Internal derangement of the knee after ipsilateral femoral shaft fracture: MR imaging findings

OBJECTIVE: This study uses magnetic resonance (MR) imaging to delineate the types and frequencies of injuries seen in the knee after ipsilateral femoral shaft fracture. We also compare the results of the orthopedic knee examination with the MR findings. DESIGN AND PATIENTS: MR imaging of the ipsilateral knee was performed on 34 patients with closed femoral shaft fractures. Indications for knee MR imaging included knee pain at the time of fracture, soft tissue swelling or an effusion of the knee, or a positive knee examination under anesthesia. The patients had a mean age of 27 years and all were stabilized with intramedullary nails. Imaging was performed a mean time of 2.5 days after surgery. All patients had knee examinations done under anesthesia, and the MR results were compiled and compared with the clinical examinations. RESULTS: Ninety-seven percent of patients demonstrated knee effusions. Twenty-seven percent of patients demonstrated meniscal tears, with the posterior horn of the medial meniscus most frequently torn. The medial collateral ligament was the most frequent site of ligamentous injury (38%) followed by the posterior cruciate ligament (21%). Fifty percent of patients had injuries of the extensor mechanism. Bone bruises were noted in 32% of patients. Articular cartilage injuries were confined to the patella in four cases. One occult tibial plateau fracture and one meniscocapsular separation were seen. CONCLUSIONS: There is a common incidence of both ligamentous and meniscal injury to the knee after ipsilateral femoral shaft fracture. MR imaging can be useful in assessing the extent of injury, and may reveal findings unsuspected after clinical examination of the knee.     

Minimally invasive radioguided parathyroidectomy in the reoperative neck

BACKGROUND: Operations for hyperparathyroidism (HPT) in a previously operated neck present a significant challenge and carry much higher morbidity rates than first-time operations. Our extensive experience with minimally invasive radioguided parathyroidectomy (MIRP) for first-time surgery for HPT has shown this method to be a directed approach to the offending adenoma, suggesting that the technique could be used to minimize reoperative neck surgery as well. METHODS: Over an 11-month period 24 consecutive patients with primary HPT who had undergone at least one previous neck operation were referred for re-exploration. All patients underwent preoperative sestamibi scanning; 21 localized sufficiently to undergo MIRP. RESULTS: All patients were cured after reoperation. Eighteen patients underwent MIRP under local anesthesia as outpatients; 3 MIRPs were done under general anesthesia. Average total operative time was 44 minutes, average incision length was 3.0 cm +/- 0.2 cm. Nineteen of the procedures were completed without any frozen sections. There were no complications. CONCLUSION: MIRP is extremely effective in patients with HPT who have undergone previous neck exploration for parathyroid or thyroid disease. The technique allows for such a directed dissection that smaller incisions and local anesthesia in an outpatient setting are routine.     

Sociogenic stress and rodent reproduction

Between 1993 and 1995, we operated on 18 patients for split lesions of the peroneal brevis tendon associated with chronic ankle instability. Five patients were competitive athletes, seven were recreational athletes, and six were persons. Symptoms developed in three phases: ankle sprain, chronic instability, and posterolateral pain. The mean delay between sprain and posterolateral pain was 6 years. At the time of surgery the main complaint was retromalleolar pain in nine patients, pain and instability in eight patients, and instability only in one patient. Diagnosis of tendinous lesions was based on clinical examination in three cases, preoperative magnetic resonance imaging in eight cases, preoperative tenography in one case, and surgical exploration in six cases. The lesion was localized at the tip of the lateral malleolus and was visible only after opening the peroneal retinaculum. In three cases an accessory peroneal muscle was present. A Chrisman-Snook procedure was performed in 13 cases and a simple tendinous repair in 5 cases. The split lesion of the peroneus brevis tendon may be the result of chronic ankle laxity. This lesion needs a specific surgical treatment and the peroneal tendon must be checked in case of surgical procedure for ankle laxity. After ligamentous repair, residual pain can be due to a neglected peroneus brevis tear.     

