Narūnas Porvaneckas

A mini volume loading test for indication of preoperative dehydration in surgical patients.

BACKGROUND AND OBJECTIVE Previously, a mini volume loading test (mVLT) detected signs of dehydration in healthy volunteers after an overnight fast. Our objective was to investigate whether mVLT could indicate preoperative dehydration in patients after an overnight fast. MATERIALS AND METHODS The mVLT was performed in 36 elective primary total knee arthroplasty patients. Each subject received three fluid challenges before anesthesia induction. These consisted of 5 mL/kg boluses of Ringers acetate infused over 3-5 min and followed by a 5-min period without fluids. Invasive (arterial, venous) and noninvasive (capillary) measurements of hemoglobin concentration were performed before and after each fluid challenge, as well as after a 20-min period without fluids which followed the last bolus. Arterial, venous and capillary plasma dilutions were calculated in every data point. Dilution values were used to calculate the plasma dilution efficacy of each fluid challenge. RESULTS Venous dilution was higher than capillary after the first fluid challenge (P=0.030), but lower than capillary after 20 min period following the last bolus (P=0.009). Arterial dilution was lower than capillary (P=0.005) after 20 min following the last bolus. Veno-capillary and arterio-capillary plasma dilution efficacy differences decreased (P=0.004 and P=0.033, respectively) from positive to negative during mVLT. These are signs of re-hydration from pre-existing dehydration according to a transcapillary reflux model. CONCLUSIONS Signs of dehydration were observed during mVLT in patients after pre-operative overnight fast. A revised transcapillary reflux model was proposed to explain the results.

Identification of the location of the A1 pulley combining palpation technique with palm landmarks and percutaneous release of A1 pulley with a 19-gauge needle: A cadaveric study:

The aims of this study were to identify the location of the A1 pulley combining palpation technique with superficial palm landmarks and to determine the efficacy and safety of A1 pulley percutaneous release with a 19-gauge needle. Fourteen fresh frozen cadaveric specimens were used: 56 fingers and 14 thumbs. The location of the A1 pulley was based on anatomical landmarks and was identified in all digits. Complete release of the A1 pulley occurred in 60 of the 70 digits (85.7%). The length of the A1 pulley in thumbs was 5.7 mm and in other fingers 4.5 mm. There were no signs of neurovascular bundle injuries. The mean distance between needle pathway and neurovascular bundle was 4.3 mm in the thumbs and 6.5 mm in the other fingers. There were no total flexor tendon injuries. The location of the A1 pulley can be predicted with success. Percutaneous release of the A1 pulley with a 19-gauge needle shows acceptable results in both safety and efficacy.

Biomechanical evaluation of native acromioclavicular joint ligaments and two reconstruction techniques in the presence of the sternoclavicular joint: A cadaver study:

Background: Where is over 100 reconstruction techniques described for acromioclavicular (AC) joint reconstruction. Although, it is not clear whether the presence of the sternoclavicular (SC) joint influences the biomechanical properties of native AC ligaments and reconstruction techniques. The purpose of the present study was to investigate the biomechanical properties of native AC joint ligaments and two reconstruction techniques in cadavers with the SC joint still present. Materials and Methods: We tested eight fresh-frozen cadaver hemithoraces for superior translation (70 N load) and translation increment after 1000 cycles (loading from 20 to 70 N) in a controlled laboratory study. There were three testing groups created: native ligaments, the single coracoclavicular loop (SCL) technique, and the two coracoclavicular loops (TCL) technique. Superior translation was measured after static loading. Translation increment was calculated as the difference between superior translation after cyclic and static loading. Results: Native AC ligaments showed significantly lower translation than the SCL (p = 0.023) and TCL (p = 0.046) groups. The SCL had a significantly lower translation increment than native AC ligaments (p = 0.028). There was no significant difference between reconstruction techniques in terms of translation (p = 0.865) and translation increment (p = 0.113). Conclusions: Native AC joint ligaments had better static properties than both reconstruction techniques and worse dynamic biomechanical properties than the SCL technique. The SCL technique appeared to be more secure than the TCL technique. The presence of the SC joint did not have an observable influence on test results.

Non-anatomic fixation for longstanding traumatic pubic diastasis using a bone graft: A report of two cases

The incidence of internal fixation failure of symphysis diastasis varies from 6% to 75%. Hardware breakage or migration and symphysis disruption recurrence are often asymptomatic and only in a few cases reoperation is required. This report describes the managements of two cases after failed internal fixation and neglected traumatic symphysis diastasis when it was technically impossible to achieve anatomical reduction of the anterior pelvic ring. Internal fixation and a bone graft for the symphysis without anatomical reposition were performed. Both of the patients achieved good results and had no complaints of pain during daily activities. Restoration of the anatomy should not be the aim in treating recurrence of the symphysis diastasis after failed fixation. The aim of the surgery was static fixation of the anterior pelvic ring with bone grafting.

