Efficacy and safety of dexmedetomidine versus propofol for the sedation of tube-retention after oral maxillofacial surgery.

PURPOSE: To compare the safety and efficacy of sedation induced by dexmedetomidine and propofol after oral and maxillofacial surgery. MATERIALS AND METHODS: In this trial, 66 patients 18 to 50 years old received oral and maxillofacial surgery and required postoperative nasal endotracheal intubation under overnight sedation with dexmedetomidine or propofol. The dexmedetomidine group (group D) received dexmedetomidine 1.0 µg/kg intravenously for 10 minutes after entering the recovery room. The dose was maintained by giving an intravenous injection of dexmedetomidine 0.4 µg/kg. The injection rate could be modulated from 0.2 to 0.7 µg/kg/hour in the intensive care unit (ICU). If the Ramsay score was lower than 2 and involuntary limb movement occurred, other sedatives were used. The propofol group (group P) was given propofol 0.1 mg/kg intravenously for 10 minutes after entering the recovery room and then maintained with intravenous injections of propofol 1 to 2 mg/kg/hour in the recovery room and ICU. RESULTS: The oxygen desaturation of group P was higher than that of group D (at the first sedation time of 30 minutes), but the mean blood pressure of group P was significantly lower than that of group D at the 10-minute time point. The Ramsay score was higher in group D after the first 3 hours of sedation than in group P (P < .05). CONCLUSION: Dexmedetomidine showed similar safety and efficacy as propofol and could be used for tube-retaining sedation after oral and maxillofacial surgery.

Biomechanical analysis of the calcaneocuboid joint pressure after sequential lengthening of the lateral column.

BACKGROUND: Lengthening of the lateral column by means of the Evans osteotomy is commonly used for reconstruction of adult and pediatric flatfoot. However, some reports have shown that the Evans osteotomy is linked with increased calcaneocuboid joint pressures and an increased risk of arthritis in the joint. The purpose of this study was to measure the pressure across the calcaneocuboid joint and demonstrate the changing trends of the pressure within the calcaneocuboid joint after sequential lengthening of the lateral column. METHODS: Six cadaver specimens were physiologically loaded and the peak pressure of the calcaneocuboid joint was measured under the following conditions: (1) normal foot, (2) flatfoot, and (3) sequential lengthening of the lateral column by means of the Evans procedure (from 4 mm to 12 mm, in 2 mm increments). RESULTS: Peak pressures across the joint increased significantly from baseline in the flatfoot (P < .05). In the corrected foot, with the increment of the graft, the peak pressure decreased initially and then increased. The pressure reached its minimum value (11.04 ± 1.15 kg/cm(2)) with 8 mm lengthening of the lateral column. The differences were significant compared to the flatfoot (P < .05) and corrected foot with the other sizes of grafts (P < .05), but differences were not significant compared to the intact foot (P = .143). CONCLUSIONS: Lateral column lengthening within a certain extent will decrease the pressure in calcaneocuboid joint with a flatfoot deformity. CLINICAL RELEVANCE: Performing the procedure with an 8 mm lengthening may reduce the risk of the secondary calcaneocuboid osteoarthritis.

[Surgical treatment for Müller-Weiss disease].

