Impact of Open Reduction on Surgical Strategies for Missed Monteggia Fracture in Children

PURPOSE: The aims of this study were to review our cases of missed Monteggia fracture treated by open reduction of the radial head with or without ulnar osteotomy and to investigate the indications for open reduction alone in surgical treatment of missed Monteggia fracture. MATERIALS AND METHODS: We retrospectively reviewed 22 patients who presented with missed Monteggia fracture. The patients' mean age at the time of surgery was 7.6 years. The mean interval from injury to surgery was 16.1 months. The surgical procedure consisted of open reduction of the radiocapitellar joint followed by ulnar osteotomy without reconstruction of the annular ligament. The mean period of follow-up was 3.8 years. Radiographic assessment was performed for the maximum ulnar bow (MUB) and the location of the MUB. Clinical results were evaluated with the Mayo Elbow Performance Index and Kim's scores. RESULTS: Five patients underwent open reduction alone, and 17 patients underwent open reduction and ulnar osteotomy. When the MUB was less than 4 mm and the location of the MUB was in the distal 40% of the ulna, we could achieve reduction of the radial head without ulnar osteotomy. The radial head was maintained in a completely reduced position in 21 patients and was dislocated in one patient at final follow-up. CONCLUSION: Open reduction alone can be an attractive surgical option in select patients with missed Monteggia fracture with minimal bowing of the distal ulna. However, ulnar osteotomy should be considered in patients with a definite ulnar deformity.

Limb Lengthening in Patients with Achondroplasia

PURPOSE: Although bilateral lower-limb lengthening has been performed on patients with achondroplasia, the outcomes for the tibia and femur in terms of radiographic parameters, clinical results, and complications have not been compared with each other. We proposed 1) to compare the radiological outcomes of femoral and tibial lengthening and 2) to investigate the differences of complications related to lengthening. MATERIALS AND METHODS: We retrospectively reviewed 28 patients (average age, 14 years 4 months) with achondroplasia who underwent bilateral limb lengthening between 2004 and 2012. All patients first underwent bilateral tibial lengthening, and at 9-48 months (average, 17.8 months) after this procedure, bilateral femoral lengthening was performed. We analyzed the pixel value ratio (PVR) and characteristics of the callus of the lengthened area on serial radiographs. The external fixation index (EFI) and healing index (HI) were computed to compare tibial and femoral lengthening. The complications related to lengthening were assessed. RESULTS: The average gain in length was 8.4 cm for the femur and 9.8 cm for the tibia. The PVR, EFI, and HI of the tibia were significantly better than those of the femur. Fewer complications were found during the lengthening of the tibia than during the lengthening of the femur. CONCLUSION: Tibial lengthening had a significantly lower complication rate and a higher callus formation rate than femoral lengthening. Our findings suggest that bilateral limb lengthening (tibia, followed by femur) remains a reasonable option; however, we should be more cautious when performing femoral lengthening in selected patients.

Retrospective Study of Cysts in the Oral and Maxillofacial Regions: Statistical and Clinical Analysis

Changes of Compound Muscle Action Potential in Short-term Steroid Therapy for Compression Injury of Rat Sciatic Nerve

0.05).CONCLUSION: This study did not show any therapeutic effect of short-term administration of steroids on injured rat sciatic nerve. Further studies are needed.

Functional Outcome of Transphyseal Reconstruction of the Anterior Cruciate Ligament in Skeletally Immature Patients

PURPOSE: In anterior cruciate ligament (ACL) injury, conventional adult reconstruction techniques have to face the potential risk of growth disturbance or angular deformities in skeletally immature patients. The aim of this study was to evaluate the clinical outcomes of ACL reconstruction by conventional transphyseal tunnel technique. MATERIALS AND METHODS: On a retrospective basis, we reviewed 25 skeletally immature patients; all the patients showed skeletal maturity at last follow-up, and the mean age was 16.4 years. The average injury to surgery interval was 12.6 months. Clinical outcomes were assessed at a mean of 74.4 months postoperatively using the Lysholm Knee Scoring Scale, the Tegner activity level, the International Knee Documentation Committee (IKDC), and plain radiographs. RESULTS: All the patients had undergone transphyseal reconstruction of ACL. The mean Lysholm score was 48.36 points preoperatively and 93.32 points postoperatively; the mean Tegner activity level was changed from 3.0 points to 5.6 points. The mean IKDC level was categorized as C preoperatively and changed to A postoperatively. CONCLUSIONS: Our midterm outcome at an average 6 years after surgery was satisfactory without significant leg length discrepancies or abnormal alignment of the knee joint. Transphyseal reconstruction of ACL is a good treatment modality in the skeletally immature patient.

