Chloroprocaine 40 mg produces shorter spinal block than articaine 40 mg in day-case knee arthroscopy patients.

BACKGROUND: Articaine and chloroprocaine have recently gained interest as short-acting spinal anaesthetics. Based on previous work comparing articaine 60 mg with chloroprocaine 40 mg, we hypothesised that articaine 40 mg and chloroprocaine 40 mg would produce similar spinal anaesthesa regarding block onset, maximal spread, and recovery. METHODS: In this randomised, double-blind study, adult patients (18-70 years, American Society of Anaesthesiologists physical status I-III, BMI < 36 kg/m(2) ) scheduled for day-case knee arthroscopy received either articaine 40 mg (20 mg/ml) (group A40, n = 16) or chloroprocaine 40 mg (20 mg/ml) (group C40, n = 18) intrathecally. Telephone interviews were performed on the first and seventh postoperative day to disclose possible side effects, e.g. transient neurological symptoms (TNS). RESULTS: The groups were comparable regarding demographic data, onset and maximal spread of spinal anaesthesia, and duration of surgery. Surgery could be performed successfully under spinal anaesthesia except once in A40 (insufficient block) and once in C40 (prolonged surgery). Complete recovery was significantly slower in A40 vs. C40 for both motor block (105 (94/120) vs. 75 (71/90) min) [P < 0.001, Mann-Whitney U-test (MW-U)] and sensory block [135 (109/176) vs. 105 min (90/124)] (P < 0.02, MW-U), respectively [data are median (25th/75th percentiles)]. One patient from A40 showed mild TNS. CONCLUSION: Both A40 and C40 provided mainly adequate spinal anaesthesia for day-case knee arthroscopy. While onset and maximal spread were comparable, the recovery from motor block was clearly faster with chloroprocaine after equivalent doses of spinal articaine and chloroprocaine.

Chloroprocaine vs. articaine as spinal anaesthetics for day-case knee arthroscopy.

BACKGROUND: Chloroprocaine and articaine have recently gained interest as short-acting spinal anaesthetics. They have not, however, previously been compared in an ambulatory surgery setting. METHODS: In this double-blind, randomised, controlled trial, adult patients (≤65 years, ASA I-II, body mass index<36 kg/m2) underwent day-case knee arthroscopy under spinal anaesthesia with either 40 mg of plain chloroprocaine (20 mg/ml) (group C40; n=39) or 60 mg of plain articaine (40 mg/ml) (group A60; n=39). Study parameters included the onset, degree, and regression of both sensory and motor block. Standardised telephone interviews on the first and seventh post-operative day were aimed at detecting any untoward sequelae, e.g., transient neurologic symptoms (TNSs). RESULTS: The groups were comparable regarding demographic data, onset and maximal spread of spinal anaesthesia, and duration of surgery. All arthroscopies were performed successfully under spinal anaesthesia, except for one patient (C40, unforeseen delay in the start of surgery). The duration of sensory block≥dermatome L1 was significantly shorter in C40 vs. A60. Correspondingly, complete recovery was significantly faster (P<0.0001, Mann-Whitney U-test) in C40 vs. A60 for both motor [75 (60/90) vs. 135 (105/150) min] and sensory [105 (105/135) vs. 165 (135/180) min] block, respectively [data are median (25th/75th percentiles)]. No TNSs were noted. CONCLUSIONS: Both anaesthetics used provided a rapid onset of spinal anaesthesia of about 1 h and were satisfactory for day-case knee arthroscopy. Recovery, however, was significantly faster in group C40. The data add to earlier results that TNSs seem to be uncommon after spinal chloroprocaine and articaine.

Mid-term results for three contemporary total knee replacement designs - a comparative study of 104 patients with primary osteoarthritis.

