requirements for obtaining high-quality images and intraoperative usability of the surgical instruments being employed. Moreover, the intraoperative monitoring can be exercised under control of fluoroscopy as well as with the use of the portable computed radiography scanners and navigation systems. The postoperative monitoring is carried out with the use of transorbital X ray visualization, multi-slice computed tomography, cone beam computed tomography, and digital tomosynthesis. Each of the listed methods has specific advantages and disadvantages, but there is yet neither a universally recognized systematic approach to the assessment of their effectiveness nor the generally acceptable criteria for the evaluation of the image quality.

Design of a sensorized guiding catheter for in situ laser fenestration of endovascular stent

Purpose: The in situ fenestration of a standard endograft is currently limited by difficulties in targeting the fenestration site under fluoroscopic control and by the lack of a safe method to perforate the graft. Evidence in the literature suggests the use of a 3 D electromagnetic navigator to accurately guide the endovascular instruments to the target and a laser to selectively perforate the graft. The aim of this work is to provide design guidelines to develop a sensorized catheter to guide the laser tool to the fenestration site and conduct preliminary testing of the feasibility of the proposed solution.Matherials and methods: Different catheter designs were delineated starting from engineering considerations, then prototypes were preliminarily tested to collect surgeon opinions and to steer the design process toward the preferred solution reported by the user. Finally, mechanical simulations were performed with CathCAD, a design software system for the development of composite tubing for endovascular catheters.Results: Based on surgeon feedback, a 9-French steerable catheter with a stabilization system was designed. CathCAD simulations allowed us to define the construction parameters (e.g., materials and geometric constrains) for the fabrication of composite tubes with mechanical properties (flexural, axial, and torsional rigidities) compatible with target values in the literature for guiding catheters.Conclusion: The presented results preliminarily demonstrate the clinical reasonability and feasibility of the designed tool in terms of mechanical properties. Further mechanical tests and extensive in vitro clinical trials are required prior to animal testing.

Arthroscopic-assisted retrograde mosaicplasty for an osteochondral defect of the femoral head without performing surgical hip dislocation.

Osteochondral autograft transplantation (mosaicplasty) for the osteochondral defects of the femoral head is generally performed with safe dislocation of the hip joint. Here, we present a 27-year-old male patient who had a symptomatic osteochondral defect of the femoral head and underwent mosaicplasty applied by hip arthroscopy without surgical hip dislocation. The preoperative radiological evaluation showed a focal osteochondral defect on the weight-bearing surface of the femoral head. With the assistance of hip arthroscopy, the defect area was reconstructed with osteochondral plug, which was taken from the ipsilateral knee, inserted in a retrograde fashion, and positioned with the spherical surface of the femoral head cartilage under fluoroscopic and arthroscopic control. At the final follow-up (26 months postoperatively), he had full range of motion (ROM) without pain and radiographic evaluation showed near complete incorporation of the graft with preservation of the native joint space. Mosaicplasty can be applied in a retrograde fashion with the assistance of hip arthroscopy without using surgical hip dislocation and may be an alternative treatment option for the osteochondral defects of the femoral head in young patients.

Complex Proximal Humeral Fractures (Three or Four Part) with Dislocation: Outcome Analysis of Percutaneous Reduction and External Fixation

1.1.Background: The complex fractures of the proximal humerus remain dilemmas far as treatment is concerned. Although better-quality techniques of internal fixation and prosthetic replacement are introduced effectively in the field of operative fracture care, management of complex fractures of the proximal humerus for head preserving modalities in injuries involving the humeral head remains to be a major factor concerning the trauma surgeon. 1.2.Materials & Methods: Thirty nine patients with complex three or four part proximal fracture of humerus with dislocation of humeral head were treated and analyzed for results of percutaneous reduction and external fixation. All Patients were subjected to careful closed reduction under general anesthesia with optimal relaxation and fluoroscopic control followed by percutaneous external fixation of proximal humerus in optimal position. The patients were evaluated clinically and radiologically for a period till union or 10 months, whichever was earlier. One patient had an incomplete brachial plexus injury, which was yet to recover completely at the end of last follow up 10 months, with acceptable hand, elbow and shoulder function. 1.3.Results: Percutaneous reduction & external fixation to treat complex fractures of the proximal humerus produces good results, if correct re-position and biological principles are respected. Most of the patients were pain-free and the shoulders functioned well despite the severity of shoulder injury. 1.4.Conclusion: Percutaneous reduction and external fixation is a reasonable and logical approach to treat complex proximal humeral head fractures, rather than conservative treatment and before hemi-arthroplasty by prosthesis is considered, in view of the acceptable results obtained. Our study shows that complex fractures of the proximal humerus should be treated initially by head preserving procedures. The probable revascularization of the humeral head occurs by creeping substitution as the shoulder is non weight bearing joint.

