BIS values and hypnotic sedation/anesthesia levels.
\\n\\n
IntechOpen Book Series will also publish a program of research-driven Thematic Edited Volumes that focus on specific areas and allow for a more in-depth overview of a particular subject.
\\n\\nIntechOpen Book Series will be launching regularly to offer our authors and editors exciting opportunities to publish their research Open Access. We will begin by relaunching some of our existing Book Series in this innovative book format, and will expand in 2022 into rapidly growing research fields that are driving and advancing society.
\\n\\nLaunching 2021
\\n\\nArtificial Intelligence, ISSN 2633-1403
\\n\\nVeterinary Medicine and Science, ISSN 2632-0517
\\n\\nBiochemistry, ISSN 2632-0983
\\n\\nBiomedical Engineering, ISSN 2631-5343
\\n\\nInfectious Diseases, ISSN 2631-6188
\\n\\nPhysiology (Coming Soon)
\\n\\nDentistry (Coming Soon)
\\n\\nWe invite you to explore our IntechOpen Book Series, find the right publishing program for you and reach your desired audience in record time.
\\n\\nNote: Edited in October 2021
\\n"}]',published:!0,mainMedia:{caption:"",originalUrl:"/media/original/132"}},components:[{type:"htmlEditorComponent",content:'With the desire to make book publishing more relevant for the digital age and offer innovative Open Access publishing options, we are thrilled to announce the launch of our new publishing format: IntechOpen Book Series.
\n\nDesigned to cover fast-moving research fields in rapidly expanding areas, our Book Series feature a Topic structure allowing us to present the most relevant sub-disciplines. Book Series are headed by Series Editors, and a team of Topic Editors supported by international Editorial Board members. Topics are always open for submissions, with an Annual Volume published each calendar year.
\n\nAfter a robust peer-review process, accepted works are published quickly, thanks to Online First, ensuring research is made available to the scientific community without delay.
\n\nOur innovative Book Series format brings you:
\n\nIntechOpen Book Series will also publish a program of research-driven Thematic Edited Volumes that focus on specific areas and allow for a more in-depth overview of a particular subject.
\n\nIntechOpen Book Series will be launching regularly to offer our authors and editors exciting opportunities to publish their research Open Access. We will begin by relaunching some of our existing Book Series in this innovative book format, and will expand in 2022 into rapidly growing research fields that are driving and advancing society.
\n\nLaunching 2021
\n\nArtificial Intelligence, ISSN 2633-1403
\n\nVeterinary Medicine and Science, ISSN 2632-0517
\n\nBiochemistry, ISSN 2632-0983
\n\nBiomedical Engineering, ISSN 2631-5343
\n\nInfectious Diseases, ISSN 2631-6188
\n\nPhysiology (Coming Soon)
\n\nDentistry (Coming Soon)
\n\nWe invite you to explore our IntechOpen Book Series, find the right publishing program for you and reach your desired audience in record time.
\n\nNote: Edited in October 2021
\n'}],latestNews:[{slug:"intechopen-supports-asapbio-s-new-initiative-publish-your-reviews-20220729",title:"IntechOpen Supports ASAPbio’s New Initiative Publish Your Reviews"},{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"}]},book:{item:{type:"book",id:"7557",leadTitle:null,fullTitle:"Recovery and Utilization of Metallurgical Solid Waste",title:"Recovery and Utilization of Metallurgical Solid Waste",subtitle:null,reviewType:"peer-reviewed",abstract:"At present, a lot of metallurgical solid wastes have not been timely and effectively recycled, resulting in serious problems of environmental pollution and waste of resources. As a result, large-scale comprehensive utilization technologies have been initiated, including slag dry granulation technology, steel slag cement technology, slag wool technology, slag waste heat recovery technology, etc. The comprehensive utilization of metallurgical solid waste has attracted worldwide attention. It is an effective way to improve the utilization efficiency of resources and the added value of products by using scientific metallurgical solid waste recycling methods. This book intends to provide the reader with a comprehensive overview of metallurgical solid wastes comprehensive utilization technology. The comprehensive utilization methods of four representative metallurgical solid wastes are emphatically described, such as blast furnace slag, steel slag, tailings and metallurgical dust.",isbn:"978-1-78985-102-1",printIsbn:"978-1-78985-101-4",pdfIsbn:"978-1-83962-031-7",doi:"10.5772/intechopen.76826",price:119,priceEur:129,priceUsd:155,slug:"recovery-and-utilization-of-metallurgical-solid-waste",numberOfPages:110,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"e9d20f98cdcbb7b5d0c35f53e06c74be",bookSignature:"Yingyi Zhang",publishedDate:"February 20th 2019",coverURL:"https://cdn.intechopen.com/books/images_new/7557.jpg",numberOfDownloads:6522,numberOfWosCitations:8,numberOfCrossrefCitations:11,numberOfCrossrefCitationsByBook:1,numberOfDimensionsCitations:20,numberOfDimensionsCitationsByBook:1,hasAltmetrics:1,numberOfTotalCitations:39,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"April 11th 2018",dateEndSecondStepPublish:"May 2nd 2018",dateEndThirdStepPublish:"July 1st 2018",dateEndFourthStepPublish:"September 19th 2018",dateEndFifthStepPublish:"November 18th 2018",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"221673",title:"Dr.",name:"Yingyi",middleName:null,surname:"Zhang",slug:"yingyi-zhang",fullName:"Yingyi Zhang",profilePictureURL:"https://mts.intechopen.com/storage/users/221673/images/system/221673.png",biography:"Yingyi Zhang is an Associate Professor at the Anhui University of Technology. \n\nHe has presided and participated in more than 20 research projects. He is mainly engaged in the research of development of new ironmaking technology, comprehensive utilization of metallurgical solid waste, and the preparation of high temperature coating. \n\nWith more than 50 publications and 30 patents, Prof. Zhang is a leader in the reactive melt infiltration technology field. In recent years, he hosted one China postdoctoral science foundation program, one national natural science foundation program, and two national key research and development programs. \n\nIn addition, he has participated in two national science and technology support programs as the backbone, one international science and technology cooperation and exchange program, and six national natural science foundation programs.",institutionString:null,position:null,outsideEditionCount:null,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"Anhui University of Technology",institutionURL:null,country:{name:"China"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"889",title:"Recycling",slug:"recycling"}],chapters:[{id:"65036",title:"Introductory Chapter: Metallurgical Solid Waste",doi:"10.5772/intechopen.83587",slug:"introductory-chapter-metallurgical-solid-waste",totalDownloads:1079,totalCrossrefCites:3,totalDimensionsCites:3,hasAltmetrics:0,abstract:null,signatures:"Yingyi Zhang",downloadPdfUrl:"/chapter/pdf-download/65036",previewPdfUrl:"/chapter/pdf-preview/65036",authors:[{id:"221673",title:"Dr.",name:"Yingyi",surname:"Zhang",slug:"yingyi-zhang",fullName:"Yingyi Zhang"}],corrections:null},{id:"63935",title:"Antimicrobial Efficiency of Metallurgical Slags Suitable for Construction Applications",doi:"10.5772/intechopen.81527",slug:"antimicrobial-efficiency-of-metallurgical-slags-suitable-for-construction-applications",totalDownloads:781,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:0,abstract:"The chapter deals with studying antimicrobial efficiency of granulated blast-furnace slag with fineness of 340 (1Sa) and 520 m2/kg (1Sb), air-cooled blast-furnace slag (2S), demetallized steel slag (3S), calcareous ladle slag (4S) and copper slag (5S), respectively. The efficiency has been tested on G+ bacteria—Staphylococcus aureus, Bacillus subtilis, Micrococcus luteus; G− bacteria—Pseudomonas aeruginosa, Escherichia coli, Serratia marcescens; yeasts—Rhodotorula glutinis, Candida albicans; filamentous fungi—Penicillium funiculosum, Aspergillus niger, Alternaria alternata, Chaetomium globosum, Cladosporium herbarum, Trichoderma viride. The efficiency has been determined by dilution methods in agar media for that reason the resulting concentration of slags has been 10, 20, 40 and 60%, respectively. The antibacterial efficiency decreased as follows: S4 > S3 > S2 > S1a = S1b > S5, whereas anti-yeast efficiency decreased as follows: S4 > S1a = S1b = S3 > S2 > S5. Filamentous fungi were selectively sensitive to slags, that way there is approximate order of efficiency S4 > S3 = S1a = S1b > S5 > S2. Application of metallurgical slags into construction materials provides them increasing biodegradation resistance.",signatures:"Július Strigáč, Nadežda Števulová, Jozef Mikušinec, Ľudovít Varečka\nand Daniela Hudecová",downloadPdfUrl:"/chapter/pdf-download/63935",previewPdfUrl:"/chapter/pdf-preview/63935",authors:[null],corrections:null},{id:"63272",title:"Treatments and Recycling of Metallurgical Slags",doi:"10.5772/intechopen.80595",slug:"treatments-and-recycling-of-metallurgical-slags",totalDownloads:1453,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:1,abstract:"Steelmaking plants continuously strive to reduce the environmental load in the steelmaking process, resulting in the recycling of energy, water, and other byproducts. In this chapter, techniques for the treatment and recycling of metallurgical slags are described. Metallurgical slags are considered secondary raw materials and are used or added during the process to improve steelmaking practice. Steelmaking slag added into ladle slags makes it possible to minimize slag line wear. BOF-converter slags are also applied in buildup, foaming, or slag splashing practices carried out to prolong the lifespan of refractory lining. Also, EAF slags are commonly used to avoid refractory wear and decrease energy consumption. It is known that cement concrete is one of the most common building materials. Blast furnace crystallized slags are used in cement production, in different percentages. In this sense, understanding the properties of slags is a prerequisite to apply them in different functions. This chapter deals with the measurement and modeling of thermochemical properties of slags, thermophysical properties, and interproperty correlations. Different experimental tests applied in slag characterization are also detailed.",signatures:"Elena Brandaleze, Edgardo Benavidez and Leandro Santini",downloadPdfUrl:"/chapter/pdf-download/63272",previewPdfUrl:"/chapter/pdf-preview/63272",authors:[null],corrections:null},{id:"63982",title:"The Comprehensive Utilization of Steel Slag in Agricultural Soils",doi:"10.5772/intechopen.81440",slug:"the-comprehensive-utilization-of-steel-slag-in-agricultural-soils",totalDownloads:1091,totalCrossrefCites:3,totalDimensionsCites:6,hasAltmetrics:1,abstract:"The use of metallurgical solid wastes such as steel slag, in agricultural activity, has become very important to contribute to reducing the accumulation of such wastes in the environment and to increase crop production. So, this chapter aims to emphasize the main aspects of the application of slags to soil chemical attributes as elevation of pH and neutralization of Al3+ toxic in acid soils and increase nutrient content as phosphorus, calcium, magnesium, some micronutrients, and silicon. In addition, the advance in studies of the utilization of these residues in no-tillage systems in tropical soils will be discussed. Aspects related to monitoring the presence of heavy metals will be addressed.",signatures:"Angélica Cristina Fernandes Deus, Rosemary Marques de Almeida Bertani,\nGuilherme Constantino Meirelles, Anelisa de Aquino Vidal Lacerda Soares,\nLais Lorena Queiroz Moreira, Leonardo Theodoro Büll and\nDirceu Maximino