Arthroscopic findings at the time of patellar realignment surgery in adolescents

ABSTRACT: Articular cartilage injuries and loose bodies have been associated with patellar dislocations. At the time of patellar realignment surgery (PRS), direct intraarticular visualization of the structures of concern may be limited with the use of a small arthrotomy. Concomitant diagnostic arthroscopy can improve the identification of intraarticular abnormalities, both patellofemoral and nonpatellofemoral, because of the better field of view. PURPOSE: This report details the findings from knee arthroscopy performed concomitantly with PRS in adolescents. METHODS: All patients underwent knee arthroscopy and open PRS for patellar instability, performed by a single surgeon, during a 4-year period. Patient demographics, knee history, clinical examination, operative findings, and treatment details were collected on all patients. RESULTS:: Thirty-eight patients (mean age, 14.9 years; 41 knees) were included in this analysis. Patellar osteochondral lesions were present in 30 knees (73%; mean size, 112 mm). Femoral lesions were documented in 11 knees (23%; mean size, 81 mm). Loose bodies were present in 6 knees (15%). In 8 patients (20%), an additional 11 nonpatellofemoral diagnoses were made at the time of arthroscopy: lateral tibiofemoral chondroses (n = 4), medial meniscal tear (n = 2), lateral meniscal tear (n = 2), discoid lateral meniscus (n = 1), partial anterior cruciate ligament tear (n = 1), and medial tibiofemoral chondrosis (n = 1). Because of these findings, 5 additional procedures were performed in 4 patients: partial lateral meniscectomy (n = 2), medial meniscal repair (n = 1), discoid meniscus saucerization (n = 1), and staged distal femoral valgus-correcting osteotomy (n = 1). CONCLUSIONS: By performing concomitant knee arthroscopy at the time of PRS, we were able to identify significant tibiofemoral abnormality in 4 patients, which would have been missed with direct inspection by a limited arthrotomy at the patellofemoral joint. In addition, precise evaluation of the patellofemoral joint permits customization of the PRS and aids in establishing appropriate patient expectations postoperatively. We advocate diagnostic knee arthroscopy at the time of PRS in adolescents to identify all intraarticular abnormalities and to optimize discussions with the patient and the caregivers on the long-term prognosis of the knee. SIGNIFICANCE: Arthroscopic inspection of the knee at the time of PRS permits identification of abnormality that is not routinely visual by using open arthrotomy. Twenty percent of patients had additional pathological findings; of these patients, 50% underwent an additional surgical procedure.     

股神经联合坐骨神经阻滞应用在踝关节镜手术中的效果评价

目的 比较两种不同的麻醉方式在踝关节镜手术中的应用效果。方法 选择2018年1月至2019年12月在中山大学孙逸仙纪念医院行踝关节镜手术的患者60例,随机分为股神经组和腰丛组,每组各30例,股神经组实施股神经联合坐骨神经阻滞,腰丛组实施腰丛联合坐骨神经阻滞。比较两组患者术中和术后的麻醉和镇痛效果、麻醉操作时间、不同时间的心率及平均血压和麻醉并发症及不良反应。结果 两组患者术中额外使用局麻药和麻醉性镇痛药人数、术后24小时内静息或运动的VAS评分及额外使用镇痛药的人数和使用时间差异均无统计学意义;股神经组麻醉操作时间显著少于腰丛组;股神经组在麻醉操作过程中的心率和平均血压显著低于腰丛组;两组患者术后不良反应比较差异无统计学意义。结论 股神经联合坐骨神经阻滞与腰丛联合坐骨神经阻滞在踝关节镜手术中的麻醉和术后镇痛效果无显著差别,但前者麻醉操作时间更短,围术期生命体征更平稳。     

A new rule for femoral nerve blocks

BACKGROUND AND OBJECTIVES: Acupuncture points are described by use of a proportional system that is based on the width of the thumb at the level of the distal interphalangeal joint, defined as 1 CUN. Our study tested first the correlation between the CUN and weight and height in 500 Americans and second the hypothesis that the CUN system is superior to the conventional landmarks to localize the femoral nerve 1 or 2 cm lateral to the artery in a prospective, double-blinded, randomized study. METHODS: Sixty-two patients were randomized to receive a femoral nerve block by a needle entry point either 1 CUN lateral, 1 cm lateral, or 2 cm lateral to the femoral artery at the level of the inguinal crease. The time from needle entry to injection of local anesthetic was measured by an investigator blind to the technique, who also counted the frequency of needle repositioning, graded the ease of the block and its success, and registered complications. RESULTS: Good correlation occurred between weight and CUN (r = 0.79) and height and CUN (r = 0.83), which indicates that the CUN of a normal person (predefined as 175 cm tall and 70 kg weight) is 18.7 +/- 1 mm. In the CUN group, the femoral block was achieved significantly faster (P < .01) with fewer attempts (P < .003). The success rate was the same and complications did not differ significantly between the groups. CONCLUSION: A needle insertion point 1 CUN lateral to the midpoint of the palpated femoral artery at the level of the inguinal crease makes femoral nerve blocks faster and easier compared with conventional landmark 1 cm to 2 cm lateral to the artery.     

