Sub-trochanteric fractures. A comparative study between gamma nail and angular osteosynthesis with lateral cortical support]

METHODS: Thirty-three children and young adults with congenital aortic valve disease underwent pulmonary autograft replacement of the aortic valve between October 1993 and March 1997. There wer six females and 27 males; at operation, median age was 16 years (range: 3 to 41 years) and median body weight 60 kg (range: 14 to 121 kg). Fifteen patients (46%) had undergone one or more previous cardiac surgical procedures. A bicuspid aortic valve was present in 31 patients (94%); moderate to severe aortic stenosis and regurgitation was present in 10 (30%) and 26 (79%), respectively. RESULTS: All patients underwent the Ross procedure while in NYHA class I (64%) or class II (36%). A preoperative shortening fraction of 41 +/- 1.4% suggested well-preserved systolic function, but the mean left ventricular end-diastolic pressure of 16.6 +/- 1.3 mmHg was consistent with preoperative left ventricular pressure and volume overload. The aortic root was replaced using an interrupted suture technique in two patients and with three separate running sutures in 31. The right ventricular outflow tract was reconstructed in all classes with a cryopreserved pulmonary homograft valved conduit (median diameter 23 mm; range 19 to 30 mm). Intraoperative complications included transient atrioventricular dissociation (one), permanent atrioventricular dissociation (one), and left coronary artery distortion relieved by shortening the distal ascending aorta (one). Postoperatively, postpericardiotomy syndrome developed in six patients (18%), supraventricular tachycardia in three (9%), and ventricular tachycardia in one (3%). At three days after surgery, one patient developed ischemic left ventricular dysfunction requiring repositioning of the distorted left coronary artery higher on the neo-aortic root. Hospital survival rate was 100%. During a median follow-up of 17 months (range: 1 to 41 months) one patient suffered a non-cardiac death due to blunt trauma. there has been a significant postoperative improvement in NYHA class among surviving patients (class I, 94%; class II, 6%; p = 0.004 versus preoperative). Postoperative aortic regurgitation was absent or trivial in 17 (60%) and mild in the remaining 11 (40%) patients for whom follow-up echocardiographic data are available. One patient required reoperation 16.5 months after the Ross procedure to replace a rapidly degenerating pulmonary homograft, and one with moderately severe homograft stenosis and five with mild homograft stenosis are being monitored. Postoperatively, a gradual early expansion in the diameter of the neo-aortic root and reduction in echocardiographic indices of left ventricular hypertrophy and dilatation occurred. CONCLUSIONS: Pulmonary autograft replacement of the aortic valve in young patients with congenital aortic valve disease has produced excellent short-term anatomic/physiologic results and symptomatic relief with no mortality. Indices of left ventricular dilatation and hypertrophy regress after repair when the Ross operation precedes important deterioration in preoperative ventricular function. Important technical considerations include: (i) the native distal ascending aorta should be sufficiently shortened before performing the distal aortic anastomosis; and (ii) the left coronary anastomosis should be positioned relatively high on the neo-aortic root with a slight amount of tension. Both of these maneuvers reduce the likelihood of coronary artery distortion. Rapid degeneration of the pulmonary homograft and the propensity towards progressive dilatation of the neo-aorta are important postoperative considerations. Until more is known about the etiology and natural history of these two potential complications, postoperative anti-inflammatory and/or immunosuppressive therapy and strict control of hypertension should be strongly considered.     

A comparison of the modified gamma nail and the ender nail for treatment of intertrochanteric fractures

We made a comparison between the modified Gamma nailing and the Ender nailing in the treatment of 102 patients with intertrochanteric fracture. Sixty patients were treated with the modified Gamma nailing and forty-two patients with the Ender method. The preoperative conditions of the patients in the two groups were similar as showed by statistical analysis. More intraoperative bleeding was recorded in the modified Gamma nail group. However, there were a earlier full weight -bearing, a better hip function and a lower rate of operative complication in the patients treated with the modified Gamma nailing. We conclude that with the modified technique and the modified femoral component the Gamma nail is advanced in the treatment of intertrochanteric fracture. However, it is danger to apply in elderly patients accompanied with certain vital problems. For these patients the Ender nail may be considered.     

