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.

Effect of Epidural Morphine and Bupivacaine with Hypertonic Solution on the Duration of Analgesia / 대한마취과학회지

Recent studies have shown that narcotic druga produce an unusually intense, prolonged and segmental analgesic action in man when injected into the spinal subarachnoid or epidural space (Wang et al, 1979; Behar et al, 1979; Cousins et al, 1979; Magora et al, 1980, Johnston and McCaughey, 1980). Since 1960, many investigatora claimed that low molecular weight(LMW) dextran increased the clinical duration of lidocaine(Loder, 1960; Loder, 1962), tetracaine(Chinn and Wirjoatmadja, 1967) and bupivacaine(Kaplan et al, 1975) in man but the mechanism of the action of dextran was unclear. But Curtiss and Scurlock(1979), and Buckley and Fink(1979) claimed that LMW dextran has no effect on the duration of action of bupivacaine in animal studies. The present study was performed to evaluate the clinical efficacy of analgesia by the thoracic epidural injection of morphine and bupivacaine mixture for the relief of pain due to fractured or contused ribs, to evaluate the duration of analgesic effect by the use of the above mixture in a hypertonic solution(dextran 70 or 50% dextrose in water) and to observe the possibility of improvement in the lung function after the pain block. The complications following the pain block were also observed. The 50 single thoracic epidural injections of the mixture were divided into three groups: Group 1(n=15) served as a control group and drugs used for the relief of pain were as follows(Mean+/-S.D.): morphine(2.13+/-1.64 mg), 0.5% bupivacaine(3.10+/-1.04 ml) and 0.9% saline(3.64+/-1.11 ml). Group 2(n=16) served as an experimental group and drugs were as follows(Mean+/-S.D.): morphine(2.13+/-0.72 mg), 0.5% bupivacaine(3.06+/-0.77 ml) and dextran 70(3.75+/-1.29 ml). Croup 3(n=19) served as an experimental group and drugs were as followa(Mean+/-S.D.): morphine(2.42+/-0.51 mg), 0.5% bupivacaine(3.21+/-0.71 ml) and 50% dextrose in water(3.68+/-1.11 ml). The results are were follows: 1) The number of patients who obtained excellent and good analgesic effecta following the block were greater in the experimental Group 2(94%) and Group 3 (90%) than those of the control GrouP 1 (80%). 2) The duration of pain relief which lasted more than 3 days after the epidural block was longer in the experimental Group 2 (81%) and Group 3 (75%) than those of the control Group 1(67%). 3) The pulmonary reserve(FVC%+FEV1.0%) of 27 caaes who were treated by the pain block between 1 and 31 days following the chest injury was increased to about 13% than those before the block, and that of 13 cases between 32 and 82 days following the chest injury was decreased to about 4% than those before the block. 4) Of the complications following the pain block, there were 5 cases(10%) of nausea within 2 hours following the block, 4 cases(8%) of vomiting after 2 hours following the block, 10 cases(20%) of pruritus after 3-4 houra following the block, 17 cases(34%) of transient urinary retention which lasted 8 to 19 hours, 3 cases(6%) of headache within 2 hours following the block and 2 caaes(4%) of dural puncture. In conclusion, it is suggested that the clinical duration of analgesic effect produced by morphine and bupivacaine mixture can he prolonged by addition of the hypertonic solution to the mixture.

Clinieal Evaluation of Caudal Block / 대한마취과학회지

Caudal block has been evaluated clinicallyy from the material of anesthesia records in 1097 cases for anorecral, lower urinary tract and gynecologic surgery during the past 20 years(from Jan.1957 to Dec. 1967). We have assessed caudal block for age, sex, operation, failure rate, supplementay anesthesia and complications. The most frequent indication for caudal block was anorectal surgery(72.7%) followed by gynecologic and urologic surgery( respectively 25.65% and 1.7%). We failed in 5.9% of the cases which needed substitution with spinal anesthesia(90.7%), intraveneous or inhalation general anesthesia and epidural block. The incidence of complications was very low and the most common complication seen in this study was hypotension. However, there was no difficulty in treating complications symptomatically and there were no fatal cases.

