Prevalence of unsuspected myopathy in infants presenting for clubfoot surgery

The objective of this study was an evaluation of the prevalence of myopathies in paediatric patients scheduled for orthopaedic surgery (clubfoot) performed under regional anaesthesia. Seventeen infants scheduled for lower limb orthopaedic surgery were studied to verify coexisting neuromuscular disorders with electromyography and muscle biopsy during surgery. All surgical procedures were performed under caudal block or spinal anaesthesia, associated with light general anaesthesia. No major cardiorespiratory, neurological or malignant hyperthermic complications (muscle rigidity, arrhythmias, hyperpyrexia) were observed. Combined neurological, electromyographic and biopsy studies showed a high rate of myopathic changes (70%). Performance of clubfoot surgery under light general anaesthesia with regional techniques was free from any problems. The high rate of myopathic changes (70%) observed in the muscle biopsies suggests that precautions should be taken with paediatric patients for clubfoot surgery and a regional anaesthesia technique with adequate monitoring may be helpful to prevent possible malignant hyperthermia related problems.     

Bloqueos del plano fascial ecoguiados,como única técnica anestésica para mastectomía total en la era de la COVID-19: caso clínico

IntroductionRegional anesthesia techniques were recently introduced to provide analgesia for breast surgery. These techniques are rarely used as the primary anesthesia due to the complexity of breast innervation, with numerous structures that can potentially be disrupted during breast surgery.Case reportA female patient in her sixties diagnosed with invasive ductal carcinoma on her left breast was scheduled for a simple mastectomy. After anesthetic evaluation, identification of high risk perioperative cardiovascular complications, it was proposed to perform the surgery only with regional anesthesia. A combination of pectoral nerve block (Pecs II), pecto-intercostal fascial block (PIFB) and supraclavicular nerve block ultrasound-guided were successfully performed.ConclusionThis is the first case reporting a novel approach in a patient with severe cardiopulmonary disease who underwent breast surgery in a COVID-19 era.     

Use of talectomy in modern foot and ankle surgery

Talectomy is a procedure that is undertaken rarely in modern orthopedic surgery; however, it has been performed for many years. Talectomy has been used most commonly in pediatric orthopedics with some degree of success in severe clubfoot deformity, arthrogryposis multiplex congenita, myelomeningocele, tuberculosis, and tumors. In adults, talectomy has been used in salvage procedures that involve nonunion of ankle fusions, failed total ankle arthroplasty, inflammatory arthropathy, neuroarthropathy, failed talar prostheses, failed pantalar fusions, adult neglected clubfoot, posttraumatic avascular necrosis talus, and deformities that are due to sciatic nerve palsy and compartment syndrome. This article consider what place talectomy has in modern adult foot and ankle surgery.     

Ponseti Idiopathic and Nonidiopathic Clubfoot Correction With Secondary Surgeries

The Ponseti method has revolutionized clubfoot treatment for not only idiopathic clubfoot but also non-idiopathic clubfoot. This study aimed to validate the existing literature with respect to the Ponseti method serving as first line treatment for clubfoot. The purpose of this study was to compare clubfoot type and recurrence with secondary surgical procedures following Ponseti method. Kaiser Permanente Northern California database was queried to identify clubfoot children under 3 years old with a consecutive 3-year membership. Associated comorbidities and operative procedure codes were identified. Chart review was performed on all surgical clubfoot patients who completed Ponseti method. Patients’ average age at time of surgery, frequency of surgeries, and types of procedures performed were recorded. A logistic regression analysis assessed the adjusted association between surgery status and clubfoot type. Clubfoot incidence was about 1 in 1000 live births. Of the 375 clubfoot children, 334 (89%) were idiopathic and 41 (11%) were non-idiopathic. In the total study population, 82% (n = 309) patients maintained Ponseti correction without a secondary surgery; 66 patients (18%) underwent subsequent secondary surgeries. The non-idiopathic clubfoot underwent surgery more frequently compared to idiopathic clubfoot patients (41.5% vs 14.7%, respectively, p = .0001). Non-idiopathic clubfoot children underwent surgery at a younger age. This study validates the Ponseti method is the first line treatment for clubfoot correction despite etiology. However, patients with recurrent clubfoot may require secondary surgery following Ponseti method. Clubfoot recurrence surveillance is key for identifying early symptomatic recurrence in order to minimize foot rigidity and the need for osseous procedures.     