Attention of Cancer Care for Totally Implantable Venous-access Ports Associate Complications the Latest 6 Years Analysis of 400 Cancer Chemotherapy Patients

Background: Regardless of the fact that we often perform totally implantable venous-access ports (TIVAPs) for cancer chemotherapy, there have been several reports regarding complications of its use in the world. The objective of this study was to summarize the TIVAPs idiopathic complications of 400 cancer chemotherapy patients in latest 6 years. The patients underwent TIVAPs in the internal jugular or subclavian vein via the seldinger techniqueunder fluoroscopic control by surgeon.We used two different devices, which were the Bard X-Port™, used from 2009 to 2012, and the Power Port™ used from 2012 to present. These devices are composed of titanium and silicone rubber port (DomePort™, Bard Inc., Salt Lake City, UT, USA) connected to an 8Fr silasticGroshong™ catheter tube. Results: Four hundred fourdevices in 400 patients, a total of 121,856 days’ insertions, with a median follow up of 388 days. There were 30 idiopathic complications. The total complication rate was 7.5% (30/400). The early complication rate was 0.75% (3/400) which reason was pneumothorax under the seldinger technique even used ultrasonic machine. The late complications consisted of eleven complete occlusions (2.75%), eight pocket infections (2%), three of pneumothorax (0.75%), two pinch-off (0.5%), two slip-off due to pedunculated breast (0.5%), one catheter-related bacteremia (0.25%), one wound dehiscence due to bevacizumab™ (0.25%), one rubber port disconnection (0.25%), and one rubber port rotation (0.25%) in pocket. Especially, we experienced 12cm length red thrombus and elevated D-dimer which possibility triggered Trousseau syndrome in parallel. Conclusion: Although there were only 7.5% (30/400) catheter-related complications with these TIVAPs, justifying its use, we have to be careful with complications such as a pinch-off, slip-off, infection, disconnection and occlusion.

Arthroscopic scapholunate posterior capsulodesis, cadaveric preliminary study comparing two techniques of fixation: Trans-osseous suture and suture anchors

Arthroscopic capsuloligamentous dorsal repair in chronic scapholunate tear (Mathoulin) has become a common surgical option. Questions remain about this technique particularly for the avulsions of the ligament on scaphoid or lunate. We propose modified procedures with 2 types of bone anchorage: trans-osseous suture and suture anchors. The aim of this study is to assess and compare the primary stabilization. Ten fresh cadaveric forearms were used. One wrist was excluded because of severe radius malunion with osteochondral lesions. Scapholunate instability was obtained by cutting scapholunate inter-osseous ligament and carpal insertions of DRC and DIC ligaments through MC portal. Bony abrasion of dorsal areas of scaphoid proximal pole and lunate dorsal horn was performed trough 6R and 1-2 portals. A 1 cm enlarged 3–4 portal was used to drill the tunnels or fix the anchors, the 3rd and 4th compartments were opened leaving the dorsal capsule unharmed. In group 1 (5 wrists), the dorsal capsule was fixed with 2 anchors (mini Pushlock, Arthrex, Napples, USA) on the abraded areas of scapoid and lunate. Each strands of the lunate anchor were knotted with each strands of the scaphoid anchor. In group 2 (4 wrists), dorsal capsule was fixed with a u-shaped fiber wire (Arthrex, Napples, USA) trans-osseous self locking stitch. Trans-osseous tunnels were drilled on scaphoid and lunate from mid carpal to radio carpal joint under arthroscopic and fluoroscopic control. Scapholunate stability was evaluated before and after the procedures using EWAS arthroscopic classification and fluoroscopic measures of scapholunate angle and diastasis. One wrist of group 2 had static instability before ligaments cutting. Except for this wrist, no static instability was found after ligaments cutting. EWAS stages were 3C to 5. In group 1, stabilization was obtained for 3 wrists. Two wrists were not stabilized (stage 3A and 4). There was an anchor loosening for one of this wrist. In group 2, procedure could not be achieved because of fracture of the scaphoid tunnel in 2 cases. The wrist with static instability was fairly stabilized (no static instability, stage 1). One wrist was only partially stabilized (stage 3C). Except for the osteochondral lesion of scaphoid in group 2, no iatrogenic lesions were observed. Trans-osseous suture is a difficult procedure and can lead to osteochondral lesions. Anchors seemed to be easier and provide sufficient primary stabilization. Secondary stabilization should be evaluated in a clinical study.

