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BACKGROUND: The paediatric preoperative fasting time of 2 h for clear fluids, as suggested by guidelines, is often exceeded. Shorter preoperative fasting has been proposed to avoid potential outcomes such as dehydration, ketoacidosis, reduced arterial blood pressure, and patient discomfort. The aim of this study was to investigate whether liberal clear fluid intake until premedication significantly reduces actual fasting time and impacts gastric pH and residual volume. METHODS: Children (1-16 yr old, ASA I or II) undergoing elective procedures with general anaesthesia requiring tracheal intubation were randomised for clear fluid intake until premedication with midazolam (liberal) or 2 h fluid fasting (standard). Actual fasting times were recorded. Gastric content was sampled after tracheal intubation with an orogastric tube to determine gastric pH and residual volume. Data are presented as median [interquartile range]. RESULTS: We included 162 children aged 1.1-16 yr; gastric pH was determined in 138 patients. Patients' characteristics were similar in the two groups. The liberal fasting group had significantly shorter fasting times (48 [18.5-77.5] vs 234 [223.5-458.5] min; P<0.001). No significant difference was observed regarding gastric pH (1.6 [1.5-1.8] vs 1.6 [1.4-1.7]; P=0.237) or residual volume (0.38 [0.1-1.1] vs 0.43 [0.13-0.73] ml kg-1; P=0.535). Twelve patients (15%) in the liberal group (median fluid fasting 32 min) vs one patient (1%) had gastric residual volumes >2 ml kg-1 (P=0.001). CONCLUSION: Fluid intake until premedication allows for significantly shorter fasting times. Elevated gastric residual volumes may occur more often in patients with fasting times of 30 min or shorter. CLINICAL TRIAL REGISTRATION: NCT02603094.
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Anestesia General/métodos , Ingestión de Líquidos/fisiología , Ayuno/fisiología , Cuidados Preoperatorios/métodos , Adolescente , Niño , Preescolar , Procedimientos Quirúrgicos Electivos , Femenino , Determinación de la Acidez Gástrica , Jugo Gástrico/metabolismo , Contenido Digestivo , Humanos , Concentración de Iones de Hidrógeno , Lactante , Intubación Intratraqueal , Masculino , Premedicación , Periodo PreoperatorioRESUMEN
Gonadotropin-releasing hormone (GnRH) agonists have gained extensive clinical use, ranging from reproduction to oncology. There are many clinically available GnRH agonists and these can be used via various methods of delivery, ranging from nasal application to daily subcutaneous injection and various forms of depot preparations. The depot preparations are available as once-monthly intramuscular or subcutaneous injections or 3-month depot moieties. In addition, there is also a 1-month subcutaneous implant available. However, the mode of action of all preparations is identical. The question arises of whether or not the mode of application is important for the treatment effects of endometriosis. Indeed, the course and extent of circulating serum estradiol level are different when comparing nasal with depot preparations. The serum estradiol concentration decreases more rapidly and distinctly with depot than with nasal preparations. Over a period of 24 weeks, the levels of serum estradiol remain higher under nasal GnRH agonist treatment, compared with the depot preparations. Histomorphological changes, such as gland diameter, gland area, cytoplasm and nuclear area, and stromal extension, change less with nasal GnRH agonist therapy than under depot GnRH-agonist treatment. This is also reflected in the spectrum and severity of side effects of nasal and depot preparations. Side effects were more prominent with depot preparations. In addition, bleeding/spotting control was better with the depot preparations. Furthermore, depot preparations had a lower recurrence rate and the time till recurrence was longer. In addition, subsequent surgical and/or medical treatments were significantly less often required with depot preparations (p < 0.05).
