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Compartment syndrome after intraosseous infusion: An experimental study in dogs
Compartment Syndrome After Intraosseous Infusion: An Experimental Study in Dogs By lzge Gihal,
Nusret K&e, and Deniz Gijrer Eskigehir, Turkey
l An experimental study was designed to investigate the development of compartment syndrome with the use of an intraosseous line in dogs. We used an open technique for insertion of a 20-gauge spinal needle to the tibia. The needle was secured to the tibia with bone cement. Throughout the intraosseous infusion of saline with radio-opaque dye (rate, 480 mL/ h), serial radiographic examination and pressure monitoring of the anterolateral compartment of the leg was performed. Although there was no change up to approximately 350 mL of fluid infusion, the radio-opaque dye was detected in the soft tissues and compartment pressure increased to more than 35 mm Hg. Compartment pressure continued to increase in direct proportion to the amount of dye infused. In the present study, the possible technical errors, which may cause compartment syndrome, have been eliminated. However, compartment syndrome developed because of the failure of microvasculature within a muscle adjacent to bone. We suggest that there is a need for a doseand time-dependent Scala for safe intraosseous infusion. Copyright o 1996 by W. B. Saunders Company INDEX sion.
WORDS:
Compartment
syndrome,
intraosseous
infu-
I
NTRAOSSEOUS infusion is a technique for the administration of fluids and drugs to a child who is in hemodynamic collapse and in whom conventional attempts to access the vascular system have been unsuccessful.’ The use of this technique is usually limited to young children because of the physiologic replacement of the red marrow by less vascular yellow marrow at approximately 5 years of age. The distal part of the femur and the proximal part of the tibia are used for the insertion of the intraosseous infusion line. Infused fluid is absorbed by the microvasculature in the cancellous bone, which communicates with the nutrient and emissary veins.2-4 Although the venous blood flow is mainly centripetal to the bone marrow, the periosteal anastomosis offers an alternate centrifugal route.5 In the long bones, cortical veins anastomose directly with the periosteal vascular bed system, emerging from the vessels that supply the neighboring muscles.h,7 All these vessels later drain into the systemic circulation.2-a Possible complications of the technique include, infection, fat emboli, a fracture at the intraosseous entry site, injury to local soft tissues or physes, and compartment syndrome.1~2~4,8-” The aim of this study was to investigate the mechanism of the development of the compartment syndrome after intraosseous infusion in an animal model. J~~rnalofPediafr~
Surgery,
Vol31,
No 11 (November),
1996: pp 1491.1493
MATERIALS
AND METHODS
We used seven mongrel dogs weighing 13 to 17 kg for the experiment. General anaesthesia was induced by intravenous phentobarbital sodium (25 mg/kg body weight). A small incision about 1 to 1.5 cm long was made on the anteromedial side of the leg and the tibia was exposed through muscle planes. Then, a 20-gauge spinal needle with a stylet was inserted perpendicular to the bone. A screwing motion was used until penetration into the marrow, which was noted by decreased resistance, was achieved. The stylet was removed and marrow was aspirated into a saline-filled syringe. Two mililiters of saline was infused by syringe to clear the needle of any clot. Then the insertion site of the needle to the bone was covered with bone cement to avoid extravasation from the puncture site. The layers were closed in a normal manner and skin was sutured tightly with uninterrupted stitches, and an adhesive drape was applied. An H-gauge needle was inserted into the anterolateral compartment of the leg, and tissue pressures were measured as described by Whitesides et al.‘: Radiopaque dye (Urografin 76%, Schering, Turkey) was infused at the rate of 480 mL/h (8 mL/min) through the syringe under image-Intensifier control and when necessary radiographs were taken. Throughout the study serial pressure measurements were taken.