Prognostic Factors of Modified Thompson Quadricepsplasty for the Stiff Knee / 대한정형외과학회잡지

PURPOSE: This study evaluated the prognostic factors of modified Thompson quadricepsplasty for a stiff knee. MATERIALS AND METHODS: From February 1987 to February 2007, 38 knees of 38 patients were managed with modified Thompson quadricepsplasty for a stiff knee. Thirty three males and 5 females were enrolled with a mean age of 36 years. The average follow-up duration was 92 months (range, 18 to 133 months). The most common cause of the stiff knee was a fracture around the knee in 33 cases. Multivariate logistic regression analysis was performed to evaluate the prognostic factors. RESULTS: Multivariate analysis showed that the gain of ROM after surgery was negatively correlated with the ROM before surgery (p<0.0001), and flexion contracture at the last follow up was positively correlated with the initial flexion contracture (p<0.0001). CONCLUSION: In a stiff knee, modified Thompson quadricepsplasty should be considered as soon as possible if the patient cannot gain an acceptable ROM through conservative management. More improvement in the ROM can be obtained in those with a more severe limitation of motion.

Immunohistochemical Analysis of the Bullae in Patients with Primary Spontaneous Pneumothorax / 대한흉부외과학회지

BACKGROUND: Bulla is an air-filled space within the lung parenchyma resulting from deterioration of the alveolar tissue. Molecular mechanism of the formation of the bulla is not well described. Fibroblast growth factor(FGF)-7, bone morphogenetic protein(BMP) receptor, and transforming growth factor(TGF)-beta receptor are known to have a stimulatory or inhibitory role in the lung formation. We investigated to see if these growth factor or cytokine receptors are involved in the bulla formation by immunohistochemical staining of bullous lung tissues from patients with primary spontaneous pneumothorax. MATERIAL AND METHOD: Bullous lung tissues were obtained from 31 patients with primary spontaneous pneumothorax, including 30 males and 1 female from 15 to 39 years old. The bullous tissues were obtained by video-thoracoscopic surgery and/or mini-thoracotomy and fixed in formalin. Blocks of the specimens were embedded with paraffin and cut into 5~6 micrometer thick slices. The sections were deparaffinized and hydrated and then incubated with primary antibodies against FGF-7, BMP-RII, or TGF-RII. RESULT: Of the 31 patients, 24 were TGF-RII positive including 18 strong and 6 weak positives. Observation with high magnification showed that strong immunostaining was detected in the boundary region between bullous and normal lung tissues. In contrast, all of the sections were negative with FGF-7 or BMP-RII antibodies. CONCLUSION: These results suggest that overexpression of TGF-beta RII may be involved in the formation of bulla, although further molecular studies are needed to find out more detailed molecular mechanisms.

Cardiovascular Collapse during Gynecologic Endoscopy: Report of 2 cases / 대한마취과학회지

Hysteroscopy is an established gynecologic procedure that has been used for the past 20 years as a diagnostic technique. It is also used therapeutically. Hysteroscopy is commonly performed with CO2insufflation and its complications are rare. The sudden decrease of end-tidal partial pressure of carbon dioxide, associated with mill-wheel murmur, loss of cardiac output and sinus tachycardia on the ECG are highly suggestive of massive gas embolism during laparoscopy and hysteroscopy. We report 2 cases of cardiac arrest and severe bradycardia. The second patient's expired CO2 concentration fell rapidly to 7 mmHg and blood pressure and heart rate dropped suddenly after resection of the uterine septum and adhesiolysis. We performed cardiac resuscitation with cardiotonic drugs, cardiac compression, defibrillator and resulted in good recovery. At the time of discharge 10 days and 2 days later, the patients had recovered almost completely.