Spontaneous elimination by the natural tracts of screws of anterior cervical osteosynthesis. Apropos of a case]

Secondary amyloidosis frequently involves the gastrointestinal tract and may result in ulceration, hemorrhage, and protein-losing enteropathy. We report a patient with severe hypoalbuminemia in whom endoscopy revealed widespread ulceration of the small intestine. The protein-losing site was detected by 99mTc-diethylene triamine pentaacetic acid human serum albumin (99mTc HSA-D) scintigraphy. This evidence suggests that the ulcers and mucosal lesions associated with amyloidosis contribute to abnormal protein loss from the gastrointestinal tract.     

Clinical results of primary intramedullary osteosynthesis with the unreamed AO/ASIF tibial intramedullary nail of open tibial shaft fractures

From 04/91 to 06/96 sixty-nine open fractures of the tibia were primarily treated on the day of the accident with unreamed nailing (UTN, Synthese). The distributions of fracture type according to the AO classification and of soft tissue injury according to Gustilo were as follows: fracture type: A: 28%, B: 52%, C: 20%; soft tissue injury: I: 30%, II: 28%, IIIA: 12%, IIIB: 12%, IIIC: 6%. Of the 65 fractures assessed 46 (71%) healed within 18 weeks without secondary intervention. There was delayed healing in three fractures requiring secondary conversion to reamed nailing. Eight fractures (12%) developed pseudarthrosis of which five (8%) healed uneventfully. Deep infections was manifest in four fractures (6%). Three of these infections developed after secondary intervention to treat pseudarthrosis. Seven of the eight pseudarthroses and three of the four infections healed eventually. Revision procedures were necessary in 11 patients (17%) to deal with disturbed fracture healing or infection (10 reamed nailing procedures, three cancellous bone grafts, and one of each of the following: sequestrectomy, fibular osteotomy, plate fixation, external fixator, monorail procedure). The results show that the same good infection rates were achieved for the UTN as for the external fixator. The advantages of the UTN are, however, a lesser need for secondary intervention and greater patient comfort. Therefore, we find the UTN to be a good alternative to the external fixator in the treatment of open fractures with severe soft tissue damage.     

Retrograde nailing of humerus shaft fractures with the unreamed humerus nail. An international multicenter study

Combined with the new unreamed humeral nail (UHN) (Synthes), the retrograde approach to the endomedullary canal of the humeral shaft promises careful reduction and fixation of humeral shaft fractures. This prospective multicenter study reports and analyses 102 retrograde nailings with the UHN and their operative procedures. Seven patients with pathological fractures have died meanwhile, but 75 patients could be followed up until bone healing. Seventy-three fresh humeral shaft fractures, 12 pseudarthrosis, 3 refractures and 14 pathological fractures have been treated with the UHN. In 98 cases (96.1%) the surgeon estimated fracture stability well enough to initiate immediate postoperative elbow and shoulder mobilization. The difficulties involved with free-hand interlocking proximally at the nail tip in 5.9%, fissure or avulsion at the insertion point in 3.9% and radial nerve palsy also in 3.9% of the cases were the most important intraoperative complications. In all 75 patients followed up, bone healing occurred, but five fractures (6.7%) needed more than 8 months connected with a second operative procedure. In one case spongious bone transplantation and new locking bolts had been performed. In three cases a special compression device has been used, whereas in one case also a new nail and in the second spongious bone transplantation had been added. In the fifth case plate osteosynthesis had been performed. At the end of treatment 89.4% of the patients had excellent shoulder function and 88.0% excellent elbow function. Once the indication for surgery is established, the UHN can be considered a reliable and safe implant for stabilizing humeral shaft fractures.     