Electromyography nerve conduction velocity evaluation of children with clubfeet

Neurologic deficit has been implicated as a possible etiology for clubfoot and a cause for recurrent deformity in patients who have undergone clubfoot surgery. In the study reported here, we wanted to determine if clubfoot patients with peroneal weakness had any neurologic deficits on electromyography nerve conduction velocity (EMG-NCV) studies before surgery and if there was any association between neurologic deficit and clubfoot recurrence. We reviewed the EMG-NCV studies of 36 patients involving 57 cases of idiopathic clubfoot and recurrence of the deformity or muscle weakness. In the clubfoot patients with weak peroneal muscle and no prior surgical history, 45% of the studies were interpreted as normal, 20% as neuropathic, 15% as mixed myopathic and neuropathic, 10% as radicular, and 10% as myopathic. In the clubfoot patients with recurrence after clubfoot repair surgeries, 57% had abnormal EMG-NCV studies. Specifically, peroneal mononeuropathy was the most common disorder (41% of clubfoot patients treated surgically). Awareness of a significant incidence of neurologic deficit may help in preoperative planning by indicating that ultimately a tendon transfer may be necessary to obtain a plantigrade foot.     

Bloc ≪ 3 en 1 ≫ ou bloc femoral. Que faut-il faire et comment le faire ?

The “3 in 1” block and the femoral nerve block are widely used for lower limb surgery and postoperative analgesia. Whether these blocks are in fact a same regional block with two different names or represent definitively two different blocks remains controversial. A large number of anatomical as well as functional variations of the lumbar plexus have been described and complicate a rational analysis of the spread of local anaesthetics following these blocks. Anatomical, radiological and especially clinical data seem to confirm that these blocks are to be distinguished from one another. Femoral nerve block requires the use of a nerve stimulator and has a high success rate in the territory of the femoral nerve; a spread towards other lumbar nerves, especially the lateral femoral cutaneous nerve, is sometimes observed. The “3 in 1” block is supported by the idea of diffusion within a space that is located after going through two fascial layers. Even in experienced hands, the success predictive value is not high. However, once the “3 in 1” block is well performed, a complete anaesthesia covering the territories of the femoral nerve, the lateral femoral cutaneous nerve, and the obturator nerve occurs. Specific indications of each technique are different: major knee surgery and postoperative analgesia for the “3-in-1” block and leg surgery for femoral nerve block. The best approach for knee arthroscopy remains open for discussion.     

Severe respiratory failure after infraclavicular block with 0.75% ropivacaine: a case report

Upper extremity surgery is usually performed with an axillary block. There is a risk of pneumothorax and phrenic nerve block when interscalene or supraclavicular block are used in day case surgery, or in patients with chronic obstructive pulmonary disease. The infraclavicular block is a simple, reliable, and easy to learn method to block the brachial plexus. No clinically relevant respiratory effects have been reported with infraclavicular block. Nonetheless, we report a case of a chronic obstructive pulmonary disease patient who developed severe respiratory failure requiring tracheal intubation after an infraclavicular block.     

A comparison of regional versus general anesthesia for ambulatory anesthesia: a meta-analysis of randomized controlled trials

Both regional anesthesia and general anesthesia have been proposed to provide optimal ambulatory anesthesia. We searched MEDLINE and other databases for randomized controlled trials comparing regional anesthesia and general anesthesia in ambulatory surgery patients for meta-analysis. Only major conduction blocks were considered to be regional anesthesia. Regional anesthesia was further separated into central neuraxial block and peripheral nerve block. Fifteen (1003 patients) and 7 (359 patients) trials for central neuraxial block and peripheral nerve block were included in the meta-analysis. Both central neuraxial block and peripheral nerve block were associated with increased induction time, reduced pain scores, and decreased need for postanesthesia care unit analgesics. However, central neuraxial block was not associated with decreased postanesthesia care unit bypass or time or reduced nausea despite reduced analgesics, and it was associated with a 35-min increase in total ambulatory surgery unit time. In contrast, peripheral nerve block was associated with decreased postanesthesia care unit need and decreased nausea but, again, not with decreased ambulatory surgery unit time. This meta-analysis indicates potential advantages for regional anesthesia, such as decreased postanesthesia care unit use, nausea, and postoperative pain. Although these factors have been proposed to reduce ambulatory surgery unit stay, neither central neuraxial block nor peripheral nerve block were associated with reduced ambulatory surgery unit time. Other factors, such as unsuitable discharge criteria and limitations of meta-analysis, may explain this discrepancy.     