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A total of 108 consecutive Press-Fit Condylar total knee arthroplasties were performed in 94 patients. All patients had implantation with a cemented posterior cruciate-retaining design, which included resurfacing of the patella. Mean age at surgery was 70 years (range, 35-87 years). Patients were followed for a mean of 9 years (range, 8-10 years) with follow-up for all surviving patients. The average postoperative functional knee score was 96 points. Nonprogressive radiolucent lines were present in 59%. One patellar component was radiographically loose. Five knees underwent revision procedures, none for aseptic loosening. Survivorship was 93.4% at 9 years with revision for any reason as the endpoint and 98.7% with aseptic loosening as the endpoint. This knee arthroplasty shows excellent results at 8 to 10 years with no patients lost to follow-up.
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Artroplastia de Reemplazo de Rodilla/instrumentación , Adulto , Anciano , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Rótula , Complicaciones Posoperatorias , Diseño de Prótesis , Reoperación , Resultado del TratamientoRESUMEN
BACKGROUND: Prosthetic impingement due to poor positioning can limit the range of motion of the hip after total hip arthroplasty. In this study, a computer model was used to determine the effects of the positions of the acetabular and femoral components and of varying head-neck ratios on impingement and range of motion. METHODS: A three-dimensional generic hip prosthesis with a hemispherical cup, a neck diameter of 12.25 millimeters, and a head size ranging from twenty-two to thirty-two millimeters was simulated on a computer. The maximum range of motion of the hip was measured, before the neck impinged on the liner of the cup, for acetabular abduction angles ranging from 35 to 55 degrees and acetabular and femoral anteversion ranging from 0 to 30 degrees. Stability of the hip was estimated as the maximum possible flexion coupled with 10 degrees of adduction and 10 degrees of internal rotation and also as the maximum possible extension coupled with 10 degrees of external rotation. The effects of prosthetic orientation on activities of daily living were analyzed as well. RESULTS: Acetabular abduction angles of less than 45 degrees decreased flexion and abduction of the hip, whereas higher angles decreased adduction and rotation. Femoral and acetabular anteversion increased flexion but decreased extension. Acetabular abduction angles of between 45 and 55 degrees permitted a better overall range of motion and stability when combined with appropriate acetabular and femoral anteversion. Lower head-neck ratios decreased the range of motion that was possible without prosthetic impingement. The addition of a modular sleeve that increased the diameter of the femoral neck by two millimeters decreased the range of motion by 1.5 to 8.5 degrees, depending on the direction of motion that was studied. CONCLUSIONS: There is a complex interplay between the angles of orientation of the femoral and acetabular components. Acetabular abduction angles between 45 and 55 degrees, when combined with appropriate acetabular and femoral anteversion, resulted in a maximum overall range of motion and stability with respect to prosthetic impingement. CLINICAL RELEVANCE: During total hip arthroplasty, acetabular abduction is often constrained by available bone coverage, while femoral anteversion may be dictated by the geometry of the femoral shaft. For each combination of acetabular abduction and femoral anteversion, there is an optimum range of acetabular anteversion that allows the potential for a maximum range of motion without prosthetic impingement after total hip arthroplasty. These data can be used intraoperatively to determine optimum position.
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Artroplastia de Reemplazo de Cadera , Articulación de la Cadera/fisiología , Rango del Movimiento Articular , Acetábulo , Simulación por Computador , Fémur , Humanos , RotaciónRESUMEN
One hundred ninety-nine patients who underwent primary total hip arthroplasty and used in hospital pneumatic compression stockings and aspirin as thromboembolic prophylaxis were screened for deep venous thrombosis using duplex ultrasonography on the fourth postoperative day. Of the initial 98 patients, 21 underwent noncemented arthroplasty, maintained touchdown weightbearing for 6 weeks after surgery, and then began progressive partial weightbearing. Of the subsequent 101 patients, 28 underwent noncemented arthroplasty and began progressive weightbearing immediately after surgery. All other patients underwent hybrid arthroplasty and began weightbearing to tolerance immediately after surgery. After duplex screening examination, patients with proximal deep venous thrombosis were given anticoagulation therapy, and patients with negative study results were observed clinically. The relative risk of proximal deep venous thrombosis after noncemented arthroplasty using delayed weightbearing was compared with that after noncemented arthroplasty using immediate progressive weightbearing. Of patients with noncemented arthroplasty, the prevalence of proximal deep venous thrombosis was significantly lower in those using progressive weightbearing immediately after surgery (none) than in those using delayed weightbearing rehabilitation (19%). This study showed that patients undergoing noncemented total hip arthroplasty with delayed weightbearing rehabilitation risk greater potential for deep venous thrombosis after hospital discharge. This study suggests consideration for continued thromboembolic prophylaxis or routine deep venous thrombosis surveillance, or both measures, after hospital discharge, unless more rapid progression of weightbearing is allowed.