A prospective evaluation of the value of preoperative laboratory testing for office anesthesia and sedation

PURPOSE: The purpose of this investigation was to determine whether routine laboratory testing affected the clinician's preoperative evaluation and decision-making process for patients undergoing general anesthesia or intravenous sedation in the oral and maxillofacial surgery office. PATIENTS AND METHODS: This was a prospective evaluation of the records of 458 who required an office general anesthetic or intravenous sedation for routine dentoalveolar surgery. The patients ranged in age from 15 to 54 years and were categorized as American Society of Anesthesiologists Classification I or II. Fifty-two percent were female. All patients underwent a history and physical examination, complete blood cell count, and urine analysis. Female patients were tested for pregnancy by measuring the serum beta human chorionic gonadotropin level. All patients older than 40 years of age were further evaluated by posterior-anterior and lateral chest radiographs, as well as electrocardiography. On the day of surgery, the data were reviewed and analyzed, and specific components of the history were reassessed. The results of the decision-making process were evaluated by one investigator. RESULTS: From the 458 patients initially enrolled, 78 failed to return on the appointed day. Of the 235 patients requiring general anesthesia who did return on the appointed day, five had aberrant laboratory values (2%). These consisted of one patient with a low hematocrit, one with a low red blood cell count, one with a low white blood cell count, and two with a urine analysis positive for blood. No procedure was canceled based on the aberrant data. Of the 145 patients requiring intravenous sedation who did return on the appointed day, six had aberrant laboratory values (4%). Two patients exhibited elevated white blood cell counts, two possessed low red blood cell counts, one known to have diabetes had an elevated urine glucose, and one patient with an elevated human chorionic gonadotropin level realized that her menstrual cycle was delayed. The latter two patients had their procedures deferred. CONCLUSIONS: Based on the results of this study, a good history and physical examination and then reassessment of key portions of the history were the major factors in the development of the anesthetic treatment plan. Laboratory data had little if any effect on the decision-making process.     

Analysis of the IgG autoantibody repertoire in endocrine ophthalmopathy using the MegaBlot technique

The cervical spine is frequently involved in rheumatoid arthritis and yet there exists no consensus on the need to screen for cervical spine subluxations preoperatively. We reviewed retrospectively 77 patients who underwent 132 operations under general or regional anaesthesia over a 44-month period. We found that while the majority of patients had received preoperative X-ray screening for cervical spine instability, a third of the X-ray examinations done had been inadequate. Many anaesthetists did not repeat cervical spine X-rays if there were previously performed views available. We showed that a complete X-ray examination of the cervical spine should include flexion and extension stress views in addition to frontal views of the odontoid and entire cervical spine. Anterior atlantoaxial subluxation was the most common subluxation encountered in our study population. The detection of cervical spine instability was found to significantly affect anaesthetic management, favouring techniques that avoided unprotected manipulations of the neck under anaesthesia.     

Preoperative diagnosis with video-assisted thoracoscopy with miniaturized endoscopes in general thoracic surgery: a preliminary study

Video-assisted thoracoscopy using a miniaturized endoscope (mini-VAT) was applied for preoperative diagnosis in general thoracic surgery. Thirty-one patients, including 27 with indeterminate pulmonary nodule and 4 with suspected pleural involvement of lung cancer or metastatic pleural tumor, underwent mini-VAT. As a pilot study, 14 of the former 27 patients underwent mini-VAT while receiving general anesthesia. As a prospective study, all the remaining 17 patients underwent mini-VAT while receiving local anesthesia. Solid scopes of three different sizes, 0.9, 1.9, or 4.0 mm diameter, were used. An artificial pneumothorax for scope introduction was produced by needle thoracentesis under atmospheric pressure. Automatic cutting needle biopsy was used for tissue sampling. In the pilot study group, mini-VAT with a 4.0-mm scope provided excellent visibility and diagnostic sensitivity of 100%. This study group showed the diagnostic sensitivity of needle biopsy for pulmonary nodule to be 100%. Hemorrhages and air leaks at biopsy sites were sealed with blood coagulation in a short time. In the prospective study group, mini-VAT with a 4.0-mm scope with the patients receiving local anesthesia provided a diagnostic sensitivity of 91% for pulmonary nodule and a diagnostic accuracy of 100% for suspected pleural involvement. Causes of failure of mini-VAT with the use of local anesthesia were cough reflex during needle biopsy and incomplete lung collapse for deeply located target in two cases. The adverse effects of the mini-VAT were paradoxical respiration in two cases in which local anesthesia was used. The patients who received only local anesthesia required no chest tube drainage. Mini-VAT is a simple, minimally invasive procedure suitable as a preoperative examination technique for histologic diagnosis, evaluation of disease progression, and selection of strategy in thoracic surgery.     

