Accuracy and Efficacy of Ultrasound-Guided Pes Anserinus Bursa Injection

The term “pes anserinus tendinobursitis (PATB)” is generally used to describe the inflammatory condition of pes anserinus bursa (PAB). Ultrasound (US) is widely used as a diagnostic and therapeutic tool to improve the assessment and management of joints and soft tissues. We performed the study to prove the accuracy and efficacy of US-guided injections in patients with PATB by comparing blind interventions. Forty-seven patients were randomly assigned to an US-guided and a blind injection group. The patients in the US-guided group were given injections under sonographic visualization. Otherwise, in the blind group, injections were provided in the conventional technique without any sonographic guidance. After the management, the accuracy of the injections was assessed by identifying the injectate location using the US. Treatment efficacy was evaluated using the visual analog scale (VAS) of knee tenderness. The US-guided group showed that the injectates were located at the PAB accurately in all participants, whereas the blind group revealed that the materials were found to be at the bursa side only in 4 out of 22 patients. VAS scores of the US-guided group significantly improved compared to the blind group. In conclusion, US-guided PAB injections are more accurate and efficacious than blind approaches.

Is a Block of the Femoral and Sciatic Nerves an Alternative to Epidural Analgesia in Sheep Undergoing Orthopaedic Hind Limb Surgery? A Prospective, Randomized, Double Blinded Experimental Trial

Peripheral nerve blocks are commonly used in human and veterinary medicine. The aim of the study was to compare the analgesic efficacy of a combined block of the femoral and sciatic nerves with an epidural injection of ropivacaine in experimental sheep undergoing orthopaedic hind limb surgery. Twenty-five sheep were assigned to two groups (peripheral nerve block; sciatic and femoral nerves (P); epidural analgesia (E)). In group P 10 mL ropivacaine 0.5% was injected around the sciatic and the femoral nerves under sonographic guidance and 10 mL NaCl 0.9% into the epidural space while in group E 10 mL ropivacaine 0.5% was injected into the epidural space and 10 mL NaCl 0.9% to the sciatic and the femoral nerves. During surgery, heart rate, respiratory rate and mean blood pressure were used as indicators of nociception. In the postoperative phase, nociception was evaluated every hour by use of a purposefully adapted pain score until the animal showed painful sensation at the surgical site. The mean duration of analgesia at the surgical wound was 6 h in group P and 8 h in group E. Mean time to standing was 4 h in group P and 7 h in group E. In conclusion time to standing was significantly shorter in group P while the duration of nociception was comparable in both groups. The peripheral nerve block can be used as an alternative to epidural analgesia in experimental sheep.

Mini-Invasive, Ultrasound Guided Repair of the Achilles Tendon Rupture—A Pilot Study

Percutaneous acute Achilles tendon rupture suturing has become a leading treatment option in recent years. A common complication after this mini-invasive procedure is sural nerve injury, which can reduce the patients’ satisfaction and final outcomes. High-resolution ultrasound is a reliable method for localizing the sural nerve, and it can be performed intra-operatively; however, the long-term results are yet unknown. The aim of the study was to retrospectively evaluate the long-term results of percutaneous Achilles tendon repair supported with real-time ultrasound imaging. We conducted 57 percutaneous sutures of acute Achilles tendon rupture between 2005 and 2015; 30 were sutured under sonographic guidance, while 27 were performed without sonographic assistance. The inclusion criteria were acute (less than 7 days) full tendon rupture, treatment with the percutaneous technique, age between 18 and 65 years, and a body mass index (BMI) below 35. The operative procedure was carried out by two surgeons, according to the surgical technique reported by Maffulli et al. In total, 35 patients were available for this retrospective assessment; 20 (16 men and 4 women) were treated with sonographic guidance, while 15 (12 men and 3 women) underwent the procedure without it. The mean follow-up was 8 years (range, 3–13 years). The sural nerve was localized 10 mm to 20 mm (mean, 15.8; SD, 3.02) laterally from the scar of the Achilles tendon tear. There was no significant difference between groups with respect to the FAOQ score (P < 0.05). High-resolution ultrasounds performed intra-operatively can minimize the risk of sural nerve injury during percutaneous Achilles tendon repair.

