Anterior interbody lumbar fusion in severe low back pain

Clinical, functional, and radiographic results of 83 patients treated by anterior interbody lumbar fusion are presented. Seventy-two percent of patients previously had undergone 1 or more spine operations. In 54% of patients, the main indication for anterior fusion was failed back surgery. There were 52 women and 29 men. The mean age of patients at operation was 43.6 years (range, 21-60 years). The mean followup time was 5 years (range, 2-10 years). Solid fusion was achieved in 104 (81%) of 129 levels on 59 (71%) of 83 patients. The clinical results were estimated 3 ways: the patient's own opinion, the change of Oswestry disability index, and the score rating system of the Japanese Orthopaedic Association. Patient opinions of the benefit of the procedure were the following: 74% very much improved, 12% little improved, 10% no improvement, and 4% worse. The mean Oswestry index before operation was very high at 48.8 points (range, 22-82 points), reflecting the severity of dysfunction in these patients. The mean Oswestry index at the followup study was 30.5 points (range, 0-68 points). In the score rating system of the Japanese Orthopaedic Association, the final rating of 25 points or more (regarded as satisfactory) was achieved in 22 (26.5 %) patients. The decision regarding indications for the operation and the operation itself should be made by experienced surgeons.     

Intraarticular lesions in distal fractures of the radius in young adults. A descriptive arthroscopic study in 50 patients

We examined the frequency of associated chondral and ligament lesions in distal fractures of the radius in young adults (men 20-60 years, women 20-50 years). Fifty initially displaced fractures were examined arthroscopically. Chondral lesions were found in 16 patients (32%). All patients but one were found to have a ligamentous injury in the wrist. No major instability was found. The most frequent ligament tear was the triangular fibrocartilage complex in 39 cases (78%), with a statistical correlation to ulnar styloid fractures. The scapholunate ligament was partially or totally torn in 27 cases (54%). No correlation was found between specific fracture type and pattern of ligament injury. Chondral and ligamentous lesions were frequent and may explain poor outcomes after seemingly well-healed distal fractures of the radius. The ligament lesions should also be kept in mind when early mobilization of the distal fracture of the radius is considered.     

Is surgical treatment of deltoid ligament rupture necessary in ankle fractures?

PURPOSE OF THE STUDY: Fractures of the lateral malleolus associated with rupture of the deltoid ligament are severe fractures types. There is still discussion about wether the ruptured deltoid ligament should be sutured or not. To elucidate further the need for surgical repair of this structure a comparative and retrospective review was conducted at a mean follow-up of 4 years and 8 months. MATERIAL AND METHODS: Twenty nine men and 15 women were included with a mean age of 34 years. Patients were subdivided into two groups according to the attitude regarding the ligament. In the first group (n = 18), an operative repair of the ligament was made and in the second group (n = 17) we leaved it unrepaired. Nine patients were evaluated separately because of an associated osteochondral fracture (n = 7) or a worse reduction of the fibula (n = 2). Subjective and objective clinical assessment were evaluated according to a modified Cedell classification. Roentgenograms including A.P, lateral, mortise view and a external rotation stress view described by Kleiger were obtained in all patients. RESULTS: Subjective and objective analysis showed no significant difference between the two groups, likewise no differences were observed for post operative complications rate. Medial instability was observed in four cases (2 in group 1 and 2 in group II). Roentgenographicaly, more ossifications of the deltoid ligament were founded in group II (p = 0.013), and only one degenerative osteoarthritis of the ankle was seen in group II. Clinical results in the group of patients with osteochondral fracture were statistically worse than in the two previous groups (p = 0.001), with frequent progression to osteoarthritis in four cases. DISCUSSION: In our experience it is impossible to advise surgical repair of the deltoid ligament in accordance to the type of lateral malleolar fracture like other authors have suggested. The existence of a significant widening of the medial space greater than 3 mm was nearly correlated with a deltoid ligament disruption, of the 23 patients treated with a medial approach, the ligament was ruptured in 22 cases. In this study, we may conclude than an untreated rupture of the deltoid ligament does not lead to instability. The advantages of the deltoid repair may be obtained if the fixation of the lateral malleolus allows a perfect congruency of the mortise. The most predictive radiographic factors for a poor outcome were a persistent widening of the medial joint greater than 3 mm, an associated osteochondral fracture and a poor reduction of the lateral malleolus which results in degenerative arthritis of the ankle at long term follow-up. CONCLUSION: Repair of the deltoid ligament is unnecessary if the internal fixation of the fibula achieves an anatomical reconstitution of the mortise. Exploration of the medial side is indicated only with a medial incongruency greater than 3 mm on intra operative roentgenograms.     