AIMS: The purpose of this study was to compare retrospectively the mid-term clinical and radiological results of three contemporary knee designs in cohorts operated on in the same hospital during the same time period. MATERIALS AND METHODS: We evaluated mid-term clinical and radiographic outcome of three contemporary total knee designs (the AGC V2, the Duracon and the Nexgen) in 104 consecutive patients (129 knees) operate on for primary knee osteoarthritis at our hospital. The mean indexed age at the time of the operation was 69.2 years (range, 49.3 to 81.1 years). The mean follow-up time was 6.0 years (range, 0.2 to 7.9). All patients were followed for at least three years or until the first revision. In the survival analyses, the end point was defined as, revision for any reason. RESULTS: The Kaplan-Meier survival analysis showed a 98% (95% CI 94-100) survival rate for the NexGen, a 98% (95% CI 93-100) for the AGC and a 90% (95% CI 81-99) for the Duracon design at six years. Both the mean KSS for pain, KSS for function and the mean clinical knee score improved significantly in all three groups. There was no difference between the three designs in mid-term survivorship. CONCLUSIONS: Most of the revisions could be directly linked to perioperative surgical errors. In conclusion, the most recently introduced knee replacements of the present study (Duracon and Nexgen) did not show any clinically significant benefit over the older design (AGC) in the mid-term.

Cranial subluxation of the odontoid process in rheumatoid arthritis.

In eighteen patients who had long-standing severe rheumatoid polyarthritis, cranial subluxation of the odontoid process was caused by erosion and collapse of both the occipitocervical and the atlantoaxial facet joints. In five of the patients, the subluxation caused impairment of cranial nerves. One patient was tetraparetic. Six patients had a posterior fusion of the spine; of these, three also had laminectomy of the atlas. Operative treatment seemed to arrest the subluxation, but there was appreciable functional improvement in only four of the six patients. During an average of four years of follow-up, in the twelve conservatively treated patients, the cranial subluxation of the odontoid process progressed, on average, from 8.6 to 10.5 millimeters.

Treatment of the cervical spine in rheumatoid arthritis.

Of thirty-four selected patients who had rheumatoid arthritis and subluxations of the atlanto-axial and other joints of the cervical spine, eighteen were treated operatively and sixteen were treated non-operatively. Of the subluxations of the atlanto-axial joint, nineteen were anterior; four, posterior; and eleven, vertical. Additionally, subaxial subluxations were seen in three patients. At the time of treatment, the mean duration of the rheumatoid disease was 19.4 years and the mean duration of the disorders of the cervical spine was 4.5 years. After treatment the patients were followed for an average of 2.2 years (range, six months to six years). Of the thirty-four patients, two (both of whom were treated non-operatively) died of causes unrelated to the lesions of the cervical spine and were excluded from this study. Of the remaining thirty-two patients, eighteen were treated operatively and fourteen, non-operatively. The two groups were roughly comparable with respect to the lesions of the cervical spine, but more of the patients who were treated surgically showed evidence of compression of the cord as demonstrated by computed tomography and myelography. The thirty-two patients were not randomized in the two groups; therefore, comparison of the findings in these groups is not completely valid. Surgical treatment of the eighteen patients included an atlanto-axial fusion in thirteen and an occipitocervical fusion in five. In addition, two patients who had an occipitocervical fusion also had a subaxial laminectomy and posterior fusion. There was a superficial wound infection, which was treated successfully with short-term antibiotic therapy, in two patients. No patient died postoperatively. Occipital pain was relieved in twelve of the fifteen operatively treated patients who had pain, whereas pain was relieved in only one of the eight conservatively treated patients who had pain. At follow-up, neurological function was unchanged or improved in the operatively treated group but was slightly worse in the conservatively treated group. We concluded that fusion of an unstable rheumatoid cervical spine relieves pain and prevents progression of existing neural lessons without undue risk for the patient.

Dysphagia and micrognathia in a patient with juvenile rheumatoid arthritis.

