Ibutilide: an antiarrhythmic agent for the treatment of atrial fibrillation or flutter

The results of nineteen semiconstrained modified Coonrad-Morrey total elbow arthroplasties performed in nineteen patients to treat instability were evaluated at an average of seventy-two months (range, twenty-five to 128 months) postoperatively. Preoperatively, all patients had either a flail elbow or gross instability of the elbow that prevented useful function of the extremity. The instability of sixteen elbows was the result of a traumatic injury or of the treatment of such an injury. The most recent result was satisfactory for sixteen elbows and unsatisfactory for three. The average overall Mayo elbow performance score increased from 44 points preoperatively to 86 points postoperatively. At the most recent follow-up examination, no elbow was unstable. The average arc of flexion was from 25 degrees (range, 0 to 60 degrees) to 128 degrees (range, 30 to 142 degrees), which represented a 58-degree increase from the preoperative average arc. Sixteen patients had little or no pain after the arthroplasty. There were four complications in four patients. Three complications (loosening of the humeral component in one patient and a fracture of the ulnar component in two) occurred postoperatively; all three were treated with a revision procedure. The other complication (a fracture of the olecranon) occurred intraoperatively and was treated with tension-band fixation; the most recent outcome was not affected. Radiographically, one patient had complete (type-V) radiolucency about the humeral component. None of the nine patients for whom true anteroposterior radiographs were available had evidence of wear of the bushings. The bone graft behind the anterior flange of the humeral prosthesis was mature in fourteen elbows, incomplete in two, and resorbed in two. One patient was excluded from this analysis because radiographs were not available. Instability of the elbow resulting in the inability to use the extremity is a challenging clinical situation. However, in patients who are more than sixty years old and in selected patients who are less than sixty years old but who have extensive loss of bone as a result of severe injury, have had multiple operations, or have rheumatoid arthritis, total elbow arthroplasty with a linked, semiconstrained prosthesis reestablishes a mobile, stable joint without premature loosening or failure of the components. In our experience, the use of customized implants, maintenance of the muscular attachments to the epicondyles, and reconstruction of the epicondyles to the implant were unnecessary.     

Implications of elbow arthrodesis for individuals with paraplegia

A 38-year-old woman who had a recent injury resulting in T-3 Frankel Class C paraplegia and a comminuted fracture of the right elbow is described in this case report. The elbow required an arthrodesis, but the position in which the elbow should be fused was not initially known. To illustrate to the rehabilitation team and the patient the advantages and disadvantages of each of two elbow positions under consideration for the arthrodesis, the author recruited an individual with paraplegia to demonstrate some activities of daily living with two elbow splints that stimulated the two positions of fusion being considered. The patient and the rehabilitation team concluded that the 30-degree flexion fusion offered more functional mobility than the 90-degree flexion fusion. At the completion of her initial rehabilitation, the patient was a full-time manual wheelchair user. She was independent in all self-care and transfers, including uneven transfers to heights of 22.9 cm (9 in) over and 45.7 (18 in) lower than the wheelchair seat. She drives a four-wheel-drive vehicle and is independent in stowing her wheelchair.     

Volkmann's ischemic contracture of the upper extremity

Upper extremity deformity of ischemic contracture usually includes elbow flexion, forearm pronation, wrist flexion, thumb flexion and adduction, digital metacarpophalangeal joint extension, and interphalangeal joint flexion. Treatment of mild contractures consists of either nonoperative management with a comprehensive rehabilitation program (to increase range of motion and strenght) or operative management consisting of infarct excision or tendon lengthening. Treatment of moderate-to-severe contractures consists of release of secondary nerve compression, treatment of contractures (with tendon lengthening or recession), tendon or free-tissue transfers to restore lost function, and/or salvage procedures for the severely contracted or neglected extremity.     