Rapid Tracheal Intubation with High-dose Vecuronium / 대한마취과학회지

For the rapid endotracheal intubation, the ideal neuromuscular blocking drug with short onset time, short duration and few side effects has so far not been found. Succinylcholine is still, inspite of its side-effects and contraindications, the standard drug of choice for rapid intubation. But, high-dose vecuronium as an alternative to succinylcholine for rapid intubation may be recommended. To compare the intubating conditions with that in succinylcholine, the onset and cardiovascular effects of high-dose vecuronium(0.3 mg/kg) were evaluated clinically with a scoring system. The results are as follows ; 1) High-dose vecuronium may provide an alternative means of achieving a rapid onset of neuromuscular blockade. 2) High-dose vecuronium shows minimal effects on cardiovascular system. In concluson, high-dose vecuronium as an alternative method for rapid endotracheal intubation may be recommended without any significant cardiovascular change if succinylcholine is contraindicated.

Effects of propofol and thiopental sodium on the intracranial pressure under halothane or isoflurane anesthesia in the rabbit

The effects of halothane or isoflurane, alone and in combination with propofol or thiopental were investigated for their effects on intracranial pressure (ICP) in the rabbit, with inducing artificially-increased ICP with an intracranial balloon. The higher the end-tidal concentrations of either halothane or isoflurane, the lower the mean arterial pressures (MAP) and cerebral perfusion pressures (CPP). However, the ICP was not influenced by the depth of anesthesia for either inhalation anesthetics. The mean ICPs at 1.5 MAC of halothane and isoflurane were 14 +/- 2 and 20 +/- 2 mmHg, respectively. With the increase of intracranial volume using a 0.7 ml-saline balloon, the ICPs were increased to 193 and 205% in halothane and isoflurane anesthesia, respectively. The ICPs were returned to the levels prior to balloon inflation by the injection of thiopental or propofol. The authors conclude that propofol could be used to reduce ICP under halothane or isoflurane anesthesia if it is ascertained to have the characteristics of a balanced coupling between cerebral metabolism and blood flow like barbiturates do and that either halothane or isoflurane with increased concentrations may decrease MAP without significant change of ICP.

Effects of Propofol and Thiopental Sodium on the Intracranial Pressure under Halothane or Isoflurane Anesthesia in the Rabbit / 대한마취과학회지

The effects of halothane or isoflurane, alone and in combination with propofol or thiopental were investi Rated for their effects on intracranial pressure QCP) in the rabbit, with inducing artificially-increased ICP with intracranial balloon. The higher the end-tidal concentrations of either halothane or isoflurane, the lower the mean arterial pressures(MAP) and cerebral perfusion pressures(CPP). However, the ICP was not influenced by the depth of anesthesia for either inhalation anesthetics. The mean ICPs at 1.5 MAC of halothane and isoflurane were 14+/-2 and 20+/-2mmHg, respectively. With the increase of intracranial volume using 0.7 ml-saline balloon, the ICPs were increased to 193 and 205% in halothane and isoflurane anesthesia, respectively. The ICPs were returned to the levels prior to balloon inflation by the injection of thiopental or propofoL The authors conclude that propofol could be used to reduce ICP under halothane or isoflurane anesthesia if it is ascertained to have the characteristics of balanced coupling between cerebral metabolism and blood flow like barbiturates do and either halothane or isoflurane with increasing the concentrations may decrease MAP without significant change of ICP.

Effects of Single and Long - term Phenytoin Therapy on the Neuromuscular Blocking Actions of Vecuronium in the Rat / 대한마취과학회지