OBJECTIVE: To discuss operative methods and effects for Müller-Weiss disease. METHODS: From March 2005 to May 2011, 15 patients were operated. There were 2 males and 13 females, with an average age of 51.8 years (range, 26 to 62 years). The preoperative American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was (42 ± 13) points. According to the Maceira Staging system, 1 foot was grade 2, 6 feet were grade 3, 4 feet were grade 4, and 4 feet were grade 5. The technique consisted of arthrodesis of the talonaviculocuneiform joints with plate, arthrodesis of the talonavicular joint and arthrorisis of naviculocuneiform joint with plate, or triple arthrodesis with screws, according to the preoperative evaluation. RESULTS: Ten feet were treated with arthrodesis of the talonaviculocuneiform joints, 3 feet were treated with arthrodesis of the talonavicular joint and arthrorisis of naviculocuneiform joint and 2 feet were treated with triple arthrodesis. Two patients were lost to follow-up. The average follow-up after operation was 19.2 months (range, 9 to 38 months). All feet were solid fusion and the average duration of union was 13.3 weeks (range, 12-16 weeks). The AOFAS ankle-hindfoot score at the last follow-up was (83 ± 6) points. Two feet were excellent, 10 feet were good, and 1 foot was fair. The length of feet was (14.2 ± 1.0) cm before surgery and (15.7 ± 0.9) cm at the last follow-up (t = 11.570, P < 0.05). The Meary's angle was -6.1° ± 13.1°before surgery and 1.1° ± 3.0° at the last follow-up (t = 2.248, P < 0.05). The talocalcaneal angle was 4.5° ± 2.2° before surgery and 18.0° ± 4.0° at the last follow-up (t = 11.700, P < 0.05). One foot had breakage of the plate and screws at arthrorisis of naviculocuneiform joint and none had complications related to the incision. CONCLUSION: Operations for Müller-Weiss disease, according to concrete conditions using different therapeutic program, may achieve a satisfactory outcome.

[Surgical treatment of flatfoot resulting from calcaneal fractures malunion].

OBJECTIVE: To explore the operative approach and efficacy of flatfoot after calcaneal fractures malunion. METHODS: A total of 116 flatfoot patients after old calcaneal fractures were treated from January 1998 to January 2008. There were 94 males and 22 females with an average age of 33.5 years old (range: 16 - 46). They included unilateral flatfoot after old calcaneal fractures (n = 110) and bilateral flatfoot after old calcaneal fractures (n = 6). The surgical treatments included open reduction, calcaneal osteotomy without subtalar fusion or a reconstruction of calcaneal thalamus and subtalar arthrodesis. RESULTS: A total of 101 patients were followed up for an average of 14 months (range: 12 - 24). No wound healing problem or infection was observed. Solid union was obtained without redislocation in all patients. The mean time of bone union was 12 weeks (range: 10 - 14). The mean time of complete weight loading was 13 weeks (range: 11 - 15 weeks). The height of foot arch increased from 4.2 mm ± 1.7 mm to 14.1 mm ± 4.1 mm (P < 0.05). Calcaneal inclination angle increased from 11.2° ± 2.5° to 19.1° ± 4.4° (P < 0.05). Bohler angle increased from 5.4° ± 3.5° to 25.8° ± 5.2° (P < 0.05). Meary angle recovered from 22.2° ± 4.4° to 5.1° ± 3.2° (P < 0.05). The mean AOFAS Ankle and Hindfoot score increased from 33.4 (range: 27 - 43) to 85.8 (range: 78 - 98). CONCLUSION: As to flatfoot after old calcaneal fractures, surgical treatment has a favorable efficacy. A customized operative approach may achieve a satisfactory outcome.

[Characteristics and surgical treatment of combined calcaneal fractures].

OBJECTIVE: To discuss the characteristics and experience for surgical treatment of combined calcaneal fracture. METHODS: Between February 2004 and September 2007, 17 feet of 13 patients with combined calcaneal fractures underwent surgical operations. Among 17 calcaneal fractures, 8 combined with ipsilateral talus fractures, 5 combined with trimalleolar fractures, 4 combined with Pilon fractures. Firstly, fractures of hinder foot were treatment with open reduction and internal fixation according to the principle. Of all, 15 fractures were treated with screws or titanic plate plus open reduction and internal fixation, the rest 2 fractures were treated with subtalar arthrodesis. Postoperative X-ray assessed the internal fixation and union of fractures. The foot function was evaluated by the Maryland Foot Score. RESULTS: A total of 13 patients were all followed up for 16.0 - 33.0 months (average 26.5 months), superficial infection was found in a patient with open wound 10 d after surgery. All the bone fractures united after surgery from 4 to 6 months. Morphous improvement of the calcaneal were proved by X-ray films and there here was no plates and screws' breakage, loosening. Mild osteoarthritis in Subtalar and ankle joints were found by X-ray after surgery from 9 months to last follow-up. Cystic degeneration and necrosis were found in 5 and 2 cases of talus fractures respectively. According to Maryland Foot Score, excellent was in 3 feet, good in 6 feet, fare in 5 feet and poor in 3 feet, with excellence rate of 52.9%. CONCLUSIONS: Combined calcaneal is a calcaneus-based concomitant ankle and foot fractures after a high-energy injury. Good deal of soft tissue and correct design of operation pre-operatively, restoration of form and power lines of calcaneal, effective bone graft, right place of simple internal fixation or subtalar arthrodesis and good reduction and internal fixation of other fracture in hinder feet intra-operatively and correct function postoperatively are key points to have a relatively satisfied treating effect of combined calcaneal fractures.