Fernandes",downloadPdfUrl:"/chapter/pdf-download/63982",previewPdfUrl:"/chapter/pdf-preview/63982",authors:[null],corrections:null},{id:"63364",title:"Comprehensive Utilization of Iron-Bearing Converter Wastes",doi:"10.5772/intechopen.80329",slug:"comprehensive-utilization-of-iron-bearing-converter-wastes",totalDownloads:1154,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:0,abstract:"Basic oxygen furnace (BOF) sludge is composed of not only valuable iron but also impurities like Zn, Pb, and some alkaline oxides. It is collected from wet cleaning system in steelmaking plants. How to deal with these double identity wastes? Will the traditional landfill treatments result in environmental pollution? What technologies have been developed recently, and is it actually useful? In this chapter, physical-chemical properties and mineralogical phases of converter sludge were characterized, and different recycling technologies were introduced. The proven metalized pellet-producing process would be highlighted that green pellets made from iron-bearing sludge are dried and preheated in a traveling grate firstly, and then reduced at high temperature in a rotary kiln or a rotary hearth furnace (RHF) to get direct reduced iron (DRI), served as a good iron source for blast furnace.",signatures:"Hu Long, Dong Liu, Lie-Jun Li, Ming-Hua Bai, Yanzhong Jia and Wensheng Qiu",downloadPdfUrl:"/chapter/pdf-download/63364",previewPdfUrl:"/chapter/pdf-preview/63364",authors:[null],corrections:null},{id:"63120",title:"The Comprehensive Utilisation of Red Mud Utilisation in Blast Furnace",doi:"10.5772/intechopen.80087",slug:"the-comprehensive-utilisation-of-red-mud-utilisation-in-blast-furnace",totalDownloads:965,totalCrossrefCites:4,totalDimensionsCites:8,hasAltmetrics:0,abstract:"State-of-the-art formation of red mud during industrial processing of bauxite in the Sverdlovsk region (Russian Federation) is presented. Red mud chemical composition is presented, and an analysis of existing ways in which they are utilised is executed. In the Institute of Metallurgy of the Ural Branch of the Russian Academy of Sciences, red mud is utilised by introducing it into the charge for the production of iron ore sinter and pellets following the use of sinter and pellets in the blast furnace charge. Metallurgical properties of sinter and pellets (reducibility, strength, softening and melting temperatures) with different contents of red mud in iron ore raw materials are also presented, including the technology of red mud usage in ferrous metallurgy carried out through industrial and laboratorial tests. Additionally, the main technical and economic indicators of blast furnace smelting (productivity, coke consumption, chemical composition of pig iron and slag, etc.) are presented. The possibility and expediency of utilisation of red mud in a blast furnace are shown.",signatures:"Andrey Dmitriev",downloadPdfUrl:"/chapter/pdf-download/63120",previewPdfUrl:"/chapter/pdf-preview/63120",authors:[null],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},subseries:null,tags:null},relatedBooks:[{type:"book",id:"2254",title:"Post-Consumer Waste Recycling and Optimal Production",subtitle:null,isOpenForSubmission:!1,hash:"aecfc52fb19d9de94ca93473cbe7fd74",slug:"post-consumer-waste-recycling-and-optimal-production",bookSignature:"Enri Damanhuri",coverURL:"https://cdn.intechopen.com/books/images_new/2254.jpg",editedByType:"Edited by",editors:[{id:"96952",title:"Prof.",name:"Enri",surname:"Damanhuri",slug:"enri-damanhuri",fullName:"Enri Damanhuri"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10855",title:"Waste Material Recycling in the Circular Economy",subtitle:"Challenges and Developments",isOpenForSubmission:!1,hash:"d19317ef8e4a35c32f3af20bd8d5d829",slug:"waste-material-recycling-in-the-circular-economy-challenges-and-developments",bookSignature:"Dimitris S. 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Overlapping clinical symptoms and the multitude of genes to be analyzed for an accurate diagnosis make it difficult to identify the type of dystrophy. The continuous evolution of molecular techniques and the accumulation of knowledge about the pathophysiology of these diseases have led to improved accuracy of diagnosis and approach to different therapeutic strategies.
\r\n\r\n\tThis book will aim to provide an overview of the recent advances in the muscular dystrophy field, addressing the cellular and molecular basis of muscular dystrophy, biomarkers, available animal models for research, diagnostic methods, and the newest therapeutic strategies related to these diseases.
",isbn:"978-1-83768-156-3",printIsbn:"978-1-83768-155-6",pdfIsbn:"978-1-83768-157-0",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"8438d4a2b753a62d529eb68d6ade6597",bookSignature:"Dr. Gisela Gaina",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11894.jpg",keywords:"Classification and Characterization, Phenotypes Features, Epigenetic Modification, Myogenic Regulatory Factors, Animal Models, Cellular Models, miRNA Profiling, Serum Biomarkers, Stem Cell, Myostatin Inhibition, Muscle Biopsy, CGH-Array",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"May 24th 2022",dateEndSecondStepPublish:"June 21st 2022",dateEndThirdStepPublish:"August 20th 2022",dateEndFourthStepPublish:"November 8th 2022",dateEndFifthStepPublish:"January 7th 2023",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"2 months",secondStepPassed:!0,areRegistrationsClosed:!1,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:"Dr. Gaina Received her Ph.D. in Biology from the University of Bucharest, Romania. She is a research scientist working in the field of skeletal muscle. The primary focus of her research activities is on skeletal muscle regeneration. She has been involved in a number of research projects funded by regional, national, and international public agencies. She is an author and/or co-author of more than twenty scientific papers and conference abstracts and three book chapters.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"242747",title:"Dr.",name:"Gisela",middleName:null,surname:"Gaina",slug:"gisela-gaina",fullName:"Gisela Gaina",profilePictureURL:"https://mts.intechopen.com/storage/users/242747/images/system/242747.jpg",biography:"Florina Gisela Gaina, PhD, currently works at 'Victor Babes” National Institute of Pathology, Bucharest, Romania. She received her PhD in Biology from the University of Bucharest, Romania, in 2009 with a thesis project based on the study of the proteins involved in muscular dystrophies. She is a research scientist working in the field of skeletal muscle. The primary focus of her research activities is on skeletal muscle regeneration. She has been involved in a number of research projects funded by regional, national, and international public agencies. 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Mauricio Barría"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9500",title:"Recent Advances in Bone Tumours and Osteoarthritis",subtitle:null,isOpenForSubmission:!1,hash:"ea4ec0d6ee01b88e264178886e3210ed",slug:"recent-advances-in-bone-tumours-and-osteoarthritis",bookSignature:"Hiran Amarasekera",coverURL:"https://cdn.intechopen.com/books/images_new/9500.jpg",editedByType:"Edited by",editors:[{id:"67634",title:"Dr.",name:"Hiran",surname:"Amarasekera",slug:"hiran-amarasekera",fullName:"Hiran Amarasekera"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1591",title:"Infrared Spectroscopy",subtitle:"Materials Science, Engineering and Technology",isOpenForSubmission:!1,hash:"99b4b7b71a8caeb693ed762b40b017f4",slug:"infrared-spectroscopy-materials-science-engineering-and-technology",bookSignature:"Theophile Theophanides",coverURL:"https://cdn.intechopen.com/books/images_new/1591.jpg",editedByType:"Edited by",editors:[{id:"37194",title:"Dr.",name:"Theophile",surname:"Theophanides",slug:"theophile-theophanides",fullName:"Theophile Theophanides"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3161",title:"Frontiers in Guided Wave Optics and Optoelectronics",subtitle:null,isOpenForSubmission:!1,hash:"deb44e9c99f82bbce1083abea743146c",slug:"frontiers-in-guided-wave-optics-and-optoelectronics",bookSignature:"Bishnu Pal",coverURL:"https://cdn.intechopen.com/books/images_new/3161.jpg",editedByType:"Edited by",editors:[{id:"4782",title:"Prof.",name:"Bishnu",surname:"Pal",slug:"bishnu-pal",fullName:"Bishnu Pal"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"371",title:"Abiotic Stress in Plants",subtitle:"Mechanisms and Adaptations",isOpenForSubmission:!1,hash:"588466f487e307619849d72389178a74",slug:"abiotic-stress-in-plants-mechanisms-and-adaptations",bookSignature:"Arun Shanker and B. Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3092",title:"Anopheles mosquitoes",subtitle:"New insights into malaria vectors",isOpenForSubmission:!1,hash:"c9e622485316d5e296288bf24d2b0d64",slug:"anopheles-mosquitoes-new-insights-into-malaria-vectors",bookSignature:"Sylvie Manguin",coverURL:"https://cdn.intechopen.com/books/images_new/3092.jpg",editedByType:"Edited by",editors:[{id:"50017",title:"Prof.",name:"Sylvie",surname:"Manguin",slug:"sylvie-manguin",fullName:"Sylvie Manguin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"2270",title:"Fourier Transform",subtitle:"Materials Analysis",isOpenForSubmission:!1,hash:"5e094b066da527193e878e160b4772af",slug:"fourier-transform-materials-analysis",bookSignature:"Salih Mohammed Salih",coverURL:"https://cdn.intechopen.com/books/images_new/2270.jpg",editedByType:"Edited by",editors:[{id:"111691",title:"Dr.Ing.",name:"Salih",surname:"Salih",slug:"salih-salih",fullName:"Salih Salih"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"117",title:"Artificial Neural Networks",subtitle:"Methodological Advances and Biomedical Applications",isOpenForSubmission:!1,hash:null,slug:"artificial-neural-networks-methodological-advances-and-biomedical-applications",bookSignature:"Kenji Suzuki",coverURL:"https://cdn.intechopen.com/books/images_new/117.jpg",editedByType:"Edited by",editors:[{id:"3095",title:"Prof.",name:"Kenji",surname:"Suzuki",slug:"kenji-suzuki",fullName:"Kenji Suzuki"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"67212",title:"Arthroscopic Anatomy of the Knee Joint and Portals",doi:"10.5772/intechopen.81678",slug:"arthroscopic-anatomy-of-the-knee-joint-and-portals",body:'The anatomical definition of the knee is determined by the fact that the knee connects the upper and lower leg, made up of the knee joint, the patelofemoral joint, and the proximal tibiofibular joint, and the soft tissues surrounding them. In the frontal plane of the femur and tibia, an angle of 174° is made, which makes the physiological valgus of the knee. In women, valgus and recurvatum are slightly higher. The borders of the joint are on the buttock, the line that passes at 2–3 cm above the base of the patella, and on the lower leg, the circular line that passes directly below the tibial tubercle [1].
Anatomically speaking, the knee consists of bone and soft tissue structures, which built four topographic regions. In clinical knee arthroscopy, the following division proved to be very useful: the medial part consists of a medial femoral condyle, medial tibial plateau, medial meniscus, and medial part of the capsule and ligaments. The lateral part consists of a lateral femoral condyle, lateral tibial plateau, lateral meniscus, and lateral ligaments and capsules, including arch complex (lig. arcuatum). The central part or central pivot is composed of an intercondylar notch, which comprises crossed ligaments, anterior and posterior intercondylar field of the tibia (lower part of the attachment of crossed ligaments of the knee), and intercondylar eminences and tubercles. The femoropatelar part consists of a femoropatelar joint, an infrapatellar fat tissue, a patellar ligament, and a quadriceps tendon and normally presents medial and lateral patellar plicas and suprapatellar recess [2, 3].
