Acute Pain Management in a Multi-site Trauma Patient.

Pain management is often difficult in the setting of multi-site trauma such as that caused by motor vehicle accidents (MVA), which is especially compounded in the setting of polysubstance abuse. This often results in patients with poor pain tolerance requiring escalating doses of opioid therapy, which creates a vicious cycle. The use of peripheral nerve blocks (PNB) has been shown to decrease overall opioid consumption and can be used effectively to manage postoperative pain in this patient population. Our case report aims to highlight the importance of PNBs as part of a multimodal approach to pain management in patients with polytrauma in the setting of polysubstance abuse.

Comparative study of two different access points, one tibial vein and the popliteal vein, for catheter-directed thrombolysis in the treatment of acute mixed lower extremity deep vein thrombosis 1.

BACKGROUND: Although the popliteal vein approach is commonly used for catheter-directed thrombolysis (CDT) treatment in patients with acute lower extremity deep vein thrombosis (DVT), CDT via a new access route, the posterior tibial vein, is also used and has demonstrated good results. However, this tibial approach has not been tested in large samples. OBJECTIVE: To compare the early efficacy of CDT using the tibial and popliteal vein approaches for the treatment of acute mixed lower extremity DVT. METHODS: In this retrospective cohort study, 87 patients with acute mixed lower extremity DVT treated at the Department of Interventional Medicine of Zhuhai People's Hospital were enrolled; those with tibial vein access and popliteal vein access were included in the observation (n = 55) and control (n = 32) groups, respectively. The safety and efficacy of CDT via tibial vein access were investigated by collecting and comparing indicators such as venous patency, thrombus removal effect, thigh and calf circumference difference, swelling reduction rate of the affected limb, surgical complications, and post-discharge complication rate of the patients in the two groups. RESULTS: The postoperative thrombus clearance effect of the observation group was significantly better than that of the control group (P < 0.05), and the postoperative venous patency rate of the observation group was 83.2 ± 15.7%, which was higher than that of the control group (62.2 ± 38.2%) (P = 0.005). The swelling reduction rate of the lower extremity was 74.0 ± 33.8% in the observation group and 51.4 ± 30.0% in the control group, with a statistically significant difference (P = 0.002). However, there was no statistically significant difference (P > 0.05) in the rates of thigh swelling reduction, bleeding-related complications, or postoperative complications between the two groups of patients. CONCLUSIONS: CDT via the tibial vein approach is safe, effective, and may be a better approach for CDT access, offering superior thrombus clearance, venous patency, and lower extremity swelling reduction postoperatively.

Femoro-popliteal endovascular interventions.

Peripheral artery disease (PAD) is a worldwide major health challenge, and it is a strong predictor of mortality and morbidity. The advances in PAD treatment have resulted in many therapeutic options or endovascular interventions (EVIs) for endovascular revascularization if drug therapy does not lead to substantial improvement. Randomized controlled trials (RCTs) have reported the efficacy of various EVIs such as atherectomy, stents, and medicated balloons over the traditional transluminal angioplasty; however, the standard treatment for PAD remains unclear due to the lack of head-to-head comparative studies between different EVIs. Additionally, the variable outcomes between clinical trials regarding the functional capacity and quality of life (QoL) make it difficult to ascertain the superiority of one particular EVI over another. Therefore, the latest PAD clinical trials should include head-to-head comparisons between different EVIs, and this review aimed to highlight the femoro-popliteal EVIs, evidence supporting each intervention and why those EVIs are used.

Residual Popliteal Aneurysm Perfusion Leading to Embolic Complications: A Case Report.

Introduction: Surgical management of popliteal artery aneurysms has been described for half a century. Long term development of the excluded aneurysm sac in the popliteal segment however remains widely unknown, with only a few small series describing outcomes. Residual aneurysm perfusion has the potential to lead to serious complications. Report: A 63 year old man presents with skin and soft tissue necrosis of the right calf two years after proximal and distal aneurysm ligation and great saphenous vein bypass for a popliteal artery aneurysm. Computed tomography and magnetic resonance angiography show perfusion of the excluded aneurysm as well as extensive necrosis of the gastrocnemius muscle. Direct angiography of the aneurysm demonstrated retrograde aneurysm perfusion due to insufficient distal ligation with recurrent micro-embolisation to the calf via geniculate arteries. Coiling of the geniculate arteries was performed, plugging the connection to the tibiofibular trunk and embolisation of the aneurysm sac. After the intervention, no flow was seen in the aneurysm sac and the patient made full recovery. Discussion: Residual aneurysm sac perfusion can lead to complications long after successful aneurysm exclusion. Follow-up after surgery of popliteal aneurysms should include observation of the excluded aneurysm sac with control of residual blood flow. For persistent sac perfusion, aneurysm enlargement or symptoms, further treatment should be considered. Surgical aspects such as complete transection of the artery after aneurysm ligation or end to end anastomosis of the bypass may be considered, to prevent such complications.