[Surgical treatment of malunited or nonunited talus fractures].

OBJECTIVE: To explore the operative methods of malunited or nonunited talus fractures. METHODS: Twenty-two patients of malunions or nonunions after displaced talar fractures were treated from January 2000 to January 2008. There were 17 males and 5 females with an average age of 34 years (ranged from 15 to 52 years). According to classification of posttraumatic talar deformities (Zwipp 2003), there were 10 cases of type I (malunion and/or joint displacement), 8 cases of type II (nonunion with joint displacement), 4 cases of type III (type I/II with partial AVN). The surgical treatments included open reduction, osteotomy, correction and internal fixation with plate, screw or K-wire, or the ankle, subtalar arthrodesis. RESULTS: Seventeen patients were followed up for 14 months in average (ranged from 12 to 24 months). No wound healing problems or infections were observed. Solid union was obtained without redislocation in all patients. The mean time of bone union was 14 weeks (ranged from 12 to 18 weeks). The mean time of completely weight loading was 14 weeks (ranged from 12 to 18 weeks). The mean AOFAS ankle and hindfoot score increased from 35.4 (ranged from 28.0 to 41.0) to 86.6 (ranged from 78.0 to 98.0). CONCLUSIONS: As to posttraumatic talar deformities, surgical treatment can lead to a favorable outcome. According to concrete status of malunions or nonunions after displaced talar fractures, suitable surgical treatment should be applied to obtain satisfactory outcome.

Distally based sural fasciomyocutaneous flap: anatomic study and modified technique for complicated wounds of the lower third leg and weight bearing heel.

The reconstruction of the distal third leg and weight-bearing heel, especially when complicated with infection and/or dead space, remains a challenge in reconstructive surgery. The distally based sural neurofasciomyocutaneous flap has been proved a valuable tool in repair of the soft tissue defects of those areas. In this report, we present the results of the anatomical study on vascular communication between the suprafascial sural neurovascular axis and the deep gastrocnemius muscle and a modified technique in clinical applications for reconstruction of the soft tissue defects in the distal lower leg and heel. Six lower limbs of fresh cadavers were injected with red gelatin and dissected. A constant vascular connection with average four musculo-fasciocutaneous perforators with diameter 0.2-0.5 mm was identified in the overlapping area between the suprafascial sural neurovascular axis and the deep gastrocnemius muscle. Based on these findings, a modified distally based sural neurofasciomyocutaneous flap including the distal gastrocnemius muscle component was designed and used for repairs of the soft tissue defects in the distal lower limb and plantar heel pad in six patients. The blood supplies of flaps comprised either the peroneal perforator and adipofascial pedicle or the peroneal perforator only. The average size of the fasciocutaneous flap was 51 cm(2), and the muscle component 17.7 cm(2). All flaps survived uneventfully. Our results suggest that this technical modification could provide wider range for applications of the distally based sural neurofasciomyocutaneous flap in repair of the soft tissue defects of the lower extremity and heel.

Use of surgical glue for Mason type III radial head fractures: A case report.