Haglund disease treated by simple resection of calcaneus tuberosity. An angular and therapeutic study. Apropos of 74 cases with 2 years follow-up

PURPOSE OF THE STUDY: The authors report the treatment of Haglund's disease, using a simple os calcis tuberosity resection. They reviewed long term results and the value of radiological criteria for pre-operative evaluation. MATERIAL: The series included 54 patients (74 feet) mostly female and young. The simple resection of os calcis tuberosity was performed without further operation or post-operative splint. METHODS: Post-operative results were appreciated according to 3 criteria: pain, functional activity and shoe wearing. Radiological criteria used Fowler and Philip angle, angle of calcaneal inclinaison, total angle, CL angle, Denis and Huber-Levernieux test and Heneghan and Pavlov parallel lines. Correlation tests with simple regression were used for statistical analysis. RESULTS: Results were graded as excellent and good in 73 per cent fair in 16.2 per cent and poor in 10.8 per cent cases. DISCUSSION: Results were compared to other series. Neither radiological criteria, angular or not, can rule out simple tuberosity resection, because results showed no relation between test and angle measurements. There is no correlation between post-operative radiographs and final result. The only efficient criteria of resection is the difference between Fowler and Philip, and CL angles. This technique may be recommended after few months of medical treatment, without using calcaneal osteotomies of Zadek type. CONCLUSION: The simple resection of os calcis tuberosity showed good results in 73 per cent cases at an average follow up of 6 years 9 months.     

Treatment of pseudarthroses and ununited crural bone fractures with transosseous compression-distraction osteosynthesis

The materials of clinical observations of 103 patients with pseudarthrosis and unhealing crural fractures, in whom 104 operations of compression-distraction osteosynthesis were accomplished, are analysed. The results of the treatment in various groups of patients are described.     

Osteoporotic vertebral crush fractures with severe neurologic manifestations. Apropos of 6 cases

Osteoporotic vertebral crush fractures with neurologic complications are rarely reported in the literature. We report six new cases particularly severe in which death occurred in two cases. The study group included four women and two men with a mean age of 75 years (range: 72-79). Vertebral collapse causing neurological deficit was T5, T9, T11 in two cases, L1 and L3. The mean number of vertebral collapses was three per patient (range: 1-9). Back pain appeared without traumatism 6 weeks before admission (range: 1-24). Neurological complications appeared 2.5 weeks after back pain (range: 1-8). One patient suffered from a paraplegia, three from a paraparesia with bladder dysfunction (n = 1). In one case there was a severe weakness of the levator muscles of the foot and in another a L3 femoral neuralgia with severe bowel and bladder dysfunction. X-rays demonstrated backwards displacement of the posterior cortex in three cases, an intravertebral vacuum phenomenon in two cases and a heterogeneous appearance suggesting a malignancy in two cases. Computed tomography, performed in four patients and tomography in one patient, demonstrated fragmentation of the vertebral body in all the cases and vacuum phenomenon in four cases. Magnetic resonance imaging performed in four cases has confirmed the absence of epiduritis and a compression due to bony structures in two cases. A vertebral biopsy was performed in three cases. Osteoporosis was observed in all the cases and in two cases there was also an osteonecrosis. Surgical treatment was performed in three cases and conservative medical treatment in the other cases. After surgical treatment we have observed an absence of improvement of neurological complications in one case, an improvement in another and finally a full recovery in the last case. After conservative treatment we have noted in two cases an absence of improvement of neurological complications and in one case an improvement of neurological deficit. Two patients died (one after medical treatment and another after surgical treatment).     

Treatment of pathological fractures of the humeral shaft due to bone metastases: a comparison of intramedullary locking nail and plate osteosynthesis with adjunctive bone cement

The assessment of myocardial viability is of increasing clinical relevance in the era of thrombolytic therapy and coronary revascularization. Dobutamine stress echocardiography has been proposed as a method of detecting residual viability. The echocardiographic hallmark for viability of a dyssynergic segment is improvement of wall thickening after inotropic challenge. Several clinical studies published over the past year have shown the value of dobutamine stress echocardiography in predicting improvement in regional and global ventricular function after revascularization.     

Non-operative treatment versus tension-band osteosynthesis in three- and four-part proximal humeral fractures. A retrospective study of 34 fractures from two different trauma centers

Thirty-four patients with three- and four-part proximal humeral fractures from two different trauma centres were studied retrospectively. Sixteen were treated without osteosynthesis and compared with 18 patients treated with tension-band fixation. Fracture classification and clinical examination were made by the same persons in both groups. Most of the three-part fractures healed with good pain relief and good function in daily life but often with a loss of motion. Four-part fractures often led to pain, loss of motion and of function. Conservative treatment seemed superior to tension-band fixation for three-part fractures. Four-part fractures healed with better function and range of motion after tension-band fixation.     