Measured distance from posterior tibia to popliteal artery increases with flexion and subluxation of the knee.

Purpose: Popliteal artery laceration is a devastating complication in total knee arthroplasty (TKA). Its anatomic position relative to the tibia has been studied using ultrasound or magnetic resonance imaging. This is the first study performed in a laboratory using radiographic measurements to determine if increased flexion and subluxation of the knee increase the distance between the tibia and popliteal artery. Methods: The femoral artery was infused with radiopaque dye in six cadavers. The knee was placed in two different degrees of flexion and three of subluxation. The radiographic distance between standardized markers in the posterior tibia and popliteal artery was measured. Results: The average distance from the tibial peg to the popliteal artery at 90° of flexion increased from 0% to 50% to 100% subluxation. The increase was statistically significant (Friedman test p = 0.016). The contrast between neutral and 100% subluxation was statistically significant (Sign test p = 0.031). At 115° flexion, average distance from the peg to popliteal artery significantly increased as subluxation increased (Friedman test p = 0.05). In three specimens, at 115° of flexion and 100% subluxation, a line perpendicular to the axis of the tibia, failed to intersect the popliteal artery. The measured distance increased from 90° to 115° of flexion at a given degree of subluxation, but this difference did not reach statistical significance. Conclusions: Increasing flexion and subluxation of the tibia results in increasing distance between the cut plane of the tibial plateau and popliteal artery and decreases risk of laceration. Level of Evidence: Not applicable.

Efficacy of adding infiltration between the popliteal artery and the capsule of the posterior knee (IPACK) to adductor canal block and local infiltration analgesia in total knee arthroplasty: A retrospective cohort study.

OBJECTIVE: Local infiltration analgesia (LIA), adductor canal block (ACB), and infiltration between the popliteal artery and the capsule of the posterior knee (IPACK) are popular multimodal analgesia techniques used during total knee arthroplasty (TKA). This study aimed to explore the efficacy of adding the IPACK technique to ACB and LIA in patients undergoing TKA. METHODS: In this retrospective cohort study, patients who underwent primary unilateral TKA were divided into two groups based on their date of admission. Sixty-three patients underwent IPACK, ACB and LIA (IPACK group) during surgery, while 60 patients underwent ACB and LIA (control group). The primary outcome was the postoperative administration of morphine hydrochloride as a rescue analgesic. Secondary outcomes included time to first rescue analgesia, postoperative pain assessed using the visual analog scale (VAS), functional recovery assessed by knee range of motion and ambulation distance, time until hospital discharge, and complication rates. RESULTS: The two groups were similar in average postoperative 0-to-24-h morphine consumption (11.8 mg for the control group vs 12.7 mg for the IPACK group, p = .428) and average total morphine consumption (18.2 mg vs 18.0 mg, p = .983) during hospitalization. There were also no significant differences in the secondary outcomes. CONCLUSIONS: The addition of IPACK to ACB and LIA did not provide any clinical analgesic benefits. Orthopedic surgeons and anesthesiologists are justified in using ACB and LIA without IPACK for TKA.

An in-vitro three-dimensional surgical simulation technique to predict tibial tunnel length in transtibial posterior cruciate ligament reconstruction.

