Femoral nerve block in extracapsular femoral neck fractures

We randomised 50 patients with extracapsular fractures of the femoral neck to receive either a bupivacaine femoral nerve block or systemic analgesia alone. A femoral nerve block was found to be an easy and effective procedure which significantly reduced perioperative analgesic requirements and postoperative morbidity.     

Comparison of caudal block using bupivacaine and ketamine with ilioinguinal nerve block for orchidopexy in children

Forty boys weighing less than 25 kg undergoing unilateral orchidopexy were randomly allocated to receive one of two analgesic regimens. Group C received a caudal epidural block with 0.25% bupivacaine 1 ml.kg-1 and preservative-free ketamine 0.5 mg.kg-1; Group L received an ilioinguinal nerve block with 0.25% bupivacaine 0.5 ml.kg-1 and infiltration of the wound with 0.25% bupivacaine 0.5 ml.kg-1. All subjects received diclofenac sodium 1-2 mg.kg-1 as a rectal suppository. Postoperative pain was assessed by means of a modified Objective Pain Score and analgesia was administered if this exceeded a value of 4. The median duration of analgesia was 10 h (range 2.6 to > 24 h) in Group C and 2.9 h (range 0.7 to > 24 h) in Group L (p < 0.05). There were no differences between groups in the incidence of motor block, urinary retention, postoperative vomiting or postoperative sedation. Subjects in Group L required significantly more doses of postoperative analgesia than those in Group C (p < 0.05).     

Continuous extrapleural intercostal nerve block for post thoracotomy analgesia in children

The influence of the nicotine antagonist dihydro-beta-erythroidine (DH beta E) was examined on various behavioural effects of nicotine in rats. Motor activity was recorded in photocell cages whereas discriminative stimulus effects were examined using two-lever drug discrimination procedures with a tandem schedule of food reinforcement (n = 8 throughout). DH beta E (0.1-3.2 mg/kg) failed to antagonise the decreases in motor activity that nicotine (0.4-0.6 mg/kg) produced in experimentally naive rats, whereas mecamylamine (1.5 mg/kg) completely blocked this effect of nicotine. DH beta E (0.1-3.2 mg/kg) antagonised the increases in motor activity that nicotine (0.4 mg/kg) produced in rats with extensive previous exposure to both nicotine and the photocell apparatus. In rats trained to discriminate either 0.1 or 0.4 mg/kg nicotine from saline, DH beta E (0.1-3.2 mg/kg) blocked the discriminative stimulus effect of nicotine. The block of the discriminative effect could be reversed by increasing the dose of nicotine; DH beta E (1.6 mg/kg) shifted the dose-response curve for nicotine discrimination to the right by a factor of 9.4. In addition, nicotine in doses of 0.32-0.64 mg/kg decreased the overall rate of lever pressing but DH beta E (1.6 mg/kg) did not influence the dose-response curve for this effect. Thus, DH beta E potently blocked the locomotor activating and discriminative stimulus effects of nicotine at doses that did not antagonise its locomotor depressant and operant response rate-reducing effects. This selective blockade supports the involvement of different subtypes of nicotinic receptor in the mediation of diverse behavioural effects. Furthermore, the rightward shift of the dose-response curve for nicotine discrimination suggested a competitive mode of action for DH beta E.     

Examination of the lateral antebrachial cutaneous nerve: an anatomic study in human cadavers

Variations in the anatomic course of the cutaneous nerves about the lateral aspect of the elbow are important when surgical exposures and the establishment of arthroscopic portals are considered. The specific anatomic course taken by the lateral antebrachial cutaneous nerve and its relationship to the lateral epicondyle were determined by studying 33 upper extremities in 22 preserved adult cadavers. Considerable anatomic variation was found regarding the location of the lateral antebrachial cutaneous nerve as it crossed the elbow. The nerve pierced the brachial fascia an average of 3.2 cm proximal to the lateral epicondyle and was located an average of 4.5 cm medial to the lateral epicondyle as it crossed the interepicondylar line. In two instances, the nerve passed through the biceps muscle directly, prior to piercing the brachial fascia.     

