[Bony contact in arthritic and healthy elbow joints : Studies in cadaveric specimens]. / Knöcherne Kontaktpunkte im arthrotischen und gesunden Ellenbogengelenk : Studie am humanen Leichenpräparat.

BACKGROUND: Arthroscopic and open debridement arthroplasty for elbow arthrosis produce excellent results. Resection of the tip of the olecranon and coronoid, as well as debridement of the associated fossae, is frequently described as sufficient for restoring range of motion and reducing pain. OBJECTIVES: The purpose of this study was to demonstrate that medial and lateral osteophytes of the olecranon and the coronoid usually mark the first bony contact and may, therefore, restrict range of motion. MATERIAL AND METHODS: 11 fresh-frozen elbows were dissected. The fossae were coated with Optosil P Plus (C-silicone), and maximal flexion and extension was simulated. The distribution of C­silicone impressions was documented. 6/7 donors were male. The mean age at the time of death was 82 . RESULTS: Out of 11 elbows, 4 exhibited arthritic changes. All arthritic elbows showed marginal osteophytes of the olecranon without characteristic dipping of the olecranon into its fossa. In 1/4 cases, additional osteophytes at the side of the coronoid were detected (in comparison to 1/7 in healthy elbows). CONCLUSION: The distribution of osteophytes in elbow arthrosis may be underestimated. Many clinicians describe a resection of the tip of the olecranon and the coronoid and debridement of the related fossa as sufficient. Our study supports the theory that marginal osteophytes, especially of the olecranon, should be resected during debridement arthroplasty, since the distribution of bony contact differs in arthritic and healthy elbows.

[Performance control after arthroscopic arthrolysis with capsulectomy in fresh-frozen elbow joints]. / Erfolgskontrolle nach arthroskopischer Arthrolyse mit Kapsulektomie am Ellenbogengelenk im Fresh-frozen-Präparat.

BACKGROUND AND OBJECTIVE: Posttraumatic or postoperative movement restrictions in elbow joints can often occur (including capsular contracture) and can generate everyday limitations. In persistent elbow stiffness, arthroscopic arthrolysis with removal of the dorsal and ventral capsule portions can be carried out. The purpose of this study was to assess the efficacy of arthroscopic capsulectomy by means of an in vitro anatomical study. METHODS: A standardized elbow arthroscopy with ventral and dorsal capsulectomy was performed and image-documented in five fresh-frozen elbow specimens. Subsequently, open dissection of the elbow joint was performed to analyze the amount of residual capsule by means of photodocumentation of the specimens. RESULTS: Regardless of the surgeon and surgical experience, anterior and posterior remnants of the capsule remained in all specimens. Dorsal capsule strands around the standard arthroscopy portals were noticed particularly more often in the area of the high dorsolateral camera portal. An incomplete capsulectomy was seen on the ulnar side at the level of the posterior medial ligament (PML) in the immediate vicinity of the ulnar nerve. Ventrally, a capsulectomy was performed from the radial side and also the ulnar side until the brachialis muscle and additionally a complete capsulectomy as far as the anterior medial ligament (AML) and radial collateral ligament (RCL) was achieved. The capsule was completely resected in a proximal direction. Distally, irrelevant capsular remnants were found in the region of the annular ligament and distal of the tip of the coronoid process. CONCLUSION: Arthroscopic arthrolysis can be performed with a high degree of radicality. The radicality must be self-critically taken into account in one's own action. The radicality of the portal change may even be higher ventrally than with an isolated column procedure. On the other hand, it must be critically considered that posteriorly, the PML cannot be adequately addressed by means of arthroscopy due to the risk of ulnar nerve injury. Portal changes might help to enable a more complete visualization of the joint capsule and may avoid leaving possibly relevant remnants of the capsule. If a release of the PML is required, this may have to be carried out in combination with an ulnar nerve release in a mini-open technique.

[Hybrid operating theater]. / Hybridoperationssaal.

