Preoperative Clinical Examination Research Articles

Cleft-Orthognathic Surgery

We reviewed the complications and long-term results of a consecutive series of adolescents (67 males, 49 females; age range 15 to 25 years; mean 18 years) born with a cleft who underwent primary repair in childhood and later developed a jaw deformity and malocclusion that required orthognathic surgery. Between 1986 and 1992, 116 adolescents with either unilateral cleft lip and palate (n = 66), bilateral cleft lip and palate (n = 33), or isolated cleft palate (n = 17) underwent an orthognathic procedure that included a Le Fort I osteotomy; 32 also underwent simultaneous sagittal split osteotomies of the mandible; and 87 underwent osteoplastic genioplasty. Clinical follow-up ranged from 1 to 7 years (mean 40 months) at the close of the study. The preoperative clinical examination varied according to cleft type and individual variation, but all patients had maxillary hypoplasia. Additional cleft-related deformities included residual oronasal fistula and bony defects, clefted alveolar ridges that retained dental gaps, and mobile premaxilla that lacked union to the lateral segments. Overall, 89 percent of residual fistulas underwent successful closure as part of the orthognathic procedure. Surgical cleft dental gap closure was achieved and maintained to the extent planned at 92 percent of the cleft sites. A fixed (prosthetic) bridge was used successfully for dental rehabilitation to close the gap in all other patients at each cleft site (n = 9). All patients with alveolar clefts (n = 99) maintained keratinized mucosa along the labial surface of the cleft-adjacent teeth (n = 264 teeth). Complications were few and generally not serious. There was no segmental bone loss of teeth because of aseptic necrosis or infection. Only 5 percent of cleft adjacent teeth underwent a degree of gingival recession and root exposure as a result of the maxillary osteotomy procedure; all were retained long term. The long-term maintenance of overjet and overbite measured directly from the late (> 1 year) postoperative lateral cephalometric radiograph indicated that 97 percent of patients maintained a positive overjet and 89 percent maintained a positive overbite; 5 percent shifted to a neutral overbite. The methods used to manage jaw deformity, malocclusion, residual oronasal fistula, and bony defects in adolescents born with a cleft are safe and reliable and offer the patient an enhanced quality of life. They also provide a stable foundation in which final soft-tissue lip and nose revisions may be carried out.

A clinical, mammographic, sonographic and histologic evaluation of breast cancer

Objective: To evaluate histologic tumor size in comparison with preoperative determination of tumor diameter by palpation, mammography and sonography. Methods: In a retrospective analysis we compared the histologic, clinical, mammographic and sonographic findings obtained from 160 patients with breast carcinoma. Results: The histologically determined tumors showed an average diameter of 25.7 mm. By comparison, the average tumor diameter determined by mammography, sonography and palpation was 23.8, 26.1 and 30.6 mm, respectively. Mammography was capable of detecting 94.5% of breast carcinomas, breast sonography 91% and palpation 87%. The combinations of mammography and sonography or mammography and palpation detected 99% of carcinomas, and sonography and palpation 95% of carcinomas. Conclusion: As supplementary methods to preoperative clinical examination, mammography and breast sonography are mutually complementary, high-resolution imaging techniques of utmost importance in the preoperative diagnosis and surgical treatment of breast cancer patients.

Arthroscopic treatment of anterolateral ankle impingement: Correlating surgical results with preoperative clinical examination and magnetic resonance imaging findings

Arthroscopic treatment of anterolateral ankle impingement: Correlating surgical results with preoperative clinical examination and magnetic resonance imaging findings

A Comparison of Dipyridamole Thallium 201 Scintigraphy and Clinical Examination in the Determination of Cardiac Risk Before Arterial Reconstruction