Comparison between the scintigraphic uptake and plasma clearance of 99mTc-diethylenetriaminepentacetic acid (DTPA) for the evaluation of the glomerular filtration rate in dogs

Over the last few years, there has been increased emphasis on early discharge of patients following carotid endarterectomy in the United States. Recent studies have shown that short-stay hospitalization for carotid endarterectomy may be safe and cost-effective. However, this is not always possible because of reasons that are not clearly delineated. In order to optimize the early discharge of patients following carotid endarterectomy, an analysis of the causes of delayed discharges was performed in the present series. Since hemodynamic instability has been shown to be the most frequent complication following carotid endarterectomy, the authors investigated whether it was an important factor preventing early postoperative discharge. This study reviewed the data of 100 consecutive patients admitted for elective carotid endarterectomy. The incidence of post-carotid endarterectomy hemodynamic instability was 37% (n = 37), with hypertension occurring in 25 patients (68%) and hypotension occurring in 12 patients (32%). Hemodynamic instability tended to occur with the use of general anesthesia as compared with regional anesthesia. Hemodynamic instability did not correlate with pre-existent history of hypertension, nor with the type of drug used when general anesthesia was applied. All the patients were successfully treated either in the recovery room or in a monitored area. The average total length of stay was 1.65 days with 79% of the patients being discharged on the first postoperative day and 21% having delayed discharge ranging from 2 to 15 days (mean 4 days). The main reasons for delayed discharges were cardiac and urinary tract complications. Blood pressure instability accounted for only 2% of cases. Thus, these data show that hemodynamic instability does not significantly affect early discharge.     

Diaphragmatic paralysis

Ankle inversion injuries are the most common injury in sport and yet treatment is controversial. One result is chronic ankle instability, an injury for which criteria for surgical intervention are unclear. This prospective study of 14 patients showed that a large proportion of patients had no detectable abnormality on preoperative investigation, but were subsequently shown to have an abnormality under general anaesthesia. This suggests that a good history of chronic instability is more sensitive an indicator than conventional investigations. Stress views under anaesthesia may confirm the problem.     

A measurement of the ability to drive after different types of inguinal hernia repair

Recovery following different types of inguinal hernia repair has been objectively assessed by measuring reaction times when the subject performs an emergency stop in a driving simulator. A control group of patients who underwent varicose vein surgery to the groin under general anaesthetic without any muscle dissection demonstrated no alteration in response times. Eighty-two percent of those who underwent laparoscopic repair and 64% of those who underwent Lichtenstein repair returned to their preoperative times by 7 days after surgery. There was no difference in recovery of response times after Lichtenstein repair performed under local or general anaesthetic, in comparison with 33% of patients after Bassini repair. These results may influence the advice given by surgeons to patients after inguinal hernia surgery.     

Knee injury in children

The diagnosis approach after knee injury in children must be carefully taken care of the growth plates but it is necessary to emphasize the frequency of the ligament and intra-articular lesions, and on the other hand to consider their benign reputation. Clinical and conventional radiologic examination give in most of the cases the correct diagnosis. For the others an examination under general anesthesia ++ is necessary to distinguish the ligament and the growth plate lesions. MRI must not replace the arthroscopy which is necessary for an haemarthrosis with a stable knee or a little isolated anterior instability. The non-surgical treatment is indicated for benign sprain and non-displaced or mid-displaced fractures if the reduction is perfect and stable. All the other lesions need a surgical treatment which must be the most conservative as possible, especially for the meniscus, because their integrity is a guarantee for the quality of the long term result.     

'Clearing' cervical spine injuries in polytrauma patients: is it really safe to remove the collar?

Polytrauma patients are at increased risk for occult cervical spine injuries. Those unable to provide clinical clues to injury either remain in hard collars until they are able to cooperate with the physical examination or are deemed "clear of cervical injury" if the emergency room screening radiographs are without obvious bony abnormality. Cervical immobilization for a lengthy period of time is not without morbidity. Missed ligamentous injuries can lead to cervical instability, which in turn can result in permanent neurologic sequelae. This article reviews the current methodologies to "clear the cervical spine" and highlights the inadequacies.     