This report describes the case of a 35-year-old man with juvenile rheumatoid arthritis. The patient experienced swallowing difficulties that were initially thought to be a result of the disease affecting the cervical spine. A maxillofacial examination, however, showed a total loss of the mandibular condyles, short rami and bodies, and a retrusion of the jaw. This was considered to be the main cause of the dysphagia, and not a glossopharyngeal nerve compression. The surgical-orthodontic management of these difficult cases is discussed.

A COMPUTATIONAL MEASURE THEORETIC APPROACH TO INVERSE SENSITIVITY PROBLEMS II: A POSTERIORI ERROR ANALYSIS.

In part one of this paper [T. Butler and D. Estep, SIAM J. Numer. Anal., to appear], we develop and analyze a numerical method to solve a probabilistic inverse sensitivity analysis problem for a smooth deterministic map assuming that the map can be evaluated exactly. In this paper, we treat the situation in which the output of the map is determined implicitly and is difficult and/or expensive to evaluate, e.g., requiring the solution of a differential equation, and hence the output of the map is approximated numerically. The main goal is an a posteriori error estimate that can be used to evaluate the accuracy of the computed distribution solving the inverse problem, taking into account all sources of statistical and numerical deterministic errors. We present a general analysis for the method and then apply the analysis to the case of a map determined by the solution of an initial value problem.

Post-operative use of knee brace in bone-tendon-bone patellar tendon anterior cruciate ligament reconstruction: 5-year follow-up results of a randomized prospective study.

Sixty patients were prospectively randomized to brace and no-brace groups after bone-tendon-bone patellar tendon anterior cruciate ligament (ACL) reconstruction. The brace group wore a rehabilitation knee brace for 12 weeks post-operatively, while the no-brace group was mobilized immediately, and crutches were discarded 2 weeks post-operatively. The groups were comparable with respect to age, gender, time from injury to surgery and concomitant injuries. There were no differences either pre-operatively or 5 years post-operatively (80% of patients reviewed) between the groups in terms of the knee score (Lysholm), activity level (Tegner), degree of laxity or isokinetic peak muscle torque. Thus it appears that knee braces are not needed in the post-operative rehabilitation after ACL reconstruction with the patellar tendon graft.

Patellofemoral relationships and cartilage breakdown.

We evaluated the association between patellofemoral relationships and cartilage lesions in patients (age range 15-49) with anterior knee pain without patellar dislocation (n = 24) and in patients with isolated meniscal rupture without a high energy trauma (n = 21). The position of the patella was assessed from knee radiographs, and cartilage lesion was graded and mapped at arthroscopy. In subjects with lateral patellar cartilage lesion the patella tilted laterally (p < 0.01) and was clearly laterally displaced (p < 0.001), compared to those without patellar cartilage lesion. In subjects with central patellar cartilage lesion the patella located high according to the Insall-Salvati index (p < 0.01) and was somewhat laterally displaced (p < 0.05). Compared to subjects without cartilage lesion in the femoral trochlea, the patella was laterally displaced in subjects with lesion in the lateral trochlea (p < 0.001). In conclusion, our results suggest that specific malalignments predispose to patellofemoral cartilage lesion, but prospective studies are needed to confirm the finding.

Endoscopic surgery in orthopaedics.

Arthroscopy and operative arthroscopy of the knee joint is today the most common orthopaedic procedure. However, some fifteen years ago it was almost unknown and used only by a small group of enthusiasts. With progress in the development of arthroscopic equipment, it is possible to examine all of the major joints, such as the wrist, ankle, elbow and shoulder, and therapeutic procedures can be undertaken to correct pathological findings in all of these joints. The advantages of endoscopic joint surgery are indisputable, with short rehabilitation periods, precise surgery, short hospital stays and lower costs mentioned being of primary importance. The technique, however, is difficult to learn and should be taught individually and step by step by experienced endoscopists. With the development of refined technology and better endoscopic equipment the need for open arthrotomy in the treatment of joint disorders has virtually been eliminated.

Acute sports injuries requiring hospital care.