Outside, superficially through the articular capsule, the horizontal part of the m. vastus medialis (m. vastus medialis obliquus) is provided. The attachment of the pes anserinus (m. sartorisu, m. gracilis, m. semitendinosus) extends from the back and down in the upper two-thirds of the tibia. The medial patellar retinaculum extends from the upper two-thirds of the medial part of the patella and is attached to the outside of the medial femoral condyle. Medial longitudinal patellar retinaculum originates from a wide base between the patella, the medial vastus, and the upper attachment of the medial collateral ligament and descends to the upper part of the tibia where it is attached behind the pes anserinus and in front and above the attachment of the medial collateral ligament. Both retinacula cover the anterior part of the joint, and their fibers come from the medial vastus and quadriceps tendon, which allows them to function as dynamic stabilizers. The individual fibers of the medial longitudinal retinaculum are drowned in the medial collateral ligament, and the other is joined to the tendon of the pes anserinus and extends to the popliteal fascia. Deep fibers extend beyond the superficial fascia to the medial collateral ligament and semimembranosus. Retinacula controls the movements of the patella toward the femur (limits the lateral deviation) and equalizes the pressure of the lateral and medial joint surface of the patella and the internal rotation of the tibia (via m. vastus medialis obliquus and patellar ligament). The pes anserinus-conjoined tendon, by its superficial position, acts as a ligament-muscle protector of the medial side of the joint in flexion and extension. Functionally, it represents an active duplicative of the medial collateral ligament [2, 3].
In the middle third, the dominant structure is the medial collateral ligament as a deep tensioner under the tendon of the pes anserinus. It extends sloping down and backward from the lateral femoral condyle to the upper tibia. It consists of two thin layers, structurally different. The deep layer consists mainly of femoro-meniscal and menisco-tibial fibers. The superficial layer is structurally separate from the medial meniscus and has nothing to do with it, except in the back part where the superficial and deep layer joins and builds a posterior oblique ligament, which is attached to the posterior horn of the medial meniscus. The fibers are further arranged to “divide” the ligament into the triangles so that they are tilted selectively toward the position of the knee. This reduces the change in force, e.g., the longest fibers are tight in flexion and the shortest in the extension. In moderate flexion of the knee, all the fibers are loose and allow rotatory knee movements.
The upper third of the ligament is attached to the femur, and the lower for the tibia. During the flexion that begins with the rolling of the femoral condyle, the front fibers move backward through the femoral and tibial surfaces. That’s why the ligament must be freely movable in these places (as well as through the medial meniscus) to glide over the bones and must not have a deep-coated attachment.
The superficial fibers are connected in the posterior part with the deep fibers (and built posterior oblique ligament) and with fibers of m. semimembranosus, and therefore the superficial fibers of the ligaments are dynamized by this muscle, especially in the position of flexion. The attachment of the remainder of the fiber to the fascia and tendon of the adductor magnus contributes to the further dynamization of the ligament. The relationship of the m. vastus medialis to the medial patellar retinaculum has already been described. A passive, firm bone attachment is present in the deeper parts of the ligament. Superficial fibers are largely dynamically bound to muscles, so passive instability can be compensated by a good muscular function, and the fibers can adequately adapt to great demands and work [2, 3, 4].
The posterior medial third of the knee—the “semimembranosus angle”—represents a functionally important part. It is separated from the medial collateral ligament in spite of the topographical close relationship. The structurally and functionally key element of this angle is the lig. posterior obliquus, which extends between the tendons of adductor magnus and semimembranosus. The main active rear stabilizer is semimembranosus muscle, which stabilizes the knee posteriorly. Semimembranosus muscle is attached to the posteromedial angle by five separate finger extensions. The first two, which go directly to the lig. obliquus posterior and climb straight through the posterior capsule as lig. popliteus obliquus, make semimembranosus an active stabilizer of the posteromedial angle. The attachments are arranged so that at least one is taut in every position of the flexion and directs the traction in the appropriate direction to give the angle of flexion. The finer are the backward fibers that flow from the m. vastus medialis. At maximal extension, the angle of semimembranosus is below the maximum tension due to the associated posteromedial sliding of the medial femoral condyle. In extension, semimembranosus helps in stabilization of the entire medial side. In 90° flexion, it has an additional role in the transmission of tension to the free capsule-ligament fibers and stabilizes the knee to prevent external rotation [2, 4].
The structural element of the medial compartment, from the anterior to the posterior third, is medial meniscus. It has a crescent shape, it is narrower in the front, and it extends to the rear. The free edge is facing the knee joint, and the rim is attached to the articular capsule. In the anterior third, it is relatively narrow, it is attached to the tibial plateau with a fibrous bundle that extends the meniscus anteriorly, and there is also a medial part that secures the anterolateral part of the meniscus to the anterior intercondylar area. The anterior horns of the medial and lateral meniscus are connected by the fibrous bridge that makes the transversal knee ligament. The medial patello-meniscal ligament extends from the anterior edge of the medial meniscus to the patella. In the middle third, the meniscus is still narrow. At the outer edge, there are femoral-meniscal and tibial-meniscal fibers (coronary ligament) but without an attachment to the medial collateral ligament. In the posterior third, the meniscus is spreading to the posterior horn. The femoro-meniscal fibers and the coronary ligament join to the posterior oblique ligament and fix the last horn of the meniscus for the ligament. The fibers at the lower part of the posterior horn link the meniscus for the posterior intercondylar area. The horn must be firmly attached to the coronary and anteromedial collateral ligament in order to participate in anteroposterior stabilization and perform the essential role of a stress-transfer gearbox (“brakes” that limit the frontal movement of the tibia and the last displacement of the femur). This function is only possible if the femoro-meniscal part of the posterior oblique ligament and the posterior horn of the medial meniscus are intact (femoral condyle can “settle down”), and the semimembranosus attachment is not damaged (to maintain rotatory stability). ACL works synergistically with the posterior oblique ligament, by both of them tightening during the front translation of the tibia. Approximately 80% of ACL ruptures are associated with lesions of medial ligaments (the posterior oblique ligament, medial collateral ligament) [5, 6, 7, 8, 9].
The outer compartment has relatively weak passive stabilizers. Active stabilizers are dominant and those are: iliotibial tract (m. tensor fasciae latae and m. gluteus maximus), m. biceps femoris, and m. popliteus. The relative dominance of dynamic structures is in correlation with a higher degree of displacement during flexion (m. biceps femoris, m. popliteus, and m. tensor fasciae latae). In the lateral part, three subregions are described.
Similar to the medial part, characteristic are lateral superficial and longitudinal patellar retinacula. The attachment of the lateral longitudinal retinaculum is somewhat different from the medial, due to the more limited extension of m. vastus lateralis, as well as due to the presence of an iliotibial band outside the retinaculum. A part of the fibers of the iliotibial band ends at the lateral femoral condyle, the part extends to the patella, and the main part goes to Gerdy’s tubercle. Lateral patellar retinaculum is attached to the iliotibial band with multiple fibers, and from there it extends to the patella. The lateral longitudinal retinaculum fibers originate from three different sites, patella, m. vastus lateralis, and iliotibial band, and some extend (to the lateral femoral epicondyle or tibia—Gerdy’s tubercle) from the lateral iliotibial band. The lateral longitudinal patellar retinaculum is attached to the medial portion of Gerdy’s tubercle and adjacent proximal to tibia parts.
Both lateral retinacula are dynamically linked to m. vastus lateralis, tensor fasciae latae (iliotibial tract), and gluteus maximus muscle (iliotibial tract). The main role of lateral retinaculum is to maintain the femoro-patellar sliding (by preventing the medial deviation of the patella) and the equalization of the pressure between the lateral and the medial half of the patella.
Due to its position and attachment, the iliotibial tract acts as a “lateral femoro-tibial collateral ligament” and plays an important role in the function of the femoro-tibial joint. Its dynamic parts end up on the lateral femoral condyle (Kaplan’s complex fibers at the Krakow spot) and proximal tibia (Gerdy’s tubercle). The passive fibers are placed forward and deeper and establish a firm connection between the lateral condyle and Gerdy’s tubercle, so they are often distinguished as an “anterolateral femoro-tibial ligament.”
The iliotibial band synergistically works with two groups of muscles. In the position from 0 to 40° of flexion, it moves forward with respect to the axis of rotation and thus supports the extensor muscles. By increasing the flexion, it slides backward through the lateral epicondyle (behind the axis of flexion) and becomes synergistic to the flexor muscle group when the flexion exceeds 40° (the launch of the iliotibial band via the femoral epicondyle plays an important role in the existence of the pivot shift). The iliotibial band functionally helps in anterolateral rotatory stability by fixing the knee toward the lateral opening (stress varus). It also stabilizes the lateral tibial plateau, preventing sliding forward with rotary movements.
In the deep layer of the front and middle third, there is a joint capsule. It consists of a synovial coat, and, in the absence of reinforcement by the ligament fibers, it is very stretchable. Only the lateral patello-meniscal ligament fibers pass from the outer edge of the meniscus to the patella and are sometimes incorporated into the capsule. The ligament serves as a receptor for the reflex stabilization of femoro-patellar and femoro-tibial movements, analogously to the medial menisco-patellar ligament. The anterior part of the deep articular capsule is freely movable in relation to the iliotibial band. It is covered with fatty tissue that is absorbed into the infrapatellar fat tissue. It is firmly attached to the edge of the lateral meniscus. The fibers of the transferal ligament of the knee pass from the anterior horn of the lateral meniscus to the opposite side [2, 3].
Structurally and functionally, the middle and posterior thirds are closely related. Most elements show hierarchical arrangement from the front to the rear or vice versa.
The most superficial in this area is the wide tendon of biceps femoris muscle. It extends downward and forward in the outer part of the last third and connects on the head of the fibula with two arms: the back, the greater part, and the front (middle attachment of the biceps tendon together with the fibular collateral ligament). Trauma is a common cause of bone tendon avulsion, and also high muscular strain can cause dislocation of the fibular head. The biceps femoris tendon is attached to the tibia by the extensions that pass over and below the lateral collateral ligament. Biceps femoris muscle is an important stabilizer of varus angulation in extended knee and internal rotation in flexion (more specifically, the short head of biceps femoris muscle is the main antagonist of the popliteal muscle and thus the internal rotation). In addition to being an important external rotator, biceps femoris muscle is also a flexor, due to the position behind the axis of flexion.
The lateral collateral ligament descends back and forth from the femoral condyle to the fibula’s head. It is smaller than the medial collateral ligament but can be identified as a separate structure. It contributes to passive stabilization of the outside of the knee, and synergist is to the posterior cruciate ligament (PCL). Deep and completely separated from the lateral collateral ligament is the popliteal muscle tendon, which starts from the lateral femoral condyle and descends backward where it connects with the body of the popliteal muscle in the last third of the lateral section. The articular capsule is very thin and is not firmly attached to other structural collagen elements. It is noticeable that there is no anatomical connection with the lateral meniscus, whose edge is freely moving in the middle third of the outer compartment [2, 3].