Saline magnetic resonance arthrography in the evaluation of glenohumeral instability

Sixty-five patients underwent magnetic resonance (MR) shoulder arthrography. Forty-eight of these patients underwent examination under anesthesia (EUA). MR images were retrospectively evaluated for signs felt to be imaging indicators of shoulder instability, including evaluation of various capsular measurements and the presence of glenoid labral tears, as well as Hill-Sachs fractures. Statistical analysis of the results showed that no correlation between capsular indicators with EUA-documented instability was found. However, there was a statistically significant correlation between the presence of a Bankart cartilaginous deformity (p = 0.000) and Hill-Sachs fractures (p = 0.022) with EUA-documented instability. Sensitivity to labral tears was 89% and specificity was 98%, whereas Hill-Sachs fracture detection was 69% and 87%, respectively. We believe that MR saline arthrography is of benefit in the evaluation of the anterior labrum when unenhanced MR imaging is inconclusive, and we speculate on the role of MR arthrography as a primary investigative tool.     

Use of preoperative subcutaneous "wetting solution" and epidural block anesthesia for liposuction in the office-based surgical suite

Uniform saturation of subcutaneous fat using the "wetting solution" formula described by Klein for his "tumescent technique" has been shown to decrease operative blood loss associated with liposuction procedures and to eliminate the requirement for general anesthesia for selected patients. However, we found this infusate provided an inadequate level of anesthesia for many of our patients. We use preoperative infusion of Klein's epinephrine and lidocaine containing wetting solution in our lipoplasty practice only for control of blood loss and postoperative pain. Our anesthetic of choice for liposuction is the epidural block technique, which provides consistent intraoperative comfort for the patient. We report our experience with 85 consecutive lipoplasty patients who underwent liposuction under epidural anesthesia after subcutaneous fat perfusion with Klein's wetting solution. Our epidural block technique uses the rapidly metabolized local anesthetic agent, chloroprocaine, which has the lowest systemic toxicity risk of any local anesthetic agent. Chloroprocaine's anesthetic characteristics are particularly well suited for the outpatient surgery patient with few undesirable side effects.     

Ophthalmic surgery with local anesthesia or intubation anesthesia at the Leipzig University Ophthalmology Clinic

BACKGROUND: Different opinions about the reliability and serious complications after regional anesthesia have been reported. The paper describes our experiences in deciding about regional or general anesthesia for ophthalmic surgery. PATIENTS AND METHODS: For this report we analyzed retrospectively our protocols of all operations performed in 1995. Eight categories of procedures were developed to give an insight in our way of decision for local or general anesthesia. We imagine the applied technique of peribulbaranesthesia. RESULTS: 3184 patients were operated on in 1995, in the regional anesthesia group the age ranges from 17 to 96 years, in the general anesthesia group from 3 months to 85 years. In 69.9% of all patients we performed a local anesthesia and in 30.1% we chose general anesthesia. The spread of cases and the surgical procedure corresponding to one of these eight classes below are described in this survey. CONCLUSIONS: Almost 70% of our patients who underwent an ophthalmosurgical procedure were operated on under regional anesthesia. No serious complications have occurred and no procedure had do be stopped off due to an insufficient analgesia or akinesia. We demonstrate some observations concerning the duration of pain after the injection and our indications for general anesthesia in ophthalmic surgery.     

Sodium nitroprusside-induced hypotension for supine total hip replacement

Deliberate hypotension was produced during general anesthesia by the infusion of sodium nitroprusside in 13 patients undergoing total hip replacement. Hemodynamic data from these patients were compared with those obtained from 5 patients under normotensive anesthesia for the same procedure. During the hypotensive period, which averaged 1.5 hours, the cardiac index rose 20 percent compared with controls. No acidotic tendency was seen. Blood loss in the study group averaged 475 ml, compared with 1475 ml in controls. From these data, a dose-response curve was derived which may allow the accurate prediction of the minute dosage of sodium nitroprusside required to safely induce hypotension during anesthesia.     