The present investigation reports 138 consecutive patients injured in sports, who needed treatment as in-patients in a one year period. More injuries were sustained in soccer than in other sports. The lower extremity was the site of most injuries, fractures and dislocations being the most common type of injury. At follow-up 50% of the patients complained of discomfort. The average stay in hospital after a sports injury requiring hospital care was 6 days. In 52% of the patients the duration of sports incapacity was at least six months and in seven per cent the sports incapacity after the sustained injury was permanent.

Occurrence and epidemiology of sports injuries in Finland.

The popularity of different sports activities has increased during the last three decades, a development that has been considered beneficial in many respects for society as well as the individual. One of the deleterious effects of this development, however, is an increased number of sports injuries. The exact incidence of sports injuries is difficult to calculate due to many potential biasing circumstances like data collection, definition of sports injuries and the lack of suitable control subjects. In a large study where the acute accidents in Finland were examined the incidence of sports injuries was 670/10,000 inhabitants in 1987. Seven per cent of the total number of injuries seen at a large casualty department were sports injuries. The main purpose of studying sports injuries is to identify the sportsmen at high risk of injury and the main risk factors. Only in this way can preventive measures be undertaken in an effort to make participation in sports safe, regardless of the level or type of sports practiced.

Prospective long-term results of operative treatment in primary dislocation of the patella.

Among 53 prospectively studied patients who had undergone operative treatment of primary patellar dislocation, 9 (17%) suffered recurrence within an average follow-up of 6.5 years. All the redislocations occurred in female patients. The patients with recurrence also suffered first-time patellar dislocation in their unoperated knee during the follow-up significantly more often (P < 0.01) than the patients with stable knees. Patients with redislocations were more often dissatisfied with their outcome than the stable group, mainly because of annoying anterior knee pain (P < 0.05). Preoperatively the patients with redislocation had had more pronounced pathological patellofemoral congruity (Laurin's projections) in both the operated knee (P < 0.05) and the, at the time uninjured, control knee (P < 0.05). To improve the results of operative treatment for acute patellar dislocation, surgery should be aimed at correcting the underlying pathology. In grossly and symmetrically pathological cases of patellofemoral articulation, a distal realignment procedure should be considered. Otherwise conservative treatment may be justified.

Revision anterior cruciate ligament surgery. A review of the literature and results of our own revisions.

Revision anterior cruciate ligament surgery has become a more commonly performed operation. Reasons for this are an increased number of first-time operations, some with technical faults. Patients can also sustain a new injury severe enough to rupture their reconstructed ligament. Results of the revision operations are not as good as those of well executed primary reconstructions. Re-reconstruction is usually technically feasible but the surgeon has to be prepared to encounter many demanding technical problems.

Injuries of competitive skiers in Finland: a three year survey.

The present investigation reports on the injuries of competition skiers in Finland during the period 1976 to 1978. This investigation was made possible through the present system in Finland where an obligatory competition licence is always linked with accident insurance and the authors were able to base their work on an insurance company's records. The total number of licensed competition skiers in 1978 was 7814, 7052 being cross-country skiers, 275 skijumpers and 487 downhill skiers. During the period under investigation 180 accidents leading to an injury were rcorded. Cross-country skiers had 47% of these injuries, downhill skiers 23% and skijumpers 30%. The injury risk in skijumping (47%) proved to be highly significantly (p < 0.001) greater than in the other events (3% and 18%). In the comparison of the injury risk, men (8.5%) outnumbered women (4.4%) (p < 0.001). Men under 30 had more injuries than the older age group (p < 0.001). Muscle and tendon injuries were most common in cross-country skiing. The risk of sustaining a fracture was higher in skijumping than in the downhill events (p < 0.001) and higher in downhill skiing than in cross-country (p < 0.001). On the basis of the present investigation cross-country skiing seems to be a safe activity, but downhill skiers and especially skijumpers seem to be subject to a relatively high risk of injury.