In the posterior part of the lateral side dominates, structurally and functionally, the popliteal muscle. More superficial are the fibers of the oblique popliteal ligament. The fibers end up on the fabella or, if this does not exist, extend outer and upward to the attachment of the lateral head of the gastrocnemius muscle. In this way, the fabella and the oblique popliteal ligament are bound structurally and functionally to the lateral tendon of gastrocnemius muscle. In this area, the deep part of the muscle tendon strengthens the joint capsule. Distally, the fabella joint capsule and the tendon of gastrocnemius muscle are separated. On the distal part of the fabella, the arch ligament (which is a tendon extension from popliteal muscle) and a fabello-fibular ligament are attached (Vallois). These extensions emphasize the role of the fabella as the point where stress is transmitted (although it is present in only about 20% of the population).
The arch ligament extends from the posterior part of the tibia and the head of the fibula to the middle of the joint capsule. Some fibers are projecting to the fabella, but it also receives fibers from m. popliteus (the beginning of the tendon is branching) and allows the muscle to tighten the ligament to the fabella. The deep part of the ligament is attached to the posterior horn of the lateral meniscus with the tendons of the popliteal muscle, so popliteal muscle actively pulls the meniscus during flexion until the femoral condyle is rotated backward.
The popliteal muscle is originated from the posteromedial tibial surface and is initially parallel to the arch ligament. After giving extensions for the arch ligament and the posterior horn of the lateral meniscus, the muscle continues laterally forward and upward. In a deep layer, the tendon passes behind the arch ligament; enters the popliteal aperture; then goes over the outer part of the upper tibia, below the lateral collateral ligament; and is attached to the lateral femoral condyle. The tendon has the thickness of the pencil. Besides attachments to the arch ligament, the lateral meniscus, and the femur, there are also deep direct tendon attachments for the posterior joint capsule. Popliteal muscle also acts as an internal rotator of the tibia in flexion.
The posterior part of the capsule is reinforced with fibers which are sometimes referred to as the posterolateral collateral ligament. The fibers enter the capsule as a ligament, and they are almost parallel with the popliteal tendon and are attached to the posterior horn of the lateral meniscus and to the tibia. The most important active stabilizer of the posterolateral angle is the popliteal muscle with its deep attachments.
The posterior part of the lateral meniscus is directly linked to the posterior capsule, the popliteal tendon, and the arch popliteal ligament (most common site of avulsions and ruptures). Popliteal muscle actively pulls and puts the lateral meniscus under the lateral femoral condyle during flexion and prevents the meniscus from incarceration under the condyle. The popliteal aperture gives more space that is necessary for the lateral meniscus for its high mobility (thus reducing the incidence of rupture in this area). In the popliteal aperture, the tendon is completely separated from the meniscus. The posterior horn of the meniscus is tied to the central part of the joint. The posterior menisco-femoral ligament (Wrisberg) attaches the meniscus to the posterior intercondylar area of the tibia, while the anterior menisco-femoral ligament (Humphry) attaches the front part of the posterior horn to the posterior part of an anterior intercondylar area.
There is a symmetrical, functionally connected triad of elements of the posteromedial and posterolateral parts of the joint. On the medial side, there are the posterior horn of the medial meniscus, the posterior oblique ligament, and the semimembranosus muscle and on the lateral side posterior horn of the lateral meniscus, arch complex, and popliteal muscle. Further symmetry is observed in relation to the synergistic function. The internal posteromedial elements are in functional correlation with ACL (combined lesion in 80% of cases) and posterolateral angle with PCL (again, combined lesions in 80% of cases) [2, 3].
The dominant structures of the central pivot are cruciate ligaments, anterior (ACL) and posterior (PCL). Both ligaments together form a line of femoral condyles and kinematic laws of joint movements. The anterior third of the central pivot, bounded by the intercondylar area of the tibia and the intercondylar groove of the femur, is the site of the attachment of the anterior horns of medial and lateral meniscus and the transverse ligament of the knee. Between them, the relatively wide space of the intercondylar area is occupied by a tibial attachment of the ACL. With the extended knee, the ACL extends vertically over the intercondylar groove to the attachment back on the lateral femoral condyle. In hyperextension it retracts under the vault of the groove in the intercondylar notch called “Grant’s groove.” At this point the ligament can be twisted or even ruptured if it is too tight on the groove. Grant’s groove is a measure of the width of the ACL. In the knee flexion, the ACL comes in a horizontal position and is closely related to the PCL at the point where they cross, directly above the vascular pedicle.
ACL stabilizes the tibia toward the frontal translation relative to the femur. The elements of the posteromedial angle of semimembranosus and anterolateral femoro-tibial ligament also act synergistically. Approximately one-third of the capacity of the anterior stabilization is due to ACL, and the remaining are of two structural elements (the isolated rupture of the ACL leaves two-thirds of the capacity intact). The structure of the ligament is such that it almost never transmits load through the entire surface; individual fibers are loaded selectively during a particular movement or in a particular position of the joint. Anteromedial fibers are most affected when the knee is almost extended, posterolateral fibers when the knee is flexed in a higher degree, and intermediate fibers stabilize the internal rotation, during which the fibers of the ligaments rotate.
ACL vascularization comes from the branches of the middle geniculate artery. This blood vessel connects the ACL and PCL at the crossing point. The artery enters the ACL from the subcortical web, but does not feed the whole ligament but only the sites of attachment.
Both cruciate ligaments have a common frontal synovial sheath. In spite of the intra-articular position, both ligaments are extrasynovial. The common synovia originates from the crossed “central pivot,” and it is vascularized by the branches of the middle geniculate artery.
PCL is better vascularized; it receives four branches of the middle geniculate artery that are arranged throughout the entire length of the ligament. Its origin from a wide area on the medial part of the medial femoral condyle passes downward and backward and is attached to the posterior intercondylar area of the tibia on a small surface. During knee extension it is relatively flat and rises during knee flexion, but it does not have the risk of collapsing under the front edge of the intercondylar groove. After achieving vertical position during flexion, the PCL becomes the central point of the knee rotation and has a significant stabilization effect. The only synergistic effect in the flexion has a quadriceps femoris muscle. In the knee extension, because of PCL-like orientation, the posterior oblique ligament and posteromedial capsule are acting synergistically, and they rupture together in the trauma. Like the ACL, the PCL consists of three strands of fibers that are loaded depending on the position of the joint. Posteromedial fibers tighten in the extension and limit hyperextension (their attachment is furthest on the intercondylar area). The central and anterolateral bundles are tense at medium and full flexion (their attachment is on the outside of the posterior intercondylar area, near the lateral meniscus). In addition to other functions, the PCL is the posterior translation stopper, although in the case of internal rotation, this role can be partly taken by the Humphry and Wrisberg menisco-femoral ligaments that are tightened in that position (and therefore may mask the posterior instability in the position of the internal rotation of the knee). On the medial side, PCL is connected by fibers with the posterior horn of the medial meniscus.
Intercondylar eminence of the tibia is the basic axis of rotation of the knees in small and middle flexion. It is covered with a thick, strong layer of cartilage and is located between the medial surfaces of the femoral condyles, which are also covered with cartilage. The posterior part of the meniscal cartilage, which differs in hardness, thickness, and resistance, can act as a duplication of intercondylar eminence. The axial role of eminence in moderate flexion is important for guiding an articular surface in varus, valgus, or rotatory loads and for the absorption of compressive forces, especially since the peripheral joint structures in this position is loosened.
Cruciate ligaments can protect the joint from varus and valgus stress by assuming the role of “inner” collateral ligaments for a particular femoral condyle in case the collateral ligaments are ruptured. The next important role of cruciate ligaments is in the mechanism of terminal locking of the knee. This automatic terminal rotation is caused by the position of the cruciate ligaments and the unequal length of the femoral condyles. The lateral femoral condyle, due to its smaller length, is first placed on the tibial plateau and ends its rolling, while the longer medial condyle continues rolling [2, 3, 8, 10, 11].
The central structure of the patellofemoral joint is patella, a sesamoid bone which, although mobile, is a fixed point for the attachment of ligaments and tendons. Analogue to the fabella in the posterolateral corner of the flexor side, the patella is a key point for forces transmitted from multiple directions: longitudinal traction forces across the quadriceps tendon and patellar ligament and transverse traction forces through the menisco-patellar ligaments and transverse retinacula. Accordingly, the function of the patella depends entirely on the action of quadriceps femoris muscle. The upper part of the patella (base) has grown in the quadriceps tendon, extra-articular, and has no joint surface. Intra-articular space extends from the tip of the patella to the quadriceps tendon, along the front side of the femur, forming a suprapatellar recess. The lower, articular surface of the patella does not fit smoothly on the trochlea all over its surface in flexion or extension. The medial part of the patella is covered with a thin layer of cartilage, and the joint surface is incorrectly curved and does not fully attach to the medial part of the trochlea; this occasionally creates a free space between the hinged surfaces in which the synovia retract, which contributes to a more uniform distribution of loads. The outer part of the patella corresponds to the outer part of the trochlea. In the extension of the knee, the patella is completely attached to the femoral joint surface. In full flexion, the lower part of the patella lies in front of the condylar part of the femorotibial joint. Sulcus terminalis separates the femoral patellar surface, with relatively high edges, especially laterally, from the area of the femorotibial joint. The distal part of the patella, as well as the upper end, grew into the ligament tissue—the patellar ligament. Posteriorly, there is a well-vascular infrapatellar fat tissue (Hoffa). It is held in place by the patellar ligaments, bilateral longitudinal retinaculum, and infrapatellar synovial plaque (odd structure centrally positioned and posteriorly up to the roof of the intercondylar groove). Movement of the patella is consistent with a fine control mechanism in which medial and lateral patello-meniscal ligaments play an important role (receptor function). This explains the identical clinical picture of medial patellar chondropathy and the lesion of the medial meniscus.
The function of the patello-femoral joint is completely dependent on the function of quadriceps. The action of the muscle causes sliding of the patella through the trochlea. This action exerts a greater pressure on the lateral part of the condyle than on the medial, since the main vector of the quadriceps force is lateral (Q angle). This causes a slight posterior movement of the lateral femoral condyle associated with the internal rotation of the tibia. Vastus medialis muscle and vastus medialis obliquus muscles are antagonists of these forces and take the patella medially. The large contact pressure of the patella on the lateral femoral condyle occurs in conjunction with angulation and external rotation, and vastus obliquus muscle is again an antagonist. Conversely, the patellar pressure on the medial femoral condyle increases during angulation in the internal rotation, and vastus lateralis muscle performs an antagonistic traction role. In the neutral rotation position, the lateral and medial vastus muscle acts equally as an agonist and antagonist, resulting in constant pressure changes on different contact surfaces in the medial, lateral, proximal, and distal directions. The normal mobility of the patella is based on a separate action of the different parts of quadriceps. A small disorder in this complex functional sequence leads rapidly to the decompensation of a finely balanced system. This particularly applies to the medial joint surface, where even moderate disorder rapidly leads to abnormalities in nutrition and diffusion [2, 3].
Menisci represented a pair of the C-shaped and wedge cartilages interposed between the femur and tibia in the knee joint.
Menisci play an important role in the distribution of loads, shock absorption, joint stability, and lubrication of joint surfaces. Histologically, they are built from three different types of tissue. At the cross section, the outer part consists of a thick connective tissue that contains nerve endings and is abundantly bled. The middle part is predominantly fibrocartilaginous with fibers of different tensions. The central tissue is predominantly hyaline and contains fewer fibers and blood vessels than the more superficial fibrous tissue. The inner part of the meniscus consists of a pure hyaline cartilage that is avascular and without innervation.