RATIONALE: A Mason type III radial head fracture, which is characterized by comminuted fragments of the radial head, is a severe injury. Open reduction and internal fixation (ORIF) is an alternative treatment method; however, the technique of using an on-table reduction in combination with surgical glue is rarely reported. PATIENT CONCERNS: A 48-year-old man was admitted to our department with complaints of elbow pain after falling down. Elbow radiography and computed tomography (CT) demonstrated characteristics of fractures before the operation. DIAGNOSIS: Radiographic images showed a Mason type III radial head fracture. INTERVENTIONS: The patient underwent ORIF at our hospital. During the operation, the technique of on-table reconstruction combined with surgical glue was used. OUTCOMES: The patient recovered well and was able to participate in his usual work. LESSONS: Mason type III radial head fractures could be treated with ORIF, and a satisfactory result could be anticipated, thus avoiding a radial head replacement or resection. Anatomical reduction of a comminuted radial head could be obtained via an on-table reconstruction and application of surgical glue.

Assessment of subtalar joint neutral position: a cadaveric study.

BACKGROUND: Subtalar joint (STJ) neutral position is the position typically used by clinicians to obtain a cast representation of a patient's foot before fabrication of biomechanical functional orthosis. But no method for measuring STJ neutral position has been proven accurate and reproducible by different testers. This study was conducted to investigate the STJ neutral position in normal feet in cadavers. METHODS: Twelve fresh-frozen specimens of amputated lower legs were used. Pressure-sensitive films were inserted into the anterior and posterior articulation of STJ. The contact areas for various foot positions and under axial loads of 600 N were determined based on the gray level of the digitized film. The STJ neutral positions were determined as the ankle-foot position where the maximum contact area was achieved, because the neutral position of a joint was defined as the position where the concave and convex surfaces were completely congruous. RESULTS: In ankle-foot neutral position, the contact area of STJ was (2.79 +/- 0.24) cm(2). In the range of motion of adduction-abduction (ADD-ABD), the maximum contact area was (3.00 +/- 0.26) cm(2) when the foot was positioned 10 degrees of ABD (F = 221.361, P < 0.05). In the range of motion of dorsiflexion-plantarflexion (DF-PF), the maximum contact area was (3.61 +/- 0.25) cm(2) when the foot was positioned 20 degrees of DF (F = 121.067, P < 0.05). In the range of motion of inversion-eversion (INV-EV), the maximum contact area was (3.14 +/- 0.26) cm(2) when the foot was positioned 10 degrees of EV (F = 256.252, P < 0.05). CONCLUSIONS: Joints, such as STJ, therefore, are not necessarily in neutral position when the ankle-foot is placed in the traditional concept of neutral position. The results demonstrate that the most approximate STJ neutral position was in the foot position of 10 degrees of abduction, 20 degrees of dorsiflexion and 10 degrees of eversion.

Open reduction and internal fixation of posterior pilon fractures with buttress plate.

OBJECTIVE: Posterior pilon fractures are rare injuries and have not yet gained well recognition. The purpose of this study was to present the treatment outcome for patients with posterior pilon fractures treated with buttress plate. METHOD: In this retrospective study we identified patients with posterior pilon fractures of the distal tibia who had undergone open reduction and internal fixation at our institute. Between January 2007 and December 2009, 10 patients (mean age, 46.5 years) who had undergone buttress plating via either a posterolateral approach or a dual posterolateral-posteromedial approach, were selected. All 10 patients were available for follow-up. The clinical outcome was evaluated with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and the visual analogue scale (VAS). The radiological evaluation was performed using the osteoarthritis-score (OA-score). RESULTS: Satisfactory reduction and stable fixation were accomplished in all patients. At a mean follow-up of 36.2 months, all patients had good radiological results and showed satisfactory clinical recovery. The mean AOFAS sore was 87.8, the mean OA-score was 0.6, and the mean VAS scores during rest, active motion, and weight-bearing walking were 0.6, 0.8, and 1.4, respectively. CONCLUSION: Buttress plating for posterior pilon fractures gave satisfactory clinical outcomes. It also ensured rigid fixation which in turn enabled earlier postoperative mobilization. Level of Evidence IV, Retrospective Study.