Preoperative clinical examination, including a 12-lead resting ECG, and planar dipyridamole thallium imaging (DTI) were compared in a prospective study of 65 vascular surgical patients in regard to their value for predicting postoperative cardiac complications. Fifty-three patients underwent abdominal vascular procedures and 12 were operated on for peripheral artery disease. Thirty-six patients had ischemic heart disease (IHD) and/or abnormal findings from 12-lead resting ECG. Of these 36 patients, 11 had nonfatal cardiac complications. The remaining 29 patients were free of IHD and had normal results from ECG. No complications occurred among these 29 patients. There was no postoperative death. Thallium imaging results were abnormal in 45 patients, showing either redistribution and/or scar tissue or low washout. In 18 of these patients major changes with redistribution were present in all projections. Among these patients, 9 had a nonfatal cardiac complication. In the 27 patients with abnormalities in only one or two projections, only 2 had a cardiac event postoperatively. No cardiac complications occurred in patients with normal thallium scintigraphy findings. The patients were operated on irrespective of the results of the scans, and all recovered from any cardiac complications that occurred. In vascular surgical patients with previous IHD and/or abnormal findings from resting ECGs further risk stratification is achieved with DTI.

The Evaluation of Preoperative Clinical Examination for the Patients with Jaw Deformities in Our Department

Orthognathic surgery under general anesthesia was performed on 255 patients from April 1982 through December 1992 at the First Department of Oral and Maxillofacial Surgery, Osaka Dental University. Based on preoperative examinations of those patients, the following prevalence rates of diseases were obtained, reinforcing the need for preoperative examinations:1. Anemia was found in21patients (8.2%); two (2.3%) of them were male and19 (10.9%) were female.2. Abnormality of liver function was found in 17 patients (6.7%); nine (11.1%) were male and eight (4.6%) were female.3. Arrthythmia was found in 6 patients (2.4%); one (1.2%) was male and five (4.6%) were female.4. Allergic disease was found in 47 patients (18.4%); 15 (18.5%) were male and 32 (18.4%) were female. Eighteen out of 47 patients suffered from asthma.5. Hyperthyroidism was found in two patients (0.8%).

Recurrent varicose veins: correlation between preoperative clinical and hand-held Doppler ultrasonographic examination, and anatomical findings at surgery

A consecutive series of 118 patients (148 legs) presenting with recurrent varicose veins underwent preoperative clinical and hand-held Doppler ultrasonographic examination by a single observer. The presence of saphenofemoral, mid-thigh perforator and saphenopopliteal refux was noted. Ultrasonography markedly improved the accuracy of clinical assessment at all three potential sites of reflux compared with operative findings. Of 71 patients undergoing repeat groin dissection, only 20 (28 per cent) had a tied saphenofemoral junction, 31 (44 per cent) had intact major tributaries and52 (73per cent) had an intact long saphenous vein (LSV) in the thigh. There was a positive association between mid-thigh perforator reJrux giving rise to recurrent varices and the presence of an intact LSV in the thigh. Of 45 legs with saphenopopliteal reJux, only four had previously undergone saphenopopliteal ligation, suggesting that most short saphenous varicosities had either appeared after or had not been recognized at the time of primary surgery. This study indicates that even an experienced vascular surgeon can have d@culty in assessing the presence or absence of recurrent deep to superficial reflux by means of clinical examination alone and that Doppler ultrasonographic examination is mandatory. Recurrence continues to be associated with persistent or recurrent incompetence at the site of previous inadequate surgery.

肋骨に発生した骨内分化型骨肉腫の一例

Intraosseous well-differentiated osteosarcoma is a rare subtype of osteosarcomas and must be distinguished from benign tumorous conditions due to its similarity on preoperative clinical examination and from conventional osteosarcoma because of its much better prognosis. We now report a very rare case of intraosseous well-differentiated osteosarcoma, primarily occurring in the right third rib of a 9-year-old boy. The plain and CT scan films showed protruded tumor mass arising from the right third rib, and bone scinti scan film revealed marked high uptake. Histologically, the resected mass showed proliferation of short-fusiform or spindle-shaped cels with little nuclear atypia, intermingled with fibrous dysplasia-like immmature bone trabeculae in the medullary cavity. Moreover, the tumor mass continuously protruded into the extramedullary adjacent soft part with destruction of the cortex. These features are compatible with intraosseous well-differentiated osteosarcomas. Although the follow-up period is short, the patient is well with no local recurrence or distant metastasis.