3-in-1 lumbar plexus block for muscle biopsy in malignant hyperthermia patients. Amide local anaesthetics may be used safely

A 3-in-1 lumbar plexus block with the aid of a nerve stimulator was performed in 32 patients and a psoas compartment block was performed in five patients for muscle biopsy of the upper leg for diagnosis of malignant hyperthermia (MH) susceptibility. Twenty-two patients were found to be MH susceptible by the in vitro contracture test. Twenty patients received 40 ml prilocaine 1.5% with epinephrine 1:200,000 and two received 40 ml bupivacaine 0.5% with epinephrine 1:200,000 without any untoward reaction. The 3-in-1 block provides a high success rate and excellent analgesia for muscle biopsy of the upper leg. Amide local anaesthetics are safe in MH-susceptible patients.     

Contributory etiologic factor for talipes equinovarus in congenital myotonic dystrophy: comparative biopsy study of intrinsic foot musculature and vastus lateralis in two cases

Biopsy specimens from the feet and proximal thigh musculature of two patients with congenital myotonic dystrophy with talipes equinovarus were compared. The findings were also compared with those reported in muscle biopsy of idiopathic clubfoot. It was concluded that structural change in intrinsic foot muscle can contribute to the force imbalance that produces clubfoot in this disease.     

Administering caudal anesthesia at completion of clubfoot surgery does not affect postoperative use of narcotics

In the pediatric population, control of postoperative pain is a challenging and important issue. We conducted this retrospective study to determine whether single-dose caudal anesthesia administered after club-foot surgery helps to decrease postoperative use of narcotics. Fifty-one patients given an injection of caudal anesthesia (bupivacaine) at completion of clubfoot surgery were compared with 41 patients who did not receive a caudal block. Postoperative pain control was assessed by recording how much narcotic was used by each patient during time in the recovery room and during the first 8 hours after surgery. Results show that a single dose of caudal anesthesia administered at completion of clubfoot surgery is not associated with a statistically significant change in use of narcotics during either postoperative period.     

恶性骨肿瘤活检安全性评估

目的 研究恶性骨肿瘤穿刺及切开活检道后被肿瘤污染的发生率及活检的安全性.方法 选取2005年7月至2007年10月恶性骨肿瘤行穿刺活检后的病理标本48例,男37例,女11例;年龄10～64岁,平均23.3岁;骨肉瘤37例,恶性纤维组织细胞瘤5例,皮质旁骨肉瘤1例,髓内高分化骨肉瘤1例,骨膜骨肉瘤1例,骨原发恶性黑色素瘤1例,软骨肉瘤2例.活检至再次手术间隔0～2个月,平均1.3个月;均行保肢治疗.选取同期行切开活检病理标本26例,男21例,女5例;年龄8～59岁,平均21.9岁;骨肉瘤20例,Ewing肉瘤1例,软骨肉瘤2例,间叶性软骨肉瘤1例,恶性纤维组织细胞瘤1例,淋巴瘤1例.活检至再次手术间隔1～4个月,平均2.3个月.活检道的手术切除范围均为其内外各2cm,连同瘤段整块切除.对活检道途经的组织取材,以病理为标准判断活检道途经的组织有无恶性肿瘤污染,并确定被肿瘤污染的发生率及范围.结果 48例穿刺活检患者中44例获得随访,随访时间4～39个月,平均17.6个月.4例(4/48,8.3%)活检道存在恶性肿瘤种植污染.末次随访时,4例发生非活检道肿瘤复发.26例切开活检患者均获得随访,随访时间2～29个月,平均12.9个月.2例活检道病理可见肿瘤,阳性率为7.7%(2/26).末次随访时,3例发生非活检道肿瘤复发.结论 恶性骨肿瘤进行穿刺活检和切开活检虽存在活检道被肿瘤污染的危险,但在最终手术时活检道连同肿瘤一同切除后不会发生因活检而造成的肿瘤复发.