A mini volume loading test (mVLT) using 2.5-mL kg−1 boluses of crystalloid for indication of perioperative changes in hydration status

BACKGROUND AND OBJECTIVE A mini volume loading test (mVLT) evaluating hemodilution during step-wise crystalloid infusion has established that the arterio-capillary plasma dilution difference is inversely correlated to the body hydration level of subjects. This observational study aimed to test whether this can be replicated in a perioperative setting using a 2.5-mLkg-1 boluses. MATERIALS AND METHODS The mVLT was performed before induction of regional anesthesia and 24h later. Step-wise infusion implied six mini fluid challenges. These consisted of 2.5-mLkg-1 boluses of Ringers acetate infused during 2-3min and followed by 5-min periods with no fluids. Invasive (arterial) and noninvasive (capillary) measurements of hemoglobin were performed before and after each mini fluid challenge, as well as after a 20-min period without fluid following the last bolus. Hemoglobins were used to calculate the arterio-capillary plasma dilution difference which is used as an indication of changes in body hydration level. The 24-h fluid balance was calculated. RESULTS Subjects were 69.5 (6.0) years old, their height was 1.62m (1.56-1.65), weight was 87.0kg (75.5-97.5) and body mass index (BMI) was 33.5kg/m2 (31.0-35.1). Preoperative arterio-capillary plasma dilution difference was significantly higher than postoperative (0.085 [0.012-0.141] vs. 0.006 [-0.059 to 0.101], P=0.000). The perioperative 24-h fluid balance was 1976mL (870-2545). CONCLUSIONS The mVLT using 2.5-mLkg-1 boluses of crystalloid was able to detect the higher postoperative body hydration level in total knee arthroplasty patients.

Different Stabilization Techniques for Type 62B3 Acetabular Fractures in Combination With Primary Total Hip Arthroplasty in Elderly Patients: A Biomechanical Comparison

Introduction: The total hip arthroplasty (THA) as part of acute fracture management is used for acetabular fractures in elderly patients. Our objective was to assess the stability of osteosynthesis performed using 2 different techniques in combination with THA in an experimental model. Materials and Methods: We conducted 20 experiments using the left-side hemipelves composite bone models. There were 2 testing groups: 1- and 2-stage osteosynthesis. The acetabular fractures of the anterior column and posterior hemitransverse were simulated. The same THA technique was used in both groups. The stability of osteosynthesis was explored and compared between the groups by measuring the fracture displacement of anterior and posterior columns under the standardized test load (1187 N) protocol. Load distance diagrams were generated. Results: The 0.680-mm gap (0.518; 1.548) of the posterior column in the 1-stage group (n = 10) was higher than the 0.370-mm gap (0.255; 0.428) in the 2-stage group (n = 10; P = .002). There was no significant difference between the gap of the anterior column in the 1- and 2-stage groups (0.135 [0.078; 0.290] mm vs 0.160 [0.120; 0.210] mm; P = .579). Conclusion: The 2-stage osteosynthesis of the anterior and posterior columns in combination with THA provides better stability of posterior column when compared to 1-stage method in composite bone models.

Hipotenzinė anestezija atliekant klubo ir kelio sąnarių endoprotezavimą: į tikslą nukreiptas skysčių terapijos algoritmas