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Artroplastia de Reemplazo de Cadera , Pierna/irrigación sanguínea , Trombosis de la Vena/etiología , Soporte de Peso/fisiología , Anticoagulantes/uso terapéutico , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Cadera/métodos , Aspirina/administración & dosificación , Aspirina/uso terapéutico , Vendajes , Cementación , Estudios de Cohortes , Femenino , Heparina/uso terapéutico , Humanos , Pierna/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Alta del Paciente , Inhibidores de Agregación Plaquetaria/administración & dosificación , Inhibidores de Agregación Plaquetaria/uso terapéutico , Prevalencia , Factores de Riesgo , Tromboembolia/prevención & control , Ultrasonografía Doppler Dúplex , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/tratamiento farmacológico , Trombosis de la Vena/prevención & control , Warfarina/uso terapéuticoRESUMEN
This article describes a technique to aid in removal of polymethylmethacrylate during total hip arthroplasty revision. The technique is a modification of prior windowing techniques and requires no specialized instruments, offers substantial flexibility regarding cement removal and femoral prosthetic choice, and minimizes the amount and duration of stress on the femur. The technique involves making an oblong window in the anterior or anterolateral femur. Proximal and distal osteotomies are made with a crescentic oscillating saw and connected by straight beveled anterior and posterior longitudinal osteotomies using a straight oscillating saw. Once the intramedullary canal is prepared, either a nonecmented or cemented femoral prosthesis can be placed. The cortical window is replaced with a single cable used for fixation.
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Cementos para Huesos , Fémur , Cuerpos Extraños/cirugía , Prótesis de Cadera/efectos adversos , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Polimetil Metacrilato , Falla de Prótesis , Necrosis de la Cabeza Femoral/diagnóstico por imagen , Necrosis de la Cabeza Femoral/cirugía , Cuerpos Extraños/etiología , Humanos , Masculino , Persona de Mediana Edad , Radiografía , ReoperaciónRESUMEN
Four patients with six knees with patellofemoral instability and severe trochlear dysplasia were treated with creation of a femoral sulcus. None of the six knees have had recurrent dislocations at 3- to 11-year follow-up. All patients had chromosomal abnormalities and limited motor demands. We recommend this procedure for children with patellar instability refractory to standard treatment methods who have severe trochlear dysplasia and limited motor demands.
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Fémur/anomalías , Fémur/cirugía , Luxaciones Articulares/cirugía , Inestabilidad de la Articulación/cirugía , Articulación de la Rodilla/cirugía , Adolescente , Adulto , Niño , Humanos , Estudios Retrospectivos , TrisomíaRESUMEN
Early spica cast treatment is one method used for children's femoral shaft fractures; it is increasingly advocated as treatment that allows early hospital discharge. The outcome of early spica cast treatment in 100 children, ages 2 to 10 years, with uncomplicated and isolated closed femoral shaft fractures treated at Johns Hopkins Hospital between October 1987 and March 1994 were analyzed. The objective was to identify those children who can be treated safely and dependably with early spica casting without excessive shortening of the fracture fragments. Eighty-one (81%) children had an acceptable outcome and 19 (19%) had an unacceptable outcome by the definition of more than 25 mm of fracture fragment overlap after clinical healing. A new clinical test, the telescope test, was statistically significant for correlation with spica cast outcome. Age, gender, fracture, location, mechanism of injury, fracture type, and resting radiograph of fracture fragment overlap were not statistically significant. The telescope test had a sensitivity of 80% and a specificity of 85% for predicting outcome. The relative risk for failure of spica cast treatment with a positive telescope test was 20.4 (95% confidence limits = 2.7-225.1). Children 2 to 10 years of age with uncomplicated femoral shaft fractures and a negative telescope test can be treated appropriately in most cases with early application of a spica cast.