Endomyocardial biopsy via the femoral access - still safe and valuable diagnostic tool.

BackgroundThe endomyocardial biopsy has proven to be an integral diagnostic tool for surveillance of cardiac allograft rejection and identification of myocardial diseases. Nevertheless, this invasive procedure is not risk-free. This study focuses on the risk of complications and diagnostic performance of right ventricular endomyocardial biopsy (EMB).MethodsIn this single-center retrospective study, we analyzed 315 EMB procedures performed between July 2008 and May 2015 in 73 patients. All EMBs were made via the right femoral vein approach under fluoroscopic control to evaluate suspected myocarditis, unclear heart failure, unexplained cardiomyopathy, assumed infiltrative and storage disease or as a part of routine allograft rejection monitoring and clinically suspected rejection diagnosis after heart transplantation (HTx). Obtained specimens were diagnosed histopathologically by one experienced pathologist. All patients underwent a 12-lead electrocardiogram (ECG), ECG monitoring, transthoracic echocardiography before and after EMB to obtain a detailed assessment of the incidence of heart rhythm disorders, pericardial effusions or worsening valve insufficiency. Complications resulting from the procedure were classified as major or minor according to the risk of death.ResultsAmong all the 315 biopsies, 86.67% were performed in 32 patients after HTx, 3.81% in patients with myocarditis, 2.54% in patients with dilated cardiomyopathy and 1.9% in patients with amyloidosis. The overall complications rate was 1.9% (6 of 315 procedures). Major complications included perforation with pericardial tamponade requiring surgical intervention (0.64%, 2 of 315 procedures). Minor complications included: pericardial effusion (0.32%, 1 of 315 procedures), local hematoma (0.64%, 2 of 315 procedures) and right coronary artery-right ventricle fistula in HTx recipient (0.32%, 1 of 315 procedures).ConclusionsEMB is a safe procedure with low risk of serious complications and high effectiveness for the evaluation of unexplained left ventricle dysfunction and monitoring allograft rejection after HTx.

A New Technique for the Treatment of Lumbar Facet Joint Syndrome Using Intra-articular Injection with Autologous Platelet Rich Plasma

Background and Objectives: Lumbar facet joint syndrome is currently suggested to be a main source of axial low back pain, and a large portion of axial low back pain is caused by disorders in lumbar facet joints. Intra-articular injection is one of the most common treatment methods in the early clinical application. Therefore, we attempt to seek a new injectable material, autologous platelet rich plasma (PRP), to treat lumbar facet syndrome, as well as to assess its therapeutic effectiveness and safety. Study Design: A prospective clinic evaluation. Setting: The outpatient clinic of a single academic medical center. Methods: Total 19 patients with lumbar facet joint syndrome (8 men, 11 women; mean ages: 52.53 ± 6.79 years, range: 38 – 62 years) were enrolled to receive lumbar facet joint injection with autologous PRP under x-ray fluoroscopic control. Patients were followed up immediately, at one week, one month, 2 months, and 3 months following treatment, and the elements of this analysis included low back pain visual analogue scale (VAS) at rest and during flexion, Roland-Morris Disability Questionnaire (RMQ), Oswestry Disability Index (ODI), and modified MacNab criteria for the pain relief. Results: All the 19 patients completed the intra-articular injections with autologous PRP successfully. At one week after treatment, low back pain reduced significantly compared with prior to treatment both at rest and during flexion. The outcomes were assessed as “good” or “excellent” for 9 patients (47.37%) immediately after treatment, 14 patients (73.68%) at one week, 15 patients (78.95%) at one month, 15 patients (78.95%) at 2 months, and 15 patients (78.95%) at 3 months. Statistically significant differences were observed based on RMQ and a more than 10% improvement in lumbar functional capacity was observed based on ODI between pre-treatment and post-treatment. In addition, there were no severe relevant complications during the whole process of injection and follow-up period. Limitations: A control group and the curative effect observations with longer follow-up may lead to a more convincing result for our study. Conclusions: In the short-term period of 3 months, the new technique of lumbar facet joint injection with autologous PRP is effective and safe for patients with lumbar facet joint syndrome. Key words: Low back pain, lumbar facet joint syndrome, autologous platelet rich plasma, intra-articular injection

