Ajsa Nikolic

Open Meniscal Repair: Clinical and Magnetic Resonance Imaging Findings After Twelve Years

The purpose of this study was to document the long-term clinical, radiographic, and magnetic resonance imaging results after open meniscal repair. Twenty-two patients, with 23 open meniscal repairs, were evaluated after a mean follow-up of 12.9 years using patient history, physical examination, KT-1000 arthrometer testing, the “Orthopaedische Arbeitsgemeinschaft Knie” knee evaluation scheme, Tegner activity score, weightbearing radiographs, and magnetic resonance imaging. Two of the 22 patients had retears and both occurred in unstable knees. Radiographs revealed no degenerative changes in 17 of the 23 compartments. Grade III and IV signal alterations were present on magnetic resonance imaging scans in more than 50% of the repaired menisci. We concluded that the long-term survival rate of repaired menisci was 91%, and that magnetic resonance imaging is unsuitable for diagnosis of the healing process of a repaired meniscus.

Analgesic Effects of Caudal and Intramuscular S (+)-Ketamine in Children

BackgroundPrevious studies suggest that caudal administration of ketamine cause effective analgesia. The purpose of the current study was to compare the clinical effectiveness and plasma concentrations of S(+)-ketamine after caudal or intramuscular administration in children to distinguish between local and systemic analgesia. MethodsAfter induction of general anesthesia, 42 patients, aged 1 to 7 yr, scheduled to undergo inguinal hernia repair randomly received a caudal (caudal group) or intramuscular (intramuscular group) injection of 1 mg/kg S (+)-ketamine. Intraoperatively, heart rate (HR), mean arterial pressure (MAP) and arterial oxygen saturation were measured. Postoperative measurements included duration of analgesia, a four-point sedation score, and hemodynamic and respiratory monitoring for 6 h in the recovery room. Analgesic requirements in the recovery room were assessed by an independent blinded observer using an observational pain/discomfort scale (OPS). Plasma samples for determination of ketamine concentrations were obtained before and 10, 20, 30, 45, 60, 90, 120, and 180 min after injection of S (+)-ketamine. ResultsA significantly longer duration of analgesia (P < 0.001) was observed after caudal administration (528 min [220–1,440 min]; median [range]) when compared with intramuscular administration (108 min [62–1,440 min]) of S (+)-ketamine. Plasma levels of ketamine were significantly lower from 10 to 45 min after caudal administration than after intramuscular injection. ConclusionCaudal S (+)-ketamine provides good intra- and postoperative analgesia in children. Despite similar plasma concentrations during most of the postoperative observation period, caudal S (+)-ketamine provided more effective analgesia than did intramuscular S (+)-ketamine, indicating a local analgesic effect.

Shortening of the Patellar Tendon After Anterior Cruciate Ligament Reconstruction

In this prospective study, patellar height changes were investigated after anterior cruciate ligament (ACL) reconstruction with a mean follow-up of 22.4 months. A total of 114 patients were included. Fifty-two patients (group A) were treated by multiple suture repair, 27 patients (group B) underwent acute ACL reconstruction, and 35 patients (group C) underwent ACL reconstruction > or =6 weeks after injury with a patellar tendon graft. The patellar vertical height ratios (VHR) were evaluated preoperatively (VHR 1), 6 months postoperatively (VHR 2), and at follow-up (VHR 3). For the studied questions, the following answers were obtained: (1) The change of the patella height was the same in all three groups (i.e., disregarding the different surgical procedures). (2) The time elapsed between injury and ACL reconstruction did not influence the shortening of the patellar tendon. (3) Women showed a more pronounced shortening of the patellar tendon than did men. (4) A significant shortening of the patellar tendon occurred in 30% of our patients, and the process of shortening was finished 6 months postoperatively. (5) Anterior knee pain was present in 27.2% of our patients and occurred significantly more often after patellar tendon graftings. (6) Age had no influence on the changes of the patellar height.

New instrument that uses near-infrared spectroscopy for the monitoring of human muscle oxygenation.

BACKGROUND Early detection of vascular impairments after free tissue transfers are essential to prevent flap failure. Near-infrared spectroscopy showed good promise to monitor flaps at deep levels successfully without being invasive. The purpose of this study was to test whether the INVOS 3100 cerebral oxymeter is capable of detecting circulatory impairments. METHODS In 10 healthy adults, near-infrared spectroscopy was used to measure regional saturation values during tourniquet ischemia and venous outflow restriction, in two test cycles. The probe, containing an infrared-light-emitting source and two infrared-light sensors, was placed below the elbow above the brachioradialis muscle. Statistical comparison of the data was performed using the Friedman test and the Wilcoxon-Wilcox test. RESULTS Venous and arterial occlusions were characterized by an instantaneous fall of the regional saturation. Arterial occlusion showed a mean decrease of the saturation values down to 28+/-9%, whereas venous occlusion showed a mean fall of saturation values down to 51+/-12%. These falls were significant after 3 minutes of occlusion compared with baseline values (74+/-6%). The differences between arterial and venous occlusions were statistically significant. CONCLUSION This study, designed to test less-expensive equipment, was able to measure absolute values, and was not prone to interference caused by probe movement, providing information on the oxygenation profile accurately and noninvasively, and distinguishing between arterial and venous occlusion.