Macular Phototoxicity Caused by Fiberoptic Endoillumination During Pars Plana Vitrectomy

Three cases of retinal phototoxicity were caused by light from the endoilluminator used in vitrectomy. Preoperative clinical examination, color photography, and fluorescein angiography in all three cases failed to disclose retinal pigment epithelial changes. Postoperative clinical findings, photographs, and fluorescein angiograms are highly suggestive of the presence of retinal phototoxicity. The characteristics of these lesions and surgical conditions implicate the endoilluminator as the source of photic injury. The macular lesions were noted within one week of the surgical procedure, measured between 2 and 5 disk diameters in size, involved the fovea in two eyes, and resulted in marked decrease in visual acuity in two of three eyes, with persistence in one eye. Initially, whitening of the outer retina was present, but was replaced by pigmentary mottling at the level of the retinal pigment epithelium within a few weeks. Preventive measures to avoid macular phototoxicity associated with vitrectomy are discussed.

Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: An arthroscopic study

Seventeen athletes presenting with unexplained shoulder pain on throwing underwent arthroscopic examination. All but one practiced a throwing sport. The dominant arm was involved in all patients except one bodybuilder. Their mean age was 25 years (range 15 to 30 years), and they had symptoms present for a mean of 27 months. None had clinical, radiologic, or arthroscopic evidence of anterior instability. Preoperative clinical examination typically revealed localized pain on full external rotation and 90° abduction, signs of rupture of the rotator cuff, and positive impingement sign. In 10 cases computed tomographic arthrogram showed evidence of abnormality at the posterior edge of the glenoid. The mean humeral retrotorsion was 10° (range 5° to 30°). Under arthroscopy, with the arm placed in full external rotation and 90° abduction (the throwing position), impingement was found between the posterosuperior border of the glenoid and the undersurface of the tendinous insertions of supraspinatus and infraspinatus. A partial rupture of the cuff, which was demonstrated by arthrogram, was confirmed in eight patients, whereas a partial capsulotendinous rupture, which was not demonstrated by arthrogram, was seen in nine patients. Twelve patients had further lesions of the posterosuperior labrum. This study suggests that in addition to Neer's "impingement syndrome" and Jobe's "instability with secondary impingement," impingement of the undersurface of the cuff on the posterosuperior glenoid labrum may be a cause of painful structural disease of the shoulder in the thrower.

Pre-operative evaluation of patients with low rectal carcinoma.

Advances in surgical technique and adjuvant therapy have broadened the spectrum of treatment available for patients with low rectal cancer. Combination of careful pre-operative clinical examination with newer, more sophisticated techniques, particularly in the field of imaging, can stage the extent of disease more accurately then previously. Adoption of an extended pre-operative evaluation allows a more rational approach to treatment in the individual, and standardizes criteria for entry into, and interpretation of, future clinical trials.

Staging Proposal for External Auditory Meatus Carcinoma Based on Preoperative Clinical Examination and Computed Tomography Findings

An accepted staging system for squamous cell carcinoma of the external auditory meatus is currently lacking and would permit accurate comparison of treatment strategies and results for patients with this unusual neoplasm. In order to develop such a staging system we reviewed the prognostic variables and the accuracy of radiographic diagnosis in 39 patients undergoing temporal bone resection for squamous carcinoma of the external auditory meatus. Predictors of poor survival were extensive tumor involvement, facial nerve paralysis, middle ear involvement, and cervical or periparotid lymphadenopathy. In a comparison of 12 specific anatomic sites, computed tomography was found to be an accurate indicator of histopathologically proven tumor invasion. On the basis of this clinical radiographic-histopathologic analysis, we propose a TNM staging system for external auditory meatus carcinoma utilizing preoperative computed tomography and physical examination. This system fulfills the requirements of the American Joint Committee on Cancer that a staging system should provide a sound basis for therapeutic planning for cancer patients by describing the survival and resultant treatment of different patient groups in comparable form.