Capsulodèse scapho-lunaire sous arthroscopie, étude cadavérique préliminaire comparant 2 techniques de fixation : suture trans-osseuse et ancres

Arthroscopic capsuloligamentous dorsal repair in chronic scapholunate tear (Mathoulin) has become a common surgical option. Questions remain about this technique particularly for the avulsions of the ligament on scaphoid or lunate. We propose modified procedures with 2 types of bone anchorage: trans-osseous suture and suture anchors. The aim of this study is to assess and compare the primary stabilization. Ten fresh cadaveric forearms were used. One wrist was excluded because of severe radius malunion with osteochondral lesions. Scapholunate instability was obtained by cutting scapholunate inter-osseous ligament and carpal insertions of DRC and DIC ligaments through MC portal. Bony abrasion of dorsal areas of scaphoid proximal pole and lunate dorsal horn was performed trough 6R and 1–2 portals. A 1 cm enlarged 3–4 portal was used to drill the tunnels or fix the anchors: the 3rd and 4th compartments were opened leaving the dorsal capsule unharmed. In group 1 (5 wrists), the dorsal capsule was fixed with 2 anchors (mini Pushlock, Arthrex, Napples, USA) on the abraded areas of scapoid and lunate. Each strands of the lunate anchor were knotted with each strands of the scaphoid anchor. In group 2 (4 wrists), dorsal capsule was fixed with a U-shaped Fiber wire (Arthrex, Napples, USA) trans-osseous self locking stitch. Trans-osseous tunnels were drilled on scaphoid and lunate from mid carpal to radio carpal joint under arthroscopic and fluoroscopic control. Scapholunate stability was evaluated before and after the procedures using EWAS arthroscopic classification and fluoroscopic measures of scapholunate angle and diastasis. One wrist of group 2 had static instability before ligaments cutting. Except for this wrist, no static instability was found after ligaments cutting. EWAS stages were 3C to 5. In group 1, stabilization was obtained for 3 wrists. Two wrists were not stabilized (stage 3A and 4). There was an anchor loosening for one of this wrist. In group 2, procedure could not be achieved because of fracture of the scaphoid tunnel in 2 cases. The wrist with static instability was fairly stabilized (no static instability, stage 1). One wrist was only partially stabilized (stage 3C). Except for the osteochondral lesion of scaphoid in group 2, no iatrogenic lesions were observed. Trans-osseous suture is a difficult procedure and can lead to osteo chondral lesions. Anchors seemed to be easier and provide sufficient primary stabilization. Secondary stabilization should be evaluated in a clinical study.

Minimally invasive costotransversectomy for the resection of large thoracic dumbbell tumors

Background: Due to their important size and complex localization, the management of thoracic dumbbell tumors is challenging, frequently requiring the need for an anterior approach. Our study aims to first report the feasibility and safety of a single-stage posterior minimally invasive procedure in achieving complete resection of voluminous thoracic dumbbell tumors.Methods: We retrospectively reviewed the medical records of five consecutive patients, who underwent the minimally invasive resection of a type III thoracic dumbbell tumor in our institution between March 2007 and March 2012. There were two men and three women, with a mean age at diagnosis of 57 years (range 41–68 years). After the placement of a non-expandable tubular retractor under fluoroscopic control, a costotransversectomy was achieved. By moving the retractor in all directions, the tumor was largely exposed and resected with the cavitron ultrasonic surgical aspirator. Clinical and radiological monitoring was performed before discharge, at 6 months, 1 year and 2 years.Results: No major intraoperative complication was reported. Gross total resection was achieved in four patients. The mean operative time was 219 mins (range 75–540 mins) and the mean estimated blood loss was 230 ml (range 50–500 ml). No postoperative complication was reported. The mean length of hospital stay was 3.6 days (range 2–6 days) and all patients were discharged home. Histological analysis confirmed the diagnosis of grade 1 schwannoma in four patients and revealed a hemangiopericytoma in one patient. No tumor recurrence was noted with a mean follow up period of 46 months (range 32–54 months).Conclusion: Thoracic dumbbell tumors can be safely and completely resected using a single-stage minimally invasive procedure. The costotransversectomy can be performed through a non-expandable retractor allowing sufficient access to all parts of the tumor.