Patellar alignment evaluated by MRI

We analyzed the congruence of the articular cartilage surfaces and the corresponding subchondral bone in the patellar joint. 20 volunteers underwent MRI investigations of the right patellar joint in 20 degree and 45 degree flexion in the axial plane. The sulcus, congruence, and lateral patellofemoral angles, measured on MRI slices centered through the midtransverse patella, were recorded. In 20 degree and 45 degree knee flexion, the bony sulcus and lateral patellofemoral angles were significantly different from the respective cartilagineous angle. We conclude that 1) measurement of the bony sulcus and lateral patellofemoral angles does not allow conclusions about the articular cartilage surface and its thickness, 2) the bony congruence angle corresponds well to the articular cartilage surface as an indicator of patellar centralization.

Intrathoracic fluid volumes and pulmonary function during orthotopic liver transplantation

BACKGROUND Impaired pulmonary function is a frequent finding in patients undergoing orthotopic liver transplantation (OLT). Experimental data suggest an essential contribution of splanchnic ischemia and reperfusion as a result of intraoperative volume shifts, i.e., the accumulation of extravascular lung water (EVLW). Increases of intrathoracic blood volume (ITBV) and pulmonary blood volume (PBV) might additionally influence pulmonary capillary fluid filtration. The main objective of this study was to determine the intrathoracic volume changes during OLT and to test whether there were any relationships between intra- and extravascular volume shifts and pulmonary function, as determined by the calculation of venous admixture (QS/QT) and alveolar-arterial oxygen gradient (AaDO2). METHODS Twenty-five patients undergoing OLT were studied. Using the transpulmonary double indicator dilution method, ITBV, PBV, and EVLW were determined from the mean transit times and exponential decay times of the indocyanine green and the thermal indicator curves recorded simultaneously with a fiberoptic catheter in the descending aorta. Recordings were made after induction of anesthesia, at the end of the anhepatic stage, immediately after reperfusion, and 1 and 4 h postoperatively. RESULTS Significant increases in QS/QT related to changes of ITBV were observed after reperfusion. Only a minor impact on AaDO2 was perceived. EVLW remained constant during the study period. CONCLUSIONS Postreperfusion increases of ITBV influence pulmonary function, as demonstrated by the increase in QS/QT. However, they need not be associated with greater EVLW levels, and impact on oxygenation is less severe than assumed. Hence, sufficient mechanisms protecting oxygenation and stalling increased EVLW seem to be present during uncomplicated human OLT.

Esophageal Rupture Associated with the Use of the Combitube[trade mark sign]

Can one justify intubating an otherwise normal infant with pyloric stenosis awake? Provided the gastric contents are evacuated by orogastric suctioning before induction, the infant is rendered “fasted.” Then the question is somewhat simplified: how experienced is the practitioner (presumably more so than the residents and fellows in our article) at handling the infant airway? Would this practitioner intubate a 4-wk-old, fasted infant for elective herniorrhaphy awake? Why should the infant not be spared the traumatic experience of awake tracheal intubation? Our article suggests the awake technique takes longer, is associated with more attempts, and does not protect against bradycardia and decreased Spa,. If intubation attempts fail, there is a certain safety in using an awake technique that preserves spontaneous ventilation. It may be equally safe, and more humane, when an anesthesiologist experienced in infant airway management induces anesthesia and either promptly places the tracheal tube or effectively ventilates the infant by using a bag and mask.

Recommendations for the Diagnosis of Traumatic Meniscal Injuries in Athletes

It has always been difficult to develop a method of correctly evaluating knee injuries and, in turn, to devise the appropriate rehabilitation programme. Flawless diagnosis of meniscal injury is necessary, considering the diverse consequences of this injury for patients, and even more so in relation to athletes, bearing in mind the intensified physical demands on their bodies. There is no doubt that an accurate and concise clinical evaluation of patients with injuries to the knee is the basis for an exact diagnosis and successful treatment. The use of noninvasive methods, such as magnetic resonance imaging, in addition to clinical evaluation is recommended because of their high accuracy and negative predictive value. The use of invasive methods, such as arthroscopic operations, should be restricted to treatment, and not be used for diagnosis.

The role of magnetic resonance imaging in routine decision making for meniscal surgery.

Abstract This clinical study evaluated factors affecting the decision for meniscal surgery in a patient population seen routinely at a trauma clinic. The study hypothesis was that patients who sustain a traumatic injury to the knee or have a long history of clinical symptoms are likelier to be operated on. We investigated 149 patients clinically and by magnetic resonance imaging (MRI). Group A (n = 62) underwent arthroscopic surgery and group B (n = 87) were treated conservatively. Multiple logistic regression analysis was used to examine correlations with regard to age, gender, injury pattern, period between the injury and first clinical examination, and MRI results. We found no significant difference between the two groups with regard to gender (P = 0.1), injury pattern (P = 0.44), or period between injury and first clinical examination (P = 0.5). Patients in group A were significantly older than those in group B (P = 0.044), and, as expected, MRI signal alterations were significantly higher in group A than in group B (P = 0.001). In acutely injured patients MRI helps to establish an accurate diagnosis, and in cases of positive MRI findings in a symptomatic patient, the surgeon should not wait 4–6 weeks but should immediately recommend surgery.

The use of a tracheostomy tube for enteral stomal control

We found that the use of a zero-pressure tracheal foam cuff was the ideal way to drain the intestines through a colostomy, reducing skin irritations and mucosal damage.