Special importance is attributed to the meniscus architecture. The external parts are partially integrated into the capsuloligamentar system. Some fiber bundles are arranged in arches whose base is directed toward the inside of the joint. In the outer third, the fibers are parallel and in the inner part are more radial. The chemical structure also varies, in the fibrous connective tissue of the outer third, pre-type collagen type I and type III; there are also types V and VI. Elastin and proteoglycans are less represented but functionally relevant. Hyaline cartilage in the inner part consists of collagen type II and proteoglycan. Shorter-chain collagens (type V, IX, XI), as well as different matrix proteins (tenascin and chain proteins), are less represented.
The middle third is histologically and chemically distinct, with a defined topographic difference that causes changes from superficial to deep parts of the meniscus [7, 9, 12, 13].
The structure of the articular capsule shows significant local variations. In some places it has grown into a periarticular ligament system and forms a very strong, mechanically stable layer. In other places, the capsule makes only a thin synovial membrane with surrounding fat and fibrous tissue.
Synovia (synovial membrane, also known as stratum synoviale) consists of two morphologically different tissues. The first (intima) is a superficial cell layer that includes an articulate cavity. By its characteristics, it is epithelial, with a thickness of three to four cells. Between the cells are frequent jaws that open in a subintimal layer of loose connective tissue, which contains abundance of lymph and blood capillaries and numerous scattered fat cells.
Cells of synovial intima do not form a continuous basal membrane that separates the epithelial from the subepithelial connective tissue. Morphologically, three types of cells are distinguished: type A (or type M for “macrophages similar”) whose cytoplasm contains a developed Golgi apparatus, a lot of vacuoles, and lysosomal bubbles but a scarcely rough endoplasmic reticulum and long cell prolongation.
Type B (or F of “fibroblasts similar”) contains abundant coarse endoplasmic reticulum but a little vacuum, lysosomal bubbles, and Golgi’s lamellas. Cellular attachments are poorly developed. Mixed cell type (sometimes called AB) is also described. Synoviale cells are responsible for the formation of hyaluronic acid, glycosaminoglycan, and some glycoproteins of synovial fluid. Thanks to numerous vesicles, they have the ability of phagocytosis of particles from synovial fluid—this is attributed mainly to M cells. A significant portion of the synovial fluid protein passes from the subintimendous connective tissue directly through the intercellular channels into the synovial fluid. Most proteins are micromolecular plasma proteins that can diffuse through the walls of the capillary from the blood plasma into the intercellular space of the subintimal connective tissue. Free nerve endings were not found in the subintimal region, although there are fibers of the autonomic nervous system that undergo the advent of blood vessels. In deeper layers away from the intima, the number of collagen fibers (stratum fibrosum) increases, in which articular capsules give the characteristics of the ligaments and supply the capsule with numerous nerve fibers, for the transmission of pain, along with blood vessels. This layer establishes numerous structural contacts with periarticular ligaments and creates strong enhancements in some parts of the capsule [7].
A patient scheduled for knee arthroscopy is placed on the operative table with the leg planned for arthroscopy placed on the leg holder and opposite leg on side holder (Figures 1 and 2). Arthroscopy could be done in general, regional, or local anesthesia, with or without tourniquet. Landmarks for arthroscopy are the patella, patellar ligament, and upper edge of the tibial plateau. The basic portals are anterolateral and anteromedial, and auxiliary portals are suprapatellar medial and lateral, central, posteromedial, and posterolateral (Figure 3). Knee arthroscopy starts by making anterolateral portal [2, 3]. The entry point is localized by palpation. The thumb is placed to the soft tissue groove in triangle that is formed by lateral border of patellar ligament, upper lateral part of the tibial plateau, and tip of the patella. Knee is flexed. Above the thumb and near the patellar ligament, we place a 1.2 gauge needle (Figure 4). With the tip of the needle, we try to reach a lateral tibial plateau. After pulling the needle out, the skin incision is made at the point that is marked by the needle. Making 0.5–1 cm horizontal incision is a good way to avoid cutting the meniscus. Incision is pointed in 45° angle to the frontal plane. After the incision is made, Kellys clamp is introduced through it in the same direction (Figure 5). After touching the medial condyle, the clamp is turned parallel to the condyles and pushed medially, while it can be palpated under the skin on medial side (Figure 6). While pulling the clamp back, soft tissue is spreading with Kelly’s clamp in a manner to open and close it. The next step is introducing the 4 mm scope in the same manner. Then, slightly extend the knee and hold it in valgus (Figure 7). When the medial meniscus is in the field of view, the anteromedial portal is prepared. The entry point should be close to the patellar tendon on the medial border (Figure 8). The needle is introduced again from the medial side. We could make a pressure to the skin by the finger looking inside the joint by scope to determine the appropriate entry point. After the needle is visualized in the joint, the skin incision is made. By the visual control, the knife is then used to make the skin incision and to avoid damage of the cartilage or meniscus. Through the anteromedial portal, the probe is introduced in the joint (Figure 9).
Knee arthroscopy preparation: Placing the patient on the operative table – frontal view.
Knee arthroscopy preparation: Placing the patient on the operative table – side view.
Basic portals and auxiliary portals are marked on the knee.
1.2 gauge needle is placed near the patellar ligament.
Kelly’s clamp introduced through the horizontal incision (45° angle to the frontal plane).
The clamp is turned parallel to the condyles and pushed medially.
While pulling the clamp back, soft tissue is spread with Kelly’s clamp; then, the 4 mm scope is introduced in the same manner.
Anteromedial portal is prepared. The entry point should be close to the patellar tendon on the medial border.
Through the anteromedial portal, the probe is introduced in the joint.
Examination begins with the suprapatellar recess, then medial compartment, intercondylar notch, and lateral compartment. For placing scope in the suprapatellar recess, the knee has to be extended, and the patella is free to be moved. The main structure in the recess is the so-called suprapatellar plication, which is a white band of connective tissue, sometimes separating the recess in two compartments, and can cause the symptoms like pain and snapping. The synovium is orange and red colored and we can see small blood vessels (Figure 10). Recess is often placed where we could find loose bodies (Figure 11). After examining recess, slightly pull the camera to see the femoral trochlea. The cartilage is white, shiny, and smooth. By rotating the optical for 90°, we can see articular surface of the patella, with the same characteristics (Figure 12). Then, slide with the scope medially. At that point we can see cartilage border of the medial femoral condyle and the soft tissue that covers the medial epicondyle. By flexing the knee, the medial collateral ligament can be identified. Sliding down in the field of vision appears the menisco-capsular junction, well vascularized, and we can clearly identify the medial meniscus as white semilunar structure with the inner edge free. Above is the visualized part of the medial femoral condyle, and beneath is the medial tibial plateau. Healthy meniscus is white, smooth, with sharp inner edge, and in full length connected to the capsule (Figure 13). Placing the scope beneath the femoral condyle, we should see the attachment of the posterior horn of the medial meniscus (Figure 14). The knee should be positioned in semiflexion and valgus. By extending and flexing the knee, we could examine the whole cartilage of the medial femoral condyle, and next is the intercondylar notch. The main structure is the ACL; it is represented like a white, pale band that arises from the anterior intercondylar area and goes upward and backward to the attachment on the posterior part of the lateral femoral condyle. The course of the ligament is best viewed by flexing the knee (Figure 15). Moving the scope near the central position and pushing it slightly, we can identify the femoral site insertion. PCL is covered by synovial sheet and is not routinely visible until the synovium is removed by a power shaver. Placing the scope beneath ACL and medial femoral condyle and pushing the scope slightly posteriorly, we can identify posterior horn of the medial meniscus and posterior joint capsule. For better visualization the posteromedial portal is used. In the front part, we can see the anterior attachments of both menisci and transvers knee ligament. For examination of the lateral compartment, we must place the knee in the “figure of four” position. Attachments of anterior and posterior horns of the lateral meniscus are near each other. The inner edge is similar to the medial meniscus. In the central third, there is no menisco-capsular junction, and when we lift up the meniscus, the popliteal tendon is visible in the popliteal aperture (Figure 16). Ligaments of Wrisberg and Humphry are sometimes visible.
The synovium is orange and red colored and we can see small blood vessels.
Recess is often placed where we could find loose bodies.
The cartilage is white, shiny, and smooth. By rotating the optical for 90°, we can see articular surface of the patella, with the same characteristics.
Healthy meniscus (white, smooth, with sharp inner edge).
The attachment of the posterior horn of the medial meniscus.
Course of the ligament (best viewed by flexing the knee).
Lifting up the meniscus, the popliteal tendon is visible in the popliteal aperture.
Knee arthroscopy is one of the most performed procedures in orthopedic surgery. Nowadays, it is mostly a therapeutic procedure, only in rare cases is diagnostic. Knowing arthroscopic anatomy is essential. The ability to recognize normal shape and appearance of the knee joint structures is the first step in long learning curve for further arthroscopy surgeon.
Elective cosmetic surgery
While all cosmetic surgery can be performed under local anesthesia only, most surgical candidates desire to not hear, feel or remember their procedures. Most surgeons prefer to concentrate on their surgery and not to have to speak with their patients during surgery. As such GA is commonly requested by many surgeons. Brain monitored propofol ketamine (“Goldilocks”) anesthesia (not too much, not too little, but just right) bridges the patient care gap between surgery under local only and the more commonly performed GA. “Goldilocks” anesthesia simulates GA conditions (nonverbal, predominantly immobile patients) while
Friedberg’s triad.
What was true for temperature measurement more than a century ago is also true for the direct measurement of patient’s cortical response to anesthetics. Without such measurement, there can be no science. Without science, there can be no reproducibility across the broad, and often unpredictable yet well-recognized, spectrum of individual patient response to medications.
Brain weight does not vary with body weight (i.e. the brain weight of a 100-kg male is
Further adding to the possibility of dosing error is the twentieth century practice of relying on heart rate (HR) and blood pressure (BP) changes to ascertain cortical drug response.
Pain and consciousness are processed at higher cortical levels (Figure 2). Fifty percent of patients experiencing awareness with recall under anesthesia had no HR or BP changes with which to alert their anesthesiologist [1]. Preventing anesthesia awareness is the
Cortex and brain stem.
Hypnosis + analgesia = anesthesia.
Complex mathematical modeling, i.e. pharmacodynamics (PD) and pharmacokinetics (PK), is based on body weight that may not accurately reflect individual cortical sensitivities. While currently unavailable in the US, target controlled infusion (TCI) only infers cortical response based on blood drug concentrations, again with possible error.
With the Federal Drug Administration (FDA) 1996 approval of the bispectral index™ (BIS) brain monitor, the promise of
Anesthesia may be defined as the sum of hypnosis plus analgesia (Figure 4). Implicit in “hypnosis” is amnesia for surgery and within “analgesia” is sufficient muscle relaxation to imbricate the rectus abdominis sheath for classical abdominoplasty. Measured hypnosis enables differentiation of cortical- versus spinal cord–originated patient movement. As opposed to cortically originating patient movement, spinal cord–originated patient movement is devoid of awareness with recall concerns. Knowledge of the origin of patient movement facilitates origin-appropriate treatment of patient movement, thus assuring adequate local anesthesia during sedation (Table 1).
The value proposition of direct cortical monitoring.