Examples of recapitulation of the phylogenetic stages of development of the wakefulness-sleep cycle in mammalian ontogenesis

The purpose of this study was to determine the relationship between the ulnar nerve and the cubital tunnel during flexion of the elbow with use of magnetic resonance imaging and measurements of intraneural and extraneural interstitial pressure. Twenty specimens from human cadavera were studied with the elbow in positions of incremental flexion. With use of magnetic resonance imaging, cross-sectional images were made at each of three anatomical regions of the cubital tunnel: the medial epicondyle, deep to the cubital tunnel aponeurosis, and deep to the flexor carpi ulnaris muscle. The cross-sectional areas of the cubital tunnel and the ulnar nerve were calculated and compared for different positions of elbow flexion. Interstitial pressures were measured with use of ultrasonographic imaging to allow a minimally invasive method of placement of the pressure catheter, both within the cubital tunnel and four centimeters proximal to it, at 10-degree increments from 0 to 130 degrees of elbow flexion. As the elbow was moved from full extension to 135 degrees of flexion, the mean cross-sectional area of the three regions of the cubital tunnel decreased by 30, 39, and 41 per cent and the mean area of the ulnar nerve decreased by 33, 50, and 34 per cent. These changes were significant in all three regions of the cubital tunnel (p < 0.05). The greatest changes occurred in the region beneath the aponeurosis of the cubital tunnel with the elbow at 135 degrees of flexion. The mean intraneural pressure within the cubital tunnel was significantly higher than the mean extraneural pressure when the elbow was flexed 90, 100, 110, and 130 degrees (p < 0.05). With the elbow flexed 130 degrees, the mean intraneural pressure was 45 per cent higher than the mean extraneural pressure (p < 0.001). Similarly, with the elbow flexed 120 degrees or more, the mean intraneural pressure four centimeters proximal to the cubital tunnel was significantly higher than the mean extraneural pressure (p < 0.01). Relative to their lowest values, intraneural pressure increased at smaller angles of flexion than did extraneural pressure, both within the cubital tunnel and proximal to it. With the numbers available, we could not detect any significant difference in intraneural pressure measured, either at the level of the cubital tunnel or four centimeters proximal to it, after release of the aponeurotic roof of the cubital tunnel.     

The effect of a flexion contracture of the elbow on the ability to transfer in patients who have quadriplegia at the sixth cervical level

We studied six patients (twelve upper extremities) who had quadriplegia at the sixth cervical level. Our purpose was to evaluate how the loss of terminal extension of the elbow adversely affected the ability of the patient to perform transfers with a sliding board and so-called depression raises (lifting of the body with use of the extended upper extremities to reduce the pressure on the ischial tuberosities). Function of the triceps muscle was considered to be absent in eight upper extremities and present in four. A flexion contracture of the elbow was simulated with use of a specially fabricated, hinged elbow brace. Terminal extension was progressively limited, in 5-degree increments, until the patient was no longer able to perform the transfer or the depression raise. The mean flexion contracture at which the patient could not perform the transfer or the depression raise was approximately 25 degrees when function of the triceps was absent and approximately 50 degrees when function of the triceps was intact. The results of this study emphasize the importance of maintaining the full range of motion of the elbow in a patient who has high-level quadriplegia. In a patient who has quadriplegia at the sixth cervical level who otherwise would be independent with regard to transfer skills and mobility in bed, a flexion contracture of the elbow of approximately 25 degrees or more can result in the loss of a functional level and render the patient as dependent as one who has quadriplegia at the fifth cervical level.     

Prolonged fasting in pediatric outpatients does not cause hypoglycemia

The long-term results after the manipulation and strapping in flexion of selected extension supracondylar fractures of the humerus were evaluated in 43 children. Reduced fractures that were stable when immobilized in approximately 110 degrees of flexion, without producing circulatory obstruction, were treated in this manner. After a minimum review of 4 years, 95 per cent of the children had an excellent or good range of elbow motion and 88 per cent had excellent or good elbow alignment. No child had Volkmann's ischaemic contracture. Five children had cubitus varus which was due to malunion in three, but was unrelated to the treatment of the supracondylar fracture in two children. If these two latter children were excluded then excellent or good alignment was observed in all children who had a Baumann (humerocapitellar) angle of 80 degrees or less at the time of reduction and 84 degrees or less 10 days after the fracture. We concluded that manipulation and strapping in flexion was suitable for approximately 60 per cent of children with isolated displaced supracondylar fractures of the humerus.     

