New concepts for endoprostheses of the distal radio-ulnar joint

The primary mechanism and most common cause of hemolytic disease in patients with prosthetic heart valves are mechanical trauma to red blood cells and paraprosthetic valvular regurgitation, respectively. Presenting features in patients with this condition include anemia, congestive heart failure, fatigue, jaundice, dark urine, and a regurgitant murmur. Various laboratory studies can be utilized to diagnose hemolytic anemia and to assess the severity of hemolysis. Transthoracic echocardiography, transesophageal echocardiography, and Doppler studies including color Doppler are useful imaging methods to assess valve function. Treatment is usually medical (oral iron); however, in patients with paravalvular regurgitation, surgery is often required to correct the anemia.     

The management of acute fractures involving the distal radio-ulnar joint and distal ulna

The acute management of fractures involving the distal radio-ulnar joint and distal ulna is controversial. The primary goal is recognition and differentiation between stable and unstable fracture patterns. Although an operative approach is adopted in the treatment of these injuries, the optimal management protocol awaits good prospective randomized studies.     

Isolated traumatic dorsal dislocation of the distal radio-ulnar joint. Report of seven cases

The authors report seven cases of isolated dorsal dislocations of the distal radio-ulnar joint. Four were recent dislocations and three were old, chronic dislocations. Acute dislocations were treated surgically. An anatomic study on human cadavers enabled us to define the injuries responsible for radio-ulnar dislocations. An electromyographic study of the extensor carpi ulnaris confirmed its role as a dynamic stabilizer of the ulnar head. Two of the three old dislocations were revised after an attempt at ligamentous reconstruction. These patients benefitted from a resection of the ulnar head. The third patient one underwent a Sauve-Kapandji procedure. Cadaver studies underline the fact that ligamentous reconstruction procedures are actually tenodeses.     

Lateral sellar compartment: history and anatomy

The pertinent history leading to our current knowledge of the anatomy in the lateral sellar compartment is presented along with the known and unknown anatomic details of this region. The reasons why "cavernous sinus" is a misleading term for this compartment are presented.     

Surgical anatomy of the temporal lobe

The complex functional and anatomic relationships between the structures in and around the temporal lobe are central to the problem of intractable partial complex seizures. Resecting those areas that are responsible for seizures and protecting those that are essential for the normal functioning of the patient are the fundamental tasks of the epilepsy surgeon. A thorough understanding of the structural and functional anatomy of this region is essential to achieve these goals.     

Surgical anatomy of the greater pectoral muscle

In 41 preparations of the m. pectoralis major it has been stated by means of anatomical methods that the vascular "hilus" is projected on the upper third of its middle part and represented by the thoracic branch of the thoracoacromial artery. The latter has several variants dividing into branches of the successive orders. It has been stated that the muscle has a wide network of anastomoses at the macro-microscopic level. For plastic purposes, it is expedient to use the external and middle parts of the m. pectoralis major which have more favourable conditions of the blood supply. Owing to the data obtained and the technique, developed on 25 corpses, for cutting out and graft transplantation in the thoracic cavity, it has been possible to operate 9 patients.     

Surgical anatomy of the internal thoracic artery

BACKGROUND: The internal thoracic artery (ITA) has become increasingly important in coronary artery bypass grafting due to the excellent long-term results. This study reviews its anatomic characteristics. METHODS: The ITAs of 100 cadavers were examined and their origin, relation to the phrenic nerve, presence of lateral costal branch; origin of pericardiacophrenic arteries, length, level and type of ITA termination, relation with the transverse muscle of thorax, collateral parietal branches, and distance between the ITA and sternal margins were studied. RESULTS: The ITA was present in all cases, originating directly from the subclavian artery or from a common trunk with other arteries. Its length was 20.4 cm on average, and the most frequent level of termination was at the sixth intercostal space, existing as a bifurcation in 93% and as a trifurcation in 7%. The pericardiacophrenic artery originated from the ITA in 89%. The lateral costal branch was present in 15% of the cases. The ITA was covered by the transverse muscle of the thorax for 7.5 cm (average) and was crossed anteriorly by the phrenic nerve in 70.0%. CONCLUSIONS: Information provided by this study may contribute to knowledge of its anatomic characteristics and in turn help prevent complications in ITA dissections.     

The surgical anatomy of the fat in the upper eyelid medial compartment

The surgical anatomy of the upper eyelid fat in the medial compartment was investigated in 388 patients and in 12 cadavers. We found two individual fat pads comprising this compartment. The difference among the investigated cases was found to be the extent of their separation. In 16.7 percent of the cadavers' eyelids the fat pads were entirely separated, in 45.8 percent they were separated to about half their length, while in 37.5 percent only the tips were separated. Among the patients in whom only the protruded fat was inspected, 59.8 percent of the fat pads were separated, and in the rest, only the tips were isolated. On histologic examination we could always identify two well-circumscribed fat pads, each surrounded by a fibrocollagenous tissue. At the level of their interconnection, a loose fibroareolar tissue was found. In practice, during blepharoplasty, both fat pads should be addressed in order to achieve the expected results.     