RESULTS
The resting pressure in the anterolateral compartments of the dogs’ legs were about 5 to 7 mm Hg. With the infusion of the first 10 mL of the radiopaque dye, it became visible on radiographs (Fig 1) and immediately escaped from bone marrow and moved into the systemic venous circulation (Fig 2). With up to 350 mL of radiopaque dye infused, no change was observed in the radiographic visualization of the limb, nor was any increase in the pressure of the compartment detected. After infusion of approximately 360 mL (range, 350 to 370 mL), radiopaque dye was detected radiographicaly in the soft tissues (Fig 3). Also compartment pressure rose over 35 mm Hg. After this critical point, the pressures recorded were directly proportional to the amount of infused dye. For amounts less than 300 mL of intraosseous infusion, the mean compartment pressure was 5.43 mm Hg (SD, 0.79). After 350, 400, 450, and 500 mL of infusion, the mean pressures and standard deviations From the Department of Orthopedics, School of Medicine, Osmangazr Umverslty and the Animal Hospital, Eskifehir, Turkey. Address reprint requests to Dr Izge Gunal, Porsuk B&an, Mart1 Apt, No. 651526010, Eskisehir, Turkey. Copyright o 1996 by W B. Saunders Company 0022.34681961311I-0005$03.0010 1491
1492
Fig 1.
Radiograph
taken
after
infusion
of 10 mL of radiopaque
GtiNAL,
KOSE,
compartment
after
AND
GtiRER
dye. Fig 3. 350 mL.
were 36.43 mm Hg (SD, 2.44), 38.0 mm Hg (SD, OSS), 46.43 mm Hg (SD, 1.Q and 52.0 mm Hg (SD, 2.52), respectively (Fig 4). DISCUSSION
The rate of complications with the use of an intraosseous line is low and has been well documented.1J*4,9-11J3The possible mechanism of the development of the compartment syndrome with intraosseous infusion has been attributed to the technical errors, which may cause local fluid escape from the bone.1,8J0 The technical errors include incomplete penetration of the cortex, penetration of the needle through the posterior aspect of the cortex, extravasation through a previous intraosseous puncture site, and extravasation through the foramina of the nutrient vessels.‘*8J0 To avoid these complications, it was recommended (1) to use a needle strong enough to penetrate the bone easily and withstand bending forces, (2) to attach the lower limb to a splint, (3) not to transport the patient with the needle in the bone, (4) not to use
Radiopaque
dye
in the
infusion
a fractured bone, and (5) to avoid repeated penetration of the cortex.1,2,4,8-11 In the present study, we used an open technique for needle insertion, and the needle was secured to the bone with bone cement. We performed serial radiographic examinations and pressure monitoring. It can be argued that technical errors were eliminated, but the occurrence of the compartment syndrome after approximately 350 mL of infusion in all dogs (Fig 4) suggests that a dose- and time-dependent relationship exists in the development of compartment syndrome with intraosseous infusion. In the long bones the marrow sinusoids drain into medullary venous channels. The central medullary sinus drains to the exterior via the nutrient vein, emissary veins, and epiphysial-metaphysial veins. Most of the venous drainage occurs via the numerous veins in the epiphysial-metaphysial area. Within the cortex, the branches of the transverse vascular system anastomose profusely with the capillaries of the perpendicular system, and the arterioles and veins of transverse system anastomose with each other. The venous branches drain into the sinusoids in the marrow. and 60
i
50 t -2
40.
5 e
30
: t:
20.
l"f"510"
Fig 2.
Radiopaque
dye in the systemic
circulation.
of
Fig 4.
Mean pressure/volume
volume (mL)
curve
of intraosseous
infusion.
COMPARTMENT
SYNDROME
1493
in the periphery they anastomose with the veins of the superficial layer of the periosteum, emerging from the vessels that supply the neighboring muscles.6s7 With intraosseous infusion, the pressure in the bone increases and many vascular channels in the cortex, which are not always functional, drain fluid to the veins of the superficial layer of the periosteum.‘” It is well known that when the pressure within the capillaries increases greatly, fluid leaks from the circulatory system into the tissue spaces by hydrostatic pressure. I5 When the critical pressure is over increased in the veins of the superficial layer of the periosteum, the fluid leaks from vessels in the muscular microcirculation adjacent to the bone. A review of the literature reveals a wide range of flow rates, from 102 mL/h to 2,500 mL/h in children,‘4.8-11~13~16 but compartment syndrome developed in only a small percentage. This can be owing to the critical pressure above which compartment syndrome develops in humans, although this is not clear.17J8 The anterolateral compartment of dogs contains five
anatomically and functionally distinct muscles (compared with only three muscles in the human anterior compartment), and the compartment in humans is well over 10 times as large as the dog’s anterolateral compartment.lyJn We used the injection technique of Whitesides et all? to measure the compartment pressure because of its simplicity and our familiarity with the method. The values obtained were consistently higher than those measured with the other methods,“2 therefore the pressure values of the present study can not be directly applicable to clinical situations. The present study indicates that compartment syndrome may develop despite the meticulous utilization of intraosseous infusion technique. We suggest that there is a need for a dose- and time-dependent Scala if complications are to be avoided. ACKNOWLEDGMENT The authors thank Ocal Keresteci Kurt for preparing the manuscript.