Severe lumbar lordosis after dorsal rhizotomy

The purpose of this study is to compare the safety, efficacy, and potential benefits of vaginal radical hysterectomy (VRH) versus abdominal radical hysterectomy (ARH) in the treatment of early-stage cervical cancer. We reviewed the charts of our first 52 patients with cervical cancer. We reviewed the charts of our first 52 patients with cervical cancer who underwent a laparoscopic pelvic lymphadenectomy (LPL), followed either by a VRH (Schauta) in 25 cases or ARH in 27 cases. For the 52 patients, the mean lymph nodes count obtained by LPL was 27 (range 8-59), and the only complication was an external iliac vein trauma requiring laparotomy. Both VRH and ARH groups were comparable in terms of age, weight, parity, stage, histology, and tumor volume. The mean blood loss was 400 cc for VRH vs 450 cc for ARH, operating time was 270 min vs 280 min, blood transfusion in 5 vs 4 women, and postoperative stay was 7 days for both groups. The only intraoperative complication in addition to the vein trauma was a cystotomy which occurred in 2 VRH patients. Febrile morbidity was noted in 4 VRH patients vs 9 ARH patients. There were one preperitoneal abscess and one hematoma in the VRH group vs 4 wound infections and 1 hematoma after ARH. Ileus occurred in 1 VRH vs 4 ARH patients. The current mean follow-up time is 27 months (8-52) and there has been one recurrence so far in the ARH group. Even though this is a retrospective study, our data indicate that VRH and ARH are comparable, except for the absence of an abdominal scar and less febrile morbidity with the vaginal approach. However, in our opinion, the main advantage in learning the Schauta operation is that the experience gained allows one to offer radical trachelectomy to selected young patients who wish to preserve their fertility.     

Halm-Zielke instrumentation for primary stable anterior scoliosis surgery: operative technique and 2-year results in ten consecutive adolescent idiopathic scoliosis patients within a prospective clinical trial

OBJECTIVE: To determine the efficacy and safety of a new continence procedure, tension-free vaginal tape (TVT) placement for surgical treatment of stress urinary incontinence in women. STUDY DESIGN: Eighty-three women with demonstrable stress urinary incontinence underwent a nonrandomized, prospective study using the TVT procedure. The procedure was previously described by Ulmsten et al. In the present study, instead of local anesthesia, epidural blockade with 20 mL of 2% xylocaine was used. Preoperatively the patients were evaluated with a one-hour pad test, full urodynamic testing using either a double-lumen catheter or microtip transducer catheter and were instructed to maintain an one-week baseline urinary diary one week before and two months after the operation. Another one-hour pad test and complete urodynamic evaluation using microtip transducer catheters were offered to 20 patients postoperatively. The period of follow-up ranged from 3 to 18 months. RESULTS: Thirteen women were excluded for various reasons; thus, 70 subjects were enrolled in the study. The urodynamic diagnosis of the 83 women revealed that 71 had genuine stress incontinence, 11 had mixed incontinence and 1 was normal. Mean operation time was 29 minutes (range, 20-51) and mean hospital stay 3 days (range, 2-8). Three bladder perforations occurred intraoperatively. No patients had intraoperative bleeding > 300 mL, but 11 (16%) had blood loss > 200 mL, necessitating an indwelling catheter and vaginal tamponade. No evidence of defect healing or rejection of the tape occurred. Urine leakage observed on the pad test was significantly reduced from a mean of 63 g (range, 10-213) before to a mean of 5 g (range, 0-42) after surgery. The objective cure rate was 83%, and the subjective rate was 87%. CONCLUSION: Although the follow-up period was short, the TVT procedure seemed to be a safe and effective method for the treatment of stress urinary incontinence.     