BACKGROUND: During the transtibial posterior cruciate ligament (PCL) reconstruction, drilling depth excessively longer than the tibial tunnel length (TTL) is an important reason to cause popliteal neurovascular bundle injury when preparing the tibial tunnel. This study aims to develop an in-vitro three-dimensional surgical simulation technique to determine the TTL in anteromedial (AM) and anterolateral (AL) approaches. METHODS: A total of 63 knees' 3-dimensional (3D) computed tomography models were included in this study. The SuperImage system was used to reconstruct the 3D knee model and locate the tibial PCL site. The established 3D knee model and the coordinates of the tibial PCL site were imported into Rhinoceros 3D modeling software to simulate AM and AL tibial tunnel approaches with different tibial tunnel angles (TTA). The TTL and the tibial tunnel height (TTH) were measured in this study. RESULTS: In AM and AL tibial tunnel approaches, the TTL showed a strong correlation with the TTA (for AM: r = 0.758, p < 0.001; for AL: r = 0.727, p < 0.001). The best fit equation to calculate the TTL based on the TTA was Y = 1.04X + 14.96 for males in AM approach, Y = 0.93X + 17.76 for males in AL approach, Y = 0.92X + 14.4 for females in AM approach, and Y = 0.94X + 10.5 for females in AL approach. CONCLUSION: Marking the TTL on the guide pin or reamer could help to avoid the drill bit over-penetrated into the popliteal space to damage the neurovascular structure.

Exploring the Effects of Local Air Pollution on Popliteal Artery Aneurysms.

Objectives: A growing body of evidence highlights the effects of air pollution on chronic and acute cardiovascular diseases, such as associations between PM10 and several cardiovascular events. However, evidence of the impact of fine air pollutants on the development and progression of peripheral arterial aneurysms is not available. Methods: Data were obtained from the multicenter PAA outcome registry POPART and the German Environment Agency. Means of the mean daily concentration of PM10, PM2.5, NO2, and O3 concentrations were calculated for 2, 10, and 3650 days prior to surgery for each patient. Additionally, weighted ten-year averages were analyzed. Correlation was assessed by calculating Pearson correlation coefficients, and regression analyses were conducted as multiple linear or multiple logistic regression, depending on the dependent variable. Results: For 1193 patients from the POPART registry, paired air pollution data were available. Most patients were male (95.6%) and received open surgical repair (89.9%). On a regional level, the arithmetic means of the daily means of PM10 between 2000 and 2022 were neither associated with average diameters nor runoff vessels. Negative correlations for mean PAA diameter and mean NO2, as well as a positive correlation with mean O3, were found; however, they were not statistically significant. On patient level, no evidence for an association of mean PM10 exposure over ten years prior to inclusion in the registry and PAA diameter or the number of runoff vessels was found. Weighted PM10, NO2, and O3 exposure over ten years also did not result in significant associations with aneurysm diameter or runoff vessels. Short-term air pollutant concentrations were not associated with symptomatic PAAs or with perioperative complications. Conclusions: We found no indication that long-term air pollutant concentrations are associated with PAA size or severity, neither on a regional nor individual level. Additionally, short-term air pollution showed no association with clinical presentation or treatment outcomes.

High-Grade Malignant Peripheral Nerve Sheath Tumor Arising From Common Peroneal Nerve Neurofibroma.

This article presents a case report of a 45-year-old male with neurofibromatosis type I (NF1) who developed a high-grade malignant peripheral nerve sheath tumor (MPNST) originating from a neurofibroma within the common peroneal nerve over popliteal fossa. MPNSTs are aggressive tumors associated with NF1, causing significant mortality. The patient underwent tumor resection surgery and received postoperative radiation therapy. Follow-up examinations showed no impairment of motor function and no tumor recurrence after regular MRI evaluation for four years. This article explores the challenges of distinguishing benign neurofibromas from malignant MPNST via MRI image and biopsy, and achieving a balance between tumor excision and preserving nerve functionality during surgical treatment. However, caution is warranted due to the risk of recurrence.

A Case of Popliteal Venous Aneurysm Diagnosed after Sudden Cardiac Arrest.

A popliteal venous aneurysm (PVA) is a rare vascular disorder. We report a case of PVA discovered through further evaluation of sudden cardiac arrest (CA) caused by a pulmonary embolism (PE). It is well-known that PVA causes PE; however, there are few reports of PVA causing CA. A tangential aneurysmectomy and lateral venorrhaphy were performed. The patient's postoperative course was uneventful. When contrast-enhanced computed tomography is performed to search for the cause of CA, PVA should be considered and thus, screening below the knee is recommended. At 1-year follow-up, there were no complications.