for photographs
and Tulay
REFERENCES 1. Burke T, Kehl DA: Intraosseous infusion in infants. Case report of a complicatton. J Bone Joint Surg 75A:428-429, 1993 2. Fiser DH: Current concepts. Intraosseous infusion. N Engl J Med 322:1579-1581.1990 3. Rosetti VA, Thompson BM, Miller J, et al: Intraosseous infusion: An alternative route of pediatric intravascular access. Ann Emerg Med 14:885-889.1985 4. Spivey WH: Intraosseous infusions. J Pediatr 111:639-643. 1987 5. Trias A, Fery A: Cortical circulation of long bones. J Bone Joint Surg 61A:1052-1059,1979 6. Alm A, Stromberg B: Vascular anatomy of the patellar and cruciate ligaments: A microangiographic and histologic investigation in the dog. Acta Chir Stand, vol 140, suppl445, 1974 7. Kelly PJ, Montgomery RJ: Circulation in bone, in McCollister Evarts C (ed): Surgery of the Musculoskeletal System (ed 2) vol 1. New York, NY, Churchill Livingstone, 1990, pp 71-91 8. Galpin RD, Kronick JB, Willis RB, et al: Bilateral lower extremity compartment syndromes secondary to intraosseous fluid resuscitation. J Pediatr Orthop 11:773-776,199l 9. Moscaty R, Moore GP: Compartment syndrome with resultant amputation following intraosseous infusion. Am J Emerg Med 8:470-471, 1990 (letter) 10. Ribeiro JA, Price CT, Knapp R Jr: Compartment syndrome of the lower extremity after intraosseous Infusion of fluid. A report of two cases. J Bone Joint Surg 75A:430-433,1993 11. Rimer S, Wentry JA, Rodriguez RL: Compartment syndrome in an infant following emergency intraosseous infusion. Chn Pediatr 27:259-260.1988 12. Whitesides TE Jr, Haney TC. Morimoto K, et al: Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop 113:43-51, 1975
13. Toscantis LM. O’Neill therapy. Ann Surg 122:266-277.
JF: Complications 1977
14. Rhinelander FW: Tibia1 healing. Clin Orthop 105:34-81,
blood supply 1974
15. Guyton AC: Basic Human Physiology: Mechanism of Disease (ed 2). Philadelphta. 1977, pp 195-21 I 16. Runyon DE, Bruttig SP, Dubick MA, from hypovolemia in swine with intraosseous rated salt-dextran solution. J Trauma 3611-19,
of mtraosseous
m relation Normal PA,
to fracture Function Saunders
and Co,
et al: Resuscitation infusion of a satu1994
17. Rollins DL, Bernhard VM. Towne JB, Fasciotomy. An appraisal of contraversial issues. Arch Surg 116:137X-1481. 1981 18. Trithtt PD, Konig D. Harper WM. et al: Compartment pressures after closed tibia1 shaft fracture. Their relatton functtonal outcome. J Bone Joint Surg 74B:195-198. 1992
to
19. Hargens AR, Akeson WH, Mubarak SJ, et al: Fluid balance withm the camne anterolateral compartment and its relation to compartment syndromes. J Bone Joint Surg 60A:39Y-505, 1978 20. Matsen management 62A:286-291,
FA III. Winqmst of compartmental 1980
RA. Krugmire syndromes.