A hybrid suite is an operating theater with imaging equipment equivalent to that used in an angiography suite with computed tomography (CT) and magnetic resonance imaging (MRI). They are often situated outside the operating room area and typically serve as multifunctional rooms designed to support a variety of catheter-based endovascular procedures and open surgery to be performed in the same location. The possibility to perform these in the same location facilitates the combination of both approaches to so-called hybrid procedures. Typical clinical applications of hybrid suites are cardiac, thoracic and vascular surgery, neurosurgery and neuroradiology, as well as orthopedics and traumatology. Transcatheter aortic valve implantation (TAVI) is significantly less invasive than a classical approach by open surgery. Patients older than 75 years with relevant comorbidities benefit most from the minimally invasive interventional approach. There has been a paradigm shift in the management of vascular diseases from open surgical repair to new percutaneous endovascular interventions with good early outcomes. Of particular interest in this context is the ability to block the part of the aorta proximal to the aneurysm with a catheter-based dilatation balloon. Progress in image fusion technology and intraoperative navigation has led to an increased acceptance of hybrid suites in orthopedics and traumatology. The complex care of high-risk patients most often outside the operating theater area is a challenge for the anesthesia team. This demands meticulous planning on behalf of the anesthesiologist to ensure an appropriate and safe strategy for anesthesia, intraoperative monitoring, vascular access and the need for additional equipment. A thorough understanding of the complexity of procedures is vital and a series of questions must be addressed: what is needed to safely administer anesthesia in this environment? What additional resources would be needed for an emergency situation? Is the patient being kept safe from radiation hazards? Moreover, logistics may become an issue as the hybrid suite is most often delocalized. In addition, many procedures realized in a hybrid suite require a multidisciplinary approach and therefore teamwork and professional communication are mandatory. Anesthesiologists need to have an integral role in the hybrid suite team, understanding and anticipating the risks for patients and leading the organization of workflow. The challenge in anesthesia is to ensure that when patients are taken to these complex environments the resources available enable high standards of care to be provided. With future developments in imaging technology combined with more powerful hardware and software, a far greater integration of all these imaging and navigation technologies will be seen in future operating rooms. Finally, patients are becoming more aware of medical developments via the world wide web and increasingly request what they consider to be state of the art treatment.

[Residual neuromuscular blockade]. / Neuromuskuläre Restblockade.

Even small degrees of residual neuromuscular blockade, i. e. a train-of-four (TOF) ratio >0.6, may lead to clinically relevant consequences for the patient. Especially upper airway integrity and the ability to swallow may still be markedly impaired. Moreover, increasing evidence suggests that residual neuromuscular blockade may affect postoperative outcome of patients. The incidence of these small degrees of residual blockade is relatively high and may persist for more than 90 min after a single intubating dose of an intermediately acting neuromuscular blocking agent, such as rocuronium and atracurium. Both neuromuscular monitoring and pharmacological reversal are key elements for the prevention of postoperative residual blockade.

Imaging the Parasinus Region with a Third-Generation Dual-Source CT and the Effect of Tin Filtration on Image Quality and Radiation Dose.

BACKGROUND AND PURPOSE: CT is the imaging technique of choice in the evaluation of midface trauma or inflammatory disease. We performed a systematic evaluation of scan protocols to optimize image quality and radiation exposure on third-generation dual-source CT. MATERIALS AND METHODS: CT protocols with different tube voltage (70-150 kV), current (25-300 reference mAs), prefiltration, pitch value, and rotation time were systematically evaluated. All images were reconstructed with iterative reconstruction (Advanced Modeled Iterative Reconstruction, level 2). To individually compare results with otherwise identical factors, we obtained all scans on a frozen human head. Conebeam CT was performed for image quality and dose comparison with multidetector row CT. Delineation of important anatomic structures and incidental pathologic conditions in the cadaver head was evaluated. RESULTS: One hundred kilovolts with tin prefiltration demonstrated the best compromise between dose and image quality. The most dose-effective combination for trauma imaging was Sn100 kV/250 mAs (volume CT dose index, 2.02 mGy), and for preoperative sinus surgery planning, Sn100 kV/150 mAs (volume CT dose index, 1.22 mGy). "Sn" indicates an additional prefiltration of the x-ray beam with a tin filter to constrict the energy spectrum. Exclusion of sinonasal disease was possible with even a lower dose by using Sn100 kV/25 mAs (volume CT dose index, 0.2 mGy). CONCLUSIONS: High image quality at very low dose levels can be achieved by using a Sn100-kV protocol with iterative reconstruction. The effective dose is comparable with that of conventional radiography, and the high image quality at even lower radiation exposure favors multidetector row CT over conebeam CT.

[Risks acceptability related to obstetrical epidural analgesia]. / Acceptabilité des risques associés à la mise en place d'une analgésie péridurale obstétricale.