The role of body mass index in high- and low-velocity trauma causing knee injury associated with popliteal artery lesions.

BACKGROUND: Among arterial traumas, osteoarticular traumas are particularly dangerous, and those involving the popliteal artery are associated with a high amputation rate. Despite representing a minority of arterial traumas, with an incidence that varies considerably by population and geographic location, traumatic lesions of the popliteal artery are challenging. This study aimed to verify the impact of body mass index (BMI) on arterial trauma damage and patient outcomes. METHODS: Data were retrospectively collected from the electronic medical reports of all patients with osteoarticular and vascular associated lesions treated in the emergency operating room at our institution between 1 January 2005 and 1 May 2022. Forty-one patients presented with lower limb arterial trauma (43.2%); popliteal artery lesions occurred in 11 of these patients (26.8%), who were eligible for inclusion in the study. The lesion mechanism was dislocation by high-velocity trauma in 9 patients and dislocation by low-velocity trauma in 3 patients. All 7 males (63.6%) experienced high-velocity trauma, and 2 of the 3 females experienced low-velocity trauma. Only one patient had an isolated popliteal artery lesion associated with fractures in the leg or the contralateral limb. Patients with low-velocity trauma were older than 54 years, while those with high-velocity trauma were aged 22 to 71 years. RESULTS: In 10/11 patients (90.9%), revascularization was performed after osteoarticular stabilization and reduction of the dislocation or fracture. Intraoperative angiography was selectively used. Two patients required above-the-knee amputation after the procedure: one due to infection of the surgical access point and the other due to severe soft tissue injury. One patient died during hospitalization due to trauma-related complications and comorbidities. CONCLUSIONS: High-velocity trauma and low-velocity trauma in patients with a body mass index > 35 kg/m2 and knee lesions are associated with popliteal artery lesions. Revascularization success is not associated with high- or low-velocity trauma.

Deciphering Popliteal Artery Aneurysm Patient Diversity: Insights From a Cluster Analysis of the POPART Registry.

BACKGROUND: Popliteal artery aneurysms (PAAs) are the most common peripheral aneurysm. However, due to its rarity, the cumulative body of evidence regarding patient patterns, treatment strategies, and perioperative outcomes is limited. This analysis aims to investigate distinct phenotypical patient profiles and associated treatment and outcomes in patients with a PAA by performing an unsupervised clustering analysis of the POPART (Practice of Popliteal Artery Aneurysm Repair and Therapy) registry. METHODS AND RESULTS: A cluster analysis (using k-means clustering) was performed on data obtained from the multicenter POPART registry (42 centers from Germany and Luxembourg). Sensitivity analyses were conducted to explore validity and stability. Using 2 clusters, patients were primarily separated by the absence or presence of clinical symptoms. Within the cluster of symptomatic patients, the main difference between patients with acute limb ischemia presentation and nonemergency symptomatic patients was PAA diameter. When using 6 clusters, patients were primarily grouped by comorbidities, with patients with acute limb ischemia forming a separate cluster. Despite markedly different risk profiles, perioperative complication rates appeared to be positively associated with the proportion of emergency patients. However, clusters with a higher proportion of patients having any symptoms before treatment experienced a lower rate of perioperative complications. CONCLUSIONS: The conducted analyses revealed both an insight to the public health reality of PAA care as well as patients with PAA at elevated risk for adverse outcomes. This analysis suggests that the preoperative clinic is a far more crucial adjunct to the patient's preoperative risk assessment than the patient's epidemiological profile by itself.

Long-Term Results of Surgical Treatment for Popliteal Artery Entrapment Syndrome.

INTRODUCTION: Popliteal artery entrapment syndrome (PAES) is a rare disease of the lower limbs, mainly affecting young patients, due to extrinsic compression of the neurovascular bundle at the popliteal fossa. The aim of this study was to describe our experience during a median 15-year period. METHODS: Patients treated for PAES in our institution from 1979 to 2024 were included. Preoperative, intraoperative, and postoperative data were analyzed. RESULTS: A total of 47 patients with a total of 78 limbs were treated. Duplex ultrasound with active maneuvers was performed in all limbs (100%). Angiography was performed in almost all patients (97.4%), computed tomography angiography in 56 (71.8%), and magnetic resonance angiography in 22 (28.2%). Concerning surgical treatment, musculotendinous section was performed in 60 limbs (76.9%), and autologous venous bypass was achieved in 18 limbs (23.1%). The rates for freedom from target lesion revascularization-meaning that no significant stenosis or occlusion during follow-up required revascularization-and 15-year primary patency were 92.4% and 98%, respectively. CONCLUSION: Long-term results of surgical treatment for PAES seem to be very satisfying. Myotomy with or without arterial reconstruction using venous bypass can lead to good patency at 15 years of follow-up.