Regional nerve block for total knee arthroplasty

Femoral and sciatic nerve blocks have been used occasionally for unilateral total knee arthroplasty (TKA). In order to evaluate the effectiveness of this technique, combined femoral 3-in-1 and sciatic nerve blocks were performed in 20 cases of TKA, by the same surgeon. This surgeon also performed unilateral TKA under spinal anesthesia in another 20 cases. The anesthetic effectiveness of the two types of anesthesia was compared in terms of the time needed to complete the surgery, amount of intraoperative blood loss, and time interval until the first dose of analgesic. The results showed that the two types of anesthesia had comparable anesthetic effects. Ten of the 20 patients who had spinal anesthesia complained of postoperative urinary retention, while none of those who had nerve block had this complaint. Neither group experienced postpunctural headache, neurovascular damage, or drug-over-dose toxicity. We conclude that combined femoral 3-in-1 and sciatic nerve block is an effective anesthetic alternative for unilateral TKA.     

Femoral nerve transfer for treatment of brachial plexus root avulsion

Femoral nerve transfer to the muscular branches of the thenar and hypothenar muscles was performed to determine its protective effect on the hand intrinsic muscles. Seven cases of brachial plexus root avulsion treated from May of 1989 to October of 1991 were involved. The femoral nerve transfer to the muscular branches of the thenar and hypothenar muscles was done at the same stage of multiple neurotization. The muscular branches derived from the femoral nerve were isolated and coapted with the thenar muscle branch of the median nerve and the deep branch of the ulnar nerve. A groin flap was harvested simultaneously to form a skin-tube pedicle that covered the nerve bridge. At the second stage, when regeneration of the median and ulnar nerves was found to reach as far as the level of the wrist, the femoral nerve was divided and the muscular branches of the thenar and hypothenar muscles were anastomosed with the regenerated median and ulnar nerves. All the cases were followed up for more than 6 years. Six months after femoral nerve transfer, muscle power of the interosseous muscles and adductor pollicis recovered to MRC3, whereas that of the abductor pollicis brevis recovered to MRC1 to 2. Five cases underwent second-stage transfer. Four to five years of follow-up revealed that the muscle power of the interosseous muscles and adductor pollicis was MRC2 in one case, MRC1 in three cases, and MRC0 in one case. As for the donor area, muscle power of the quadriceps femoris reduced to M3 to 4 within 1 month after femoral nerve transfer and recovered to normal at 3 months. In conclusion, femoral nerve transfer to the muscular branches of the thenar and hypothenar muscles has some protective effect on the hand intrinsic muscles. The outcome of the second stage, however, is not satisfactory.     

Distal femoral osteotomy for lateral compartment osteoarthritis of the knee

Arachidonic acid (AA) in the diet can be efficiently absorbed and incorporated into tissue membranes, resulting in an increased production of thromboxane A2 by platelets and increased ex vivo platelet aggregability. Results from previous studies have shown that AA is concentrated in the membrane phospholipids of lean meats. However, the concentration of AA in the visible fat portion of meats also may be significant despite being ignored in most studies. The aim of this study was to accurately quantitate the AA content of visible fat and the lean portion of beef, lamb, pork, chicken, duck, and turkey. The visible fat of meat contained a significant quantity of AA, ranging from 20 to 180 mg/100 g fat, whereas the AA content of the lean portion of meat was lower, ranging from 30 to 99 mg/100 g lean meat. Beef and lamb meats contained lower levels of AA in both the visible fat and lean portion than that from the other species. The highest level of AA in lean meat was in duck (99 mg/100 g), whereas pork fat had the highest concentration for the visible fats (180 mg/100 g). The lean portions of beef and lamb contained the higher levels of n-3 polyunsaturated fatty acids (PUFA) compared with white meats which were high in AA and low in n-3 PUFA. The present data indicate that the visible meat fat can make a contribution to dietary intake of AA, particularly for consumers with high intakes of fat from pork or poultry meat.     

Suprascapular nerve block for persistent rotator cuff lesions

The suprascapular nerve supplies sensory nerves to the posterosuperior aspect of the shoulder, including major portions of the rotator cuff. Suprascapular nerve block using steroid/bupivacaine is temporarily effective in reducing pain in rotator cuff tendinitis and tears, improving movement range in tendinitis and is possible in an outpatient setting with little or no complication risk.     