Prognostic significance of intramural metastasis in patients with esophageal carcinoma

Clinicopathologic data on 201 patients who underwent surgical resection of esophageal squamous cell carcinoma, with or without intramural metastasis (IM), were analyzed to determine the significance of IM for patient prognosis and survival. In 24 (11.9%) patients IM was observed. There was one (1.4%) in 74 cases in Stage 0, I, or II, and 23 (18.1%) in 127 cases in Stage III or IV, based on the new pTNM classification. There was a statistically significant Cox-Mantel test difference in the percentage survival curves of the patients, both in all stages (P less than 0.01) and in only Stages III and IV (P less than 0.05), as a function of the presence or absence of IM. Lymph node metastasis and distant organ metastasis were observed in 22 (91.7%) and seven (29.2%) of the 24 patients, respectively, with IM and in 111 (62.7%) and 13 (7.3%) of the 177 patients without IM. For both types of metastasis, the incidence was significantly lower in the patients without IM (P less than 0.01). Seventy percent of IM on the proximal side was detected during preoperative clinical examination. These data indicate that the presence of IM is an important factor for preoperative and postoperative evaluation of the prognosis of patients with esophageal squamous cell carcinoma.

Complications exceptionnelles de la neurolyse du nerf médian

Two cases of acute post-operative compression of the ulnar nerve after, nerve release of the median nerve in the wrist are reported. The ulnar, nerve was free of any lesion on the preoperative clinical or electrical examination, at the elbow or the wrist. Stenosis of this nerve occurred during the month following the median nerve release as confirmed by EMG. The compression was treated by ulnar nerve release. Such a complication, representing 0.2% in a series of 982 cases of carpal tunnel syndrome, has never been mentioned in the literature. The authors suggest an etiopathogenic hypothesis which guides a new surgical approach.

Craniofacial trauma.

The treatment of combined major dislocations of the face and skull requires a craniofacial team consisting of a plastic maxillofacial surgeon, a neurosurgeon, an anesthesiologist, and radiologists. The best results can only be achieved at the primary intervention both from a functional and an esthetic standpoint. Careful preoperative clinical and radiologic examinations are mandatory to reach these high goals. In primary repair, the cranial approach aims at constructing "a monobloc bone flap" to suture meningeal tears and to reinforce them with a pericranial graft, to close the cranial base completely using cancellous bone grafts, and to exclude the frontal sinuses. The facial skeleton is repaired by constructing a rigid external facial frame and thereafter progressing centrally finishing with the "internal" orbitonasal dislocations. The reconstruction aims at a self-stabilizing bone puzzle fixed with interosseous wires, making external fixation unnecessary. Secondary repair requires osteotomies at fracture sites to reposition malunited fractures and the use of autogenous bone grafts for stabilization.

Preoperative instrumented testing of anterior and posterior knee laxity.

A prospective study was performed on 50 patients who were thought or suspected to have cruciate ligament tears. Each patient had a clinical examination preoperatively and under anesthesia and instrumented examination using the MedMetric KT-1000 arthrometer, Stryker knee laxity tester, and Genucom knee analysis. The diagnosis was confirmed by arthrotomy or arthroscopy. Thirty had acute knee injuries (within 2 weeks), 9 had subacute (2 weeks to 3 months), and 11 had chronic injuries. The surgical findings demonstrated that five had other maladies, but no cruciate ligament tears. Two had a partial ACL tear, and the remaining 43 patients had at least one cruciate tear. The preoperative clinical examination for cruciate ligament integrity was completely correct in 92%, correct but incomplete in 6%, and incorrect in 2%. Examination under anesthesia was correct in 98%, the KT-1000 was correct in 75% (involved knee minus noninvolved knee was greater than or equal to 3 mm laxity equal to ACL tear), the Stryker was correct in 75%, and Genucom in 70%. The average laxity of those with ACL tears was 4.4 mm with the KT-1000, 4.6 mm with the Stryker, and 2.0 mm with the Genucom. The methods of testing with the Stryker and the KT-1000 are similar and the laxity recorded in patients with a torn ACL were almost identical. However, the KT-1000 can be used to identify the quadriceps neutral position and therefore more accurately determine PCL instability. The Genucom has the most versatility, but the laxity recorded in patients with a torn ACL was significantly lower than the other devices.(ABSTRACT TRUNCATED AT 250 WORDS)

Preoperative and postoperative gait analyses of patients undergoing great toe-to-thumb transfer

Microvascular transfer of the great toe is a reliable method of thumb reconstruction for many patients, but the precise deficit incurred by elective amputation of the great toe has not been fully defined. Twelve patients who had this procedure were evaluated with preoperative and postoperative gait analyses and clinical examinations. The mean age was 29.3 years, with a mean clinical follow-up of 30.3 months, and a comparative follow-up gait study at a mean of 21.1 months postoperatively. Only one patient exhibited a significant motion change postoperatively, which was a reduction in ankle plantar-flexion at weight release of the operated foot (push-off). The average velocity, cadence, step length of the foot that had surgery performed, single and double limb stance times of each foot, and step width did not significantly change. There was only a slight average reduction in stride length at 4.6% (p less than 0.05), which resulted from a decrease in step length of the foot that did not have surgery 7.6% (p less than 0.02). Nine patients had no clinical complaints, two had occasional mild discomfort near the second and third metatarsal heads, and one had intolerance to cold.