Acute compartment syndrome of the thigh after joint replacement with anticoagulation

We describe three patients with a compartment syndrome of the thigh, two after total hip replacement and one after total knee replacement. Two of the patients were fully anticoagulated. A compartment syndrome of the thigh is a rare, but important complication of joint replacement surgery if patients are receiving anticoagulants. Close observation is needed and when indicated monitoring of the intracompartmental pressure should be done. Early recognition of the signs and symptoms of an acute compartment syndrome and knowledge of the anatomy of the compartments of the thigh will help in the diagnosis and treatment of this potentially devastating complication.     

Surgical anatomy, diagnosis and treatment of spigelian hernia

In reporting 11 cases of Spigelian hernia observed, the Authors describe pathological findings of this rare disease. Aetiopathogenesis as well as indication for surgery and surgical technique are stressed.     

Surgical anatomy of the infratemporal fossa: the styloid diaphragm revisited

INTRODUCTION: The infratemporal fossa (ITF) gives passage to most major cerebral vessels and cranial nerves. Dissection of the ITF is essential in many of the lateral cranial base approaches and in exposure of the high cervical internal carotid artery (ICA). We reviewed the surgical anatomy of this region. METHODS: Direct foraminal measurements were made in seven dry skulls (14 sides), and the relationship of these foramina to each other and various landmarks were determined. Ten ITF dissections were performed using a preauricular subtemporal-infratemporal approach. Preliminary dissections of the extracranial great vessels and structures larger than 1 cm were performed using standard macroscopic surgical techniques. Dissection of all structures less than 1 cm was conducted using microsurgical techniques and instruments, including the operating microscope. The anatomic relationships of the muscles, nerves, arteries, and veins were carefully recorded, with special emphasis regarding the relationship of these structures to the styloid diaphragm. The dissection was purely extradural. RESULTS: The styloid diaphragm was identified in all specimens. It divides the ITF into the prestyloid region and the retrostyloid region. The prestyloid region contains the parotid gland and associated structures, including the facial nerve and external carotid artery. The retrostyloid region contains major vascular structures (ICA, internal jugular vein) and the initial exocranial portion of the lower Cranial Nerves IX through XII. Landmarks were identified for the different cranial nerves. The bifurcation of the main trunk of the facial nerve was an average of 21 mm medial to the cartilaginous pointer and an average of 31 mm medial to the tragus of the ear. The glossopharyngeal nerve was found posterior and lateral to stylopharyngeus muscle in nine cases and medial in only one. The vagus nerve was consistently found in the angle formed posteriorly by the ICA and the internal jugular vein. The spinal accessory nerve crossed anterior to the internal jugular vein in five cases and posterior in another five cases. It could be located as it entered the medial surface of the sternocleidomastoid muscle 28 mm (mean) below the mastoid tip. The hypoglossal nerve was most consistently identified as it crossed under the sternocleidomastoid branch of the occipital artery 25 mm posterior to the angle of the mandible and 52 mm anterior and inferior to the mastoid tip. CONCLUSION: The styloid diaphragm divides the ITF into prestyloid and retrostyloid regions and covers the high cervical ICA. Using landmarks for the exocranial portion of the lower cranial nerves is useful it identifying them and avoiding injury during approaches to the high cervical ICA, the upper cervical spine, and the ITF.     

Ulnar styloid malunion with dislocation of the distal radioulnar joint

AIMS: Delayed-release formulations of mesalazine often rely on the gastrointestinal luminal pH profile to deliver 5-aminosalicylic acid (5ASA) to the colon. The aim of this study was to examine the influence of luminal pH on mesalazine release. METHODS: We studied the effect of co-administration of omeprazole and lactulose on the steady-state pharmacokinetics of Eudragit S-coated mesalazine in healthy volunteers. RESULTS: No significant changes in urinary or faecal levels of 5ASA or its main metabolite, N-acetyl 5ASA, were apparent. CONCLUSIONS: This study suggests that co-administration of omeprazole and lactulose does not impair the release of delayed-release mesalazine.     

