The efficacy of femoral nerve block in pain reduction for outpatient hamstring anterior cruciate ligament reconstruction: a double-blind, prospective, randomized trial.

The purpose of this study was to assess the efficacy of intraoperative femoral nerve block (FNB) in the reduction of postoperative pain following anterior cruciate ligament (ACL) hamstring reconstruction. Patients undergoing primary ACL reconstruction with hamstring tendon graft under general anesthetic who had signed an informed consent were included in the study. Patients were stratified to 4 surgeons and randomized to FNB with 0.25% bupivacaine or placebo of normal saline injected into the femoral nerve sheath before reversal of the general anesthetic. All patients received an intra-articular injection of bupivacaine at the beginning of their operative procedure. A single technique that included the use of a peripheral nerve stimulator was used for all FNBs. All patients were discharged on the day of surgery and given prescriptions for Tylenol 3. The Short-Form McGill Pain Questionnaire (SF-MPQ), a visual analog scale (VAS) for pain, and a medication diary recording Tylenol 3 usage were completed by patients in the recovery room, on the night of surgery, and on postoperative days 1, 2, and 3. There were complete data for 61 patients (FNB, 29; placebo, 32). An analysis of variance (ANOVA) test of the data showed no significant difference between the FNB and placebo group for pain reduction over the combined study period for both the SF-MPQ and VAS. However, the ANOVA does suggest that, on the night of surgery, there was a significant reduction in pain as measured with the VAS in the FNB group. A Student t test performed on the night of surgery data (SF-MPQ, P = .131; VAS, P = .0114; Tylenol 3, P = .076) showed a statistically significant difference between the FNB (39.4+/-21.0 mm) and placebo (56.8+/-24.6 mm) measured by VAS. Because this represented a difference of only 1.74 cm on a 10-cm VAS, it is unlikely to be clinically relevant. No difference was found in the amount of analgesic required on any day postoperatively. In conclusion, FNB may reduce pain on the night of surgery. However, this may not be clinically significant. FNB is not recommended at this time for use in outpatient ACL reconstruction with hamstring graft.

Complications of anterior spinal surgery in children.

The purpose of this study was to document the medical and surgical complications of anterior spine surgery in children and to identify risk factors for complications. A retrospective chart review was conducted of 599 anterior procedures (24 anterior only, 300 staged anterior/posterior, 175 combined anterior/posterior procedures) performed between 1967 and 1991. Major complications occurred in 7.5% of procedures and minor complications in 33%. Risk factors for major complications were age > 14 years, male gender, kyphotic curve type, curve sizes > 100 degrees, vital capacity < 40% of predicted, and use of thoracotomy. Risk factors for minor complications were age > 14 years, curves > 100 degrees, vital capacity < 40% of predicted, and use of a staged procedure. Multivariate analyses of risk factors identified age > 14 years and curves > 100 degrees as the most significant risk factors for major complications and age > 14 years for minor complications. We concluded that anterior spinal surgery can be performed in children with an acceptable level of risk and that referral for surgery before 14 years of age and before the curve size progresses will significantly reduce the risk of complications.

Functional outcome of patients with salvageable limbs with grades III-B and III-C open fractures of the tibia.

Numerous reports list predictive criteria to determine whether Gustilio-type tibial III-B and III-C fractures of the tibia are salvageable. What is lacking are long-term reports of comprehensive functional outcome of these severe injuries. We evaluated the functional outcome of patients with our own seven-scale score. Fifty-four patients with 57 types III-B (n = 41) and III-C (n = 16) open tibial fractures sustained between 1980 and 1989 were recalled for evaluation. There were 45 men and 9 women (average age, 28.4 years; range, 4-68 years). Follow-up periods averaged 48.2 months (range, 12-116 months). Salvage rate for the III-B fractures was 75% (n = 31) and for the III-C fractures 37% (n = 6). We conclude that the functional score is a simple and complete method for assessing the functional outcome of patients undergoing limb salvage procedures.

Patellar tendinitis--a case report of elongation and ossification of the inferior pole of the patella.