Estimation of Fentanyl Concentrations Based on a Pharmacokinetic Model / 대한마취과학회지

Anesthetic doses of fentanyl are sometimes determined empirically by repetetive doses which are accompanied by fluctuating concentrations. If a constant plasma concentration can be maintained the analgesis and anesthesia can be guaranteed for the duration of surgery. After an I.V. bolus injection (3mcg/kg), fentanyl (2mcg/kg/kr) was continuously infused for an average length of time of 78.3minutes in a manner analogous to the safety of the administration of inhalation anesthetics. To evaluate whether this method is applicable to the clinical situation, the decay of plasma fentanyl with time was simulated based on a population pharmacokinetic model used to predict estimated concentrations in the plasma. The clinical effect of the concentrations was determined by a scoring system which consisted of 4 components, systolic blood pressure, heart rate, sweat production and lacrimation. Using a modified computer program, the mean and 68% confidence interval of the estimated fentanyl plasma concentration (peak concentration 8.5~6.8 mcg/I, maintenance concentration 1.3~0.8 mcg/I, 10 minutes after discontinuation of infusion 0.9~0.5 mcg/I and elimination half-life 267+/-15.7 minutes) were predicted, while the clinical scores were maintained under 4 points. The pharmacokinetic model based on estimation proved to be effective and valid for all patients and predicted a steady target concentration of fentanyl in the plasma.

Clinical Observation of 496 Cases of Anesthesia for Infants / 대한마취과학회지

A total of 496 cases of infant surgery which were performed at Yonsei Medical Center from 1961 to 1970 were analyzed statistically according to sex, age, disease, anesthetic technique, anesthetics, post-op. complications, and mortality. These infants were all inpatients and were operated on under general anesthesia. The results were as follows: 1. Sex; 374 males far exceeded 122 females. 2. Age; 52.5% were in the 1~6 month age group. 3. Disease; Most common diseases in order were cleft lip (113 cases) intussusception (63 cases) and inguinal hernia (41 cases). 4. Anesthetic technique; Most cases used endotracheal intubation and non-rebreathing technique. 5. Anesthetics; Diethyl ether was mainly used (69.2%). 6. Complications; In 34 cases (6.85%) surgical and anesthetic complications occurred. 7. Mortality; 31 infants, 6.25% of the total cases, died during the operative and post-operative periods. 17 of these were 0~7 days old.

Clinical Study of Muscle Pain following Administration at Succinylcholine / 대한마취과학회지

Postoperative muscle pain and transient increase in serum potassium condcentration is well known to occur in man following intravenous administration of succinylcholine. Crawford (1971) and Datta et al, (1977) reported that the incidence of muscle pain and degree of fasciculation following administration of succinylcholine is lower in pregnant than in nonpregnant women. However Hegarty (1956) reported that there is no relationship between the incidence of muscle pain and the degree of fasciculation. To study the incidence of muscle pain and degree of fasciculation after intravenous injection of succinylcholine in pregnant and non-pregnant women, we studied two groups, an experimental pregenant group and a non-pregnant group as a control. The following results were obtained: The incidence of muscle pain was 73.3% in the non-pregnant group and 56.0% in the pregnant group, but no statistically significant difference was noticed between the two groups. 2) The most common sites of pain were, in. order of frequency, the neck, legs, entire body, back, arm and chest. There was no significant; difference between the two groups. 3) The most common sites of pain were, in order of frequency, the neck, legs, entire body, back, arm and chest. There was no significant difference between the two groups. 3) The muscle pain usually appeared within 24hours after the operation. The duration. of muscle pain was mostly less than 72hours. There was no significant difference between the two groups. 4) There was no significant relationship between the anesthetics and the incidence of postoperative muscle pain in both groups. 5) There was no significant relationship between the degree of muscle fasciculation and the incidence of muscle pain in both groups. 6) The serum potassium level following administration of succinylcholine was almost unchanged in both groups.

A Clinical Study of Endotracheal Intubation in Infants / 대한마취과학회지

The relationship between the adequate endotracheal tube size, depth of tube fixation and incisor canina distance according to age(month) and body weight(kilogram) was studied in 148 infants. Intubation was proceeded by injection of thiopental sodium 4mg/kg and succinylcholine 1.5mg/kg in infants older than two months, whereas conscious intubation was used for infants less than two months of age. The relation coefficiency between tube size and body weight(0.83) was greater than that of age(0.76). The relation coefficiency between the depth of tube fixation and body weight(0.83) was greater than that of age(0.75) or tube size(0.77). The relation coefficiency between incisor carina distance and body weight(0.87) was greater than that of age(0.78) or tube size(0.80). Endobroncheal intubation was tried intentionally to evaluate the incidence of left broncheal intubation. Only one infant among 148 exhibited left broncheal intubation. This baby was full term, weighed 2.6kg with gastroschisis. With the above results we assume that body weight is the most important determinant factor for adequate tube size, depth of tube fixation and incisor carina distance. Attention should be paied to unintentional left broncheal intubation in infants less than one month old especially in low birth weight babies.