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Moldes Quirúrgicos , Fracturas del Fémur/cirugía , Diferencia de Longitud de las Piernas/etiología , Complicaciones Posoperatorias/etiología , Niño , Preescolar , Humanos , Estudios Retrospectivos , Sensibilidad y EspecificidadRESUMEN
Twelve of 14 proximal third tibial shaft fractures were successfully treated with a new technique for intramedullary nailing of these fractures. The average anterior displacement was 3.0 mm (range 0-17). The average coronal plane alignment was 2.0 degrees valgus (range 2 degrees varus to 12 degrees valgus). There was one nonunion. The technique's success is dependent on neutralizing the primary factors causing malreduction: wide effective diameters of tibial nails, narrow diameter of the medial tibial metaphysis, and a posteriorly directed sagittal plane entrance angle.
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Fijación Intramedular de Fracturas/métodos , Fracturas de la Tibia/cirugía , Adolescente , Adulto , Anciano , Fracturas Cerradas/diagnóstico por imagen , Fracturas Cerradas/cirugía , Fracturas Abiertas/diagnóstico por imagen , Fracturas Abiertas/cirugía , Humanos , Persona de Mediana Edad , Radiografía , Fracturas de la Tibia/diagnóstico por imagen , Resultado del TratamientoRESUMEN
We analyzed the early spica casting outcomes of 50 children age 2 to 10 years with uncomplicated femoral shaft fractures treated at Johns Hopkins Hospital between October 1987 and October 1990. Our objective was to develop criteria for the prospective identification of patients who can be safely and dependably treated with early spica casting without excessive shortening of the fracture fragments. Forty-one (82%) children had an acceptable outcome and nine (18%) had an unacceptable outcome according to our definition of > 25 mm of fracture fragment overlap at 3 to 4 weeks follow-up. A new clinical test, the telescope test, was statistically significant (p < 0.001) for association with spica casting outcome. Age, sex, fracture location, mechanism of injury, fracture type, and resting roentgenogram fracture fragment overlap were not statistically significant (p > 0.10). The telescope test had a sensitivity of 78%, a specificity of 85%, and a negative predictive value of 95% for predicting spica casting outcome. The relative risk of failing spica casting after a positive telescope test was 20.4 (95% CI, 2.74-225.10). We conclude that children 2 to 10 years of age with uncomplicated femoral shaft fractures and a negative telescope test can be safely treated with early spica casting and have a 95% change of having a successful outcome with this treatment.
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Moldes Quirúrgicos , Fracturas del Fémur/cirugía , Niño , Preescolar , Femenino , Humanos , Masculino , Valor Predictivo de las Pruebas , Estudios Prospectivos , Sensibilidad y Especificidad , Insuficiencia del Tratamiento , Resultado del TratamientoRESUMEN
STUDY DESIGN: This is a report of a solitary lymphangioma in a vertebral body treated by excision and autogenous bone grafting. The literature for solitary lymphangioma is reviewed. SUMMARY OF BACKGROUND DATA: An adolescent patient presented with low back pain and an abdominal mass associated with a radiographic lytic process in the L3 vertebral body. Direct continuity of the mass with the L3 body and without involvement of neural elements was demonstrated by computed tomography. Excision of the cystic mass and L3 body with subsequent reconstruction using cancellous iliac autograft was completed. At 20 months' follow-up, the patient was without pain and without evidence of recurrence. CONCLUSIONS: This is the first reported case of the occurrence of this entity in the vertebral body. Excision and bone grafting is accepted treatment. Careful observation for local recurrence is needed.