RB: Diagnosis J Bone Joint
and Surg
21. Heckman MA, Whiteside TE Jr, Grewe SR, et al: Compartment pressure in assoctation wrth closed tibia1 fractures. The relationship between ttssue pressure, compartment and the distance from the site of the fracture. J Bone Joint Surg 76A:12851292. 1994 22. Moed BR. Thorderson PK: Measurement of intracompartmental pressure: A comparison of the slit catheter. side-ported needle. and simple needle. J Bone Joint Surg 75A:231-235, 1993
Nusret K&e, and Deniz Gijrer Eskigehir, Turkey
l An experimental study was designed to investigate the development of compartment syndrome with the use of an intraosseous line in dogs. We used an open technique for insertion of a 20-gauge spinal needle to the tibia. The needle was secured to the tibia with bone cement. Throughout the intraosseous infusion of saline with radio-opaque dye (rate, 480 mL/ h), serial radiographic examination and pressure monitoring of the anterolateral compartment of the leg was performed. Although there was no change up to approximately 350 mL of fluid infusion, the radio-opaque dye was detected in the soft tissues and compartment pressure increased to more than 35 mm Hg. Compartment pressure continued to increase in direct proportion to the amount of dye infused. In the present study, the possible technical errors, which may cause compartment syndrome, have been eliminated. However, compartment syndrome developed because of the failure of microvasculature within a muscle adjacent to bone. We suggest that there is a need for a doseand time-dependent Scala for safe intraosseous infusion. Copyright o 1996 by W. B. Saunders Company INDEX sion.
WORDS:
Compartment
syndrome,
intraosseous
infu-
I
NTRAOSSEOUS infusion is a technique for the administration of fluids and drugs to a child who is in hemodynamic collapse and in whom conventional attempts to access the vascular system have been unsuccessful.’ The use of this technique is usually limited to young children because of the physiologic replacement of the red marrow by less vascular yellow marrow at approximately 5 years of age. The distal part of the femur and the proximal part of the tibia are used for the insertion of the intraosseous infusion line. Infused fluid is absorbed by the microvasculature in the cancellous bone, which communicates with the nutrient and emissary veins.2-4 Although the venous blood flow is mainly centripetal to the bone marrow, the periosteal anastomosis offers an alternate centrifugal route.5 In the long bones, cortical veins anastomose directly with the periosteal vascular bed system, emerging from the vessels that supply the neighboring muscles.h,7 All these vessels later drain into the systemic circulation.2-a Possible complications of the technique include, infection, fat emboli, a fracture at the intraosseous entry site, injury to local soft tissues or physes, and compartment syndrome.1~2~4,8-” The aim of this study was to investigate the mechanism of the development of the compartment syndrome after intraosseous infusion in an animal model. J~~rnalofPediafr~
Surgery,
Vol31,
No 11 (November),
1996: pp 1491.1493
MATERIALS
AND METHODS
We used seven mongrel dogs weighing 13 to 17 kg for the experiment. General anaesthesia was induced by intravenous phentobarbital sodium (25 mg/kg body weight). A small incision about 1 to 1.5 cm long was made on the anteromedial side of the leg and the tibia was exposed through muscle planes. Then, a 20-gauge spinal needle with a stylet was inserted perpendicular to the bone. A screwing motion was used until penetration into the marrow, which was noted by decreased resistance, was achieved. The stylet was removed and marrow was aspirated into a saline-filled syringe. Two mililiters of saline was infused by syringe to clear the needle of any clot. Then the insertion site of the needle to the bone was covered with bone cement to avoid extravasation from the puncture site. The layers were closed in a normal manner and skin was sutured tightly with uninterrupted stitches, and an adhesive drape was applied. An H-gauge needle was inserted into the anterolateral compartment of the leg, and tissue pressures were measured as described by Whitesides et al.‘: Radiopaque dye (Urografin 76%, Schering, Turkey) was infused at the rate of 480 mL/h (8 mL/min) through the syringe under image-Intensifier control and when necessary radiographs were taken. Throughout the study serial pressure measurements were taken.