Gonadotropin triggers the generation of proteinaceous factor in vitellogenic perch (Anabas testudineus) oocyte which stimulates ovarian aromatase activity

OBJECTIVE: Evaluation of the feasibility of bilateral sacropinous ligament suspension with a stapler. Morbidity study and short term results. STUDY DESIGN: Prospective study from July 1994 to August 1996. RESULTS: Bilateral sacrospinous ligament suspension with a stapler was possible in 100% of cases and surgical technique is described. Our indications are stage III Bp and stage IV genital prolapses (according to the American Urogynecologic Society classification, 1996), with or without uterus, and when a Bologna's procedure is performed, in order to prevent enterocele. In 24 patients, the uterus was present. 20 vaginal hysterectomies and 4 conservative bilateral uterine suspensions were performed. The sacrospinous ligament suspension was associated to anterior colporrhaphy (in 74% of patients), repair of rectocele (82%), repair of enterocele (26%), posterior colpoperineorrhaphy (79%), bladder neck suspension (71%). No vascular injury nor post operative constipation was noted. In 2 patients, a small rectal laceration occurred, and in one patient one branch of the staple transfixed the rectal mucosa. Removal of the staple was easily performed without any post-operative complication. First results after an average 19 months follow-up (range 9 to 32) shows a perfect anatomic result in 77% of cases. We noted one recurrence of a vaginal vault prolapse; the patient underwent a second sacrospinous ligament fixation with good result. One patient had a stage II Aa cystocele post-operatively and three patients had a short vagina (< 6 cm). Patients who were continent before the sacrocolpopexy did not develop further urinary stress-incontinence. CONCLUSION: Bilateral transvaginal sacrospinous ligament suspension with a stapler facilitates the procedure. No post-operative constipation was noted with this method. Our first results are good. The cost of the stappler may limit its extensive use.     

Acute closed humeral shaft fractures treated with dynamic compression plate

BACKGROUND: To define the efficacy of dynamic compression plates (DCPs) for the treatment of closed humeral shaft fractures. METHODS: A total of 165 patients with closed humeral shaft fractures were studied retrospectively. There were 120 patients who underwent open reduction and internal fixation with DCPs and no bone grafting (BG). Forty-five patients received the same procedures with BG. The mean follow-up period was 93 months. RESULTS: In the DCP without BG group, the average blood loss was 350 ml, operation time was 105 minutes, hospital stay was 8.5 days and fracture union time was 13.5 weeks. In the DCP with BG group, the average blood loss was 525 ml, operation time was 115 minutes, hospital stay was 7.9 days and fracture union time was 9.2 weeks. CONCLUSIONS: In our experience, DCPs are effective for surgical fixation of humeral shaft fractures. Prophylactic BG is recommended for cases with more comminution.     

Outbreak of systemic aspergillosis in a neonatal intensive care unit

Clinical and manometric results of Delorme's operation and sphincteroplasty were assessed retrospectively in patients undergoing this procedure for fecal incontinence and rectal prolapse. A series of 33 patients (11 males, 22 females; aged 18-83 years, mean 59) with external rectal prolapse were treated by Delorme's operation between 1989 and 1996. Mean follow-up was 39 months (range 7-84). Sphincteroplasty was associated in 12 cases with severe fecal incontinence due to striated muscle defects. Good results were achieved in 27 patients (79%); prolapse recurrence was observed in 6 (21%), the mean recurrence time being 9 months (range 1-24 months). There were no postoperative deaths. Minor complications occurred in 15 patients. Changes in preoperative and postoperative manometric patterns were as follows (mean +/- SEM): voluntary contraction from 59 +/- 6.9 to 66 +/- 7.1 mmHg (P = 0.05), resting tone from 33 +/- 5 to 32 +/- 4.3 mmHg, rectal sensation from 59 +/- 5 to 61 +/- 5.2 ml of air (n.s.). A solitary rectal ulcer syndrome was detected in five patients. The histological pattern demonstrated pathological changes in 40% of cases. Fecal incontinence was resolved in 6 of 20 cases (30%) and chronic constipation in 4 of 9 (44%). Failure (n = 3) was related primarily to postoperative sepsis. The incontinence score showed a mean improvement of 35% decreasing, from 4.5 +/- 0.39 to 2.9 +/- 0.44 after surgery (P < 0.01). In conclusion, Delorme's procedure did not lead to constipation and improved anal continence when associated with sphincteroplasty.     