Dynamic radio-ulnar convergence after the Darrach procedure

We reviewed 23 patients who had had 25 Darrach procedures for traumatic or post-traumatic disorders of the wrist at a mean follow-up of 75.5 months (36 to 121). The mean age at the time of operation was 61.1 years (34 to 82). All patients were reviewed in person. Assessment included a history, a questionnaire on patient satisfaction and a detailed physical examination. Standardised radiographs of both wrists were taken with the patient's hands in a resting position and during maximal grip. Convergence of the distal ulnar stump towards the distal radius during maximal grip (dynamic radio-ulnar convergence) was seen in 14 wrists including five with actual contact (dynamic radio-ulnar impingement), but this produced symptoms in only two cases. The presence of dynamic radio-ulnar convergence did not correlate with grip strength, pinch strength, range of movement or wrist score, but was associated with increased length of excision of the distal ulna. Nineteen of the 23 patients were satisfied with the procedure. Dynamic radio-ulnar convergence is common after the Darrach procedure, but is rarely symptomatic; resection of the distal ulna remains a reliable procedure in the older patient with pain and loss of movement. Excision of the lower end of the ulna should be restricted to the least required to restore full rotation.     

Computerized tomography in the diagnosis of subluxation of the distal radioulnar joint

BACKGROUND: The diagnosis of distal radioulnar joint (DRUJ) subluxation is difficult. Routine radiographs are imprecise in clinical analysis. However, the anatomy and dynamic configuration of this articulation have been clearly defined utilizing computerized tomography (CT). Three CT criteria for the evaluation of DRUJ subluxation have been reported: Mino's criteria, the epicenter method and the congruity method. Previous reports discussed these criteria in the analysis of symptomatic DRUJ, but no clear conclusion has been reached. The purpose of this study is to investigate accurate criteria of CT in defining subluxation of the DRUJ. METHODS: Eighty distal radioulnar joints in 40 patients with suspected DRUJ subluxation underwent CT scans of both symptomatic and asymptomatic wrists. The CT scan was obtained through the DRUJ with the forearm in neutral rotation, active full supination and active full pronation. Three CT criteria were used to assess the DRUJ in all positions of unstable and normal wrists. RESULTS: Overall, 54 wrists were included in the final analysis. Seventeen symptomatic wrists had frank DRUJ instability diagnosed from true lateral radiographs, and 11 were reconfirmed from intraoperative pathology. The other 37 wrists had normal DRUJ. Among the three methods, the epicenter method had similar sensitivity to Mino's criteria and the congruity method. However, the epicenter method had much better specificity than Mino's criteria and the congruity method. CONCLUSIONS: For accurate diagnosis of subluxation of the DRUJ, CT scan through the symptomatic DRUJ in neutral rotation, active full supination, active full pronation and analysis with the epicenter method are recommended.     

Synovial chondromatosis of the distal radioulnar joint: a case report

The most definitive method for confirming the diagnosis of synovial chondromatosis is the identification of cartilaginous metaplasia within the synovium on histologic examination. In advanced stages of the disease, plain radiographs and magnetic resonance imaging (MRI) scans demonstrate calcified and cartilaginous bodies, respectively, but in earlier stages, plain radiographic findings may be normal and MRI scans may reveal only nonspecific increased fluid. Although rare in the wrist, synovial chondromatosis must be considered in the differential diagnosis in a patient presenting with pain and swelling of the distal radioulnar joint. Surgical exploration of the joint and synovectomy, alone or in combination with removal of loose bodies, is the recommended treatment.     

Surgical anatomy for endoscopic subfascial division of perforating veins

PURPOSE: This study was undertaken to define the surgical anatomy of the medial perforating veins (PVs) of the leg and to provide information on how to gain access to all medial PVs from the superficial posterior compartment during a subfascial endoscopic procedure. METHODS: The venous anatomy of 40 limbs (from 23 cadavers) were studied. Medial PVs located between the ankle and the tibial tuberosity were dissected. None of the subjects had pathologic evidence of venous disease. Each PV's type (direct or indirect), size (< 1 mm, 1 to 2 mm, > 2 mm), location (distances from ankle [D1], and tibia [D2]), and accessibility from the superficial posterior compartment were recorded. RESULTS: Five hundred fifty-two PVs were identified (mean, 13.8; range, 7 to 22). Two hundred eighty-seven PVs (52%) directly connected the superficial with the deep systems, 228 (41%) were indirect muscle perforators, and 37 PVs (7%) were undetermined. One hundred thirty-seven PVs (25%) were > 2 mm. Sixty-three percent of PVs were accessible from the superficial posterior compartment. In the distal half of the leg, two groups of direct PVs could be identified (Cockett II: D1, 7 to 9 cm; Cockett III: D1, 10 to 12 cm). In the proximal half of the leg, paratibial direct PVs (D2 < or = 1 cm) were found clustered in three groups (D1, 18 to 22 cm; D1, 23 to 27 cm; D1, 28 to 32 cm). CONCLUSIONS: Our study confirmed the presence of the Cockett II and III PVs and three groups of proximal paratibial PVs, including the "24-cm" perforators. Two thirds of the medial direct PVs are accessible for endoscopic division from the superficial posterior compartment. To divide paratibial PVs, however, incision of the paratibial deep fascia is frequently required.