RESULTS
The resting pressure in the anterolateral compartments of the dogs’ legs were about 5 to 7 mm Hg. With the infusion of the first 10 mL of the radiopaque dye, it became visible on radiographs (Fig 1) and immediately escaped from bone marrow and moved into the systemic venous circulation (Fig 2). With up to 350 mL of radiopaque dye infused, no change was observed in the radiographic visualization of the limb, nor was any increase in the pressure of the compartment detected. After infusion of approximately 360 mL (range, 350 to 370 mL), radiopaque dye was detected radiographicaly in the soft tissues (Fig 3). Also compartment pressure rose over 35 mm Hg. After this critical point, the pressures recorded were directly proportional to the amount of infused dye. For amounts less than 300 mL of intraosseous infusion, the mean compartment pressure was 5.43 mm Hg (SD, 0.79). After 350, 400, 450, and 500 mL of infusion, the mean pressures and standard deviations From the Department of Orthopedics, School of Medicine, Osmangazr Umverslty and the Animal Hospital, Eskifehir, Turkey. Address reprint requests to Dr Izge Gunal, Porsuk B&an, Mart1 Apt, No. 651526010, Eskisehir, Turkey. Copyright o 1996 by W B. Saunders Company 0022.34681961311I-0005$03.0010 1491
1492
Fig 1.
Radiograph
taken
after
infusion
of 10 mL of radiopaque
GtiNAL,
KOSE,
compartment
after
AND
GtiRER
dye. Fig 3. 350 mL.
were 36.43 mm Hg (SD, 2.44), 38.0 mm Hg (SD, OSS), 46.43 mm Hg (SD, 1.Q and 52.0 mm Hg (SD, 2.52), respectively (Fig 4). DISCUSSION
The rate of complications with the use of an intraosseous line is low and has been well documented.1J*4,9-11J3The possible mechanism of the development of the compartment syndrome with intraosseous infusion has been attributed to the technical errors, which may cause local fluid escape from the bone.1,8J0 The technical errors include incomplete penetration of the cortex, penetration of the needle through the posterior aspect of the cortex, extravasation through a previous intraosseous puncture site, and extravasation through the foramina of the nutrient vessels.‘*8J0 To avoid these complications, it was recommended (1) to use a needle strong enough to penetrate the bone easily and withstand bending forces, (2) to attach the lower limb to a splint, (3) not to transport the patient with the needle in the bone, (4) not to use
Radiopaque
dye
in the
infusion
a fractured bone, and (5) to avoid repeated penetration of the cortex.1,2,4,8-11 In the present study, we used an open technique for needle insertion, and the needle was secured to the bone with bone cement. We performed serial radiographic examinations and pressure monitoring. It can be argued that technical errors were eliminated, but the occurrence of the compartment syndrome after approximately 350 mL of infusion in all dogs (Fig 4) suggests that a dose- and time-dependent relationship exists in the development of compartment syndrome with intraosseous infusion. In the long bones the marrow sinusoids drain into medullary venous channels. The central medullary sinus drains to the exterior via the nutrient vein, emissary veins, and epiphysial-metaphysial veins. Most of the venous drainage occurs via the numerous veins in the epiphysial-metaphysial area. Within the cortex, the branches of the transverse vascular system anastomose profusely with the capillaries of the perpendicular system, and the arterioles and veins of transverse system anastomose with each other. The venous branches drain into the sinusoids in the marrow. and 60
i
50 t -2
40.
5 e
30
: t:
20.
l"f"510"
Fig 2.
Radiopaque
dye in the systemic
circulation.
of
Fig 4.
Mean pressure/volume
volume (mL)
curve
of intraosseous
infusion.
COMPARTMENT
SYNDROME
1493
in the periphery they anastomose with the veins of the superficial layer of the periosteum, emerging from the vessels that supply the neighboring muscles.6s7 With intraosseous infusion, the pressure in the bone increases and many vascular channels in the cortex, which are not always functional, drain fluid to the veins of the superficial layer of the periosteum.‘” It is well known that when the pressure within the capillaries increases greatly, fluid leaks from the circulatory system into the tissue spaces by hydrostatic pressure. I5 When the critical pressure is over increased in the veins of the superficial layer of the periosteum, the fluid leaks from vessels in the muscular microcirculation adjacent to the bone. A review of the literature reveals a wide range of flow rates, from 102 mL/h to 2,500 mL/h in children,‘4.8-11~13~16 but compartment syndrome developed in only a small percentage. This can be owing to the critical pressure above which compartment syndrome develops in humans, although this is not clear.17J8 The anterolateral compartment of dogs contains five
anatomically and functionally distinct muscles (compared with only three muscles in the human anterior compartment), and the compartment in humans is well over 10 times as large as the dog’s anterolateral compartment.lyJn We used the injection technique of Whitesides et all? to measure the compartment pressure because of its simplicity and our familiarity with the method. The values obtained were consistently higher than those measured with the other methods,“2 therefore the pressure values of the present study can not be directly applicable to clinical situations. The present study indicates that compartment syndrome may develop despite the meticulous utilization of intraosseous infusion technique. We suggest that there is a need for a dose- and time-dependent Scala if complications are to be avoided. ACKNOWLEDGMENT The authors thank Ocal Keresteci Kurt for preparing the manuscript.