Abstract：

Objective To investigate the incidence and extent of biopsy tract contamination in malignant bone tumors by either core needle biopsy or open biopsy and detect the safe extent in resection of biopsy tract. Methods Forty-eight cases were performed core needle biopsy, including 37 osteosarcomas, 5 malignant fibrous histiocytomas, 1 juxtacortical osteosarcoma, 1 low grade central osteosarcoma, 1 periosteal osteosarcoma, 1 primary malignant melanoma of bone and 2 chondrosarcomas. There were 37 males and 11 females with a mean age of 23.3 years (range, 10-64 years). The mean time between core needle biopsy and definitive surgery was 1.3 months (range, 0-2 months). All the patients were performed limb salvage surgery.Twenty-six cases were performed open biopsy, including 20 osteosareomas, 1 Ewing's sarcoma, 2 chondrosarcomas, 1 mesenchymal chondrosarcoma, 1 malignant fibrous histiocytoma, 1 lymphoma. There were 21males and 5 females with a mean age of 21.9 years (range, 8-59 years). The mean time between open biopsy and definitive surgery was 2.3 months (range, 1-4 months). The tumor and tissue around the biopsy tract at least 2 cm were resected. The pathological examination was performed in specimens via the biopsy tract, including the normal soft tissue outside the tumor, deep fascia, subcutaneous tissue and skin. The incidence and extent of biopsy tract contamination were evaluated with pathological examination. Results Forty-four cases were followed up. The mean follow-up time was 17.6 months (range, 4-39 months). In core needle biopsy group, four of forty-eight cases were found malignant tumor cells seeding in biopsy tract, the positive rate was 8.3%. In open biopsy group, all the cases were followed up with the mean time of 12.9 months (range, 2-29 months), and two of twenty-six cases were found malignant tumor cells seeding in biopsy tract,the positive rate was 7.7%. Conclusion Biopsy of malignant bone tumors has the risk of biopsy tract contamination. The tumor cell seeding exists in both core needle biopsy and open biopsy. The biopsy tract should be performed en bloc resection with the tumor.     

Anaesthesia for diagnostic muscle biopsy in an infant with Pompe's disease

The anaesthetic management of children with glycogen-storage disease type IIa (Pompe's disease) presents a variety of challenges. A modification of a femoral nerve block, the inguinal paravascular block, as described by Winnie, was used in conjunction with intravenous ketamine to provide anaesthesia for a diagnostic muscle biopsy in a 5.5-month-old infant with Pompe's disease. A peripheral nerve stimulator was used to locate the femoral nerve in lieu of eliciting a paraesthesia.     

Anaesthesia for diagnostic muscle biopsy in an infant with Pompe’s disease

The anaesthetic management of children with glycogen-storage disease type lia (Pompe’s disease) presents a variety of challenges. A modification of a femoral nerve block, the inguinal paravascular block, as described by Winnie, was used in conjunction with intravenous ketamine to provide anaesthesia for a diagnostic muscle biopsy in a 5.5-month-old infant with Pompe’s disease. A peripheral nerve stimulator was used to locate the femoral nerve in lieu of eliciting a paraesthesia.     

Accurate Prediction of the Amount of In Situ Tumor in Palpable Breast Cancers by Core Needle Biopsy: Implications for Neoadjuvant Therapy

Background: Neoadjuvant chemotherapy facilitates breast conservation in stage II breast cancer patients, whose primary tumors are assumed to be invasive because they are palpable. However, chemotherapy may not be indicated in the minority of patients whose clinically T2 tumors are completely or predominantly in situ. Almost all previous studies of core needle biopsy in breast cancer have been concerned with nonpalpable, mammographically detected tumors, and none have evaluated its ability to quantitatively determine the amounts of in situ and invasive disease.Methods: From September, 1992 to December, 1997, core needle biopsy was performed on all patients presenting to the Kings County Hospital Breast Clinic with palpable breast masses. Carcinoma was present in both core needle biopsy samples and surgical specimens subsequently obtained from 95 of 99 patients. Each specimen was evaluated for tumor type, histologic grade, and the amounts of in situ and invasive carcinoma it contained, and the results from surgical and core needle biopsy specimens from the same patients were then compared.Results: The surgical specimens of 14 patients had completely or predominantly in situ disease. Completely or predominantly invasive disease was present in 67 specimens, and the remaining 14 had significant amounts of both. The high level of agreement between the amounts of in situ and invasive disease in core needle biopsy and surgical specimens is indicated by Pearson and intraclass correlation coefficients of 0.91 (P < .001 and < .00001, respectively). Tumor type was correctly predicted by core needle biopsy in each case. Variables among these patients, including primary tumor size, interval between biopsy and surgery, or administration of neoadjuvant systemic therapy, did not alter agreement between core needle biopsy and surgical specimens.Conclusions: Core needle biopsy can identify palpable breast tumors that are predominantly or completely in situ, and, thus, avoid unnecessary neoadjuvant chemotherapy. It also can demonstrate that a tumor is predominantly invasive, but cannot rule out small invasive foci. For that purpose, complete surgical excision of the tumor is required.     