Vascular complications of tibial exostosis: A rare case of popliteal vein deep venous thrombosis.

INTRODUCTION AND IMPORTANCE: Tibial exostosis (osteochondroma) represents a prevalent benign bone tumor typically identified in young adults. Uncommonly, vascular complications can emerge, encompassing vessel perforation, thrombosis and arterial thromboembolic events. Rare instances of popliteal vein thrombosis resulting from tibial osteochondroma have been documented. CASE PRESENTATION: We report a rare case of a 25-year-old patient who presented with a red and swollen leg, and the diagnosis of deep venous thrombosis (DVT) of the left popliteal vein was established. The patient also exhibited a painless, hard swelling in the popliteal fossa. Radiography revealed an exostosis on the posterior aspect of the proximal tibia. An angioscan demonstrated close relations with the popliteal vessels, leading to venous compression. The patient underwent resection through a posterior knee approach. Histopathological analysis of the exostosis ruled out malignant transformation. CLINICAL DISCUSSION: The discussion emphasizes the need for prompt diagnostic measures when signs indicate a vascular concern in a young patient, initiating with a radiograph followed by Doppler ultrasound and/or angiography to diagnose complications and precisely delineate their relationships with the tumor. Surgical intervention is underscored as urgent, particularly in cases involving arterial thrombosis, where immediate measures such as thrombectomy or bypass with a venous graft may be necessary. CONCLUSION: Vascular complications associated with bone exostoses are rare but require prompt surgical treatment. However, it should prompt the performance of an angioscan in the presence of any abnormalities during clinical examination or an appearance raising concerns about potential vascular conflict.

Lumbar Spondylolysis in Ambulant Children with Spastic Cerebral Palsy.

Objectives: Lumbar spondylolysis is a common condition; nonetheless, its cause in patients with spastic cerebral palsy (CP) remains unknown. Furthermore, examination of children with CP may not accurately capture complaints, thus causing diseases to be overlooked. Understanding the clinical features and gait patterns of lumbar spondylolysis in CP can aid in diagnosis. This study aimed to identify the clinical features and specific gait patterns of lumbar spondylolysis in ambulatory children with CP. Methods: Seventy-three children with CP were divided into two groups according to the presence or absence of lumbar spondylolysis on X-ray and magnetic resonance imaging. Three-dimensional gait analysis (3DGA) was performed to evaluate the kinematic data of the lower limbs. Results: Eight participants (11.4%) had lumbar spondylolysis primarily affecting the L5 vertebra. The lumbar spondylolysis group had a higher body weight and Body Mass Index, along with a smaller left popliteal angle on the spastic side. In 3DGA, detailed kinematic data indicated significant group differences in the mean angles of hip internal rotation (39.6° vs. 20.2°) during an entire gait cycle. The gait profile score was 19.7° in the lumbar spondylolysis group and 14.9° in the spinal uninvolved group; the difference in gait profile score between the two groups showed a minimal clinically important difference of 2.75. Conclusions: The overall gait profile score revealed that the gait of the lumbar spondylolysis group was deteriorated. Excessive internal rotation of the hip during gait might be a contributing factor to lumbar spondylolysis in children with CP.

Management of Pseudoaneurysm as a Delayed Complication after Using Rotational Atherectomy in Popliteal Artery Atherosclerosis: A Case Report.

Although intravascular atherectomy is widely used for debulking calcified atheromas in peripheral arterial disease, it is associated with complications. Delayed rupture with pseudoaneurysm formation is rare. We report the case of a 73-year-old man who developed a 24 mm×20 mm×27 mm popliteal artery (PA) pseudoaneurysm after rotational atherectomy. Initially, the patient presented with intermittent claudication. Preoperative computed tomographic angiography (CTA) showed a severely calcified atheroma in the PA. Rotational atherectomy was performed using the Jetstream™ device (Boston Scientific). Postoperatively, the ankle-brachial index and symptoms improved. However, 6 days after the atherectomy, the patient complained of calf pain and swelling. Follow-up CTA revealed a pseudoaneurysm and hematoma in the popliteal fossa. Open conversion with removal of the heavily calcified plaque and patch angioplasty were performed via the posterior approach. Delayed PA rupture and pseudoaneurysm formation after rotational atherectomy are rare; however, they require prompt management.