The effects of phenytoin on the neuromuscular blockades(NMBs) appear to be different according to the time intervals between their administration. In general, single injection of phenytoin immediately prior to NMB may produce the augmentation of NMBs, while long-term phenytoin therapy on the neuromuscular blocking actions of vecuronium were investigated in rats using the sciatic nerve-anterior tibialis muscle preparation. Eighteen male rats were divided randomly into three groups; Group I(without phenytoin), II (single phenytoin 40 mg/kg I.V. just prior to vecuronium administration), III(phenytoin 40 mg/ kg administered intraperitoneally twice daily for 14 days). In all the groups, vecuronium with the cumulative dose-response technique of ED was administered intravenously. The results are as follows; 1) The ED of vecuronium was significantly higher in Group III(162.3+/-12.4 ug/kg) than in Group I or II(135.7+/-11.0 or 126.77 +/-16.66 u/kg, respectively), and also the ED did so(218.1 +/-28.3 or respectively). 2) In the cumulative dose-response curves with vecuronium, the slope of Group III was significantly lower than that of Group I or IL 3) The plasma concentrations of phenytoin in Group II and III were 60.9+/-15.1 ug/ml and 9.0+/-2.3 ug/ml, respectively. 4) The duration of vecuronium was significantly shorter in Group III(22.3+/-5.2 sec) than in Group I or II(34.7+/-5.7, 44.3+/-8.7 sec, respectively), and also the recovery index did so(36.8+/-4.4, 43.8+/-5.6 and 27.7+/-5.7 sec in Group I, II and III, respectively). 5) There was no statistically significant difference of mean arterial pressure, heart rate, body temperature, acid-base status and electrolytes among groups. In conclusion, pheytoin with long-term therapy may induce the resistance to vecuronium and shorten its recovery. However, there is no effect in the single injection of phenytoin on the vecuronium-induced neuromuscular block.

Effect of Mannitol on Serum and Urine Electrolyte in Neurosurgical Patients / 대한마취과학회지

Osmotic diuretics are used in neurosurgical patient to decrease intracranial pressure. Mannitol produces diuresis because it is filtered by the glomeruli and not reabsorbed from the renal tubule, leading to increased osmolarity of renal tubular fluid and associated excretion of water. There are some controversies about the effect of mannitol induced diuresis on the change of serum electrolytes. But these controversies are related to the mannitol dosage and infusion speed. We studied the effect of mannitol on serum and urine e1ectrolyte change in 10 patients undergoing operation of cerebral tumor or aneurysm. Every patient was free from cardiac and renal disease. We started infusion of 20% mannitol of which dosage is 0.6-0.9gm/kg for 5 to 10 min after cranium was opened and then injected furosemide O.l mg/kg for acceleration of diuresis. We measured serum electrolyte, urine volume and urine electrolyte before and after 30, 60 and 120 min of mannitol infusion. The results were as follows. 1) Seurm sodium and chloride level decreased significantly from 133 and 102 to l30 and 100 mEq/1 respectively after 30 min, but there was no statistic significance after 60 and 120 min of mannitol infusion. 2) Serum potassium level increased slightly from 4.2 to 4.5 mEq/1 after mannitol infusion but there was no statistic significance. 3) Urine volume increased abruptly from 57 to 477 ml/hr as soon as infusion of mannitol but the degree decreased slowly following times. 4) Urine electrolytes concentration increased abruptly as soon as infusion of mannitol but the degree decrease slowly following times. With the above results, we can conclude that intraoperative mannitol and furosemide infusion in healthy patient can cause only transient change in serum electrolyte and the magnitude of change was too small to have significant clinical effect.

The Effects of Fentanyl Preloading on the Hemodynamic Responses to Endotracheal Intubation / 대한마취과학회지

The effects of fentanyl, used as preloading drug to thiopental for induction of anesthesia, on the hemodynamic responses to endotracheal intubation were investigated in 60 surgical patients. Normotensive patients were randomly assigned to receive thiopental 5 mg/kg alone(N = 20, group A) or fentanyl 3 mcg/kg preloading 4 minutes before thiopental 3 mg/kg(N=20, group B) for induction of anesthesia. Hypertensive patients(N=20, group C) reeeived the same as group B. Electrocardiogram(EKG), mean arterial pressure(MAP), heart rate(HR), and rate-pressure product(RPP) were measured automatically before and during induction of anesthesia and after endotracheal intubation. The incidence of tachycardia were 20% in normotensive group and 25% in group C. Premature ventricular contracture or ST segment depression were appeared in 25% of patients in group C. Following intubation MAP, HR and RPP were all increased significantly but the change of them were more greater in group A than other groups. We concluded that blunting effects of the low dose fentanyl preloading used before thiopental induction to postintubation hypertension and tachycardia were statistically signifieant in normo-and hypertensive patients. But in clinical view, hypertensive patients should be managed more carefully. And further investigation seems warranted for the evaluation of preloading fentanyl dosage or combination of antihypertensive drugs and fentanyl.