Prevention of retinal detachment in Wagner-Stickler disease. Comparative study of different methods. Apropos of 22 cases

Prophylactic treatment in patients presenting Wagner-Stickler disease has not been yet well defined. We retrospectively studied twenty-two patients who had a retinal detachment on the first eye. Among the ten patients treated by peripheral confluent laser photocoagulation, five had a retinal detachment after a mean follow-up of fifteen months; with a 42% rate of spontaneous retinal detachment bilateralization, we can conclude that laser therapy has not been efficient. Four patients treated by focal or circular laser photocoagulation, cryotherapy or vitrectomy developed retinal detachment. Eight eyes treated by a preventive encircling scleral buckle did not develop retinal detachment, with a mean follow-up of twenty-one months. This follow-up is still too short, but greater than the mean bilateralization delay. Per and postoperative complications had no consequences.     

Treatment of distal femoral fractures in the elderly. Results with the retrograde intramedullary supracondylar nail

The incidence of neural tube defects including myelomeningocele, which is one of the most common causes of infant and childhood disability, can be substantially reduced by folic acid supplementation to the diet of women before and during the early stages of pregnancy. All females of childbearing age should be taking folic acid supplements of 0.4 mg/day (400 micrograms/day) and consuming a diet rich in folate. Because many pregnancies are unplanned, supplementation should not await plans for pregnancy. Because pediatric nurse practitioners are in frequent contact with both adolescent patients and patients whose mothers are of childbearing age, and because pediatric nurse practitioners have an interest in preventing neural tube defects in future pediatric patients, they are in a good position to provide the necessary anticipatory guidance regarding the critical need for adequate folic acid intake by females of childbearing age. This article discusses and includes guidelines for providing this anticipatory guidance.     

Comparative study of chronic aluminum-induced neurofilamentous aggregates with intracytoplasmic inclusions of amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) is characterized neuropathologically by chromatolysis, Bunina bodies, hyaline inclusions, skein-like inclusions and axonal spheroids. Aluminum, a known neurotoxin, is the cause of dialysis encephalopathy and is considered to be a causative agent in high incidence foci of ALS in the western Pacific. We have developed an experimental model of motor neuron degeneration in New Zealand white rabbits using chronic low-dose intracisternal administration of aluminum and compared the clinical and neuropathological changes to those of human ALS. Aluminum-inoculated rabbits developed progressive hyperreflexia, hypertonia, limb splaying, gait impairment, muscle wasting, hindlimb paralysis and impaired tonic immobility responses without overt encephalopathic features over a 14-month period. Examination of spinal cords from these animals demonstrated the frequent occurrence and progressive development of anterior horn cell lesions that included small, round, argentophilic perikaryal inclusions similar to hyaline inclusions seen in human ALS. Other inclusions were more condensed and eosinophilic, while still others had neurofibrillary tangle-like morphologies. Axonal spheroids and neuritic thickenings were also prominent and were identical to those seen in human ALS. We believe that the similar and progressive development of neuropathological changes observed in the chronic aluminum-intoxication model, compared to human ALS, warrants further study to aid in understanding the cellular and molecular mechanisms of human motor neuron disease.     

Striato-nigral degeneration. Apropos of a clinical, therapeutic, and anatomic study of 2 cases

The authors report two anatomo-clinical cases of striato-nigral degeneration with trial of L-Dopa; one of them included an olivoponto-cerebellar degeneration. The features of this degeneration are compared with the literature and related to heredo-degenerative diseases of the nervous system.     