Tele-proctoring in vascular surgery implementing percutaneous creation of arteriovenous fistula

Objective Percutaneous ultrasound-guided creation of an arteriovenous fistula (pAVF) for hemodialysis access is a relatively novel procedure with promising technical success and patency rates. The vascular surgery departments of two collaborating Swiss hospitals had decided to introduce the technique to their services. A surgeon experienced in the technique (AM) was supposed to come to Switzerland and proctor the first four procedures. Due to the SARS-CoV-2 pandemic and travel restrictions, this was not possible and we decided to perform the first four pAVF procedures tele-proctored via a video conference system. We present the setup and our experience with tele-proctoring. Methods The setup relied on an all-in-one live video production device, video encoder, video streamer and video recorder (Pearl-2, Epiphan), which made it possible to simultaneously transmit the live image from the ultrasound device (GE Logiq S8, linear probe 9L-D) and a live image from a video camera (JVC Camcorder G/-HM440E, Japan), both connected via HDMI (Figure). The live stream was shared with the proctor in France and the device support team in the US, using an encrypted Swiss video client (www.vitimway.ch). The setup was tested with all parties three days in advance. Results All 4 procedures started with a verbal briefing and a live ultrasound scan. All steps of the procedures were taken under the proctor’s instruction and supervision. The proctor gave on average 21 instructions per procedure. An average 4 were device-related but these became less frequent as we proceeded. The operators consulted the proctor on average 5 times per procedure. The average duration of the procedure was 34 min. The pAVF creation was successful in all 4 patients, with an average fistula flow measured at the end of the procedure of 600 ml/min. Conclusion Our experience showed us that pAVF creation, which is a procedure performed entirely under sonographic guidance lends itself particularly well to tele-proctoring. The simultaneous transmission of the live sonographic image and the live image of the operators' hands allowed the proctor to supervise and correct the key steps of the procedures. The simplicity of the set-up and the quality of proctor-operator interaction was such a positive experience that we can well envisage a much wider use of tele-proctoring in the future.

The efficacy of delayed, repeated reduction enema in management of intussusception

Background Management of intussusception varies according to the case, time of presentation, cause, and symptoms. In this study, we focus on describing the demographic and sonographic characteristics of children with intussusception with failed initial enema reduction who were managed by delayed repeated enema attempts and identify predictors associated with successful repeated reduction. Results This study was conducted in the period from December 2018 to April 2020 at university hospitals (pediatric surgery unit). This study included 40 patients with intussusceptions; 27 are males, and 13 of them are females. Their ages ranged from 5 months to 3 years old. Patients in this study had failed initial enema reduction attempts under sonographic guidance and had subsequent delayed (≥ 2 h from the initial attempt) repeated enemas made up the study population. Of the 40 patients, 34 patients (85%) were successfully reduced, and 6 patients (15%) failed reduction and required surgical intervention. There were no deaths, perforation, or resection of gangrenous bowel. Two cases showed recurrences, but required no surgical intervention. It is also noted that early presentation (< 12 h), stable, non-complicated, and with little or no bloody diarrhea are predictors of successful DRE. Conclusion Delayed repeated enema in the treatment of intussusception is a viable option in patients with unsuccessful initial enema reduction provided that early presentation, stable vitals, and no signs of perforation or peritonitis are present.

Ultrasound-guided fluoroscopic-verified trans-foraminal lumbar dorsal root ganglion pulsed radiofrequency modulation for radicular pain relief: clinical and cadaveric evaluation of the technique