BIS values | Hypnotic sedation/anesthesia levels |
---|---|
98–100 | Awake |
78–82 | Minimal sedation |
70–80 | Moderate sedation |
60–70 | Deep sedation |
45–60 + systemic analgesia | General anesthesia |
<45 | OVERMEDICATED |
BIS values and hypnotic sedation/anesthesia levels.
As an index, the BIS scale is from 0 to 100. The lower the number, the deeper the level of hypnosis (Table 2). Although validated in over 3500 published papers, the promise of direct brain monitoring has remained unrealized for several reasons. First, the BIS only measures response to hypnotic, not analgesic, drugs primarily acting of the cerebral cortex like propofol and inhalation agents like isoflurane, sevoflurane and desflurane. Drugs that act at lower brain centers are benzodiazepines (i.e. diazepam and midazolam), opioids (i.e. morphine, meperidine, hydromorphone, fentanyl, sufentanil, alfentanil, remifentanil), and N2O. One cannot depend on reliable BIS cortical measurement from subcortically acting agents.
Propofol titrated to 60 < BIS < 75 with baseline EMG indicated an asleep, amnestic patient. |
A blanched surgical field does not equal adequate local analgesia. |
Surgery below the clavicles with patient movement without EMG activity indicates more local analgesia in the immediate area of stimulation. |
The surgeon’s golden rules for success with brain monitored propofol ketamine.
Second, the original factory default setting included only the BIS value and horizontally displayed BIS trend. BIS values are calculated by an algorithm that delays data by 15–30 s from real time. This delay puts the anesthesiologist in the unfavorable position of catching up to dynamically changing patient hypnotic requirements as opposed to having real-time information with which to formulate a response ahead of patient movement. BIS without EMG is
The electromyogram (EMG) is the electrical activity of the
Anesthesiologists process information most consistently on the horizontal sweep as displayed in the EKG and SpO2 trends. EMG is displayed on the original factory default, but only as a vertical column. Contained in the software of every free-standing BIS unit is the option to select EMG and save it to trend below the BIS trend on a horizontal sweep display. As of 2017, the factory default setting now displays both BIS and EMG trends. However, the lower EMG trend as pictured by the recent company literature is without important EMG spikes.
There are two vertical numerical scales on either side of the BIS monitor display (Figure 5). The left side scale (yellow) for the BIS is from 0 to 100. The right side scale (red) is from 30 to 100 for the EMG. Spikes in EMG signify incipient patient arousal demanding an increase in propofol (or inhalational agent) sufficient to return the EMG to baseline (i.e. 0 on the top BIS scale and 30 on the bottom EMG scale). (Figure 6).
BIS VISTA monitor.
Why BIS is not commonly utilized.
In the pre-BIS era, anesthesiologists considered the absence of HR and BP changes with skin incision to define adequate depth of anesthesia. Nondissociative attempts at preemptive anesthesia have met with variable successes. Postoperative pain management continues to be an issue. HR and BP primarily reflect brain stem changes, while pain and consciousness are processed at higher cortical levels. Twenty-first century standard of care anesthesia monitoring demands cortical monitoring as a standard of care. It is an untenable assertion that 16 million of the 40 million (40%) American patients every year emerge from anesthesia with “brain fog” caused by a previously undiagnosed, underlying condition. Without numerically measuring the depth of sedation/anesthesia, discovering the role of routine overmedication in postoperative “brain fog” will be problematic [3].
Once sedated, the brain cannot differentiate the signal from a well-intentioned surgeon’s scalpel (or trocar) and the malevolent intentions of a mugger’s knife. Success with preemptive analgesia makes it imperative to prevent the brain from receiving the noxious input from the violation of the integument’s barrier to the outside world of danger. Although other pain receptors exist within the body, the most significant information to prevent the wind-up phenomenon and postoperative pain is that of skin incision.
The N-methyl, D-aspartate (NMDA) receptors in the midbrain are the final gatekeepers of noxious input to the cortex. Ketamine is a major NMDA antagonist (propofol has substantially less NMDA antagonism than ketamine). When the initial local anesthetic injection is performed (common to virtually all elective cosmetic surgeries), the
Absent the ability to differentiate cortical- from spinal cord–originating movement during sedation forced anesthesiologists to treat every patient movement “as if” the patient might be awake and recall his or her surgery. All patient movement does not have the same significance. Like GA, “Goldilocks” anesthesia requires patients to be retrained on the operating table. Patient movement per se can be generated without cortical input, i.e. from spinal cord reflexes. A headless chicken still generates movement.
No spinal cord pathways exist to activate the facial
It is not the absolute value (or spike) of any individual BIS reading that may determine recall. Rather, it is the area under the trend curve. Three to five minutes of a BIS >80 will more likely produce recall than less area under the curve. Restraint from the surgeon or operating room staff making loud, negative comments with patient movement deprives the unconscious patient subliminal input with which to process memories. One cannot control the emotional maturity of the personnel in the operating room. Many times, demonstrating to both the surgeon and his staff of an objective numerical measure of the patient’s level of consciousness (i.e. BIS < 75 with baseline EMG) can calm otherwise overanxious personalities and preserve a peaceful operating room.
The use of EMG spike activity enables the differentiation between cortically generated patient movement and that originating from the spinal cord. Conducting a cosmetic surgery case in this fashion assures the patient receives critical adequate local anesthesia for the case and sets the stage for minimal postoperative pain management.
Over the past two decades of experience in >4000 patients, the infrequent postoperative discomfort was readily managed with intravenous (IV) ketorolac 30–60 mg and/or oral acetaminophen 1000 mg. Rapid propofol emergence allowed patients who did request additional analgesia to safely swallow oral acetaminophen without aspiration risk. Higher acetaminophen blood levels are unquestionably achieved with the IV versus the oral preparation. However, since adequate pain relief was observed with the oral form, cost considerations precluded the use of IV acetaminophen. Very few patients required IV fentanyl (25–100 mcg) for pain management. The author’s experience was entirely in the office-based setting. There were no postoperative hospitalizations for postoperative pain management during the period 1992–2017 in >6000 patients.
Prior to BIS/EMG monitoring, treating all movement left many patients overmedicated and unable to quickly emerge from anesthesia to go home or to a recovery center. Patient movement during sedation was generally regarded by the surgeon that the patient was “too light” and needed more sedation. Anesthesiologists often responded to the surgeon’s demand with “needs more local.” A circular argument ensued, physicians’ feelings got bruised, but more importantly, the patient was ill-served, overmedicated, and often, with postoperative pain management issues.
The net effect of pre-BIS/EMG sedation attempts resulted in many surgeons encouraging (or even demanding) the abandonment of sedation in preference to GA with neuromuscular blocking agents. GA exposes the elective cosmetic surgery patient to the unnecessary risks of difficult intubation, failed intubation, misplaced endotracheal tube (ET), esophageal or endobronchial intubation, kinked or occluded ET, teeth damage, anesthesia machine mishaps (i.e. empty vaporizer, vaporizer filling error, reversed oxygen and nitrous oxide gases) and, very rarely, malignant hyperthermia (MH). No endotracheal intubations were required in the author’s 25-year experience.
The advent of the use of the laryngeal mask airway (LMA) has greatly reduced or eliminated many ET issues. This author routinely places an armored (or flexible) LMA for rhinoplasty cases both to cover the glottic chink and using the inflatable cuff to prevent blood from entering the esophagus. For nonrhinoplasty cases, airway management is dependent upon patient response (Table 3).
Chin extended, head rotated to the side (initially to the right but sometimes better airway results turning to the left). |
IV bag (not heated) under the shoulders (not the neck), increasing the force of extension on the genioglossus muscle. |
#28 Fr latex (or latex free) lubricated nasal airway, often better tolerated than oral airways. |
#4 LMA. |
Airway management flow chart (assumes incremental propofol induction).
N.B. 50–60% of brain monitored PK cases/25 years have been performed without airway instrumentation. No endotracheal intubations required in 25 years, >6000 patients.
The very small MH risk necessitates any GA facility stocking dantrolene, an expensive agent with a 3-year shelf life. Delays in treating MH are prompt recognition due to its rare occurrence and partly due to the difficulty of dissolving the treatment into solution to administer. A newer formulation of dantrolene (i.e. Ryanodex®) is easier to dissolve into solution for administration but may not be widely found.
Neither propofol nor ketamine is a triggering agent for MH. The early diagnosis of MH is most often made by unexplained tachycardia. Tachycardia is frequently observed following the injection of epinephrine containing local anesthesia at the beginning of the case. When the injection is temporally associated with the dissociative ketamine dose, some are more apt to believe the ketamine, not the epinephrine, was the source of the tachycardia. Often, in the performance of “Goldilocks” anesthesia, incremental propofol induction followed the ketamine, but the surgeon did not inject the local analgesia by as along as 10 minutes after the ketamine administration. No tachycardia or hypertension was observed when ketamine was administered well prior to the lidocaine with epinephrine solution injection. Nontriggering “Goldilocks’” anesthesia also means surgical facilities need not stock dantrolene.
Propofol is a 1,4-diisopropyl quinol with sedative-hypnotic properties. Because of its slight solubility in water, the drug is formulated as an emulsion for clinical use. It is highly lipophilic and distributes extensively in the body. The drug was introduced to the North American market in 1989 and has largely displaced both thiopental and methohexital for induction of general anesthesia and maintenance of sedation.
Propofol’s rapid metabolism accounts for its short activity. It is also a potent antiemetic, especially in the absence of concomitant opioid administration. Only after much experience with the drug for sedation was the patients’ clear head and happy affect after emergence was this quality appreciated by the author. Unfortunately, these qualities have also made propofol a drug of abuse within small numbers of the profession (“white rabbit”) as well as by celebrities like Michael Jackson.
Propofol also results in inhibition of the N-methyl, D-aspartate (NMDA) subtype of glutamate receptor [4]. Lack of recall was observed in 95% of patients at BIS of 77 [5]. Propofol at 25–50 mcg/kg/min was sufficient to produce sedation to 60 < BIS < 75 with baseline EMG for many patients. However, as little as 2.5 mcg/kg/min and as much as 200 mcg/kg/min have been required to achieve the same numerically defined level of sedation at 60 < BIS < 75 with baseline EMG. This 20-year experience represents nearly a hundred-fold variation in propofol requirements. Incrementally inducing patients starting with 50 mcg/kg propofol miniboluses (
Textbook doses for propofol sedation do not discuss the value of incremental induction not only to identify outliers but also to dramatically minimize airway management and eliminate precipitous blood pressure drops. Incremental propofol induction more often maintains the airway patency by preserving muscle tone of the
Propofol was introduced to North America in 1989 and quickly replaced both thiopental and methohexital as the preferred induction agent. As a proprietary agent, a 20 cc propofol bottle retailed around $12–15 USD, making a continuous infusion for surgery apparently prohibitive for multihour surgeries in a cost-conscious office-based cosmetic surgery suite.
After five years of performing propofol ketamine (PK) intravenous sedation using an average three 20 cc bottles of propofol per hour, the author’s surgeons kept clamoring for a less expensive way to administer it, especially for 4–6 hours rhytidectomies with or without browlifts, platysmal plications or blepharoplasties. Five years of data on 1264 patients demonstrated no reduction in propofol requirements with either 2 or 4 mg preoperative midazolam as administered [6].
