Common fibular nerve lesions. Etiology and treatment. Apropos of 146 cases with surgical treatment

Acute anterior shoulder dislocations are extremely painful conditions that force patients to present to emergency rooms or physicians' offices immediately. The diagnosis usually is established through a careful history and examination, and may be confirmed by appropriate radiography. The immediate treatment objective is to achieve reduction as early as possible, preferably through a closed reduction method with the least discomfort. Current methods of reduction are based on either traction or leverage maneuvers, with each having its own merits and disadvantages. This article, however, revisits the subject by a comprehensive literature review. It addresses obstacles to reduction and reports a closed reduction technique for the acute anterior dislocations of the shoulder that uses both traction and leverage maneuvers simultaneously. In addition, the technique eliminates failing factors of current reduction methods such as the surgeons' weakening or slippery grip when using traction methods. It is expected, by virtue of the method, that it would reduce the chances for complications such as humeral shaft fractures as can occur in leverage maneuvers. This method addresses all potential anatomical and pathological features of acute anterior dislocations of the shoulder to facilitate an earlier and more comfortable reduction.     

Gynecomastia. Management of diagnosis and therapy. Apropos of 52 cases

MARCKS is a widely expressed protein kinase C substrate that is essential for normal prenatal development of the central nervous system in mice. MARCKS-deficient mice exhibit universal perinatal mortality and numerous developmental abnormalities of the brain and retina. To determine which domains of the protein were important in complementing these neurodevelopmental anomalies, we have interbred MARCKS knockout mice with transgenic mice expressing an epitope-tagged human MARCKS transgene that can completely correct the MARCKS-deficient phenotype. Previous structure-function studies showed that a nonmyristoylatable form of MARCKS could correct all of the neuroanatomical abnormalities, and resulted in approximately 25% viable pups that grew to adulthood and were fertile. The present experiment attempted a similar complementation strategy in which a nonmyristoylatable, "pseudo-phosphorylated" form of the protein was used, which has been shown to be almost completely cytosolic in cell expression studies. Surprisingly, this transgene was able to complement almost all of the cerebral anatomical abnormalities characteristic of the knockout mice. However, these mice also exhibited a universal, novel phenotype: profound retinal ectopia, in which retinal tissue was often found in the vitreous humor as well as extraocularly. Retrospective evaluation of the original MARCKS knockout phenotype revealed that this anomaly was present in about 43% of the knockout mice, and was clearly detectable as early as embryonic day 12.5, before retinal cell differentiation begins. These data suggest that a nonmyristoylatable, pseudo-phosphorylated form of MARCKS can complement most if not all cerebral aspects of the MARCKS-deficient phenotype, but that it appears to worsen a retinal phenotype, perhaps by exerting a dominant-negative effect on a coexpressed MARCKS homologue.     

Unrecognized posterior dislocations of the shoulder. Apropos of 6 cases

Reporting six cases of posterior dislocation of the shoulder examined in a rheumatological setting, the authors emphasize the diagnostic difficulties in this condition. The post-epileptic aetiology is often unrecognized. Certain radiological techniques permit recognition of the dislocation, when the antero-posterior film shows little abnormal. The authors analyze the anatomical lesions, which sometimes include fracture, and review the orthopaedic and surgical treatments, and the results obtained.     

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).     

Bilateral acetabulum fractures of the anterior column and vertebral body fracture after alcohol-induced seizure

The case of a 54-year-old male with a compression fracture of the T 12 vertebral body and a bilateral anterior column fracture of the acetabulum is presented. The origin of this rare combination of fractures is explained by the action of the patient's own muscle force on bone of very poor quality. The treatment of these lesions is comparable to the treatment of similar fractures in bone of normal quality.     

Treatment of bleeding duodenal ulcer. A study of mortality and indication of surgical treatment. Apropos of 557 cases

From 1986 to 1996, 557 patients are treated for acute ulcer bleeding. The sex ratio is five to one for men, the average age is 40 years old. The duodenal ulcer is revelated by haemorrhage in 25.8%. 181 patients underwent a surgical operation (32%). This percentage is higher that those encountered in the literature, due probably to our specific context (patients from low socioeconomic level, can not afford medical treatment, medical surveillance or control, lack of blood products in emergency. The most practiced surgical treatment is weinberg operation: "Troncular Vagotomy" with "pyroloplasty" and "ulcer sean" practiced in 86.1% of the cases; "Troncular Vagotomy" with "Gastro-intestinal anastomosis" is operated in 7.7% of the cases; "Superselective Vagotomy" and "Seromyotomy" is practiced in 3.8%, with the "Antroduodenectomy" is practiced in 1.1% of the cases. The overall death rate observed is about 4% this value increase to 11% after surgical treatment. This death rate is lower than the literature, that's probably anociated the fact that most of our patients are young and do not hold severe weaknesses. This study indicates that mortality was related to the patient's age, the patient's condition and recurrent haemorrhages.     

Trans-symphyseal approach in the treatment of cervico-urethro-vaginal fistulas. Apropos of 2 cases

We opted for a symphysiotomy approach in the management of cervico-urethro-vaginal fistulae in two patients. This approach offers an excellent exposure of the region of the bladder neck. After section of the symphysis pubis with a Gigli's wire saw, the anterior wall of the bladder was taken down to the fistulae and we excised the fistulous tract. Longitudinal closure of the fistulae and the bladder followed. Results were satisfactory and there were no urinary incontinence.     