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.

An Experimental Comparative Study of HFJV and System J in a Lung Model / 대한마취과학회지

This experimental study was done to understand the functional difference and variables thought to be important in determing CO2 elimination and arterial oxygenation during HFJV and system J (System J means that an expiratory valve is attached to the expiratory port of the double lumen tube). In an experimental lung model, a plastic tube, simulating the traches, was intubated with a double-lumen tracheal tube. Ventilation was performed with a solenoid valve controlled high frequency ventilator. Changing the inspiratory time and driving pressure during HFJV and system J can linearly alter the tidal volume and airway pressure. There was a significant difference in airway pressure between the two modes of high frequency ventilation at I:E ratios of 1:2 adn 1:3. With air entrainment, HFJV provided more peak flow than system J and less FIO2 with and increasing driving pressures. Some functional charateristics of two high frequency ventilatory system using double-lumes tubes in a lung model are shown in this study.

Changes of Serum Transaminase Levels after Open Heart Surgery / 대한마취과학회지

This study was done to see the changes in the serum transaminase and LDH levels after general anesthesia in open heart surgery. We selected at random 60 patients who had received open heart surgery under cardiopulmonary bypass with mild to moderated hypothermia. They were divided into 3 groups depending on the anesthetic agents, halothane, penthrane and morphine group. Serum transaminase and LDH levels were checked before operation and also about 24 hours after operation; SGOP; spectrophotometirc assay by end-point method with Sequential Multiple Autoanalyser(SMA), SGPT; Spectrophotometric assay by kinetic method with SMA, LDH; Spectrophotometric assay by kinetic method. The results were as follows: 1) Serum transaminase and LDH levels were not significantly influenced by anesthetic agents after open heart surgery. 2) Serum transaminase and LDH levels were not significantly influenced by anesthetic agents in congental heart disease. 3) Serum transaminase and LDH levels were not significantly influenced by anesthetic agents in acquired heart disease.

Unilateral Tension Pneumothorax following Induction of Anesthesia A Case Report / 대한마취과학회지

Many authors have reported that the most frequent etiology of pneumothorax under general endotracheal anesthesia is high intratracheal pressure, and that bullae and certain pathologic lesions of the lung are predisposing factors for pneumothorax. We have experienced a case of sudden unilateral tension pneumothorax immedipediately following induction of anesthesia in a patient whose chest P-A X-ray revealed a stabilized old-tuberculotic lesion in the right upper lung field. We report this, case with a review of the literature of pneumothorax, especially pertaining to etlology and clinical clinical manifestations.

Controlled Hypotension for Cerebral Aneurysm Surgery in Pregnancy / 대한마취과학회지

A pregnant patient at 32 weeks gestation presented for cerebral aneurysm surgery. Int-ravenous lidocane, pancuronium was administrated with 4% lidocane spray to facilitate tracheal intubation. Anesthesia was induced with thiopental and maintained with oxygen-nitrous oxide-enflurane. Thalamonal was also used to reduce blood pressure after tracheal intubation. Monitoring included an arterial catheter for measuring blood pressure and arterial blood gas tension, an electrocardiogram, an esophageal temperature probe, end-tidal carbon-dioxide monitor and a Dopp1er ultrasound fetal heart monitor. Induced bypotension guided by fetal heat rate with high-dose enflurane and hyperventi-lation was employed to facilitate aneurysm coating. During coating of the aneurysm, mean arterial blood pressure was reduced to 67 mmHg and maintained for 10 minutes. Throughout the anesthesia, the fetal heart rate remained between 110 and 144 beats/min. Following completion of anesthesia, the patient emerged from anesthesia and about 5 hours postoperatively premature labor could be seen with an external tocodynamometer, that was relieved by intramuscular injection of pethidine, 50 mg, Postoperatively the patient was discharged from hospital with a rapid and uneventful recovery at fifteenth day of operation. The mother was readmitted for elective cesarean section at 38 weeks of pregnancy and spinal anesthesia was performed. A healthy 2.9kg infant was delivered and they were uneventfully discharged. We report successful management of anesthesia in a pregnant patient undergoing aneurysm surgery during enflorane-induced hypotension with appropriate maternal and fetal monitoring.

