Early posterior ankle release in the treatment of congenital clubfoot

Eighty-one patients (116 clubfeet) underwent posterior ankle release before the age of two years, following unsatisfactory responses to serial corrective casts applied according to the technique of Kite. Seventy-three per cent of these feet showed no or only mild talar flattening at an average follow-up of 7.5 years. Four years, following posterior ankle release there was a none-mild talar flattening rate of 69 per cent in this group compared to a 40 per cent none-mild rate in ankle release reduces the incidence of recurrent equinus deformity and the necessity for subsequent surgery in comparison to the results obtained with serial plaster casts or with tendo Achillis lengthening alone. Recent trends in clubfoot management have favored increasingly early operative intervention. Denham stated that "In the infant hard tissues (bone and cartilage) should be regarded as soft, and the soft tissues (tendon and ligament) as hard." Our operative experience with posterior ankle release supports this philosophy and indicates that early aggressive surgical management is the treatment of choice for the resistant clubfoot.     

Comparison of evaluation methods of the results of congenital clubfoot treatment

INTRODUCTION: An ideal method for the assessment of the results of treatment in congenital clubfoot should take into account the morphology of the foot and its function, the personal satisfaction of the patient of his parents, interexaminer variability, and be applied for any type of treatment. MATERIAL AND METHODS: We evaluated at- end of growth the results of treatment of 35 patients with unilateral clubfoot, and analyzed them according to 13 different rating scores already published in the literature. The material was divided in 3 groups; 15 feet having undergone multiple surgeries, 10 feet having had only one posteromedial release procedure, and 10 feet having been treated nonoperatively. RESULTS: None of the 13 reviewed rating methods seems to be ideal. The results of treatment, for one taken foot, were often different from one method to the other. DISCUSSION: The high number of rating scores published in literature, is the direct evidence that there is no concensus in the evaluation of the results of treatment in congenital clubfoot. A unanimous new method should be created and should fill all the prerequisites of the ideal method, described above. Some criteria are very important to consider: A iatrogenic deformity or disability, i.e. severe lateral translation of the foot, acquired convex foot, or calcaneus foot, should be severely penalized; hopping on one foot should be the test used to evaluate the strength of triceps surae muscle in children above 5 years of age ; Radiological evidence of talonavicular dislocation is a very important long term prognostic element. CONCLUSION: A new unanimous method for the assessment of the results of clubfoot treatment is necessary. It should be simple, easy to teach, and easy to use.     

Nonsurgical treatment of the patient with vertical discrepancy

Conventional orthodontic treatment of the patient who has excessive anterior facial height is difficult. Many times, the patient is presented only a surgical-orthodontic option. However, some "orthodontics only" options are available. These options can generally give the patient acceptable facial balance and a good functional occlusion. The two keys are differential diagnosis and a carefully monitored force system. Conventional treatment of two patients with high angle facial dimension will illustrate these concepts.     

Nonsurgical treatment of platysmal bands with injection of botulinum toxin A

Botulinum toxin A has been used therapeutically in humans for over 20 years for a variety of medical indications. For the past 7 years, the author has injected it for cosmetic purposes in a variety of muscles of the head and neck. Fifty patient-injections of the platysma muscle were performed in an attempt to correct platysmal banding. An improvement was seen in all patients who presented to the office for follow-up in a timely manner (44 injections). Results were limited by redundant skin. No incidence of dysphagia or airway obstruction was encountered. The only complication noted was bruising. Although at least a small improvement in platysmal banding was seen in all patients, in no patient was there evidence of lifting of the lower face. All results were temporary.     

Microstructure and properties of cast ingots of Al-Zn-Mg-Cu alloys modified with Sc and Zr

The effect of combined additions of Sc and Zr on the microstructure and tensile properties of the direct chill (DC) cast ingots of developmental Al-Zn-Mg-Cu alloys has been evaluated in this work. The properties in both the longitudinal and transverse directions were determined in as-cast and cast-plus-heat-treated conditions, at room temperature (RT) and cryogenic temperature (CT). Extensive microstructural evaluation was carried out using optical microscopy and scanning electron microscopy, including orientation image microscopy (OIM) by the electron backscatter diffraction (EBSD) technique. The Sc-containing developmental cast alloys showed the tensile properties, which are much better than the properties of commercial cast Al alloys and are similar or even superior to the properties of 7075-T6 alloy forgings. The microstructural evolution, the strengthening mechanisms, the optimum content of the dispersoid-forming elements, and the processing-structure-property correlations are discussed.     