親子にみられたＭａｙ‐Ｈｅｇｇｌｉｎ ａｎｏｍａｌｙ患者の抜歯経験

We have experienced two cases of teeth extraction in father and son with May-Hegglin anomaly. The diagnosis of these cases was determined by preoperative clinical examination for screening of hemorrhagic diathesis. The result of observation of the peripheral blood in patients, we found out some specific inspections of May-Hegglin anomaly. They were 1) giant bizarre blood platelets 2) DOhle inclusion bodies in the polymorphonuclear leucocytes 3) thrombopenia. We have done teeth extraction of those patients without trouble of blooding by only local haemostatic treatment.

Carpal tunnel syndrome. Anatomical and clinical investigation.

The anatomy of the carpal tunnel was studied by postmortem dissection of both wrists in ten adults with normal wrists. Preoperative clinical and EMG examinations were performed on 28 wrists in 23 patients suffering from carpal tunnel syndrome. Anatomical and histological studies were made in connection with operation, and postoperatively the condition was followed clinically and by EMG. Numbness, tingling, and pain of the hands were markedly relieved during 2 months of follow-up, whereas clumsiness and weakness showed no significant change. preoperatively, EMG showed sensory abnormalities in 96% of cases and motoric abnormalities in 82%. The diagnostic accuracy of EMG was good, in particular as regards the sensory aspect. The return to normal of EMg was slow. Pathoanatomical examination showed a normal tendon sheath and transverse carpal ligament in 52%, while rheuma was found in the specimens of 12%, fibrosis of the tendon sheath in 36%, and fibrosis of the transverse carpal ligament in 32%. No correlation was observed between the shape of the osseous carpal tunnel and the degree of clinical symptoms.

Pre- and postoperative facial nerve testing in patients with acoustic neuromas.

Clinical and electrophysiological examination of the facial nerve was performed in 49 consecutive patients, from December 1982 to January 1984, before and after surgical removal of acoustic neuroma. The electrophysiological examination included quantitative electromyography of the facial muscles and facial nerve stimulation with registration of amplitude and latency of evoked muscle potentials. 17 patients had tumours with an extrameatal size of 5-25 mm, 16 had tumours between 26 and 40 mm, and 16 (32%) tumours larger than 40 mm. At preoperative clinical examination, 9 patients had decreased facial motor function; 7 however, only by meticulous inspection, while 2 had a slight paresis. Two patients had hemifacial spasms. 25 patients had prolonged duration of motor unit potentials and/or increased incidence of polyphasic potentials by electromyography. Only one patient had denervation activity. Three patients had decreased amplitude of evoked muscle potentials to supramaximal stimulation of the facial nerve. Motor latency was normal. At the most recent examination between 3 and 12 months postoperatively, 65% of the patients had no or insignificant facial nerve involvement, 10% had slight and 25% significant involvement, of whom 6 had paralysis or only slight reinnervation. The preoperative clinical facial involvement and the degree of electrophysiological abnormality was poorly correlated to the motor function at the time of the most recent examination.

Visual Prognosis for Corneal Transplantation Based on Preoperative Visual Evoked Potential and Electroretinogram

Thirty-one corneal transplant cases underwent a visualevoked potential and electroretinogram examination prior to keratoplasty. There were 12 cases that had a good visual prognosis and 19 cases with a poor visual prognosis based on the preoperative diagnosis and clinical examination. The addition of electrophysiologic testing in the good prognosis cases did not provide additional information, but produced one false negative, whereas tests in poor prognosis cases were helpful in predicting the visual outcome after transplant. These tests were predictive of visual outcome in 71% of all cases and in 58% of the poor prognosis group.