This same paper [6] also published the lowest postoperative nausea and vomiting (PONV) rate (0.6%) in the literature without antiemetic use in an Apfel-defined high-risk patient population, i.e. nonsmoking females with positive PONV and/or motion sickness histories, having emetogenic (cosmetic) surgery. Scrupulous opioid avoidance both during and after surgery has allowed this astounding PONV rate to go unchallenged to date.
Aspect Medical Systems (Aspect Medical Systems, a venture capital company, was purchased by Medtronic that has subsequently been acquired by Covidien) exhibited their bispectral index monitor™ (BIS) for measuring cortical effect at the 1997 International Anesthesia Research Society (IARS) annual meeting in San Francisco. The author was exhibiting his Society for Office Anesthesiologists (SOFA) at the same meeting and was initially exposed to the BIS monitor there. The BIS monitor appeared to offer more promise reducing propofol requirements than previous efforts with midazolam premedication [6]. Later work validated that promise [7, 8]. Entropy™ is another depth of anesthesia monitor but has not been validated in nearly as many clinical papers as BIS [9].
In the 1950s, postoperative pain was treated with morphine or meperidine, often undertreated for two reasons: (a) fear of producing opioid addiction and (b) problems of overtreatment, respiratory insufficiency or apnea and death. Naloxone was not introduced until 1971 and pulse oximetry became commercially available in 1983.
The researchers of the day postulated that, if another class of drugs could be developed that would ameliorate pain without respiratory depression, patients could be better treated for postoperative pain with neither under- nor overtreatment.
The first class of drugs explored was the phencyclidines. The parent compound, phencyclidine phosphate, was marketed as Serenyl® by Parke-Davis in 1958 but was quickly withdrawn from the market because of the high percentage of undesirable side effects, i.e. hallucinations, mania, delirium and disorientation. Later, phencyclidine phosphate, as a drug of abuse, became better known by the initials, PCP or “angel dust.”
The researchers did not give up quickly on the phencyclidine class. They began experimenting with a modified PCP molecule, ketamine, which received FDA approval in humans in 1971. The drug, like its predecessor, was introduced as the “silver bullet,” a complete, total intravenous agent, meaning no other agents were needed. Because it supported both respiration and blood pressure, ketamine quickly gained a reputation as a safe drug but one not good for adult patients. It did become popular in children’s burn units, especially for the extremely painful dressing changes.
During the author’s anesthesia residency at Stanford 1975–1977, he was introduced to administering ketamine in small doses (10–20 mg IV) prior to positioning elderly patients about to receive spinal anesthesia for surgery on femoral head or shaft fractures. Elderly patients were not particularly susceptible to ketamine-associated hallucinations or dysphorias. Veterinarians also adopted ketamine, quickly realizing that it was nearly impossible to kill an animal, even if the per body weight dose was more than twice the recommended amount. Also, the animals did not complain about hallucinations. While ketamine was a safe drug, two generations of human anesthesiologists have avoided its use in adult day surgery. Sometime during the mid-1970s, a Las Vegas plastic surgeon, Charles Vinnik, wearied listening to his patients cry out when he injected local anesthesia under his self-directed diazepam and meperidine IV sedation. Even though the patients had amnesia for the experience, the patients’ cries were distressing to the OR staff. Vinnik asked his anesthesiologist if there was anything else he could use that would eliminate the distressing reactivity of the patients. Ketamine was suggested. Ketamine was first synthesized by Stevens in 1962 and first used in humans by Domino and Corssen in 1965. The drug was used in clinical practice barely 5 years when its use was suggested to Vinnik.
Through trial and error, Vinnik came upon his initial ketamine dose of 75 mg independent of body weight to prevent the patients from either moving or crying out after they were rendered sleepy from incremental doses of intravenous diazepam. Vinnik began with his test dose of 10 mg diazepam administered through an external jugular (to avoid venous thrombosis), followed by 5–10 mg increments to a total of 25–50 mg. Vinnik had his patients engage a 24-hour nurse to observe them after discharge to home. His cost-effective concept meant the cost of the recovery nurse did not come from him.
Although Vinnik published his diazepam-ketamine technique (i.e.
The author considered Vinnik’s use of ketamine useful but doubted diazepam would be an optimal drug for day cases expected to return to home. Propofol was then considered as an alternative to diazepam for hallucination-blocking purpose. Searching the anesthesia literature to support this use of propofol turned up no useful information. March 26, 1992 was the beginning of this author’s clinical trial of propofol followed by ketamine [11]. In the 1990s, ketamine became a drug of abuse, a “rave” drug and later lumped together with flunitrazepam and gamma hydroxybutyrate (GHB) as “date rape” drugs. Ketamine is also a drug of abuse. Heavy users can develop long-term bladder or urinary tract damage and incontinence.
Anesthesia trainees continue to be taught ketamine causes tachycardia, hypertension and hallucinations despite the knowledge that benzodiazepines [12] or propofol hypnosis blocks ketamine hallucinations [13]. In the pre-BIS era, loss of lid reflex and loss of verbal response defined adequate hallucination-blocking depth of propofol hypnosis. With real-time BIS/EMG monitoring, the level of hallucination-blocking propofol hypnosis is more numerically defined as 60 < BIS < 75 with baseline EMG. Some believe the use of ketamine defeats the ability of the BIS monitor to accurately measure propofol. This study compared ketamine doses of 0.2–0.5 mcg/kg and concluded 0.5 mcg/kg would defeat the BIS [14]. An earlier publication using
More controversial is the author’s use of
In many third world countries, ketamine infusions are still to be found as the drug was originally marketed. However, as propofol has become generic and very inexpensive, more anesthesia providers from third world countries have accessed the author’s web site to obtain information with which to execute the PK paradigm.
Ketamine, ironically, is the perfect adjuvant drug (or the ‘olive’ in the propofol ‘martini’) not the complete and total intravenous agent its makers originally intended it to be, at least in the western world.
Brain monitored PK IV sedation is less expensive, safer and simpler and gives better outcomes (i.e. virtually no PONV [16] and minimal postoperative pain). With ability to stratify anesthesia outcomes by depth of anesthesia and the negative effects of routine anesthesia overmedication (i.e. BIS <45), studies have demonstrated more apparent negative effects from this practice [17, 18, 19, 20]. Postoperative cognitive dysfunction (POCD) is the name for the pseudo-Alzheimer’s type of confusion seen more often in elderly, rhytidectomy patients. Sometimes this lasts hours, days, weeks or months. Sometimes the effects are not transitory. Rapid emergence does not preclude intraoperative overmedication. Patients are left with the long-term consequences of their anesthesiologist’s short-term care.
The brain monitored PK IV sedation technique also gives providers the ability to refrain from the nefarious practice of routinely overmedicating patients for fear of undermedicating them.
Daniel HS Lin, DO, Cosmetic surgeon
Along with the patient, many egos enter the operating room, not the least of which is that of the surgeon’s. The surgeon’s cooperation with local anesthesia is essential for success. The surgeon must also understand the need for
Prompt essentially PONV free and minimal pain recovery are the hallmarks of “Goldilocks” anesthesia. Once the surgeon observes how much better his patients do postoperatively, the need for his/her cooperation should become apparent. The office-based setting has a higher incentive for surgeon cooperation. Recovery space is limited and personnel are often multi-tasked compared with free-standing or hospital-attached day surgery center facilities. As superior and
The clinical pathway for brain monitored propofol ketamine (“Goldilocks”) anesthesia is a simple straightforward three-drug technique: glycopyrrolate, propofol and ketamine. Induce hypnosis first, next dissociate, then inject local analgesia (Table 4). (Atropine may be substituted when glycopyrrolate is unavailable. Tachycardia will more commonly result than administering glycopyrrolate). Unexplained tachycardia, not temperature elevation, is the cardinal recognition sign for MH. Once the brain is protected with propofol incrementally titrated to loss of lid reflex/loss of verbal response or 60<BIS<75 with baseline EMG, the 50mg ketaamine by itself does not cause tachycardia or hypertension!
Glycopyrrolate 0.2 mg with 30 mg lidocaine IV |
Propofol 50–100 mcg/kg−1 minibolus repeated to 60 < BIS < 75 with baseline EMG |
Propofol infusion rate start 25 mcg/kg−1/min−1 |
Adjust infusion rate as needed to maintain 60 < BIS < 75 with baseline EMG |
Ketamine 50 mg IV 3 minutes prior to local analgesia injection |
Lidocaine 1 mg/lb−1 or 2 mg/kg−1 IV STAT for laryngospasm |
Labetalol 10 mg iv for HR > 100–110. Avoid if patient asthmatic |
Clinical pathway.
Prior to placing the BIS sensor on the forehead, the patient is advised
The preoperative consultation includes disclosure of the dry mouth and the need to maintain eye lubrication with ointment. Patients are told to expect blurry vision upon awakening and that it is resolved when the ointment is wiped from their eyes. One patient in the author’s 40-year career became panic-stricken upon emergence thinking something bad had happened to her eyes. Full disclosure to avoid repetition of this unfortunate patient’s experience is strongly recommended.
Ketamine increases salivation. Glycopyrrolate causes less tachycardia and, for that reason, is chosen as an antisialagogue in preference to atropine. Because propofol can sometimes cause patient discomfort, lidocaine is added to the glycopyrrolate. The patient is advised to tell the anesthesiologist if there is additional aching during induction so that more lidocaine can be administered. Propofol ache is more common with distally placed IV.
Between 1992 and 1997, a 50-ml IV bag with 400 mg (40 ml) propofol was connected to a 60 drops/ml IV set (mini-drip, pedi-drip, micro-drip). The initial rate was set to the patient’s heart rate and adjusted until
Set the pump to deliver propofol for 50 mcg/kg minibolus. Induce with miniboluses given in
The induction goal is to observe whether or not 25 mcg/kg/min basal infusion rate is sufficient to maintain 60 < BIS < 75 with baseline EMG. Bolus with 50–100 mcg/kg to maintain BIS <75 and upwardly adjust the basal propofol rate to 35–50 mcg/kg/min to maintain that level PRIOR to administering ketamine. Most patients have been maintained at 60 < BIS < 75 with baseline EMG with propofol 25–50 mcg/kg/min. However, as little as 2.5 mcg/kg/min and as much as 200 mcg/kg/min propofol have also been observed by the author in his 20-year, >4000 patient clinical experience.
Avoid the textbook advice of 1–2 mg/kg propofol bolus for induction. A bolus will produce peak propofol levels in the brain quickly and just as quickly begin to redistribute, decreasing a protective level just as the ketamine arrives to the brain. The brain may then not be protected from ketamine side effects when that drug is administered. The value of the brain monitored, incremental induction is providing a
Only after the patient’s propofol level has stabilized should the 50 mg ketamine,
The surgeon should inject as much of the proposed surgical field(s) with the initial ketamine dose whenever possible. Review of 1000 patient records demonstrated 80% were performed with one or two 50 mg ketamine doses.