Evaluation of acupuncture and occlusal splint therapy in the treatment of temporomandibular joint disorders

One hundred patients showed signs and symptoms of temporomandibular joint disorder, were participated in a one year follow up study. The patients were randomly divided into four groups: Acuhealth treatment (group A), occlusal splint therapy (group B), Acuhealth and occlusal splint therapy (group C), and control (group D). Each group comprised 25 patients. The patients were examined before and 3, 6, and 12 months after treatment. At the three month evaluation, the patients who were not satisfied with the treatment outcome were offered additional treatment. The result showed that 87% of the patients treated by Acuhealth unit, 77.3% of the patients treated with occlusal splint therapy, and 91.3% of the patients received Acuhealth and occlusal splint therapy were improved subjectively and clinically after 3 months follow-up. The patients who responded well to treatment initially also responded well in the long run. The study showed that the Acuhealth unit proved to be an ideal early therapy for TMD, and complemented later with occlusal splint.     

Diagnosis and treatment of congenital thumb hypoplasia

The hypoplastic thumb has a variety of presentations, which have been generalized into a formal classification system that has treatment implications. In most cases, the spectrum of hypoplasia has predictable deficits in terms of tendon and bone absence. The ultimate goal is always the same--to enhance usage of the radial digit. In this article, a straightforward, reliable, and reproducible surgical technique is discussed and illustrated. Pitfalls, indications, and treatment regimes also are discussed to help the physician successfully treat the child with a hypoplastic thumb.     

Prevention of hemorrhage and dental treatment of patients with congenital or acquired coagulopathies

The physiopathology of the hemorrhagic blood coagulation disorders caused by genetic or aquired problems is described. Among the former the most frequent ones include the hemophilia of type A-B and the von Willebrand disease, among the latter the use of oral anticoagulant constitutes the most frequent cause. If the are not subjected to an adequate haemostatic prophylaxis, both patients with hemophilia and von Willebrand disease present a serious haemorrhagic risk as a consequence of dental practice. As far as the use of anticoagulants is concerned, a periodical monitoring of the time of prothrombin (PT) is needed to find the right dosage (TP between 20%-30% or INR--international normalized radio between 2 and 3.5). Values over this range cause an increase of the hemorrhagic risk, while lower values involve an increased risk of thrombotic events. According to the authors the patients with the hemorrhagic diathesis show a precise handicap, caused both by his illness and by environmental elements, such as the fear of doctors for the haemorrhagic complications consequent to a therapeutical operation, fear that often leads to neglect important medical measures, in particular dental measures. The specialized dental surgeon has to mantain a strict cooperation with the hematologist in order to arrange an appropriate procedure of the prophylaxis. As far as the hemostatic prophylaxis is concerned, the use of the dermopressin (DDAVP), in patients with hemophilia A and von Willebrand disease, guarantees the realisation of dental practice without hemorrhagic risk. On the contrary, the use of the tranhexanic acid on patients in an anticoagulant oral treatment gives hemostatic security and makes it possible to carry on the therapy and the out-patient treatment.     

Nonsurgical and surgical management of infants and children with obstructive sleep apnea syndrome

Obstructive sleep apnea (OSA) syndrome in infants and children is one of the more common problems treated by the otorhinolaryngologist-head and neck surgeon. The authors discuss diagnostic studies, nonsurgical and surgical therapies, and perioperative care, including indications for inpatient stay following surgery. Most children are successfully treated for obstructive breathing by adenotonsillectomy. An awareness of the wide range of treatment modalities, with attention to careful postoperative care, should allow for successful management of nearly all children with OSA.     

Pressure pain thresholds in patients with craniomandibular disorders before and after treatment with acupuncture and occlusal splint therapy: a controlled clinical study

Fifty-five patients (46 women and 9 men) with craniomandibular disorders and a history of pain of at least 6 months' duration participated in this trial. The patients were randomly assigned to three groups: one group to receive acupuncture; one group to receive occlusal splint therapy; and one group to act as controls. Pressure pain threshold, clinical dysfunction score, and visual analog scale measures were used to evaluate patients before, immediately after, and 6 months after treatment. A moderate, but statistically significant, correlation was found between pressure pain threshold and the number of tender spots in the masticatory muscles (tau = -.43; P < .001), degree of tenderness in the masticatory muscles (tau = -.43; P < .001), clinical dysfunction score (tau = .32; P < .001), and the visual analog scale (tau = -.25; P < .01). The short-term results showed a statistically significant improvement in all evaluations for both treatment groups. No significant differences were found in the control group. The improvements resulted in significant differences between the control and each treatment group immediately after treatment. At the 6-month follow-up, no significant differences in pressure pain threshold or clinical dysfunction score were found in the two treatment groups compared with the short-term results.     