The Effects of Fentanyl Preloading on the Hemodynamic Responses to Endotracheal Intubation / 대한마취과학회지

The effects of fentanyl, used as preloading drug to thiopental for induction of anesthesia, on the hemodynamic responses to endotracheal intubation were investigated in 60 surgical patients. Normotensive patients were randomly assigned to receive thiopental 5 mg/kg alone(N = 20, group A) or fentanyl 3 mcg/kg preloading 4 minutes before thiopental 3 mg/kg(N=20, group B) for induction of anesthesia. Hypertensive patients(N=20, group C) reeeived the same as group B. Electrocardiogram(EKG), mean arterial pressure(MAP), heart rate(HR), and rate-pressure product(RPP) were measured automatically before and during induction of anesthesia and after endotracheal intubation. The incidence of tachycardia were 20% in normotensive group and 25% in group C. Premature ventricular contracture or ST segment depression were appeared in 25% of patients in group C. Following intubation MAP, HR and RPP were all increased significantly but the change of them were more greater in group A than other groups. We concluded that blunting effects of the low dose fentanyl preloading used before thiopental induction to postintubation hypertension and tachycardia were statistically signifieant in normo-and hypertensive patients. But in clinical view, hypertensive patients should be managed more carefully. And further investigation seems warranted for the evaluation of preloading fentanyl dosage or combination of antihypertensive drugs and fentanyl.

Modification of atracurium or vecuronium blockade and their reversal by succinylcholine in the cat

The interaction between succinylcholine (SCC) and non-depolarizers, atracurium or vecuronium was investigated in 36 cats of either sex using the sciatic nerve-anterior tibialis muscle preparation. Additionally, the relation of SCC to pseudocholinesterase activity was examined. The duration of action of vecuronium (6.5 +/- 1.3 to 7.3 +/- 2.2 minutes) in cats pretreated with SCC was greater than those (2.0 +/- 0.6 minutes) in non-pretreated cats. However, SCC had no influence on the duration of atracurium. The serum pseudocholinesterase activity was decreased after the injection of atracurium or neostigmine in contrast to vecuronium. The authors conclude that the prior administration of SCC prolongs the duration of vecuronium but not that of atracurium, and pseudocholinesterase activity is not related to the prolonging effect of SCC.

The Neuromuscular Effects of Isoflurane and Enflurane on the Vecuronium - induced Neuromuscular Blockade / 대한마취과학회지

Enflurane, and isoflurane potentiated for the vecuronium-induced neuromuscular blokade in a study of 30 patients anesthetized with 1.0 or 1.5 MAC enflurane, and isoflurane or ketaminefentanyl. In the patients anesthetized with 1.0 MAC isoflurane or enflurane, 50% nitous oxide was administrated simultaneously. The median effective dose of vecuronium m the ketamine-fentanyl anesthesia patients(34,0+/-1.2 ug/kg) was higher than that in the 1.0 and 1.5 MAC enflurane or isoflurane patients(2l.2+/-3.2 and 19.4+/-2.7, or 17.8+/-4.5 and 20.0+/-5.3 ug/kg, respectively). There is no significant difference in ED 50 and ED 95 between 1.0 and 1.5 MAC with enflurane or isoflurane. The duration in patients with enflurane was longer than that in the other groups. But, there is no difference in recovery indices among all the groups. The authors conclude that enflurane or isoflurane potentiantes the vecuronium-induced neuromuscular blockade comparing with ketamine-fentanyl anesthesia. Enflurane prolongs the duration of vecuronium in contrast to isoflurane. But, there is no significant difference between 1.0 and 1.5 MAC in same anesthetic considered usually as clinical anesthetic depth.