OBJECTIVES: Evaluation of the acceptability of complications related to obstetrical epidural analgesia in two populations, parturients and anesthesiologists. STUDY DESIGN: Prospective, transversal, single center study. MATERIALS AND METHODS: Evaluation of the acceptability of complications associated with obstetric epidural analgesia performed using a questionnaire of six clinical scenarii in two populations: parturients cared at the University maternity of Nancy and anesthesiologists of Lorraine. Patients were interviewed by an anesthesiologist, physicians via Internet. Acceptability was assessed using two tools, the absolute acceptability with a visual analog scale and the relative acceptability obtained by classifying clinical scenario against each other, in ascending order of acceptability. RESULTS: One hundred and forty-six parturients and 87 anesthetists assessed the acceptability of the different scenarios. The three less serious scenarios (hypotension, failure, dural tap) were acceptable for both populations. One case (spinal hematoma) was unacceptable for parturients. Three cases of varying severity (failure, dural tap, plexus injury with sequelae) were judged significantly less acceptable by patients than physicians (5.9 vs. 7.9 [P<0.001], 5.75 vs. 8.1 [P<0.01], 4.1 vs. 5.1 [P=0.035]). Multivariate analysis did not show any predictive factor of acceptability in both populations. CONCLUSION: In this study, the overall acceptability of the inherent complications of epidural analgesia was good in the two populations. It was essentially based on the notion of severity and preventability. A large interindividual variability was observed and a better acceptance by the anesthesiologists.

[Simplified topical anesthesia protocol for ambulatory cataract surgery: safety and patient and surgeon satisfaction]. / Étude de satisfaction et de sécurité d'un protocole d'anesthésie simplifié pour la chirurgie de cataracte sous anesthésie topique.

BACKGROUND AND PURPOSE OF STUDY: The purpose of our study was to assess safety and efficacy of cataract surgery (CS) under topical anesthesia alone, i.e. without pre-anesthetic evaluation and without direct presence of an anesthesiologist. To this end we assessed the incidence of patients' preoperative anxiety, perioperative adverse events and patients' and surgeons' satisfaction. MATERIALS AND METHODS: Patients undergoing CS under topical anesthesia over a one-month period were included. An anesthesiologist and nurse anesthetist were present in the area and could intervene in case of an adverse event. Patients' anxiety was scored using the Amsterdam Preoperative Anxiety & Information Scale (APAIS), and their satisfaction with the Iowa Satisfaction with Anesthesia Scale (ISAS). Surgeons' satisfaction was scored with a VAS from 0 to 10 (0: surgery not possible & 10: excellent surgical conditions). RESULTS AND DISCUSSION: One hundred and twenty-four consecutive patients were included; mean age was 71 (±9.4) years. Mean APAIS I was 6.4/20 (±3.7). Mean APAIS II was 3.1 (±1.8). Mean ISAS score was 5.5/6 (±0.6), indicating high patient satisfaction. Surgeon satisfaction score was 8.9/10 (±1.7). Twenty-three adverse events occurred of which 16 required interventions by the anaesthesiologist or surgeon: 5 supplemental local or regional anaesthesia, 6 iv-analgesia, 5 management of hypertension. CONCLUSION: These preliminary data suggest that a simplified topical anesthesia protocol for ambulatory CS appears to be feasible and safe, as long as an anesthesia team is present in the area to intervene if needed.

[Prolonged phase II neuromuscular blockade following succinylcholine administration]. / Bloc dépolarisant de phase II et curarisation prolongée après un bolus de succinylcholine.

Patients who are given a single dose of succinylcholine normally undergo a short-acting depolarizing phase I neuromuscular block but rarely a phase II block. Prolonged neuromuscular blockade occurs after a single dose of succinylcholine in case of genetically determined abnormal plasma butyrylcholinesterase activity. It is mandatory to use monitoring to detect this side effect. We report a case of a patient with abnormal plasma butyrylcholinesterase activity undergoing a six-hour prolonged neuromuscular phase II block, after a single dose of succinylcholine.

[Neuromuscular monitoring]. / Neuromuskuläres Monitoring.

The effect of muscle relaxants varies among people and the extent, the duration and recovery from the neuromuscular block varies. Clinical tests cannot determine the effect of muscle relaxants which is only possible with neuromuscular monitoring. The relaxometry procedure measures the muscular response to electrical stimulation of the corresponding motor nerve and the adductor pollicis muscle is mostly used; however, this muscle is not representative for other muscle groups, such as the muscles of the larynx and diaphragm. The muscles of the larynx and diaphragm are more resistant against nondepolarizing muscle relaxants than the adductor pollicis muscle. The train of four (TOF) is used at the beginning of surgery for monitoring of the optimal time for tracheal intubation; moreover, the TOF is used during surgery for monitoring of the muscle blockade and at the end of surgery for monitoring recovery. Monitoring of deep muscular blockades, however, is only possible with the posttetanic count (PTC) when there are no TOF counts. The PTC allows repetition and higher doses of muscle relaxants during abdominal surgery; therefore, conditions for surgery are optimal and cumulation of muscle relaxants is avoided.

