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In syndesmosis injury, whether the syndesmosis screw should be removed prior to weight-bearing remains controversial. The aim of this study was to compare the functional outcome between removed screw and retained groups and between recurrence of diastasis and no diastasis groups.Fifty-six patients who had undergone open reduction and internal fixation due to syndesmosis injury were retrospectively evaluated and divided into four groups: (A) removed syndesmotic screw before weight-bearing (postoperative 3 months, n = 28), (B)retained (n = 28), (C) recurrence of diastasis (n = 9), and (D) no diastasis (n = 47). Radiological diastasis, American Orthopedic Foot Ankle Society Score (AOFAS), Short Form Health Survey-12 (SF-12), and complications (screw loosening and breakage) were evaluated between groups.AOFAS ankle-hindfoot score was 75.10 ± 10.40 in group A, 77.07 ± 10.60 in group B. SF-12 was 45.78 ± 5.68 in group A and 47.33 ± 5.83 in group B, showing no significant difference in AOFAS ankle-hindfoot score or SF-12 (P = .487, P = .319, respectively) between groups A and B. Radiological diastasis developed significantly (P = .025) more in group A (8/28) compared to that in group B (1/28). However, screw loosening or breakage developed significantly (P = .001) more in group B (4/28) compared to that in group A (0/28). AOFAS ankle-hindfoot score was 70.33 ± 6.22 in group C and 76.50 ± 10.26 in group D. SF-12 was 49.85 ± 3.83 in group C and 47.40 ± 8.01 in group D, showing no significant difference between groups C and D in AOFAS ankle-hindfoot score or SF-12 (P = .808, P = .948, respectively).Removal of syndesmotic screw before weight-bearing does not influence clinical outcomes. Although unrelated to clinical progress, recurrence of diastasis significantly increased in screw removed group. Therefore, removal of syndesmotic screw is unnecessary before weight-bearing.

As an anesthetic reversal agent, there are concerns with cholinesterase inhibitors regarding worsening of Parkinson's disease (PD)-related symptoms. Sugammadex, a relatively new reversal agent, does not inhibit acetylcholinesterase and does not require co-administration of an antimuscarinic agent. The present study compared the recovery profiles of 2 agents initially administered for reversal of neuromuscular blockade in patients with advanced PD who underwent deep brain stimulator implantation.A total of 121 patients with PD who underwent deep brain stimulator implantation were retrospectively analyzed. Patients were divided into 1 of 2 groups according to the type of neuromuscular blockade reversal agent (pyridostigmine vs sugammadex) initially administered. Recovery profiles reflecting time to extubation, reversal failure at first attempt, and hemodynamic stability, including incidence of hypertension or tachycardia during the emergence period, were compared.Time to extubation in the sugammadex group was significantly shorter (P < .001). In the sugammadex group, reversal failure at first attempt did not occur in any patient, while it occurred in seven (9.7%) patients in the pyridostigmine group (P = .064), necessitating an additional dose of pyridostigmine (n = 3) or sugammadex (n = 4). The incidence of hemodynamic instability during anesthetic emergence was significantly lower in the sugammadex group than in the pyridostigmine group (P = .019).Sugammadex yielded a recovery profile superior to that of pyridostigmine during the anesthesia emergence period in advanced PD patients. Sugammadex is also likely to be associated with fewer adverse effects than traditional reversal agents, which in turn would also improve overall postoperative management in this patient population.

Success of surgical free flap transfer depends on achieving and maintaining adequate perfusion across the microvascular anastomosis. The purpose of this prospective study was to determine the optimal infusion rate of dobutamine to augment duplex ultrasound measured blood flow to the tissue flap during surgery.Twenty-one patients undergoing general anesthesia for lower limb reconstructive surgery were recruited. The optimal dobutamine dose was evaluated using the modified Dixon's up-and-down method, starting at 6 μg·kg·min, and then titrated in increments of 1 μg·kg·min.The optimal dose of dobutamine for improving blood flow to the tissue flap was 3.50 ± 0.57 μg·kg·min in 50% of patients. The 95% effective dose of dobutamine calculated by probit analysis was 4.46 μg·kg·min (95% confidence interval: 3.99-7.00 μg·kg·min).The results of our study suggest that a dobutamine infusion rate less than 5 μg·kg·minprovides significant improvement of blood flow to the tissue flap, while minimizing cardiovascular side effects.