Exercise transcutaneous oximetry in functional popliteal artery entrapment syndrome diagnosis.

INTRODUCTION: Functional popliteal artery entrapment syndrome is a subtype of popliteal artery entrapment syndrome (PAES) without vascular disease or musculotendinous anomaly behind the knee. Symptoms are induced by popliteal artery extrinsic compression, leading to calf pain during lower limbs exercise. Non-invasive tests are still required to improve the diagnostic management of functional PAES. Exercise transcutaneous oxygen pressure (Ex-tcpO2) is of interest to provide objective arguments for the presence of regional blood flow impairment. OBJECTIVES: The aim of the study was to analyze whether Ex-tcpO2 could serve as a non-invasive technique for detecting ischemia resulting from PAES. METHODS: Patients with suspected PAES were recruited between 2017 and 2020. The diagnosis was confirmed or rejected, according to the surgical decision based on our diagnosis management involving a multidisciplinary team. Each patient underwent Ex-tcpO2 with specific maneuvers. The decrease from rest of oxygen pressure (DROP) index served for the interpretation of exercise results. RESULTS: Sixty-five legs with suspected PAES were recruited. Diagnosis was confirmed in 34 (52.3%) and rejected in 32 (47.7%). The average DROP values found in confirmed and rejected group at left leg were - 21.6 ± 15.4 mmHg and - 10.9 ± 11.1 mmHg, respectively (p for Mann-Whitney 0.004), and - 15.8 ± 11 mmHg and - 11.1 ± 7.5 mmHg, respectively, at right leg (p = 0.088). Ex-tcpO2 sensitivity and specificity were 52.9% and 78.1%, respectively. CONCLUSION: Ex-tcpO2 is an original non-invasive investigation for patients with claudication of doubtful arterial origin. The sensitivity and specificity are 52.9% and 78.1% in functional PAES diagnosis using 15 mmHg as threshold to detect ischemia during tiptoeing elevations.

Recanalization of superficial femoral artery chronic total occlusion through retrograde popliteal approach recanalization of superficial femoral artery chronic total occlusion.

Purpose: This retrospective study aims to evaluate the safety, practicality, and efficacy of the independent retrograde popliteal approach for recanalization superficial femoral artery (SFA) occlusions when the bilateral common femoral artery approach is unavailable, such as after endovascular aneurysm repair or common iliac artery stenting. Methods: This treatment was considered for patients with contralateral iliac artery occlusion, severe iliac tortuosity, or those who had previously undergone endovascular aneurysm repair or common iliac stenting. Patients with SFA lesions extending into the P1-P2 segment of the popliteal artery or with calcification in the P3 segment were excluded. Angioplasty and stenting were conducted via the popliteal artery approach, with hemostasis at the puncture site achieved using an EXOSEAL vascular closure device. Patients were routinely followed up at 3, 6, and 12 months, and annually thereafter. Results: Forty-eight consecutive patients with SFA occlusion who underwent endovascular treatment via the retrograde popliteal artery approach were included in this study. Retrograde puncture of the popliteal artery was successful in all cases. Six-French sheaths were utilized in all procedures. The EXOSEAL vascular closure device was successfully applied in all 48 cases. No instances of pseudoaneurysms, arteriovenous fistulas, major bleeding, or embolic complications were observed. The technical success rate for SFA recanalization was 100 %. All patients experienced clinical improvement. The ankle-brachial index significantly increased from an initial 0.33 ± 0.11 at admission to 0.81 ± 0.19 at discharge (P < 0.001). The mean follow-up period was 25.1 ± 11.7 months. Kaplan-Meier analysis revealed primary patency rates of 82.5 % at 12 months and 71.8 % at 24 months. No patients required major amputation during the follow-up period. Conclusion: The endovascular treatment of SFA occlusions via the independent retrograde popliteal approach is a viable alternative, demonstrating a low incidence of puncture-related complications and a high success rate of recanalization.