The traditional crowing sound of incompletely closed vocal cords is rarely seen with “Goldilocks” anesthesia. The type of laryngospasm is characterized by complete vocal cord closure. The only prodrome is a cough or a sneeze. The
Spontaneous ventilation preservation is a hallmark of successful “Goldilocks” anesthesia. The use of succinylcholine (SCh) will produce a patient with very painful postoperative muscle pains. SCh is not recommended as it is an MH trigger as opposed to nontriggering propofol or ketamine. Nondepolarizing rocuronium in small doses is a possibility but also defeats the value of spontaneous ventilation even with its short duration of action. Propofol elevates the lidocaine seizure threshold. The author has not observed lidocaine-induced seizures when treating laryngospasm with IV lidocaine. However, in
Anytime the words propofol and ketamine are used, readers too often think ketofol, the admixture of the two agents in the same syringe [22]. There are many permutations of the ideal ratio of propofol to ketamine. Mixing the two agents makes it very difficult, if not impossible, to differentiate when adequate hypnosis occurs as well as when midbrain NMDA receptor saturation occurs. “Goldilocks” anesthesia provides numerically reproducible propofol levels to define adequate hypnosis as well as the absence of EMG spikes with local anesthesia injection to define midbrain NMDA receptor saturation (Table 5).
Do not mix propofol and ketamine. Titrate separately to define goals of adequate hypnosis and midbrain NMDA saturation. |
Do not give ketamine before propofol. |
Do not bolus propofol for induction. Incrementally induce. |
Do not give ketamine at BIS > 75. |
Do not fail to provide adequate local analgesia. |
Do not give opioids in lieu of adequate local analgesia. |
Do not give ketamine in lieu of adequate local analgesia. |
Do not exceed an aggregate ketamine dose >200 mg. |
Do not give ketamine in the last 20 minutes of a case or for cases <20 minutes duration. |
Do not paralyze instead of using lidocaine to break laryngospasm. |
Do not use succinylcholine instead of lidocaine to treat laryngospasm. |
Pitfalls to avoid.
Propofol ketamine is like the martini cocktail wherein the propofol is the ‘vodka’ and the ketamine is the ‘olive.’ Ketofol is when the propofol in mixed with the ketamine. These are two very different approaches that should never be confused with one another.
Propofol hypnosis is protective of ketamine hallucinations [13].
Propofol at BIS < 75 with baseline EMG is a numerically reproducible protection against ketamine hallucinations.
Aggregate ketamine doses >200 mg is associated with prolonged emergence.
While many anesthesiologists have observed “Goldilocks” anesthesia administered for classical abdominoplasty, cognitive dissonance often prevents believing what they have witnessed. It is not unusual for anesthesiologists to observe patients recover in a manner totally unlike that of GA or neuraxial block for them to believe that what they formerly believed was a major invasive surgery performed with a minimally invasive anesthetic approach.
When the surgeon is properly prepared for his role giving adequate local analgesia, the stage is set for outstanding, reproducible anesthesia outcomes for elective cosmetic surgery. The anesthesiologist needs to understand the real-time value of BIS/EMG monitoring and use it for the benefit of the conduct of the case. It may also be necessary to overcome outdated, unproductive teaching about negative ketamine side effects.
Cosmetic surgery patients endeavor to improve their level of happiness by altering their body image. Propofol is a happy affect drug that nicely complements the mental recovery of these patients.
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This problematic is particularly relevant with medical imaging data, where linear techniques are frequently unsuitable for capturing variations in anatomical structures. In many cases, there is enough structure in the data (CT, MRI, ultrasound) so a lower dimensional object can describe the degrees of freedom, such as in a manifold structure. Still, complex, multivariate distributions tend to demonstrate highly variable structural topologies that are impossible to capture with a single manifold learning algorithm. This chapter will present recent techniques developed in manifold theory for medical imaging analysis, to allow for statistical organ shape modeling, image segmentation and registration from the concept of navigation of manifolds, classification, as well as disease prediction models based on discriminant manifolds. 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This has not been solved even for convex polygons. This case has intrinsic interest in view of the connection of polygons with the geometry of the universal Teichmüller space and approximation theory. This survey extends our previous survey of 2005 and presents the new approaches and recent essential progress in this field of geometric complex analysis, having various important applications. Another new topic concerns quasireflections across finite collections of quasiintervals.",book:{id:"8760",slug:"structure-topology-and-symplectic-geometry",title:"Structure Topology and Symplectic Geometry",fullTitle:"Structure Topology and Symplectic Geometry"},signatures:"Samuel L. 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Clifford algebra unifies and generalizes real number, complex, quaternion, and vector algebra and converts complicated relations and operations into intuitive matrix algebra independent of coordinate systems. By localizing the basis or frame of space-time and introducing differential and connection operators, Clifford algebra also contains Riemann geometry. Clifford algebra provides a unified, standard, elegant, and open language and tools for numerous complicated mathematical and physical theories. Clifford algebra calculus is an arithmetic-like operation that can be well understood by everyone. This feature is very useful for teaching purposes, and popularizing Clifford algebra in high schools and universities will greatly improve the efficiency of students to learn fundamental knowledge of mathematics and physics. So, Clifford algebra can be expected to complete a new big synthesis of scientific knowledge.",book:{id:"8760",slug:"structure-topology-and-symplectic-geometry",title:"Structure Topology and Symplectic Geometry",fullTitle:"Structure Topology and Symplectic Geometry"},signatures:"Ying-Qiu Gu",authors:[{id:"314607",title:"Dr.",name:"Ying-Qiu",middleName:null,surname:"Gu",slug:"ying-qiu-gu",fullName:"Ying-Qiu Gu"}]},{id:"52596",title:"Symplectic Manifolds: Gromov-Witten Invariants on Symplectic and Almost Contact Metric Manifolds",slug:"symplectic-manifolds-gromov-witten-invariants-on-symplectic-and-almost-contact-metric-manifolds",totalDownloads:1520,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"In this chapter, we introduce Gromov-Witten invariant, quantum cohomology, Gromov-Witten potential, and Floer cohomology on symplectic manifolds, and in connection with these, we describe Gromov-Witten type invariant, quantum type cohomology, Gromov-Witten type potential and Floer type cohomology on almost contact metric manifolds. On the product of a symplectic manifold and an almost contact metric manifold, we induce some relations between Gromov-Witten type invariant and quantum cohomology and quantum type invariant. We show that the quantum type cohomology is isomorphic to the Floer type cohomology.",book:{id:"5488",slug:"manifolds-current-research-areas",title:"Manifolds",fullTitle:"Manifolds - Current Research Areas"},signatures:"Yong Seung Cho",authors:[{id:"62522",title:"Prof.",name:"Yong Seung",middleName:null,surname:"Cho",slug:"yong-seung-cho",fullName:"Yong Seung Cho"}]},{id:"62804",title:"Recent Advances of Manifold Regularization",slug:"recent-advances-of-manifold-regularization",totalDownloads:1096,totalCrossrefCites:0,totalDimensionsCites:3,abstract:"Semi-supervised learning (SSL) that can make use of a small number of labeled data with a large number of unlabeled data to produce significant improvement in learning performance has been received considerable attention. Manifold regularization is one of the most popular works that exploits the geometry of the probability distribution that generates the data and incorporates them as regularization terms. There are many representative works of manifold regularization including Laplacian regularization (LapR), Hessian regularization (HesR) and p-Laplacian regularization (pLapR). Based on the manifold regularization framework, many extensions and applications have been reported. In the chapter, we review the LapR and HesR, and we introduce an approximation algorithm of graph p-Laplacian. We study several extensions of this framework for pairwise constraint, p-Laplacian learning, hypergraph learning, etc.",book:{id:"7342",slug:"manifolds-ii-theory-and-applications",title:"Manifolds II",fullTitle:"Manifolds II - Theory and Applications"},signatures:"Xueqi Ma and Weifeng Liu",authors:null},{id:"79892",title:"βI-Compactness, βI*-Hyperconnectedness and βI-Separatedness in Ideal Topological Spaces",slug:"-em-em-sub-em-i-em-sub-compactness-em-em-sub-em-i-em-sub-hyperconnectedness-and-em-em-sub-em-i-em-su",totalDownloads:76,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"Let XτI be an ideal topological space. A subset A of X is said to be β-open if A⊆clintclA, and it is said to be βI-open if there is a set O∈τ with the property 1 O−A∈I and 2 A−clintclO∈I. The set A is called βI-compact if every cover of A by βI-open sets has a finite sub-cover. The set A is said to be cβI-compact, if every cover Oλ:λ∈Λ of A by β-open sets, Λ has a finite subset Λ0 such that A−∪Oλ:λ∈Λ0∈I. The set A is said to be countably βI-compact if every countable cover of A by βI-open sets has a finite sub-cover. An ideal topological space XτI is said to be βI∗-hyperconnected if X−cl∗A∈I for every non-empty βI-open subset A of X. Two subsets A and B of X is said to be βI-separated if clβIA∩B=∅=A∩clβB. Moreover, A is called a βI-connected set if it can’t be written as a union of two βI-separated subsets. An ideal topological space XτI is called βI-connected space if X is βI-connected. In this article, we give some important properties of βI-open sets, βI-compact spaces, cβI-compact spaces, βI∗-hyperconnected spaces, and βI-connected spaces.",book:{id:"10677",slug:"advanced-topics-of-topology",title:"Advanced Topics of Topology",fullTitle:"Advanced Topics of Topology"},signatures:"Glaisa T. Catalan, Michael P. Baldado Jr and Roberto N. Padua",authors:[{id:"425714",title:"Prof.",name:"Michael",middleName:null,surname:"Baldado",slug:"michael-baldado",fullName:"Michael Baldado"},{id:"438024",title:"Dr.",name:"Glaisa",middleName:"Tinguha",surname:"Catalan",slug:"glaisa-catalan",fullName:"Glaisa Catalan"},{id:"486473",title:"Dr.",name:"Roberto N.",middleName:null,surname:"Padua",slug:"roberto-n.-padua",fullName:"Roberto N. Padua"}]},{id:"53552",title:"Sub-Manifolds of a Riemannian Manifold",slug:"sub-manifolds-of-a-riemannian-manifold",totalDownloads:1749,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"In this chapter, we introduce the theory of sub-manifolds of a Riemannian manifold. The fundamental notations are given. The theory of sub-manifolds of an almost Riemannian product manifold is one of the most interesting topics in differential geometry. According to the behaviour of the tangent bundle of a sub-manifold, with respect to the action of almost Riemannian product structure of the ambient manifolds, we have three typical classes of sub-manifolds such as invariant sub-manifolds, anti-invariant sub-manifolds and semi-invariant sub-manifolds. In addition, slant, semi-slant and pseudo-slant sub-manifolds are introduced by many geometers.",book:{id:"5488",slug:"manifolds-current-research-areas",title:"Manifolds",fullTitle:"Manifolds - Current Research Areas"},signatures:"Mehmet Atçeken, Ümit Yıldırım and Süleyman Dirik",authors:[{id:"191326",title:"Prof.",name:"Mehmet",middleName:null,surname:"Atceken",slug:"mehmet-atceken",fullName:"Mehmet Atceken"},{id:"196148",title:"Dr.",name:"Umit",middleName:null,surname:"Yildirim",slug:"umit-yildirim",fullName:"Umit Yildirim"}]}],onlineFirstChaptersFilter:{topicId:"165",limit:6,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:90,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:107,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:33,numberOfPublishedChapters:330,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:14,numberOfPublishedChapters:145,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:9,numberOfPublishedChapters:139,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:122,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:112,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:21,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:10,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:"2753-6580",doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}},{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}}]},series:{item:{id:"24",title:"Sustainable Development",doi:"10.5772/intechopen.100361",issn:"2753-6580",scope:"