Gait pattern in the early recovery period after stroke

The gait patterns of eighteen patients who had had a single infarct due to obstruction of the middle cerebral artery were evaluated within one week after the patients had resumed independent walking and before a gait rehabilitation program had been initiated. Gait was analyzed with use of motion analysis, force-plate recordings, and dynamic surface electromyographic studies of the muscles of the lower extremities. The patterns of motion of the lower extremity on the hemiplegic side had a stronger association with the clinical severity of muscle weakness than with the degree of spasticity, balance control, or phasic muscle activity. There was a delay in the initiation of flexion of the hip during the pre-swing phase, and flexion of the hip and knee as well as dorsiflexion of the ankle progressed only slightly during the swing phase. During the stance phase, there was decreased extension of the hip that was related to decreased muscle effort and a coupling between flexion of the knee and dorsiflexion of the ankle. The abnormal patterns of motion altered the velocity, the length of the stride, the cadence, and all phases of the gait cycle. The duration of the pre-swing phase was prolonged for the patients who had the slowest gait velocities. There also were abnormal movements of the upper extremity, the trunk, the pelvis, and the lower extremity on the unaffected side in an effort to compensate for the decreased velocity on the hemiplegic side. As velocity improved, these abnormal movements decreased. Therefore, the goal of therapy should be to improve muscle strength and coordination on the hemiplegic side, especially during the pre-swing phase.     

Polycentric total knee arthroplasty. A two-year follow-up study

Polycentric total knee arthroplasty provided significant relief of pain in 86 per cent of 500 knees. The independence and activity levels of the patients increased dramatically. The frequency of major complications as reflected by reoperation was 10 per cent in this series. There was a 2.8 per cent deep infection rate. One-third of the infected knees were salvaged and two-thirds required arthrodesis. Loosening of a component was noted in 2.4 per cent. After operation the average range of motion was from 6 to 101 degrees of flexion, for a range of 95 degrees; this was a 5-degree increase over average preoperative motion. Ninety-six per cent of the patients expressed satisfaction with the surgical result.     

Knowledge of diet and blood pressure among African Americans: use of focus groups for questionnaire development

The long-term results were reviewed for seventy-two patients (seventy-five knees) who had had a bone-patellar ligament-bone intra-articular reconstruction of the anterior cruciate ligament between August 1984 and May 1992. The mean age of the patients at the time of the operation was forty-five years (range, forty to sixty years). Three patients had a bilateral procedure. The primary mechanisms of injury were accidents that occurred during skiing (thirty-two knees), tennis (fourteen knees), and soccer (five knees). We analyzed the responses to subjective questionnaires, the functional results, and the objective clinical data. The clinical examination included assessment of the range of motion, performance of Lachman and pivot-shift tests, and measurements with use of a KT-1000 arthrometer. All knees were evaluated with use of three common rating scales: that of Lysholm and Gillquist; that of The Hospital for Special Surgery, as modified by Insall et al.; and the International Knee Ligament Standard Evaluation Form. At the latest follow-up evaluation, at a mean of fifty-five months (range, twenty-six to 117 months), three patients reported pain or swelling. No patient reported giving-way or symptoms related to the patellofemoral joint. The mean range of extension was -12 to 6 degrees, compared with -8 to 42 degrees preoperatively, and the mean range of flexion was 112 to 150 degrees, compared with 52 to 154 degrees preoperatively. Flexion was limited to 112 degrees in one patient, but this was 5 degrees greater than that of the uninvolved knee. Sixty knees (80 per cent) had a negative pivot-shift test, and ten knees (13 per cent) had a grade of 1+. On testing with the KT-1000 device at maximum manual pressure, the mean difference between the injured and uninjured knees was found to have improved by 5.1 millimeters, from 6.4 millimeters preoperatively to 1.4 millimeters postoperatively (p < 0.01). The grade on the International Knee Ligament Standard Evaluation Form improved markedly; seventy-two knees (96 per cent) had a grade of C or D preoperatively, whereas seventy knees (93 per cent) had a grade of A or B postoperatively. The Hospital for Special Surgery score improved from a mean of 69 points preoperatively to a mean of 92 points postoperatively (p < 0.01). The mean score according to the scale of Lysholm and Gillquist increased from a mean of 63 points preoperatively to a mean of 94 points postoperatively (p < 0.01). All patients indicated that they were pleased with the result of the procedure. Bicycling was resumed at a mean of four months; jogging, at a mean of nine months; skiing, at a mean of ten months; and tennis, at a mean of twelve months.     