406 femoral fractures in children

406 fractures of the femur in persons younger than 17 years of age were treated at Haukeland University Hospital, Bergen, from January 1980 to December 1993. The incidence was 35/100,000 per year; 57/100,000 for boys, and 24/100,000 for girls. No significant changes in the incidence occurred during the study period. 70% of the fractures occurred in boys. 78% had an isolated fracture, while 7% had other fractures, 7% head injuries and 8% injuries of multiple organs as well. Traffic accidents accounted for 35% of the fractures. 65% of the femur fractures were treated by skeletal traction (mean hospitalisation 30 days), 21% were operated on initially (hospitalisation 12 days), and 14% were given early spica cast (hospitalisation three days). The results of the treatment were generally satisfactory. Neither anisomelia (8.5% more than 10 mm) nor malrotation (12% more than 10 degrees) of the femur was a serious problem, but the length of time the patients were hospitalized was rather long.     

Neurovascular free muscle transfer combined with cross-face nerve grafting for the treatment of facial paralysis in children

Microneurovascular free muscle transfer is fast becoming a standardized procedure in the treatment of established or long-standing facial paralysis. However, there is no general agreement as to whether muscle transfer should be employed for children who still are growing. A patient's natural growth may influence or disturb reproduction of a smile, or a child may not be able to collaborate with postoperative rehabilitation sufficiently well to obtain a satisfactory result. One may hesitate to employ the procedure for children aged under 10 out of fear of its technical difficulties. To investigate the influence of age, the results experienced by 23 patients under the age of 15 who underwent free muscle transfer combined with cross-face nerve grafting were compared with those of adult patients. The treatment employed was a two-stage operation consisting of cross-face nerve grafting and subsequent free muscle transfer.     

Femoral vascular catheterization in critically ill infants and children

The success rate and complications from femoral arterial and venous catheterization in infants and children in a university affiliate pediatric intensive care unit were determined prospectively over a 2-year period. We also performed a meta-analysis from published literature to determine the combined estimates of noninfectious and infectious complications (with 95% confidence limits) using the inverse variance-weighted method. Success rates were 94.5% and 94.4% for femoral arterial (n=110) and venous (n=89) catheterizations, respectively, and were related to operator expertise, age, and hemodynamic status. Median age was 2.4 years and 1.1 year for arterial and venous catheterizations, respectively. Immediate complications were hematoma (10.9% arterial, 16.8% venous) and minor bleeding (13.6% arterial, 13.5% venous). Decreased pulses occurred with 7.7% of arterial catheterizations, and lower limb swelling occurred in 9.5% of venous catheterizations. Vascular complications occurred only in infants and resolved within 7-14 days. Catheter-related infections occurred in 1.9% of arterial and 3.6% of venous catheterizations. The mean duration of catheterization was 5.3 days and 6.3 days with femoral arterial and venous catheterizations, respectively. Meta-analysis of published studies shows that the estimates for noninfectious complications were 5.0%, 10.1%, 1.1%, and 1.8% for femoral arterial, femoral venous, axillary arterial, and nonfemoral venous catheters, respectively. The estimates for catheter-related infection were 2.5%, 3.7%, and 3.0% for femoral arterial, femoral venous, and nonfemoral venous catheters, respectively. The meta-analytic estimates for complication rates from published literature are not significantly different from the rates observed in our study. Femoral arterial and venous catheterization in infants and children are safe with an expected high success rate and acceptably low complication rates.     

Ryanodine binding sites measured in small skeletal muscle biopsies

A method allowing measurement of the concentration of [3H]ryanodine binding sites in small skeletal muscle specimens (> 10-20 mg) was developed. A membrane fraction containing 87% of the [3H]ryanodine binding sites of the tissue and exhibiting one single KD of 18-27 nmol l-1 in rat and 8 nmol l-1 in human muscles (p < 0.05) was obtained. Maximum binding to rat EDL and soleus muscles equalled 59.1 and 16.2 pmol g-1 wet wt, whereas in human gluteus muscles binding was 12.3 pmol g-1 wet wt. The [3H]ryanodine binding showed a dependency on Mg2+ and pH similar to previously published results. As measured by Ca2+ selective mini-electrodes, the [Ca2+] causing 50% of maximum [3H]ryanodine binding (K0.5) was 200-400 nmol l-1 for different muscles. [Ca2+] higher than 1 mmol l-1 caused strong inhibition of the [3H]ryanodine binding, and both high and low [Ca2+] caused rapid dissociation of the complex. At ionic strength lower than 100 mmol l-1, more than 50% of the [3H]ryanodine was bound to particles with size less than 1.2 microns which were not retained by GF/C filters. Thus, we have obtained an almost complete quantitative recovery of functional RyRs from small muscle specimens exhibiting high affinity for Ca2+, which stimulated ligand binding.     