Exercise capacity and mid-term survival in patients with tricuspid atresia and complex congenital cardiac malformations after modified Fontan-operation

A 68-year-old man experienced systemic pruritus since he was 63 years old, and systemic sclerosis and skin pigmentation were observed when he was 64. When he developed dyspnea the same year, he was admitted and SSc was diagnosed on the basis of the clinical and skin biopsy findings, lung fibrosis on X-P and TBLB findings. At 65, his dyspnea reappeared along with elevated blood pressure, acute renal failure and lung congestion, and he was diagnosed as having a scleroderma renal crisis (SRC) from the clinical and renal biopsy findings. Hemodialysis was started because he showed mental disturbance, and this and other acute symptoms were subsequently reduced. As he showed no recovery from his renal failure, the patient has been maintained on hemodialysis for over four years now. In the meantime, his sclerosis has improved and antinuclear antibody almost disappeared. Hemodialysis appears to be the most likely reason for his improvement, although spontaneous remission, D-penicillamine and angiotensin converting enzyme (ACE) inhibitor therapy may also have contributed, considering the short period and the small amount of drugs given until improvement.     

Early diagnosis and surgical treatment of children with congenital vascular rings and accompanying heart lesions

Methods of early diagnosis, operative treatment and postoperative care are described in children with congenital vascular rings. The ring types were grouped according to Cooley's classification. Among 42 recognized vascular rings 34 children required surgical treatment because of severe or noticeable compressive symptoms of esophagus and trachea. In the postoperative period early respiratory care is especially important.     

Current treatment of brain abscess in patients with congenital cyanotic heart disease

OBJECTIVE: The goal of this study was to define clearly the role of management in patients with cyanotic heart disease and brain abscesses by evaluating retrospectively the factors influencing poor outcome in these patients. METHODS: This study included 62 patients with cyanotic heart disease and brain abscesses diagnosed in the computed tomography era. Basic characteristic parameters (number, size, location, computed tomographic classification and organism type of abscess, convulsion, type of cyanotic heart disease, age distribution, immunocompromised status, pretreatment neurological state, and intraventricular rupture of brain abscess [IVROBA]) and therapeutic parameters (type of antibiotics and duration of administration, steroid medication and therapeutic modalities, aspiration with or without cerebrospinal fluid drainage, total extirpation after aspiration, or primary extirpation and medical treatment) were evaluated as independent predictors of poor outcome (totally disabled state or death) by using univariate and multivariate logistic regression analysis. We also statistically estimated the possible causes of IVROBA and the multiplicity of brain abscess. RESULTS: Although there were no statistically significant correlations between patients with good and poor outcomes in regard to other basic characteristic and therapeutic parameters, patients with poor outcomes were older (P < 0.02), more frequently had IVROBA (P < 0.005), and had a higher frequency of neurological deterioration (P < 0.01) than those with good outcomes. Multiple logistic regression analysis predicted that poor outcome increased the relative risk of IVROBA by a factor of 18.9 (odds rate, 18.9; 95% confidence interval, 1.7-211.6; P < 0.02). More patients with multiple abscesses had positive immunocompromised states than those with single abscesses (P < 0.01). Deep-located abscesses also more frequently had IVROBA (P < 0.005) and abscesses located in the parieto-occipital region ruptured into the occipital horn of the lateral ventricle in a short period (P < 0.02). CONCLUSIONS: Our findings suggest that IVROBA strongly influences poor outcome in patients with cyanotic heart disease. The key to decreasing poor outcomes may be the prevention and management of IVROBA. To reduce operative and anesthetic risk in these patients, abscesses should be managed by less invasive aspiration methods guided by computed tomography. Abscesses larger than 2 cm in diameter, in deep-located or parieto-occipital regions, should be aspirated immediately and repeatedly, mainly using computed tomography-guided methods to decrease intracranial pressure and avoid IVROBA. IVROBA should be aggressively treated by aspiration methods for the abscess coupled with the appropriate intravenous and intrathecal administration of antibiotics while evaluating intracranial pressure pathophysiology.     

Structure,mechanical properties,and fracture of 20GL cast steel

The structure and mechanical properties of 20GL steel are studied. It is shown that a significant decrease in the ductility and impact toughness of the steel is caused by intercrystalline fracture, which is induced by a weakening of the intercrystallite bonds due to the existence of coarse lamellar pearlite and nonmetallic inclusions, namely, film inclusions and eutectic-type oxysulfides, at the boundaries of primary crystals. Annealing from a temperature in the intercritical range is found to improve the mechanical properties.     

Influence of heat treatment on the phase composition and properties of high-strength cast iron

The phase composition, structure, and properties of high-strength cast iron are investigated as a function of the heat treatment. The influence of heat treatment on the wear of bainitic iron with globular graphite is also considered, in comparison with steel for the production of cast plowshares.