Familial occurrence of temporal arteritis

The incidence of difficulty in tracheal intubation in the presence of goiter was investigated. Data were collected in a series of 4742 consecutive adult patients undergoing general anesthesia. The prevalence of goiter was 6.8%. Fifteen anesthesiologists performed the preoperative airway assessment using standardized guidelines. Seven individual risk factors were correlated with the potential for difficult tracheal intubation. Whenever evidence of goiter or airway pathology was observed, the evaluation was completed by indirect laryngoscopy and radiologic examination to establish the presence of any anatomical deviation. Difficult intubation was defined as inadequate exposure of the glottis by direct laryngoscopy. There was no difference in probability of difficulty in tracheal intubation between patients who presented for thyroidectomy and patients with goiter estimated as a random finding. Statistical analysis revealed an increased risk of difficult intubation amongst goiter patients compared with patients with no evidence of any risk factor (6.8% vs 0.9%, P < 10(-8), relative risk = 7.4). We conclude that goiter, when accompanied by airway deformity, constitutes an aggravating factor for difficult intubation.     

Colonoscopic findings in Crohn''s disease--reproducible, but of questionable benefit

Between January, 1991 and December, 1993, 208 subjects with monolateral and 19 with bilateral inguinal hernia were submitted to herniorrhaphy. Thirty-four were recurrent hernias. All but one bilateral hernias were treated at the same time. Eight cases were operated in emergency condition for acute strangulated hernia. Two-hundred and ten operations were performed under local, 17 under general and 1 under spinal anesthesia. Herniorrhaphy was performed in 14 cases with the Bassini and in 38 with the Shouldice technique. In 191 instances the "tension-free" and in 3 the "plug" techniques were adopted utilizing a polypropylene mesh. Following local anesthesia 13 episodes of bradycardia with hypotension were recorded during the operation and 4 in the early postop period. There were no general complications. Two elderly patients developed urinary retention following general anesthesia. Local complications included 6 (2.4%) cases of infection and 4 (1.6%) cases of hematoma of the wound, and 5 (2.0%) cases of edema with infiltration of the cord. Percentage of follow-up at 1, 2 and 3 years was 96, 95, and 93 percent respectively. Five recurrences were recorded: in 1 case following Bassini repair (7.6%), in 2 following Shouldice (5.6%), and in 2 following tension-free (1.5%). Local anesthesia has been confirmed to be well accepted by the patients, effective an safe, especially in the elderly patients with high operative risk. Similarly, the tension-free hernioplasty has been confirmed as a simple, easily reproducible technique, followed by less pain and disability as compared with other types of herniorrhaphies, and more effective mainly in the treatment of recurrent hernia.     

The use of a video to convey preanesthetic information to patients undergoing ambulatory surgery

In a prospective, randomized, single-blind trial, we assessed the effectiveness of a preoperative video as a source of additional patient information before ambulatory surgery. One hundred twenty-seven patients were allocated to either treatment (video) or control (nonvideo) groups. Of the 127, 17 (13%) patients correctly answered all process, risk, and misconception statements using a questionnaire. Overall, the video group was 2-16 times more likely to recall all knowledge questions correctly than the nonvideo group after adjusting for previous general anesthesia experience, state (how one feels at the moment), and trait (how one generally feels) anxiety levels (relative risk 6.36, 95% confidence interval 2.01-15.82). The predictors of correct risk knowledge were those who had a video intervention (relative risk 7.12, 95% confidence interval 3.70 to 10.07) and low trait anxiety scores (relative risk 5.88, 95% confidence interval 1.69 to 25.00). A video could be an important additional component of the preoperative interview, but anesthesiologists will still need to provide patient-specific information. IMPLICATIONS: This study randomly allocated adults to see a video about anesthesia before scheduled ambulatory surgery. The video group had better recall of information. The video was a useful adjunct to routine preoperative consultations.     

Anesthesia for a patient with macrothrombocytopenia

A 56-year-old female with macrothrombocytopenia was scheduled for colectomy and hepatectomy. She had not shown significant bleeding tendency. Her preoperative platelet counts were 0.5-1.6 x 10(4) microliters-1 with the use of an automated cell counter. However, microscopic examination showed platelet number ranging 0.9-3.4 x 10(4) microliters-1 and many macrothrombocytes. Therefore, platelet biomass (platelet number x platelet volume) seemed almost normal. Bleeding time was 3 minutes and platelet function was normal. She received preoperatively high dose gamma-globulin administration and intraoperatively platelet transfusion. The operation was performed under combined epidural and general anesthesia. Intra- and post-operative course was uneventful.