Pleomorphic adenoma of the parotid gland. Results of surgical treatment

Twenty years experience of lateral parotidectomy as suspical treatment for pleomorphic adenoma are reviewed. All cases were managed at the ORL Clinic of the University of Zürich. 167 patients were followed for the frequency of possible recurrent tumors. Three patients (3/123) operated primarily developed a recurrences. Recurrences appeared after an average of 10 years, ranging from 1-30 years. The follow-up time varied from 1 to 21 years (average, 8 years). 39% (13 of 33) of the patients, who were re-operated for a recurrent tumor, developed another recurrence. The second recurrence appeared after an average of 10 years, ranging from 1-22 years. A persistent partial paresis of the facial nerve was found in 1% of the patients operated primarily and in 9% of the patients operated more than once. No paralysis was seen. We now choose "en-bloc" resections of pleomorphic adenomas without intra-operative opening of the tumor capsule as the treatment of choice. This treatment was possible in 83% of all cases, using a lateral parotidectomy. If tumor extends into the medial parotid lobe, total parotidectomy is required.     

Urethral diseases in children at surgical departments of the Cotonou Hospital. Apropos of 77 cases

Over a 6-year period in the surgical departments of Cotonou hospital, urethral diseases in children represented 20% of all infantile urological diseases and essentially consisted of urethral strictures (26 cases), hypospadias (22 cases), posterior urethral valves (12 cases), prolapsed urethral mucosa, the only disease observed in girls (9 cases). These diseases generally do not raise any diagnostic problems, but the real problem concerns follow-up of these children, who are usually lost to follow-up after discharge.     

Echo-guided percutaneous cholecystostomy in the treatment of acute cholecystitis. Apropos of 41 cases

Differents studies note many complications of the traditional cholecystectomy for acute cholecystitis in critically ill and very old patients. We report a retrospective study of ultrasound-guided cholecystostomy as an alternative treatment avoiding surgery in 41 patients between April 1988 and January 1994. Mean-age was 77.8 years (42-95). Hospital mortality concerned five (12.2%) patients. Four (9.8%) required surgical procedure, all of them with simple post-operative course. Six (14.6%) had a recurrence between 1 and 67 months after the end of the drainage. Twenty-six patients are considered as healed, without recurrence, after a mean-follow-up of 33 months. The percutaneous echoguided cholecystostomy seems to be a treatment of choice for patients with a contraindication for a surgical procedure. This technic allows an efficient treatment in patients with post-operative cholecystitis.     

Intracapsular hip fractures. Results of management adopting a treatment protocol

The results of the treatment of 166 patients with intracapsular fractures of the femoral neck during a 30-month period are reviewed. A protocol was adopted whereby patients younger than 65 years of age, together with those with undisplaced fractures, were treated with internal fixation, whereas patients older than 85 years of age were treated with primary hemiarthroplasty. The remaining 120 patients, aged 65-85 years, with displaced fractures were carefully evaluated preoperatively using a scoring system of their physiologic status. The more ambulant and independent patients who were medically fit and mentally alert, with good proximal femoral bone stock, who achieved a physiologic status score (PSS) of 20 or more from a maximum of 26, were managed by reduction and internal fixation of their fractures. Those patients with a PSS below 20 were treated with replacement arthroplasty. At a mean of 21 months postfracture, the mortality was 14%, although, among survivors, there was a low incidence of fracture-related complications, with only 5% of the total group requiring reoperation for infection, internal fixation failure, or prosthetic dislocation. The functional outcome was satisfactory in both treatment groups, although the mean scores for regained mobility and final placement more closely approximated the prefracture scores in the patients undergoing internal fixation. The authors conclude that preoperative assessment of the PSS is a useful guide in determining the appropriate treatment for these fractures, and that internal fixation in the 42% of patients aged 65-85 years with a high PSS appears to be well justified.     

Neuroglial heterotopia. Apropos of 8 cases with non-nasofrontal sites

Endothelin-1 (ET-1), a peptide isolated from the culture medium of endothelial cells, mediates a variety of physiological and pathological responses including mitogenesis. We have compared the expression of ET receptors in untransformed versus ras-transformed NIH-3T3 murine fibroblasts and in untransformed versus SV40-transformed W138 (VA13) human fibroblasts by ligand binding and Northern analysis. NIH-3T3 and W138 cells displayed high affinity (200 and 220 pM) and high density (23,000 sites/cell and 14,000 sites/cell for NIH-3T3 and W138 cells, respectively) ET receptors. Competition binding experiments using subtype-selective ligands identified these receptors as the ETA subtype. Addition of ET-1 to the cells produced a concentration-dependent increase in intracellular calcium release. Both ras-transformed NIH-3T3 cells and SV40-transformed W138 cells (VA13) completely lacked [125I]ET-1 binding and failed to release calcium when exposed to ET-1. Northern analysis of the polyadenylated RNA (polyA RNA) isolated from untransformed and transformed cells revealed that the steady-state level of ETA receptor RNA was 90-95% less in transformed cells compared to untransformed cells. Thus, the loss of ET receptors as well as the receptor-mediated responses in transformed cells can be explained by down-regulation of ET receptor mRNA.