Background Ultrasound-guided lumbar pain interventions were thought to be difficult; the high acoustic impedance of bone hides the underling structures and needle path. Reviewing the sonoanatomy of the lumbar region using different planes and angles made better sonographic guidance for spine injections. The aim of this prospective study is to assess the accuracy and safety of ultrasound (US)-guided lumbar trans-foraminal pulsed radiofrequency of the dorsal root ganglion confirmed by fluoroscopic imaging in management of chronic radicular pain. Results Thirty-two patients, with 34 lumbar interventions, were included in the study. Thirty-one interventions out of 34 were performed successfully with overall accuracy of 91.18% and with minimal complications. The successful first trial placement of the cannula was calculated in 44.1% of interventions; multiple trials were needed in 47.1% while incorrect level was encountered in 8.8%. Visual analogue scale of pain and Oswestry Disability Index decreased significantly after intervention up to 3 months compared to the pre-intervention value. The analgesic consumption was reduced by mean of 73.44 ± 31.07% 1 month after intervention. Conclusions US-guided fluoroscopic-verified trans-foraminal PR of lumbar DRG is accurate, safe, and effective for CRP.

Experience of application of interventional sonography in treatment of patients with bacterial hepatic abscesses

Objective. To analyze the possibilities and efficacy of application of the intervention sonography in complex surgical treatment of patients with bacterial hepatic abscesses. Materials and methods. Results of treatment of 39 patients with hepatic abscesses in Department of Surgery № 3 through period from 2012 till June 2019 yr was presented. The patients were treated, using the puncture aspiration or drainage of abscesses under sonographic guidance. In hepatic abscesses with diameter up to 40 mm a puncture sanation was applied. In all the patients transcutaneous drainage was performed, not depending from the abscesses dimensions and localization. Results. Treatment and application of the intervention sonography was effective in 37 (94.9%) patients. Postoperative complications have occurred in 4 (10.3%) patients: hemorrhage inside the abscess cavity (in 2), durable bile leakage via the drain (in 1), migration of the drain from the abscess cavity (in 1). Average stationary stay of the patients was (19,2 ± 1,6) bed-days. Conclusion. Application of the puncture-draining procedures under sonographic control in treatment of patients, suffering hepatic abscesses constitutes a method of choice, what is caused by their small traumaticity, availability of dynamical control and efficacy in 94.9% patients. But these procedures owe some limitations, connected by the abscesses quantity, their localization, as well as complex configuration and big possibility of presence of large sequesters of necrotized hepatic parenchyma.

AB0642 SACROILIAC JOINT INJECTIONS PERFORMED WITH ULTRASOUND GUIDANCE IN PATIENTS WITH SACROILIITIS

Background:Sacroiliitis is the hallmark of axial Spondyloarthritis (axSpA). ASAS-EULAR management recommendations for axSpA, consider glucocorticoid injections directed to the local site of musculoskeletal inflammation as a treatment option for pain relief, besides treatment with oral non-steroidal anti-inflammatory (NSAIDs) before starter biotechnological treatment. However, there are few studies to evaluate efficacy of this technique with a small number of patients and a short follow-up. Ultrasonography has been used as a valuable option to guide this technique.Objectives:To evaluate the efficacy and safety of ultrasound-guided injections of sacroiliac joints (SIJs) in patients with sacroiliitis using clinical and laboratory outcomes at baseline and at 4-6thweeks.Methods:This study involved patients with axSpA with acute sacroiliitis, ≥18 and ≤ 65 years old, with body mass index (BMI) < 30kg/m2attending the Rheumatology Outpatient Clinic, which had been poorly controlled (ASDAS>2.1) by conventional therapy (physiotherapy, NSAIDs at maximum tolerated dosing during ≥ 4 weeks). Sociodemographic, clinical (disease duration, BMI, BASDAI, BASFI, ASDAS) and laboratory (CRP) data was collected from the medical records at baseline and at 4-6thweeks.Statistical analyses were conducted using SPSS version 25. Continuous variables were described with mean/median ± standard deviation (SD).SIJs injection was performed, under ultrasound guidance, using standard procedures with 2mL of lidocaine 1% and 40mg of methylprednisolone, with a 22-gauge needle. The procedure was performed by the same operator. Written informed consents were obtained from all patients.Results:We performed eleven sacroiliac injection in eleven consecutive patients (one procedure per patient). Nine patients (81.8%) were female, mean age (±SD) of 40.6(±9.4) years, median disease duration(±SD) of 0.9(±6.2) years and median BMI(±SD) of 24.2(±3.3). Eight patients (72.7%) had Nr-axSpA. All patients were non-responders to NSAIDs.At 4-6thweeks there was a decreased in median (±SD) BASDAI (5.4±1.9 vs 4.1±1.9), BASFI (4.2±1.4 vs 3.5±2.3) and ASDAS (3.2±0.8 vs 2.2±0.6) indexes.Conclusion:As previous studies demonstrated, this technique seems to be safe and quite effective.Our goal is to increase the number of patients undergoing this technique and have a longer follow up to evaluate its efficacy. The study has several limitations: the mid- and long-term effects should be evaluated in the future based on the results of the short-term effects and the study was not conducted as a double-blinded, controlled study.References:[1]van der Heijde D, Burgos-Vargas R, Ramiro S.,et al. ASAS/EULAR recommendations for the management of ankylosing spondylitis. Ann Rheum Dis 2017; 76:978–991[2]Maugars Y, Mathis C, Vilon P, Prost A. Corticosteroid injection of the sacroiliac joint in patients with seronegative spondylarthropathy. Arthritis Rheum 1992; 35:564–8.[3]Pekkafahli MZ, Kiralp MZ, Basekim CC et al. Sacroiliac joint injections performed with sonographic guidance. J Ultrasound Med 2003;22:553–9[4]Klauser A, De Zordo T, Feuchtner G et al. Feasibility of ultrasound-guided sacroiliac joint injection considering sonoanatomic landmarks at two different levels in cadavers and patients. Arthritis Rheum 2008; 59:1618–1624.Disclosure of Interests:Ana Rita Cunha: None declared, Carolina Mazeda: None declared, Renata Aguiar: None declared, Anabela Barcelos Speakers bureau: Bene, Eli-Lilly, Pfizer, MSD, Novartis