Effects of hypotensive anesthesia with sodium nitroprusside or isoflurane on hemodynamic and metabolic changes

The hemodynamic and metabolic changes during induced hypotension with isoflurane (isoflurane group) or sodium nitroprusside (SNP group) were observed in twelve mongrel dogs. These hypotensive effects were evaluated at 30 and 60 minutes after the mean arterial blood pressure was lowered to 50% from the control. Hemodynamic changes were evaluated by measuring systemic arterial blood pressure, heart rate, central venous pressure, pulmonary capillary wedge pressure, cardiac output, systemic vascular resistance and pulmonary vascular resistance. Metabolic changes were evaluated by measuring serum lactate and pyruvate, arterio-venous oxygen content difference and oxygen extraction rate. We also compared the ventilatory effect of hypotensive anesthesia by blood gas analysis. The results were as follows: 1. Isoflurane inhalation 2-4% or SNP infusion 10-20 micrograms/kg/min was required to reduce the mean arterial pressure to 50% of the control. 2. Heart rate was decreased slightly in the isoflurane group but significantly decreased in the SNP group. 3. There were no significant changes in central venous pressure and pulmonary capillary wedge pressure in either group. 4. Cardiac output was reduced in both groups but was more severe in the isoflurane group. 5. Systemic vascular resistance was decreased by 36% in the isoflurane group and 47% in the SNP group. 6. Acidosis was apparent and did not recover to the control until 30 minutes after recovery in the SNP group. 7. Arterio-venous oxygen difference was increased during hypotension in the isoflurane group probably due to decreased cardiac output. 8. The lactate/pyruvate ratio increased slightly in the SNP group.

Unusual Prolonged Recovery of Succinylcholine - induced Neuromuscular Block Following Neostigmin / 대한마취과학회지

We report a case of slow recovery of the neuromuscular block induced by succinylcholine (SCC) immediately after administration of neostigmine for the reversal of pancuronium. Left hemithyroidectomy was performed in a 4l kg female patient under general endotracheal inhalation anesthesia with 50%-nitrous oxide and 2.0%-enflurane. Four mg of pancuronium was used for muscular relaxation to facilitate the controlled ventilaion on the anesthesia ventilator. At the end of the operation, one and a half hours from the injection of pancuronium, 10 mg of pyridostigmine was administered to reverse the neuromuscular blockade. Five minutes later, 25 mg of succinylcholine was given for reintubation. Following this event, train-of-four stimuli was applied under the uncalibrated mode with Datex Relaxograph because apnea followed by SCC appeared for more than 30 minutes. Neuromuscular monitoring revealed fade to less than 50% of the T, ratio. The ventilator was applied for the recovery of neuromuscular blockade for one hour. There was no more late complications after transfer to the ward. The literature relating to this iatrogenic complication and phase II block after SCC is reviewed and discussed.

The Antagonism Effects of Neostigmine on Vecuronium - induced Neuromuscular Blockade in Renal Failure Patients / 대한마취과학회지

The elimination of most anticholinesterases depends on the kidney, even if the main organ for their metabolism is the liver. Renal excretion of pyridostigmine, edrophonium and neostigmine accounts for 15%, 70% and 50%, respectively. In the absence of renal function, the serum half-life of neostigmine is prolonged, its plasma clearance is decreased However, the pharmacodynamics of neostigmine have not been determined in renal failure. This study was designed to compare the neostigmine dynamics in 18 patients with normal renal function to that in 18 patients with renal failure(Group I & II, respectively). Using the flexor carpi ulnaris EMG via ulnar nerve stimulation with Train-Of-Four(TOF) under the constant infusion of vecuronium to produce about 85%-twitch depression, the responses of neostigmine with three different doses were obtained. The results are follows; 1) The constant infusion rates of vecuronium to maintain sbout 15&-twitch height prior to the administration of neostigmine showed no significant difference between two groups. 2) Immediately prior to each dose of neostigmine, the mean values of twitch heights were 11.7 to 13.7%. 3) There was no significant difference in the onset time, maximum twitch responses and antagonism effects between two groups in respect to each same dose of nesotigmine. 4) The duration of neostigmine with the half of ED only in Group II was significantly longer than that in Group I, even if the durations with the other doses in Group II were not significantly longer than those in Group L These results suggest that the reversal effect of neostigmine to vecuronium-induced block- ade may be outlasted in patients with renal failure and the prolongation of neostigmine effeet may render some benefits to reverse the relaxants which have the limitation of its elimination in this patients.