Intravascular coagulation in surgical procedures on the abdominal aorta

A prospective study was performed on 32 consecutive patients undergoing elective operations on the abdominal aorta. Dacron prosthetic grafts were used to replace resected abdominal aortic aneurysms or to bypass aorta-iliac occlusive disease. Complete coagulation studies were performed preoperatively, immediately postoperatively and 24 hours postoperatively. Twenty to 30 per cent of the patients had significant postoperative alterations in prothrombin time, partial thromboplastin time and platelet count. Fibrin monomer, fibrin split products and plasminogen were abnormal in 40 to 80 per cent of the patients postoperatively. Results of preoperative studies showed no significant abnormalities. One of the 32 patients had mild clinical evidence of disseminated intravascular coagulation postoperatively, which was treated with 5 units of heparin per kilogram per hour. Results of the study indicate that aortic grafting procedures frequently produce intravascular coagulation, either local or disseminated. In most patients, this is offset by activation of the fibrinolytic system. However, clinically significant sequelae may result, requiring prompt recognition and treatment.     

Evaluation of the two-stage flexor-tendon reconstruction in severely damaged digits

From July 1971 to July 1974, the two-stage tendon-grafting procedure of Hunter and Salisbury was performed in thirty-two severely damaged digits in twenty-five patients. Of these digits, twenty-three fingers and five thumbs could be evaluated for gain in total active flexion (expressed as per cent of preoperative passive flexion) and for gain in total active motion (expressed as per cent of total preoperative passive motion) after follow-ups ranging from six to fifty months. The results for total active flexion were 60.9 per cent good, 21.7 per cent fair, and 17.4 per cent poor, and for total active motion 21.7 per cent good, 56.5 per cent fair, and 21.7 per cent poor. Complications were frequent after both stages and included infection, migration of the rod, and adhesions within the proximal end of the newly formed sheath. Flexion contractures were a significant problem.     

Late instability in cervical spine fractures secondary to laminectomy

Of 256 patients with a major spinal cord injury as a result of fracture of the cervical spine, 38 per cent had a laminectomy. Three months after injury, 33 per cent of the patients with laminectomy required fusion for instability compared to 22 per cent of the nonlaminectomy group. There were no cases of late instability in pure flexion or extension fracture groups. Ninety per cent of the late instability cases were in the groups with hyperflexion and flexion compression fractures. Laminectomy should be avoided for these fractures, but early fusion may be necessary to prevent progressive deformity.     

The function of the quadriceps muscle after a fracture of the femur in patients who are less than seventeen years old

Thirty-three patients who had been managed for an isolated, closed fracture of the femoral shaft when they were less than seventeen years old were examined at an average of thirty-three months (range, eighteen to fifty-six months) after the injury. Thirteen patients (39 per cent) had a persistent deficit in the strength of the quadriceps of the fractured limb, as identified on testing with a Cybex-II isokinetic dynamometer. Six patients (18 per cent) had a deficit according to the one-leg-hop for distance test, fourteen (42 per cent) had an average loss of ten millimeters in the circumference of the thigh, and sixteen (48 per cent) had an average loss of 10 degrees of flexion of the knee. The etiological factors that were thought to possibly be responsible for the weakness of the quadriceps were evaluated. The amount of maximum displacement of the fracture, as seen on the initial radiographs, was the only factor that was significant for the prediction of weakness of the quadriceps (p = 0.006) at both test speeds of the Cybex dynamometer and in all statistical analyses. Despite the persistent weakness of the quadriceps, none of the patients had a clinical problem at the latest follow-up examination. A subclinical deficit in the strength of the quadriceps may be related to damage sustained by the muscle at the time of the fracture. On the basis of the results of this study, we do not recommend a change from the traditional methods of treatment, which involve early application of a spica cast or use of traction followed by application of a spica cast.     