Transsplenic portal vein recanalization and direct intrahepatic portosystemic shunt placement to optimize liver transplantation

Background Percutaneous trans-splenic portal vein recanalization (PVR) has been reported for facilitation of transjugular intrahepatic portosystemic shunts (TIPS), however has not been applied to patients undergoing direct intrahepatic portosystemic shunt (DIPS). We report the utilization of trans-splenic-PVR with DIPS creation in a patient with chronic portal and hepatic vein occlusions undergoing liver transplantation evaluation. Case presentation A 48-year-old male with decompensated alcoholic cirrhosis complicated by refractory ascites, hepatic encephalopathy, and variceal bleeding underwent CT that demonstrated chronic occlusion of the hepatic veins (HV), extrahepatic portal vein (PV), and superior mesenteric vein (SMV). Due to failed attempts at TIPS at outside institutions, interventional radiology was consulted for portal vein recanalization (PVR) with TIPS to treat the portal hypertension and ascites and also facilitate an end-to-end PV anastomosis at transplantation. After an initial hepatic venogram confirmed chronic HV occlusion, a DIPS with trans-splenic PVR was planned. The splenic vein was accessed under sonographic guidance using a micropuncture set and subsequently upsized to a 6 French sheath over a stiff guidewire. A splenic venogram via this access confirmed occlusion of the PV with drainage of the splenic vein (SV) through gastric varices. The thrombosed PV was then recanalized and angioplastied to restore PV flow via the transsplenic approach. A transjugular liver access kit with a modified 21-gauge needle was advanced into the IVC through the internal jugular vein (IJV) sheath and directed towards the target snare in PV. The needle was used to subsequently puncture the PV through the caudate lobe and facilitate placement of a wire into the SV. The initial portosystemic gradient (PSG) was 20 mmHg. The IJV sheath was advanced through the hepatic parenchymal tract into the main-PV and a stent-graft was placed across the main PV and into the IVC. A portal venogram demonstrated brisk blood flow through the DIPS, resolution of varices and a PSG of 8 mmHg. One month after the procedure, the patient had a significant reduction in ascites and MELD-NA score. Patient is currently listed and awaiting transplantation. Conclusions In the setting of chronically occluded portal and hepatic veins, trans-splenic PVR DIPS may serve as an effective bridge to liver transplantation by facilitating an end to end portal vein anastomosis.