Ultrasonographic guidance for sciatic and femoral nerve blocks in children

Background: Recent studies have shown that ultrasound guidance for paediatricregional anaesthesia can improve the quality of upper extremityand neuraxial blocks. We therefore investigated whether ultrasoundguidance for sciatic and femoral nerve blocks prolongs sensoryblockade in comparison with nerve stimulator guidance in children. Methods: Forty-six children scheduled for surgery of one lower extremitywere randomized to receive a sciatic and femoral nerve blockunder either ultrasound or nerve stimulator guidance. Afterinduction of general anaesthesia, the blocks were performedusing an ultrasound-guided multiple injection technique untilthe nerves were surrounded by levobupivacaine, or by nerve stimulatorguidance using a predefined dose of 0.3 ml kg^–1 of levobupivacaine.An increase in heart rate of more than 15% of baseline duringsurgery defined a failed block. The duration of the block wasdetermined from the injection of local anaesthetic to the timewhen the patient received the first postoperative analgesic. Results: Two blocks in the nerve stimulator group failed. There wereno failures in the ultrasound group. The duration of analgesiawas longer in the ultrasound group mean (SD) 508 (178) vs 335(169) min (P < 0.05). The volume of local anaesthetic insciatic and femoral nerve blocks was reduced with ultrasoundcompared with nerve stimulator guidance [0.2 (0.06) vs 0.3 mlkg^–1 (P < 0.001) and 0.15 (0.04) vs 0.3 ml kg^–1(P < 0.001), respectively]. Conclusions: Ultrasound guidance for sciatic and femoral nerve blocks inchildren increased the duration of sensory blockade in comparisonwith nerve stimulator guidance. Prolonged sensory blockade wasachieved with smaller volumes of local anaesthetic when usingultrasound guidance.     

Ultrasound-guided combined femoral nerve and lateral femoral cutaneous nerve blocks for femur neck fracture surgery--case report

We report two cases of elderly patients who underwent ultrasound-guided combined femoral nerve and lateral femoral cutaneous nerve blocks for osteosynthesis of femur neck fracture. In both cases, neuraxial anesthesia was contraindicated due to coagulopathy, and severe restrictive ventilatory disorder was observed. The femoral nerve and lateral femoral cutaneous nerve blocks were performed with 20ml of 0.375% ropivacaine under ultrasonographic visualization using a high frequency linear probe. Ultrasonographic visualization was useful to identify the needle tip and to observe the spread of local anesthetics. Supplemental local infiltration of anesthetics and intravenous low-dose sedative drugs were administered during surgery. The perioperative course was uneventful in both cases. This combined block technique could be a choice for osteosynthesis of femur neck fracture especially in high-risk patients.     

股骨颈骨折青少年患者混合现实技术引导下微创手术的快速康复护理

报告6例混合现实技术引导下青少年股骨颈骨折微创手术患者的快速康复护理经验。提出术前向患者介绍混合现实技术,医护患三方通过混合现实技术协同制定手术方案、快速康复计划以及充分的术前准备,术后动态观察病情、疼痛管理、合理的功能锻炼是其护理要点。     

Intraoperative myocardial ischemia in peripheral vascular surgery: general anesthesia vs combined sciatic and femoral nerve blocks

STUDY OBJECTIVE: The aim of this study was to compare the frequency of intraoperative myocardial ischemia in lower extremity vascular surgery with general anesthesia vs regional anesthesia via combined sciatic and femoral nerve blocks. DESIGN: This is a prospective, randomized study. SETTING: This study was set at an academic medical center. PATIENTS: The study included 50 patients scheduled for elective lower extremity vascular surgery. INTERVENTIONS: Patients in group 1 received balanced general anesthesia, whereas patients in group 2 received combined sciatic and femoral nerve blocks with 40 mL of 0.375% bupivacaine. Monitoring included a radial artery catheter and multilead, dual-channel electrocardiogram with computerized ST-segment analysis. Blood pressure and heart rate variations were maintained within 10% of preoperative values by adjusting anesthetic depth, fluid replacement, and vasoactive drug dosages. MEASUREMENTS AND MAIN RESULTS: An ST-segment depression of at least 1 mm or elevation of at least 2 mm lasting for more than 1 minute was considered a significant episode of myocardial ischemia. Intraoperative hemodynamic data and the frequency of significant ST-segment change episodes were recorded. The number of patients with ischemic episodes and the total number of these episodes were lower in group 2 than in group 1 (1 patient vs 7 patients, P = 0.02; and 2 vs 14 episodes, P = 0.04). No significant difference was found between groups 1 and 2 regarding systolic or diastolic arterial pressures, or heart rate. CONCLUSION: Compared with general anesthesia, combined sciatic and femoral nerve blocks reduce the frequency of intraoperative myocardial ischemia in patients undergoing lower extremity vascular surgery.     