Audrius Andrijauskas 1 , Juozas Ivaskevicius 1 , Manvilius Kocius 2 , Narūnas Porvaneckas 2 , Darius Cincikas 1 , Jeugenija Olsevska 1 1 Vilniaus universiteto Anesteziologijos ir reanimatologijos klinika, Siltnamių g. 29 LT-04130 Vilnius 2 Vilniaus universiteto Reumatologijos, ortopedijos, traumatologijos, plastinės ir rekonstrukcinės chirurgijos klinika, Siltnamių g. 29 LT-04130 Vilnius El pastas: Audrius.Andrijauskas@mf.vu.lt Kontroliuojama hipotenzinė anestezija jau ilgą laiką taikoma siekiant sumažinti kraujo netektį ir kraujo perpylimo poreikį. Be to, sumažinus arterinį kraujo spaudimą, pagerėja operavimo sąlygos („sausas operacinis laukas“). Atsiranda galimybė sumažinti isorinį mechaninį spaudimą, taikomą operuojamos galūnės kraujotakai sustabdyti atliekant kelio sąnario endoprotezavimą, arba net visai jo netaikyti. Siuolaikiniai metodai grindžiami įvairiais valdomą hipotenziją sukelianciais veiksniais, kaip pavyzdžiui, tai gali būti (a) kraujagysles pleciantys vaistai, (b) centrinė simpatinė blokada ir (c) stiprų kardiodepresinį-vazopleginį poveikį turintys inhaliaciniai anestetikai. Taikant hipotenzine anesteziją, didžiausią rūpestį kelia paciento saugumo užtikrinimas. Ypatingą pavojų kelia „nebyli“ organų isemija dėl nepakankamo jų aprūpinimo krauju, nes ji gali sutrikdyti audinių ir organų funkciją ar net sukelti žūtį. Taigi, užtikrinant metodo saugumą lemiama reiksmė tenka efektyvaus cirkuliuojancio tūrio (normovolemijos) palaikymui arterinės hipotenzijos sąlygomis. Deja, iki siol nėra paprasto, patikimo ir veiksmingo metodo, kuris leistų užtikrinti sią ypac svarbią paciento saugumo sąlygą. Tradicinius kraujotakos optimizavimo metodus siuo metu keicia skyscių terapijos metodai, grindžiami į tikslą nukreiptų priemonių taikymo koncepcija. Remdamiesi sia koncepcija autoriai sukūrė klinikinį TNP algoritmą, kuris skirtas normovolemijai užtikrinti, atliekant kelio ir klubo sanario planinį endoprotezavimą hipotenzinės anestezijos sąlygomis. Algoritmas pateikiamas kartu su svarbiausių hemodinamikos parametrų taikymo ir klinikinio interpretavimo ypatumų apžvalga. Reiksminiai žodžiai: hemodinamika, į tikslą nukreipta skyscių terapija, skysciai, transfuzija, algoritmas Hypotensive anaesthesia in total hip and knee arthroplasty: algorithm for the goal-directed fluid management Audrius Andrijauskas 1 , Juozas Ivaskevicius 1 , Manvilius Kocius 2 , Narūnas Porvaneckas 2 , Darius Cincikas 1 , Jeugenija Olsevska 1 1 Vilnius University Clinic of Anaesthesiology and Intensive Care, Siltnamių str. 29 LT-04130 Vilnius, Lithuania 2 Vilnius University Clinic of Rheumatology, Orthopaedics, Traumatology, Plastic and Reconstructive Surgery, Siltnamių str. 29, LT-04130 Vilnius, Lithuania E-mail: Audrius.Andrijauskas@mf.vu.lt Hypotensive anaesthesia is a technique that deploys the controlled reduction of mean arterial pressure. It has been used for decades to reduce intraoperative blood loss and related blood transfusions, also to ensure the ‘dry operating field’ and minimize the tourniquet inflation pressure in patients undergoing total hip (THA) and knee (TKA) arthroplasty. Hypotensive anesthesia can be achieved in different ways such as (a) by decreasing cardiac output with vasodilatory agents, (b) inducing the sympathetic block by spinal and/or epidural anaesthesia, and/or (c) by using potent anesthetic gases in general anaesthesia. The major concern in the method’s clinical applicability is the patient’s safety. Inherent risks related to hypotensive anaesthesia are mainly associated with the concern of occult tissue hypoperfusion resulting from inadequately compensated relative hypovolemia. Therefore, maintaining an effective circulating volume (normovolemia) is crucial for the safe management of controlled arterial hypotension. However, the lack of a simple, reliable and effective method for the guidance of appropriate measures is an ongoing deficiency. Conventional strategies aiming to establish, monitor and maintain normovolemia are currently replaced by the goal-directed management (GDM) in fluid therapy. It has already become a standard of care in selected patients such as those undergoing major abdominal surgery. On the basis of goal-directed fluid management, authors have developed a GDM algorithm for the optimization of fluid status, aiming to secure normovolemia during hypotensive anaesthesia. The new algorithm is highlighted along with a review of related issues of its clinical application. Key words: hemodynamics, goal-directed-management, fluid, transfusion, algorithm

Pirminis mišraus ir mechaninio tvirtinimo klubo sąnario endoprotezavimas. Vėlyvieji 5–10 metų rezultatai