Gene therapy for hematological malignancies

The management of avascular necrosis of the capitellum of the adolescent elbow continues to be a dilemma. This article is a critical retrospective analysis of 12 pediatric patients (mean age at surgery 14.5 years) who underwent arthroscopic debridement alone followed by early range of motion. Follow-up at a mean of 3.2 years (range, 2.0 to 5.7 years) indicated that the average flexion contracture improved from 23 degrees preoperatively to 10 degrees postoperatively. All patients had remodeling of the capitellum by plain radiographs; however, five patients had associated enlargement of the radial head. Eleven patients had minimal mechanical symptoms after the procedure and were highly satisfied. One patient had substantial enlargement of the radial head with continued loss of supination and mechanical symptoms requiring radial head resection 2 years after the index procedure. Five patients had a triangular avulsion fragment present off the lateral capsule. A statistically significant worse subjective outcome was associated with the presence of this fragment (P < .005). There were no complications.     

Use of intra-aortic balloon pumping (IABP) in clinical cardiac surgery and management of patients with IABP

One hundred thirty eight patients were reviewed which required IABP assist. Sixty nine (84 per cent) of 82 patients who had been able to come off cardiopulmonary bypass despite increasing pharmacologic support survived operation and 56 patients (68 per cent) discharged hospital. Twenty three (75 per cent) of 31 patients who took for elective coronary artery surgery as extremely high risk because of extensive three vessel coronary artery disease and severely compromised left ventricular function discharged hospital. In summary, hospital death was 35 per cent, late death 12 per cent and long term survivors 54 per cent. Severe complication concerned with inserting balloon catheter occurred in two cases (1.4 per cent) which were abdominal aortic dissection and laceration of iliac artery. At the present time, the primary indication for IABP is in assistance of the open heart surgical patient. Thre are three important factors in successfully managing the patients with IABP. First, begin IABP assist as soon as possible if indicated. Second, keep an adequate circulating volume with mean left atrial pressure being maintained around 20 mmHg and cardiac index at 2.1 L/min./M or greater. Third, improve the peripheral vascular circulation, which might need peripheral vasodilator.     

The column procedure: a limited lateral approach for extrinsic contracture of the elbow

Thirty-eight elbows (thirty-seven patients) with an extrinsic contracture were treated operatively with a limited lateral approach to the anterior and posterior aspects of the capsule. Because the procedure elevates muscles from the anterior and posterior aspects of the lateral supracondylar osseous ridge, we called it the column procedure. The mean preoperative arc of flexion was 49 degrees (from 52 to 101 degrees). At a mean of forty-three months (range, twenty-four to seventy-four months) postoperatively, the mean arc of flexion was 94 degrees (from 27 to 121 degrees). The mean total gain in the arc of flexion-extension was 45 degrees; thirty-four elbows (89 percent) had an improved range of motion at the latest follow-up examination. Overall, thirty-one elbows (82 percent) had a satisfactory result. Greater improvement was obtained in elbows that had had severe stiffness (a total arc of 31 to 60 degrees) or very severe stiffness (a total arc of 30 degrees or less) or that had had a combined flexion and extension contracture. A complication occurred in four elbows (11 percent). A hematoma developed in two elbows and impaired the final outcome in one of them. Two elbows had transient ulnar paresthesia, which resolved spontaneously. The arc of flexion obtained at the time of the operation was lost in ten elbows (26 percent) after an initial period of improvement; at the latest follow-up evaluation, four of these elbows had a mean decrease in the arc of flexion of 24 degrees compared with preoperatively. The column procedure is associated with a low rate of complications and is safe and effective for the treatment of a limitation in flexion or extension resulting from an extrinsic contracture of the elbow.     

The effect of limb-length discrepancy on gait

We evaluated the gait of thirty-five neurologically normal children who had a limb-length discrepancy of the lower extremities that ranged from 0.8 to 15.8 per cent of the length of the long extremity (0.6 to 11.1 centimeters). The twenty-two boys and thirteen girls had an average age of thirteen years (range, eight to seventeen years). No patient had a substantial angular or rotational deformity of the lower extremities. We found no correlation between the actual discrepancy or the per cent discrepancy and any of the dependent kinematic or kinetic variables, including pelvic obliquity. Discrepancies of less than 3 per cent of the length of the long extremity were not associated with compensatory strategies. When a discrepancy was 5.5 per cent or more, more mechanical work was performed by the long extremity and there was a greater vertical displacement of the center of body mass. Clinically, this degree of discrepancy was manifested by the use of toe-walking as a compensatory strategy. Children who had less of a discrepancy were able to use a combination of compensatory strategies to normalize the mechanical work performed by the lower extremities.     