for photographs
and Tulay
REFERENCES 1. Burke T, Kehl DA: Intraosseous infusion in infants. Case report of a complicatton. J Bone Joint Surg 75A:428-429, 1993 2. Fiser DH: Current concepts. Intraosseous infusion. N Engl J Med 322:1579-1581.1990 3. Rosetti VA, Thompson BM, Miller J, et al: Intraosseous infusion: An alternative route of pediatric intravascular access. Ann Emerg Med 14:885-889.1985 4. Spivey WH: Intraosseous infusions. J Pediatr 111:639-643. 1987 5. Trias A, Fery A: Cortical circulation of long bones. J Bone Joint Surg 61A:1052-1059,1979 6. Alm A, Stromberg B: Vascular anatomy of the patellar and cruciate ligaments: A microangiographic and histologic investigation in the dog. Acta Chir Stand, vol 140, suppl445, 1974 7. Kelly PJ, Montgomery RJ: Circulation in bone, in McCollister Evarts C (ed): Surgery of the Musculoskeletal System (ed 2) vol 1. New York, NY, Churchill Livingstone, 1990, pp 71-91 8. Galpin RD, Kronick JB, Willis RB, et al: Bilateral lower extremity compartment syndromes secondary to intraosseous fluid resuscitation. J Pediatr Orthop 11:773-776,199l 9. Moscaty R, Moore GP: Compartment syndrome with resultant amputation following intraosseous infusion. Am J Emerg Med 8:470-471, 1990 (letter) 10. Ribeiro JA, Price CT, Knapp R Jr: Compartment syndrome of the lower extremity after intraosseous Infusion of fluid. A report of two cases. J Bone Joint Surg 75A:430-433,1993 11. Rimer S, Wentry JA, Rodriguez RL: Compartment syndrome in an infant following emergency intraosseous infusion. Chn Pediatr 27:259-260.1988 12. Whitesides TE Jr, Haney TC. Morimoto K, et al: Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop 113:43-51, 1975
13. Toscantis LM. O’Neill therapy. Ann Surg 122:266-277.
JF: Complications 1977
14. Rhinelander FW: Tibia1 healing. Clin Orthop 105:34-81,
blood supply 1974
15. Guyton AC: Basic Human Physiology: Mechanism of Disease (ed 2). Philadelphta. 1977, pp 195-21 I 16. Runyon DE, Bruttig SP, Dubick MA, from hypovolemia in swine with intraosseous rated salt-dextran solution. J Trauma 3611-19,
of mtraosseous
m relation Normal PA,
to fracture Function Saunders
and Co,
et al: Resuscitation infusion of a satu1994
17. Rollins DL, Bernhard VM. Towne JB, Fasciotomy. An appraisal of contraversial issues. Arch Surg 116:137X-1481. 1981 18. Trithtt PD, Konig D. Harper WM. et al: Compartment pressures after closed tibia1 shaft fracture. Their relatton functtonal outcome. J Bone Joint Surg 74B:195-198. 1992
to
19. Hargens AR, Akeson WH, Mubarak SJ, et al: Fluid balance withm the camne anterolateral compartment and its relation to compartment syndromes. J Bone Joint Surg 60A:39Y-505, 1978 20. Matsen management 62A:286-291,
FA III. Winqmst of compartmental 1980
RA. Krugmire syndromes.
RB: Diagnosis J Bone Joint
and Surg
21. Heckman MA, Whiteside TE Jr, Grewe SR, et al: Compartment pressure in assoctation wrth closed tibia1 fractures. The relationship between ttssue pressure, compartment and the distance from the site of the fracture. J Bone Joint Surg 76A:12851292. 1994 22. Moed BR. Thorderson PK: Measurement of intracompartmental pressure: A comparison of the slit catheter. side-ported needle. and simple needle. J Bone Joint Surg 75A:231-235, 1993