Cardiac Arrest in the Hyperkalemic Patient - A case report / 대한마취과학회지

A 69 year-old male patient was admitted for lumboperitoneal shunt operation due to normotensive hydrocephalus. There was not significant laboratory findings except slightly increased serum potassium(5.0 mEq/1). But we ignored this hyperkalemia probably due to hemolysis because ECG at word and operation room did not reveal any evidence of hyperkalemia. Following induction of an anesthesia with fentanyl 100 ug thiopental(2.5%) 100 mg injection, succinylcholine 60 mg was administered intravenously, and endotracheal intubation was performed. Vecuronium 5 mg was administered intravenously for neuromscular blook. Anesthesia was maintained with nitrous oxide, oxygen and enflurane. During the course of operative procedure, his vital signs were stable(blood pressure 120/70 mmHg, pulse 60/min). After lumboperitoneal shunt was completed without problem, neostigmine 5 mg and glycopyrrolate 0.2 mg was administered for reversal of vecuronium. About 10 minutes after arrival in recovery room, his general condition deteriorated suddenly and radial arterial pulse could not be palpated. Radial arteiial blood pressure wave did not appear and ECG showed asystole and stand-still. Cardiopulmonary resuscitation(CPR) was started with Ambu-bagging, sodium bicarbonate and epinephrine injection with external cardiac massage, but the immediate response was not so good. We re-examined the patients chart and found the past history of chronic renal function impairment. CPR was directed for hyperkalemia including calcium chloride, sodium bicar-bonate and 10% dextrose with insulin. At 5 minutes after CPR, ECG showed regular sinus rhythm with stable vital signs. But ECG still showed hyperkalemic pattern(high tented T wave and prolonged P-R interval). After vigorous and continous treatment for hyperkalemia in recovery room, he regained consciousness and he was transfered to the neurosurgical intensive care unit for further evaluation and treatment. Postoperative course was relatively good and he was discharged on 25th postoperative day without any sequale of cardiac arrest.

Cardiac Arrest in the Hyperkalemic Patient - A case report / 대한마취과학회지

A 69 year-old male patient was admitted for lumboperitoneal shunt operation due to normotensive hydrocephalus. There was not significant laboratory findings except slightly increased serum potassium(5.0 mEq/1). But we ignored this hyperkalemia probably due to hemolysis because ECG at word and operation room did not reveal any evidence of hyperkalemia. Following induction of an anesthesia with fentanyl 100 ug thiopental(2.5%) 100 mg injection, succinylcholine 60 mg was administered intravenously, and endotracheal intubation was performed. Vecuronium 5 mg was administered intravenously for neuromscular blook. Anesthesia was maintained with nitrous oxide, oxygen and enflurane. During the course of operative procedure, his vital signs were stable(blood pressure 120/70 mmHg, pulse 60/min). After lumboperitoneal shunt was completed without problem, neostigmine 5 mg and glycopyrrolate 0.2 mg was administered for reversal of vecuronium. About 10 minutes after arrival in recovery room, his general condition deteriorated suddenly and radial arterial pulse could not be palpated. Radial arteiial blood pressure wave did not appear and ECG showed asystole and stand-still. Cardiopulmonary resuscitation(CPR) was started with Ambu-bagging, sodium bicarbonate and epinephrine injection with external cardiac massage, but the immediate response was not so good. We re-examined the patients chart and found the past history of chronic renal function impairment. CPR was directed for hyperkalemia including calcium chloride, sodium bicar-bonate and 10% dextrose with insulin. At 5 minutes after CPR, ECG showed regular sinus rhythm with stable vital signs. But ECG still showed hyperkalemic pattern(high tented T wave and prolonged P-R interval). After vigorous and continous treatment for hyperkalemia in recovery room, he regained consciousness and he was transfered to the neurosurgical intensive care unit for further evaluation and treatment. Postoperative course was relatively good and he was discharged on 25th postoperative day without any sequale of cardiac arrest.

Changes in In sulin and Glucose Levels During Open Heart Surgery / 대한마취과학회지

At present glucose solution is commonly used as the priming solution in cardiopulmonary bypass and an elevated blood glucose level is seen throughout and following bypass. The relationship between elevated blood glucose levels and plasma insulin response during cardiopulmonary bypass has not been clearly established. Plasma immunoreactive insulin and blood glucose levels were studied in 13 adult patients undergoing open heart surgery with cardiopulmonary bypass. The following results were obtained: 1) With body cooling, plasma insulin levels fell despite the oevelopment of hyperglycemis. On rewarming plasma insulin levels rose markedly and blood glucose levels remained high until the procedure was ended. 2) During cardiopulmonary bypass, serum sodium levels did not show any marked fluctuation, but serum potassium levels were low compared to control values.