Rapidly progredient scoliosis associated with multicore disease

Multicore disease is a rare congenital myopathy that normally stops or makes slow progress. It starts with delayed motor development and frequent falls. Especially the proximal muscles are invovled. Other symptoms include contractures of joints, clubfoot, high arched palate, chest deformities, involvement of eye-muscle, cardiac abnormalities, hyperlordosis and scoliosis that normally does not require surgery. We report a rare case of advanced scoliosis in multicore disease requiring operative treatment in a 15-year-old girl. In this case the scoliosis took a rapidly progredient course in puberty close to the end of skeletal growth. A dorsal spondylodesis with USS instrumentation from T9 to L3 was performed. A significant reduction of the scoliosis was obtained. Scoliosis in multicore disease may take a rapidly progredient course. Frequent checks will lead to the initiation of surgical treatment in time. Received: 27 January 1997     

Ultrasound-guided peripheral regional blockade in patients with Charcot-Marie-Tooth disease: a review of three cases

PURPOSE: To describe the clinical presentation of three patients with Charcot-Marie-Tooth disease, who underwent uneventful upper limb surgery following successful peripheral nerve blockade, and to review the anesthetic implications in patients with Charcot-Marie-Tooth disease.Clinical features: In three patients with Charcot-Marie-Tooth disease presenting for surgery of the upper limb, the motor response, following nerve stimulation, was suboptimal. However, ultrasound guidance was effective in visualizing the needle-nerve interaction, and local anesthetic was injected around the nerves. Good block ensued and surgery proceeded in all patients without complications. No exacerbation of the neurological condition was observed in any patient.Conclusions: Charcot-Marie-Tooth disease is a demyelinating, hereditary, motor and sensory neuropathy characterized by abnormalities of nerve conduction. Regional anesthesia of the upper limb is feasible in these patients, and these cases show that ultrasound guidance makes peripheral nerve block possible in patients for whom traditional methods of nerve localization fail.     

Fulminanter Myokardinfarkt bei einem ASA-I-Patienten nach Knieoperation in Allgemeinanästhesie

Myocardial ischemia is a major complication in the perioperative period, mostly in patients with high cardiac risks. After non-cardiac surgery myocardial infarction was observed in 5.6% of patients with coronary heart disease, the rate in patients with no cardiac diseases was 0.1-0.7%. We present the case of a 21-year-old ASA I male patient who underwent surgery to reconstruct the cruciate ligament of the knee. General anaesthesia was performed in combination with a femoral nerve block. After surgery the patient suffered from myocardial infarctions on the day of surgery and the 6th day after surgery. After resuscitation, thrombolysis and percutaneous transluminal coronary angioplasty (PTCA), an intraaortic balloon pump had to be temporarily implanted due to persistent cardiogenic shock.     

Stereotactic breast biopsy: a study of first core samples.

Stereotactic core needle biopsy (SCNB) is a sensitive and specific indicator of breast pathology. Commonly the first biopsy core is taken from the center of the lesion in question. Multiple cores are then taken from points peripheral to the central core. The sensitivity and specificity of the central core to diagnose breast disease is unclear. We compared the pathology of the central core biopsy with that of the remaining cores in a prospective study to determine the sensitivity and specificity of the central core to diagnose breast disease. All patients undergoing SCNB for breast lesions in a single surgical office during a 7-month period were eligible for inclusion. One hundred thirty-three patients with first cores from 145 biopsy sites were included. The histologic diagnosis from 117 (81%) of the first cores from these 145 biopsy sites were representative of their respective samples as a whole. Seventy-seven (53%) of the first cores were in complete agreement with the final histologic diagnosis whereas 40 (28%) had minor differences with the histologic diagnosis that had little or no clinical significance. Twenty-eight (19%) central core samples did not agree with the final pathologic diagnosis. Seven of these 28 patients each had a final diagnosis of cancer missed by the central core biopsy. The first core sample had a sensitivity for cancer detection of 79 per cent and specificity 100 per cent. SCNB remains a sensitive and specific identifier of breast pathology. When mammographic evidence of calcifications was the primary indication for SCNB (n = 75) calcification was present in the central core in 51 (68%). In these 51 patients the central core biopsy was in agreement with the final histologic diagnosis in 46 (90%) specimens. Histologic review of the first core sample alone lends no increased benefits and in fact misrepresents the pathology present in a significant number of patients. When analyzed as an independent predictor of breast pathology the first core is a more sensitive indicator than subsequent individual cores, but the most accurate predictor of pathology is examination of the entire group of core samples. This study confirms the need for acquisition of multiple cores from each lesion in question.