Donor safety is the major concern in living donor liver transplantation, although hepatic resection may be associated with postoperative coagulopathy. Recently, the use of sugammadex has been gradually increased, but sugammadex is known to prolong prothrombin time (PT) and activated partial thromboplastin time (aPTT). We compared the postoperative coagulation profiles and outcomes of sugammadex versus pyridostigmine group in donors receiving living donor hepatectomy.Consecutive donor hepatectomy performed between September 2013 and August 2016 was retrospectively analyzed. For reversal of rocuronium-induced neuromuscular blockade, donors received sugammadex 4 mg/kg or pyridostigmine 0.25 mg/kg. The primary end-points were laboratory findings (PT, aPTT, hemoglobin, platelet count) and clinically evaluated postoperative bleeding (relaparotomy for bleeding, cumulative volume collected in drains). Secondary outcomes were anesthesia time, postoperative hospital day.Of 992 donors, 383 treated with sugammadex and 609 treated with pyridostigmine for the reversal of neuromuscular blockade. There were no significant differences between both groups for drop in hemoglobin and platelet, prolongation in PT, aPTT, and the amount of 24-h drain volume. Bleeding events within 24 h were reported in 2 (0.3%) for pyridostigmine group and 0 (0%) for sugammadex group (P = .262). Anesthesia time was significantly longer in pyridostigmine group than that in sugammadex group (438.8 ± 71.4 vs. 421.3 ± 62.3, P < .001). Postoperative hospital stay was significantly longer in pyridostigmine group than that in sugammadex group (P = .002).Sugammadex 4 mg/kg was not associated with increased bleeding tendency, but associated with reduced anesthesia time and hospital stay. Therefore, sugammadex may be safely used and will decrease morbidity in donor undergoing living-donor hepatectomy.

Subclavian central venous catheterization is a common procedure for which misplacement of the central venous catheter (CVC) is a frequent complication that can potentially be fatal. The carina is located in the mid-zone of the superior vena cava (SVC) and is considered a reliable landmark for CVC placement in chest radiographs. The C-length, defined as the distance from the edge of the right transverse process of the first thoracic spine to the carina, can be measured in posteroanterior chest radiographs using a picture archiving and communication system. To evaluate the placement of the tip of the CVC in subclavian central venous catheterizations using the C-length, we reviewed the medical records and chest radiographs of 122 adult patients in whom CVC catheterization was performed (from January 2012 to December 2014) via the right subclavian vein using the C-length. The tips of all subclavian CVCs were placed in the SVC using the C-length. No subclavian CVC entered the right atrium. Tip placement was not affected by demographic characteristics such as age, sex, height, weight, and body mass index. The evidence indicates that the C-length on chest radiographs can be used to determine the available insertion length and place the right subclavian CVC tip into the SVC., (Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

This is a retrospective observational study. Greater trochanteric epiphysiodesis (GTE) has been recommended to prevent Trendelenburg gait and limitation of the hip joint motion due to trochanteric overgrowth after femoral varus osteotomy (FVO) in Legg-Calvé-Perthes disease (LCPD). However, capital femoral physeal arrest frequently occurs in patients with severe disease (lateral pillar C), so GTE might not be as effective in these patients. The aim of this study was to compare trochanteric growth inhibition due to GTE after FVO between 2 age groups (<8 or >8 years) in patients with lateral pillar B and B/C border LCPD and evaluate the effectiveness of GTE compared with the normal, unaffected hip.This study included 19 children with lateral pillar B and B/C border LCPD in 1 leg who underwent FVO followed by GTE. Of the 19 children, 9 underwent GTE before the age of 8 years and 10 underwent GTE after 8 years of age. On radiographs taken at the immediate postoperative period and at skeletal maturity, the articulo-trochanteric distance (ATD), center-trochanteric distance (CTD), and neck-shaft angle (NSA) were compared between the 2 age groups. The amount of correction was compared between groups. The contralateral, unaffected hip was used as a control for trochanteric growth. The patients were clinically evaluated with Iowa hip score at the final follow-up.There was no significant difference between the 2 age groups in terms of time to GTE, length of follow-up, or lateral pillar classification. In the affected hip, the amount of correction of the ATD, CTD, and NSA was significantly greater in patients < 8 years than in patients > 8 years. However, in the unaffected hip, the change in the ATD, CTD, and NSA did not differ significantly between the 2 groups.We suggest that FVO followed by GTE for lateral pillar B and B/C border LCPD in patients under the age of 8 years can affect growth of the greater trochanter. However, effective growth inhibition due to GTE was not achieved after 8 years of age.

During liver transplantation, the thermodilution cardiac output (CO) technique cannot respond to sudden hemodynamic changes associated with postreperfusion syndrome. Photoplethysmography (PPG) can reflect changes in intravascular volume and thus can be used to assess vasomotor tone and arterial stiffness on the pressure-volume relation. We investigated whether a beat-to-beat analysis of the arterial pressure-PPG relationship can estimate dynamic changes in vascular characteristics immediately after liver graft reperfusion.In 10 recipients, arterial blood pressure and PPG waveforms recorded simultaneously were analyzed from the beginning of fall to nadir in systolic blood pressure immediately after reperfusion. On a beat-to-beat basis, we compared the ratio of the amplitude of PPG to arterial pulse pressure (PPGamp/PP, as relative vascular compliance) to total peripheral resistance (TPR) and Windkessel compliance (Cwk) obtained from the Modelflow CO algorithm.Following graft reperfusion, PPGamp/PP and Cwk increased (median 41.5%; P = .005 and 42.0%; P < .001, respectively), whereas TPR decreased (median -46.4%; P < .001). Beat-to-beat PPGamp/PP was negatively correlated with TPR (median r = -0.80 [95% CI -0.85 to -0.76] on linear regression and r = 0.84 [95% CI 0.73-0.92] on curvilinear regression), and was positively correlated with Cwk (median r = 0.86 [95% CI 0.81-0.91] on linear regression and r = 0.88 [95% CI 0.75-0.96] on curvilinear regression).Our results suggest that relative compliance, obtained from beat-to-beat analysis of PPG and arterial pressure waveforms, can track abrupt changes in vascular characteristics associated with postreperfusion syndrome. This simple index would contribute to differential diagnoses of sudden hypotension.