Thromboprophylaxis and peripheral nerve blocks in patients undergoing joint arthroplasty

This study was designed to assess the risk of hematoma related to the combination of peripheral nerve blocks and thromboprophylaxis. A total of 3588 patients undergoing joint arthroplasty were included. Blocks performed included continuous lumbar plexus, continuous femoral, and continuous or single sciatic. The perineural catheters were removed on postoperative days 2 or 3. A total of 6935 blocks were performed in patients receiving warfarin (50.0%), fondaparinux (12.8%), deltaparin (11.6%), enoxaparin (1.8%), and aspirin (23.8%). In this patient population, no perineural hematoma was recorded. Our data provide evidence that continuous/single peripheral nerve blocks can be safely performed before thromboprophylaxis initiation, and perineural catheters can be safely removed while the patient is receiving thromboprophylaxis and/or aspirin.     

The successful use of peripheral nerve blocks for femoral amputation

We present a case report of four patients with severe cardiac insufficiency where peripheral nerve blocks guided by either nerve stimulation or ultrasonography were the sole anaesthetic for above-knee amputation. The patients were breathing spontaneously and remained haemodynamically stable during surgery. Thus, use of peripheral nerve blocks for femoral amputation in high-risk patients seems to be the technique of choice that can lower perioperative risk.     

Comparison of femoral nerve block and fascia iliaca block for analgesia following reconstructive knee surgery in adolescents

Study ObjectiveTo compare the femoral nerve block with the fascia iliaca block for postoperative analgesia in adolescents undergoing reconstructive knee surgery.DesignRandomized, single-blinded study.SettingFull-service pediatric medical center.Patients23 ASA physical status I and II patients, aged 8 to 16 years, undergoing anterior cruciate ligament (ACL) repair.InterventionsPatients received either fascia iliaca or femoral nerve block prior to reconstructive surgery.MeasurementsPain scores by visual analog scale (VAS; 0-10) and morphine use were routinely recorded through to discharge from the hospital. Pain scores were assessed on days 1 and 2 at home post-discharge.Main resultsThere was no difference between the femoral nerve block and the fascia iliaca nerve block in VAS pain scores or postoperative morphine consumption.ConclusionEither the femoral nerve block or the fascia iliaca block, followed by patient-controlled analgesia with morphine, provides efficacious analgesia for adolescents undergoing ACL reconstruction.     

股神经阻滞对七氟醚抑制膝关节镜置入时肾上腺素能反应的最低肺泡有效浓度的影响

目的探讨超声引导下股神经阻滞对膝关节镜手术患者膝关节镜置入时七氟醚抑制肾上腺素能反应的最低肺泡有效浓度(MAC_(BAR))的影响。方法选择2019年5—8月拟行择期单侧膝关节镜手术患者36例,男19例,女17例,年龄18～64岁,ASAⅠ或Ⅱ级。采用随机数字表法将患者分为两组:阻滞组和对照组。阻滞组全麻诱导前于超声引导下行患侧股神经阻滞,采用针刺法评估VAS疼痛评分判断阻滞效果;对照组仅行全麻。两组全麻方法相同。采用序贯法测定七氟醚MAC_(BAR)。采用ELISA法测定膝关节镜置入前3 min、置入后3 min血浆肾上腺素及去甲肾上腺素浓度。记录拔管时间、拔管时VAS疼痛评分。结果阻滞组和对照组的MAC_(BAR)分别为2.73%(95%CI 2.65%～2.82%)和3.50%(95%CI 3.32%～3.68%)。与对照组比较,阻滞组七氟醚MAC_(BAR)明显降低(P0.05),拔管时间明显缩短(P0.05),VAS疼痛评分明显降低(P0.05)。阻滞组膝关节镜置入后血浆肾上腺素和去甲肾上腺素浓度分别为(784.82±348.52)pg/ml和(882.76±430.50)pg/ml,对照组膝关节镜置入后血浆肾上腺素和去甲肾上腺素浓度分别为(721.84±314.32)pg/ml和(806.69±467.88)pg/ml,两组差异无统计学意义。结论超声引导下股神经阻滞可明显降低膝关节镜手术患者膝关节镜置入时七氟醚MAC_(BAR),缩短拔管时间,有利于术后镇痛。当50%患者肾上腺素能反应被抑制时,血浆肾上腺素和去甲肾上腺素浓度变化不受股神经阻滞的影响。     

Evaluation of acute knee injuries with sciatic/femoral nerve blocks

A preliminary study of the applicability of sciatic and femoral regional nerve blocks in the evaluation of acute knee injuries was conducted. During the period from January 1980 to March 1981, 12 patients with acute knee injuries in whom clinical examination under local anesthesia was considered totally unreliable secondary to patient uncooperation or severe pain were examined at Grady Memorial Hospital. Each of these patients received regional anesthesia by sciatic/femoral nerve block. All patients obtained satisfactory relaxation and analgesia for complete evaluation, and 92% obtained total analgesia for the knee. A full range of motion was present in each patient after the block. No complications were encountered. A satisfactory block was obtained in one attempt in 96% of the patients. (One patient had a failed femoral nerve block, but a repeated block was successful).