Intravenous regional anesthesia for closed treatment of fractures and dislocations of the upper extremities

Intravenous regional anesthesia for the treatment of fractures and dislocations of the upper extremity is a very effective, consistent and safe form of analgesia which requires low doses of lidocaine and can be performed in an emergency room using a regular blood pressure cuff. Dosage should be related to body weight and the blood pressure cuff should be maintained at higher than systolic pressure for a minimum of 15 minutes after the lidocaine is injected. Release of the tourniquet should be staged as described. Ninety-one per cent of 77 patients had excellent analgesia following the IVRA. Eight per cent had fair results, but this was still adequate to perform the reduction with only minimal but definite discomfort to the patient. Only one patient failed to respond to the IVRA technique. Other advantages such as muscle relaxation during the anesthetic and rapid full return of sensation after cuff release, permit ease of reducion and early anticipation of cast discomfort or pressure pain from sharp edges of plaster. Unpleasant long term side effects of axillary block anesthesia, such as persistent paresthesia have not been seen.     

Proximal femoral osteotomy as the primary operation for young adults who have osteoarthrosis of the hip

We report the results of proximal femoral osteotomy that was performed to treat osteoarthrosis in twenty-three consecutive young adults (twenty-five hips) who had a mean age of thirty-eight years (range, eighteen to fifty-three years). The mean duration of follow-up was seven years (range, two to twelve years). With conversion to a total hip replacement as the end point, the rate of survival at twelve years was 67 per cent (95 per cent confidence interval, 37 to 88 per cent). Four hips (16 per cent) were converted to a total hip replacement at a mean of eight years after the osteotomy. For the patients who did not have conversion to a total hip replacement, the mean score for pain, according to the system of Merle d'Aubigné and Postel as modified by Charnley, improved from 3.4 points preoperatively to 5.1 points postoperatively, the mean score for walking ability improved from 3.9 to 4.7 points, and the mean score for range of motion improved from 3.2 to 4.2 points. These results compare favorably with those following other forms of operative treatment of osteoarthrosis of the hip in young adults. In addition, the osteotomy does not preclude subsequent replacement arthroplasty if one is necessary.     

Role of fine-needle aspiration biopsy and frozen section examination in determining the extent of thyroidectomy

Ten years' experience with neonatal necrotizing enterocolitis (NNEC) was reviewed retrospectively to determine long-term survival and quality of life and to analyze risk factors associated with in-hospital mortality. Institutional records were queried to identify all neonates who required emergent surgical intervention for NNEC. These records were then reviewed and survivors' families interviewed by phone to determine patient status, persistent gastrointestinal problems, and overall quality of life. Once identified, long-term survivors (LTSs) were compared to in-hospital deaths by the analysis of birth weight, gestational age, time interval from birth to diagnosis, indications for laparotomy, and extent of intestinal involvement. Between 1986 and 1996, 69 patients required surgical intervention for NNEC. Eleven patients were lost to follow-up. Of the remaining 58 patients, 31 were ultimately discharged home, with 28 patients having survived an average of 4.18 years. The acute, or in-hospital, mortality rate was 39.1 per cent. Infants who died did so within an average of 23 days postoperatively, and those who were discharged home required an average of 121 days of inpatient convalescence. Twenty-one of the 28 LTSs achieved a normal quality of life with no persistent health problems. One patient required a hepatic-intestinal transplant, and another six had minor problems with frequent diarrhea. Average birth weight, age at NNEC diagnosis, and gestational age were not significantly different between LTSs and those with acute deaths. Aggressive in-hospital care is warranted for infants with NNEC. The excellent quality of life achieved in 75 per cent of survivors implies that the expense of heroic surgical care for these seriously ill premature infants is a worthwhile investment.