Rigid osteosynthesis with the AO plate and Phemister''s spongioplasty in secondary treatment of diaphyseal gunshot fractures

To clarify the histogenesis and differentiation potential of central neurocytoma, a pathological investigation of seven tumors from three patients was conducted using immunohistochemistry and ultrastructural analysis in addition to systematic in vitro studies. Six tumors were studied immunohistochemically and five were examined ultrastructurally. All cases that were immunostained were positive for synaptophysin in nuclear-free neuropil islands. In five tumors, a few tumor cells, in addition to reactive astrocytes, were positive for glial fibrillary acidic protein (GFAP). Vimentin staining was also positive in a few tumor cells of five specimens. Neurofilament staining was always negative. All cases for which ultrastructure was examined showed various synaptic abnormalities. Cultured cells were subdivided into three distinct tumor cell types: neuronal cells which stained for neurofilament proteins with neurosecretory granules; small flat undifferentiated cells with a high nuclear-cytoplasmic ratio and scant cytoplasmic organelles; and small round or multipolar astrocytic cells with 10-nm intermediate filaments which stained for GFAP. Our tissue culture studies disclosed that cultured neurocytoma cells form a cellular mosaic similar to subependymal plate layers that are composed of mitotically active cells, neurons and glia.     

Deep venous thrombosis in a patient with superficial thrombophlebitis. Apropos of 2 cases]

Many schools refer children who have sustained an injury, directly to the local Accident & Emergency (A&E) department. This prospective study monitored these referrals for one school term (08.01.96-31.03.96). During this time 200 children under the age of 14 years presented from school to the A&E department of the Royal Aberdeen Childrens Hospital (RACH). The majority presented with trivial or mild injuries and 45% of parents felt that attending A&E was inappropriate. Half the accidents happened to unsupervised children. Rural children and children of working parents were less likely to attend A&E. In Grampian Region school referrals to A&E generate a significant workload for the A&E department with resultant cost implications. It would appear that a large number of these attendances are medically unnecessary and result from a desire by the school to avoid any complaint or litigation.     

Cystic lymphangioma of the mediastinum. Apropos of 3 cases, review of the literature]

New cysteine proteinase inhibitors, TMC-52A, B, C, and D, were isolated from the fungal fermentation broth. On the basis of a taxonomical study, the producing strain, F-2665, was characterized as Gliocladium sp. Spectroscopic analyses and chemical degradation have shown TMC-52A to D to be epoxysuccinyl peptides. TMC-52A to D strongly inhibited cysteine proteinases, in particular, cathepsin L with IC50 values of 13 nM, 10nM, 10nM, and 6nM, respectively.     

Recurrent parotitis in children and HIV infection. Apropos of 4 cases]

Over a 2-year period at our institution, 6 patients underwent metallic stent treatment, 5 for malignant conditions and 1 for a benign condition of the esophagus. The use of expandable metallic stents for benign strictures has paralleled malignant indications but is limited and less understood from a clinical standpoint. A review of current literature in the treatment of benign strictures is presented. Treatment of benign strictures is associated with high morbidity and mortality as demonstrated by the cumulative experience of 21 patients. Migration, hyperplastic tissue obstruction at the terminal ends, reflux, and complications of perforation occur at a prohibitive rate. We conclude that expandable metallic stents should be reserved for palliative treatment of esophageal malignant obstructions and tracheoesophageal fistulas. Pharmacological management, necessary dilatations and operative corrections (antireflux procedures, esophagectomy) are recommended treatments for benign strictures.     

Transverse and T fractures with fracture of the posterior wall of the acetabulum. Results of orthopedic and surgical treatment. Apropos of 52 cases

A patient developed delayed facial nerve palsy at the level of House-Brackmann grade I to grade III 10 days after vestibular schwannoma surgery by the suboccipital transmeatal approach. The palsy had completely recovered after one month. Immunological study showed reactivation of herpes simplex and magnetic resonance (MR) imaging demonstrated an abnormal enhancement pattern of the facial nerve; intense enhancement of the distal intracanalicular segment and labyrinthine segment, similar to the MR findings for Bell's palsy. A prospective control study on the enhancement pattern of the functionally preserved facial nerve after vestibular schwannoma surgery in six cases showed a similar pattern to that of the normal facial nerve. Based on these findings, we propose the hypothesis that herpes simplex reactivation is an underlying cause of delayed facial palsy after vestibular schwannoma surgery.