[Monitoring of neuromuscular block by acceleromyography: concepts, applications and limits of use]. / Surveillance du bloc neuromusculaire par accéléromyographie : concepts, applications et limites d'utilisation.

A recent survey among French anesthesiologists revealed that monitoring of curarization is used in approximately in 50% of cases after a unique dose of curare and in 75% of cases after repeated doses of curare. In this survey, a majority of clinicians used a quantitative monitor based on acceleromyography, i.e. that the majority of clinicians used a device from the TOF-watch(®) product line. Results obtained by these monitors depends on the model used, TOF-Watch(®), TOF-Watch S(®) or TOF-Watch SX(®), as well as if it is used for a single point measurement at the end of the operation or continuously throughout the operation, with or without calibration, and if a calibration is used, should we used Cal 1 or Cal 2? Technical specifications and their impact on results will be developed in this technical note. This will help clinicians to better interpret results obtained by TOF-watch(®) monitors in order to improve clinical decisions based on monitoring of neuromuscular transmission.

The subcutaneous fat compartments in relation to aesthetically important facial folds and rhytides.

The ideal treatment of the nasolabial fold, the tear trough, the labiomandibular fold and the mentolabial sulcus is still discussed controversially. The detailed topographical anatomy of the fat compartments may clarify the anatomy of facial folds and may offer valuable information for choosing the adequate treatment modality. Nine non-fixed cadaver heads in the age range between 72 and 89 years (five female and four male) were investigated. Computed tomographic scans were performed after injection of a radiographic contrast medium directly into the fat compartments surrounding prominent facial folds. The data were analysed after multiplanar image reconstruction. The fat compartments surrounding the facial folds could be defined in each subject. Different arrangement patterns of the fat compartments around the facial rhytides were found. The nasolabial fold, the tear trough and the labiomandibular fold represent an anatomical border between adjacent fat compartments. By contrast, the glabellar fold and the labiomental sulcus have no direct relation to the boundaries of facial fat. Deep fat, underlying a facial rhytide, was identified underneath the nasolabial crease and the labiomental sulcus. In conclusion, an improvement by a compartment-specific volume augmentation of the nasolabial fold, the tear trough and the labiomandibular fold is limited by existing boundaries that extend into the skin. In the area of the nasolabial fold and the mentolabial sulcus, deep fat exists which can be used for augmentation and subsequent elevation of the folds. The treatment of the tear trough deformity appears anatomically the most challenging area since the superficial and deep fat compartments are separated by an osseo-cutaneous barrier, the orbicularis retaining ligament. In severe cases, a surgical treatment should be considered. By contrast, the glabellar fold shows the most simple anatomical architecture. The fold lies above one subcutaneous fat compartment that can be used for augmentation.

Acceleromyography to assess neuromuscular recovery: is calibration before measurement mandatory?

BACKGROUND: Acceleromyography has been shown to be an appropriate method in the detection of residual paralysis. However, the clinical importance of an individual calibration of the device in the single patient to improve reliability in detecting residual paralysis remains unclear. METHODS: Observational study in 100 patients undergoing general anaesthesia with endotracheal intubation and a neuromuscular block with atracurium. In all patients, an individually calibrated acceleromyograph was used to estimate a possible residual block at the end of surgery. Immediately after finishing the calibrated measurements at the end of surgery, a non-calibrated measurement was performed. Agreements between the two measurements were tested using Cohen's κ and a Bland-Altman analysis. RESULTS: Data from 96 patients were analysed. At the end of surgery, a discordance in the calibrated and the non-calibrated train-of-four ratio was found in 88 patients. Bland-Altman analysis showed a mean (bias) of 0.01, with limits of agreement of 0.15/-0.15. κ was calculated with κ=0.84 for the absence or presence of a potential residual block if defined as a train-of-four ratio of 1.0 as a threshold. CONCLUSIONS: The results imply a good agreement in the detection of the presence or absence of a residual neuromuscular block between calibrated and non-calibrated acceleromyography if a train-of-four ratio of 1.0 has been chosen as the threshold. However, the estimated train-of-four values are not transferable between calibrated and non-calibrated measurements.