Although the elicited responses of motor evoked potential (MEP) monitoring are very sensitive to suppression by anesthetic agents and muscle relaxants, the use of neuromuscular blockade (NMB) during MEP monitoring is still controversial because of serious safety concerns and diagnostic accuracy. Here, we evaluated the incidence of unacceptable movement and compared false-negative MEP results between no and partial NMB during cerebral aneurysm clipping surgery. We reviewed patient medical records for demographic data, anesthesia regimen, neurophysiology event logs, MEP results, and clinical outcomes. Patients were divided into 2 groups according to the intraoperative use of NMB: no NMB group (n = 276) and partial NMB group (n = 409). We compared the diagnostic accuracy of MEP results to predict postoperative outcomes between both groups. Additionally, we evaluated unwanted patient movement during MEP monitoring in both groups. Of the 685 patients, 622 (90.8%) manifested no intraoperative changes in MEP and no postoperative motor deficits. Twenty patients showed postoperative neurologic deficits despite preserved intraoperative MEP. False-positive MEP results were 3.6% in the no NMB group and 3.9% in the partial NMB group (P = 1.00). False-negative MEP results were 1.1% in the no NMB group and 4.2% in the partial NMB group (P = 0.02). No spontaneous movement or spontaneous respiration was observed in either group. Propofol/remifentanil-based anesthesia without NMB decreases the stimulation intensity of MEPs, which may reduce the false-negative ratio of MEP monitoring during cerebral aneurysm surgery. Our anesthetic protocol enabled reliable intraoperative MEP recording and patient immobilization during cerebral aneurysm clipping surgery.

Introduction: As a common morphological change of aging heart, sigmoid ventricular septum is frequently found during routine preoperative evaluation, but often disregarded because of its little clinical importance. However, in this report, we describe a 70-year old patient with sigmoid ventricular septum who developed severe hemodynamic deterioration during liver transplantation because of its unique morphology of heart., Methods: During the course of reperfusion of the graft, patient's hemodynamics were closely monitored using transesophageal echocardiography., Results: Immediately after graft reperfusion, epinephrine was given as a treatment of choice for postreperfusion syndrome. Surprisingly, however, hemodynamic derangement persisted and became even worse. Intraoperative transesophageal echocardiography revealed left ventricular outflow tract obstruction resulting from systolic anterior motion of the mitral valve leaflet. Therefore, the patient was treated with phenylephrine and fluid bolus under the guidance of transesophageal echocardiography., Conclusion: As more elderly recipient present for liver transplantation surgery nowadays, left ventricular outflow tract obstruction should always be considered as a possible cause for hemodynamic instability during reperfusion period. In addition, transesophageal echocardiography is a useful tool for both diagnosis of hemodynamic derangement and guidance for appropriate management during liver transplantation surgery.

Acute kidney injury (AKI) is associated with extended hospital stay, a high risk of progressive chronic kidney diseases, and increased mortality. Patients undergoing radical prostatectomy are at increased risk of AKI because of intraoperative bleeding, obstructive uropathy, older age, and preexisting chronic kidney disease. In particular, robot-assisted laparoscopic radical prostatectomy (RALP), which is in increasing demand as an alternative surgical option for retropubic radical prostatectomy (RRP), is associated with postoperative renal dysfunction because pneumoperitoneum during RALP can decrease cardiac output and renal perfusion. The objective of this study was to compare the incidence of postoperative AKI between RRP and RALP.We included 1340 patients who underwent RRP (n = 370) or RALP (n = 970) between 2013 and 2014. Demographics, cancer-related data, and perioperative laboratory data were evaluated. Postoperative AKI was determined according to the Kidney Disease: Improving Global Outcomes criteria. Operation and anesthesia time, estimated blood loss, amounts of administered fluids and transfused packed red blood cells, and the lengths of the postoperative intensive care unit and hospital stays were evaluated. Propensity score matching analysis was performed to reduce the influence of possible confounding variables and adjust for intergroup differences between the RRP and RALP groups.After performing 1:1 propensity score matching, the RRP and RALP groups included 307 patients, respectively. The operation time and anesthesia time in RALP were significantly longer than in the RRP group (both P < 0.001). However, the estimated blood loss and amount of administered fluids in RALP were significantly lower than in RRP (both P < 0.001). Also, RALP demonstrated a significantly lower incidence of transfusion and smaller amount of transfused packed red blood cells than RRP (both P < 0.001). Importantly, the incidence of AKI in RALP was significantly lower than in RRP (5.5% vs 10.4%; P = 0.044). Furthermore, the length of hospital stay in RALP was also significantly shorter (P < 0.001).The incidence of AKI after RALP is significantly lower than after RRP. RALP can therefore be a better surgical option than RRP in terms of decreasing the frequency of postoperative AKI.