Association of iPACK block and adductor canal block in dogs undergoing the tibial plateau leveling osteotomy technique: Report of 4 cases.

Orthopedic procedures are associated with severe postoperative pain. In TPLO, the block commonly used is the sciatic nerve block associated with the femoral nerve block. In orthopedic surgeries in human medicine, the iPACK block associated with the adductor canal block has been used as alternatives that do not affect the strength of the quadriceps femoris muscle. The objective of this study was to evaluate the trans and postoperative analgesic effect of the association of iPACK block and adductor canal block, as well as to evaluate the patient's motor recovery after surgery. Four patients were selected, without distinction of breed and gender, weighing more than 22lb, referred to TPLO. All patients underwent the combination of iPACK block and adductor canal block with 0.5% bupivacaine. The intraoperative evaluation was carried out by measuring mean arterial pressure, heart rate and respiratory rate, and all patients were stable during the procedure. The postoperative evaluation was carried out based on the assessment of pain using the modified Glasgow scale, in which all patients scored less than 05/24, and assessment of ambulation through videos using the adapted Muzzi scale, presenting ambulation between grade 1 and 2. No patient required intraoperative or postoperative analgesic rescue.

Os procedimentos ortopédicos estão associados a dores pós-operatórias severas. Em TPLO, o bloqueio comumente utilizado é o bloqueio do nervo ciático associado ao bloqueio do nervo femoral. Nas cirurgias ortopédicas em medicina humana, o bloqueio iPACK associado ao bloqueio do canal dos adutores tem sido utilizado como alternativa que não afeta a força do músculo quadríceps femoral. O objetivo deste estudo foi avaliar o efeito analgésico trans e pós-operatório da associação do bloqueio iPACK e bloqueio do canal adutor, bem como avaliar a recuperação motora do paciente após a cirurgia. Foram selecionados quatro pacientes, sem distinção de raça e sexo, com peso superior a 10kg, e encaminhados ao TPLO. Todos os pacientes foram submetidos a uma combinação de bloqueio iPACK e bloqueio do canal dos adutores com bupivacaína a 0,5%. A avaliação intraoperatória foi realizada através da aferição da pressão arterial média, frequência cardíaca e frequência respiratória, e todos os pacientes permaneceram estáveis durante o procedimento. A avaliação pós-operatória foi realizada com base na avaliação da dor pela escala de Glasgow modificada, na qual todos os pacientes pontuaram menos que 24/05, e avaliação da deambulação por meio de vídeos pela escala de Muzzi adaptada, mostrando deambulação entre grau 1 e 2. Nenhum paciente necessitou de resgate trans ou pós-operatório.

Closure Device Migration: An Unusual Cause of Acute Limb Ischaemia Following a Simple Endovascular Procedure.

Introduction: Acute limb ischaemia resulting from foreign body embolisation is an infrequent yet critical complication associated with vascular closure devices (VCDs). Despite the widespread use of VCDs, rare complications such as fragment emboli pose unique challenges, necessitating heightened clinical awareness. This case report presents a case of acute limb ischaemia caused by a VCD malfunction following an endovascular procedure. Report: A 70 year old male who was diagnosed with a severe claudication of the lower extremity (Rutherford III) due to right common iliac stenosis, underwent angioplasty using a FemoSeal (Terumo Ltd., Surrey, UK) to close the right femoral artery access. Two weeks later, the patient presented with acute lower limb ischaemia due to a right popliteal-tibial occlusion. Emergency surgical thrombo-embolectomy was successfully performed from a medial popliteal approach, and the thrombus, which contained a polymer disc from the VCD at its distal end, was completely removed. Discussion: Despite VCDs being proven safe and efficient, rare complications such as fragment emboli can occur, and physicians should be aware of the possible delayed onset of symptoms. Moreover, the radiolucent nature of the polymer disc in a FemoSeal complicates diagnostic imaging. While endovascular approaches exist, open surgery is a safe and effective strategy for retrieving fragments and treating the patient in acute limb ischaemia cases. Conclusion: Physicians should remain vigilant for embolic risks associated with vascular closure devices, even with suitable anatomy and following guidelines, especially considering the trend toward early ambulation and discharge.