Patellar tendinitis is a condition that occurs in patients who are involved in repetitive use of the extension mechanism. The most common symptoms are pain at the inferior pole of the patella, and radiographic changes may also occur. This case report demonstrates an extreme example of elongation of the inferior pole of the patellar tendon. The ossification caused the patient pain, which was resolved with surgical removal of the bone.

The effect of deferoxamine on ischemic changes in rat skeletal muscle: a preliminary study.

The purpose of this study was to evaluate the effectiveness of deferoxamine in preventing detrimental microvascular changes in ischemically damaged skeletal muscle during the initial reperfusion stage. Sprague-Dawley rats were given saline or deferoxamine (25 or 50 mg/kg) intravenously just prior to release of an air tourniquet placed around one hindlimb for 4 h. The limb was allowed to reperfuse for 2 h. Vascular leakage of plasma protein was assayed by determining the amount of 131I-labeled serum albumin that was given intravenously 30 min prior to release of the tourniquet. The wet and dry weights of the gastrocnemius and tibialis anterior muscles and the 131I activity were evaluated in both ischemic and nonischemic limbs. Although vascular permeability and edema increased markedly in both muscles in the ischemic limbs, there were no significant differences between the saline or either treatment groups. The lack of effect of deferoxamine in this initial report suggests that skeletal muscle may differ from other tissues in the early reperfusion stage.

Cotrel-Dubousset instrumentation in idiopathic scoliosis.

Although well accepted in the patient undergoing Harrington instrumentation, the validity of King's criteria in patients undergoing correction of idiopathic scoliosis using the Cotrel-Dubousset system has been questioned. The cases of 64 patients with Type II (N = 40) and Type III (N = 24) idiopathic scoliosis treated with Cotrel-Dubousset instrumentation were reviewed. The average curve correction for Type II spinal curvature was 69.4% after surgery and 57.8% at follow-up examination. Decompensation was evident in 40% of the curves that were fused beyond the stable vertebra. However, the patients were only aware of their trunk decompensation if it was larger than 10 mm, and this was found in 35% of the patients. Decompensation occurred in 60% of those that were fused short of or to the stable vertebra. Only 42% of this group were aware of their decompensation. Decompensation was measured to the left of the spine in all patients. The difference between the subgroups based on the choice of distal fusion levels was not statistically significant (P greater than 0.05). The average curve correction for Type III scoliosis was 62.9% after surgery and 54.6% at the time of follow-up examination. There was no correlation between caudal fusion levels and the incidence of decompensation with Type III curves. It was concluded that there was no statistically significant relationship between choice of distal fusion level and the amount of decompensation, thereby indicating that the use of King's criteria for the selection of fusion levels in patients undergoing correction of idiopathic scoliosis using the Cotrel-Dubousset instrumentation may not be useful.

Priming immune response to cholera toxin induced by synthetic peptides.

A systematic study has been conducted of the priming effect in the immunization against cholera toxin (CT). We demonstrate that a priming phenomenon can be achieved by synthetic peptides of the CT B subunit, leading (after a subsequent booster with a subimmunizing dose of the intact toxin) to an efficient anti-CT neutralizing antibody response. This effect is obtained even upon a single administration of a peptide conjugate and even by peptides that as such are not able to induce CT cross-reactive antibodies whatsoever. This effect is specific and dose dependent. A macromolecular carrier as well as an adjuvant are essential for the induction of anti-toxin response. In this respect, a totally synthetic priming agent, CTP3-poly(DL-alanyl)--poly(L-lysine), was adequate for an effective priming response. The specificity of the antibodies formed after the booster was mainly towards the whole CT molecule and only a small fraction of them were specific towards the peptide used for priming. The ability of synthetic peptides to prime the immune system towards a secondary stimulus with whole organism or native protein might be of general practical value, especially in endemic areas where the population is probably constantly exposed to a low level of a particular infectious agent. This exposure, which has no influence on the unprimed immune system, could serve as a booster in the case of individuals primed with an appropriate peptide, leading to a secondary immune response.