Jaunius Kurtinaitis, Narūnas Porvaneckas, Manvylius Kocius, Rimvaldas Broga Vilniaus universiteto Ortopedijos-traumatologijos ir plastinės chirurgijos klinika Vilniaus greitosios pagalbos universitetinė ligoninė Siltnamių g. 29, LT-2043 Vilnius. El pastas: narunas.porvaneckas@mf.vu.lt Įvadas / tikslas Dažniausia endoprotezuoto klubo sąnario problema – gūžduobinio komponento intarpo susidėvėjimas arba jo isklibimas. Vieni autoriai pripažįsta cementinio, kiti – mechaninio tvirtinimo metodiką. Abiem atvejais vėlyvieji rezultatai yra panasūs. Kiekviena metodika tam tikru endoprotezuoto sąnario laikotarpiu isryskina jai būdingas problemas. Mūsų darbo tikslas – įvertinti vėlyvuosius misraus ir mechaninio tvirtinimo klubo sąnario pirminio endoprotezavimo rezultatus po operacijos praėjus 5–10 metų. Ligoniai ir tyrimo metodai 1993–1998 metais VGPUL Ortopedijos, traumatologijos ir plastinės chirurgijos klinikoje buvo operuoti 36 ligoniai, kuriems buvo atliktos 39 pirminės klubo sąnario endoprotezavimo operacijos naudojant Bi-Metric mechaninio ir misraus tvirtinimo endoprotezus (EP). Į tyrimą įtraukti 27 ligoniai (29 endoprotezai – 18 mechaninio ir 11 misraus tvirtinimo), 2002–2003 metais atvyke pasitikrinti. Vidutinis pacientų su mechaninio tvirtinimo protezais stebėjimo laikas (mediana) siekė 7 metus, o su misraus tvirtinimo – 5 metus. Visiems atvykusiems pacientams buvo atliktos ir įvertintos priekinės abiejų klubo sąnarių rentgenogramos, nustatyta klubo sąnario funkcija pagal Harris Hip Score skale. Rezultatai 2002–2003 m. istirta 29 (80%) is 36 ligonių, operuotų 1993–1998 m. Rentgenologinių tyrimų rezultatai parodė, kad aplink mechaninio tvirtinimo komponentus linijinės demarkacijos nėra. Visi komponentai buvo stabilūs. Kaulas įaugo į mechaninio tvirtinimo komponentus 100% atvejų. Įvertintos osteolizinio proceso aplink gūžduobinį ir slaunikaulinį komponentus ypatybės, polietileninio intarpo susidėvėjimo prognozės veiksniai atsižvelgiant į endoprotezo tipą, ektopinė osifikacijos įtaka vėlyviesiems klubo sąnario funkciniams rezultatams. Isvados Įvertinti pagal HHS skale mechaninio ar misraus tvirtinimo endoprotezavimo rezultatai po 5–10 metų yra geri ir labai geri. Lyginant rentgenologinius pokycius aplink gūžduobinį ir slaunikaulinį komponentus matyti, kad pokyciai aplink mechaninio ir cementinio tvirtinimo slaunikaulinius komponentus yra gerokai mažesni negu aplink gūžduobinius. Statistiskai patikimo skirtumo tarp polietileno intarpo susidėvėjimo ir panaudoto endoprotezo tipo nebuvo. Gūžduobinio ir slaunikaulinio komponentų osteoliziniai procesai yra besimptomiai. Sie procesai ir 76% atvejų nustatyta ektopinė osifikacija neturi įtakos geriems ir labai geriems vėlyviesiems operuoto klubo sąnario funkciniams rezultatams. Prasminiai žodžiai: pirminis klubo sąnario endoprotezavimas, mechaninio tvirtinimo endoprotezai, misraus tvirtinimo endoprotezai. Primary hybrid and cementless total hip arthroplasty. 5 to 10 year follow-up results Jaunius Kurtinaitis, Narūnas Porvaneckas, Manvylius Kocius, Rimvaldas Broga Background / objective The major issue of hip arthroplasty is the wearout or loosening of the acetabular component. Some authors prefer cemented and others cementless hip arthroplasty. In both cases the outcome is similiar. Each method in different periods has its own problems. The aim of the study was to evaluate the late outcome of primary cementless and hybrid total hip replacement 5–10 years after operation. Patients and methods There were 36 patients operated on and 39 operations of primary total hip arthroplasty performed using Bi-Metric hybrid and cementless endoprostheses in 1993–1998. The study included 27 patients (29 endoprostheses) who responded to invitation in 2002–2003. Anteroposterior radiographs of the hip joints were performed for the patients and the functional outcome was evaluated using the Harris Hip score scale. Results During 2002–2003 investigation was carried out on 29 (74%) of 36 hip arthroplasties performed in 1993–1998. Analysis of the data showed no radiolucency signs around the cementless fixation components. All of the components were stable. Bone ingrowth into the cementless prosthesis components was observed in 100% of cases. The osteolysis zones around the acetabular and femoral components were related to the wearout of polythene insertion, but it was asymptomatic. There was no reliable difference between polythene insertion wearout and the type of prosthesis. Ectopic ossification was observed in 76% of cases. Conclusions The study based on HHS score revealed good and very good results 5–10 years after operation. They were comparable with the findings in similar studies. Rentgenological features indicated that there were less alterations around the femoral component compared to the acetabular. Osteolysis around the femoral and acetabular components was asymptomatic and ectopic ossification found in 76% of cases did not interfere with the good functional results. Keywords: primary total hip arthroplasty, cementless prostheses, hybrid prostheses