Facial nerve outcome in lateral skull base surgery for benign lesions

OBJECTIVE: To statistically identify factors most important in affecting CN7 outcome in lateral skull base surgery for benign lesions. STUDY DESIGN: A retrospective review of 217 nonmalignancy lateral skull base procedures from 1970 to 1995 at the Otology Group in Nashville. METHODS: Charts were reviewed for epidemiology, histopathology, staging, type of CN7 mobilization (none, short, long, severance with reanastomosis, and resection), preoperative and postoperative CN7 function, surgery performed, and survival. RESULTS: Average House-Brackman (HB) scores for mobilizations were as follows: short, 1.65: long, 2.74: and grafting, 4.33. Factors found to affect outcome in a statistically significant fashion were preoperative HB score, staging, type of CN7 manipulation, and surgical approach. Meningiomas were found to have a worse outcome than glomus tumors. CONCLUSIONS: Complete resection of tumors should be performed with minimal manipulation of the facial nerve based on regional anatomy and tumor anatomy.     

Reappraisal of femoral hernia in children

We report two cases of tetraplegia caused by cervical stab wounds. In the first one, in a 34-year-old patient, the injury caused an immediate tetraplegia from cervical spine section and had a rapid lethal outcome. The second case occurred in a 30-year-old woman, who experienced a progressive tetraplegia associated with a Brown-Séquard syndrome from an oedema of the bulbo-spinal junction. Three months later, the motor recovery was satisfactory, however a thermo-algesic hemi-anaesthesia still persisted after the 6th month.     

Implantation of the lateral cochlear wall for auditory nerve stimulation

Although cochlear implants now regularly achieve gratifying results, traditional intrascalar implants have certain limitations. Extraluminal implants may offset some of these problems by accessing neurons subserving a wider tonotopic range, avoiding intracochlear insertion trauma, and offering alternatives when cochlear obliteration is present. We have investigated the utility of a lateral cochlear wall implant in a normal-hearing cat model with implants at the middle and basal turns, and found successful activation of the auditory nerve at thresholds of 28.1 and 40.6 microA, respectively. No adventitial stimulation of the facial nerve was noted within the dynamic range. Maximum responsiveness was observed with implants of the middle turn of the cochlea, an area that is not reliably approached with current intrascalar implants. These observations support and extend prior observations of the feasibility of extraluminal stimulation of the auditory nerve.     

Inflammatory infiltrates in sural nerve biopsies in Guillain-Barre syndrome and chronic inflammatory demyelinating neuropathy

Prompted by observations in experimental autoimmune neuritis we reanalyzed immunohistochemically the inflammatory infiltrates in sural nerve biopsies of 22 cases with Guillain-Barre syndrome (GBS) and 13 cases with chronic inflammatory demyelinating polyneuropathy (CIDP). Endoneurial infiltration of CD3+ T cells was found in 20 cases of GBS (median 5.5 cells/mm(2)) and in 10 cases of CIDP (5 cells). Epineurial T cells were present in all GBS cases (19.5 cells) and in 11 CIDP cases (21 cells). CD68+ macrophages were abundant in these neuropathies and often occurred in endoneurial perivascular clusters. In GBS subgroups the number of endoneurial T cells was significantly higher in patients with hypoesthesia and abnormal electrophysiological findings in the sural nerve. In CIDP hypoesthesia was associated with significantly higher numbers of macrophages. Our study also indicates that other factors including the time point of biopsy or previous corticosteroid treatment may influence the inflammatory cell profile. Quantifying cell infiltration may aid in establishing the diagnosis of an immunoneuropathy in patients with mild and noncharacteristic pathology.