Abdominal trauma and pelvic injury in the growth period

Children with pelvic fractures usually are polytraumatized. Concomitant abdominal and pelvic injuries are not uncommon. Medical records and X-rays of 54 children, in which a pelvic fracture was diagnosed at our institution from 1974-1993, were reviewed. Children ages < or = 16 years and treated as in-patients were included in this study. The fractures were classified according to the AO-Classification. 47 patients (87.0%) had concomitant injuries. The mean Polytrauma Score was 23.7 (mean Injury Severity Score 30.5). Nine Children sustained an open pelvic fracture with rectal and/or vaginal tear. 15 genitourinary lesions were found in 13 children. 18 patients underwent laparotomy. A large pelvic/retroperitoneal hematoma was found in 11 cases. There were 7 liver lacerations, 7 splenic injuries, 2 mesenteric tears, 2 kidney injuries and 1 small bowel lesion. Eight children (14.8%) died with 5 of them due to retroperitoneal or/and abdominal bleeding complications. A recent follow-up examination (81.8%) with a mean follow-up of 11.3 years showed that long-term morbidity usually was attributed to pelvic concomitant injuries.     

Vaginal hysterectomy for the large uterus

OBJECTIVE: To assess the feasibility and safety of performing vaginal hysterectomy on enlarged uteri the equivalent of 14 to 20 weeks of gestation in size. DESIGN: A prospective observational study. SETTING: The Royal Free Hospital, London. PARTICIPANTS: Fourteen consecutive women undergoing vaginal hysterectomy for uterine fibroids up to 20 weeks in size. INTERVENTIONS: Vaginal hysterectomy with or without bilateral salpingo-oophorectomy or oophorectomy. MAIN OUTCOME MEASURES: Uterine size and weight, techniques used to reduce uterine size, surgical outcome, operative time, estimated operative blood loss, intra- and post-operative complications, duration of hospitalisation. RESULTS: The mean uterine size was 16.3 weeks (range 14 to 20 weeks). All hysterectomies were completed successfully by the vaginal route. The uteri weighed 380 to 1100 g, with a mean of 638.7 g. Bisection combined with myomectomy and morcellation were used in most cases to obtain reduction in uterine size, whereas coring was only utilised in two cases. The mean operating time was 84.3 min with a range of 30 to 150 min. The only complications were transient haematuria (n = 6) and superficial vaginal grazes (n = 5). One of the women required a blood transfusion. The mean post-operative hospital stay was 3.7 days (range 2 to 9 days). CONCLUSION: Enlargement of the uterus to a size equivalent to 20 weeks of gestation should no longer be considered a contraindication to vaginal hysterectomy. Many more hysterectomies should be carried out vaginally without resorting to abdominal or laparoscopic surgery.     

Is laparoscopic hysterectomy a waste of time?

Laparoscopic hysterectomy (LH) is a way to avoid laparotomy. However, there is evidence that most women treated by abdominal hysterectomy are suitable for vaginal surgery. To test this hypothesis, and to determine the relative merits of laparoscopic and vaginal hysterectomy (VH) and the best technique for LH, we prospectively studied 98 women who had relative contraindications for vaginal surgery by traditional criteria. 75 underwent LH and 23 VH. The LH group included 22 women who had been assigned to this route of surgery as part of a prospective randomised controlled comparison with VH (23 women). Surgery was completed with the intended technique in 93.9% of cases. 5 women in the LH group (6.7%) and 2 in the VH group required laparotomy or additional procedures. In the prospective randomised study LH took longer than VH (mean duration 131 vs 77 min). VH was the faster procedure, irrespective of uterine size and need for oophorectomy. With LH, the operative time increased as more of the hysterectomy was carried out with laparoscopic rather than vaginal dissection. Complication rates, blood loss, analgesia requirements, and recovery were similar for the two techniques. Our study confirms that most hysterectomies could be performed vaginally, and that LH is a much slower procedure. If LH is done, it should be converted to a vaginal procedure as early as possible to reduce the overall operating time. LH does seem to be a waste of time for most patients.     

Urethral diverticula in women. Apropos of 15 cases

Urethral diverticulum is a rare disease, arising in the urethrovaginal septum and communicating with the urethra through an orifice. Characterised by clinical polymorphism, it is diagnosed by urethrocystography and transvaginal ultrasound. We report a series of 15 cases of urethral diverticulum over a 10-year period. The mean age of the patients was post-voiding was 36 years (range 24-50). The symptoms were recurrent urinary tract infections (66%), post-voiding urethral leakage (22%), vaginal pain (22%). Clinical examination found a vaginal mass in all patients. Retrograde urethrocystography showed the diverticulum in every cases, while IVP confirmed the diagnosis in only 62% of cases. Treatment is surgical and consists of removing the diverticulum via a vaginal approach. Short and long-term course is favourable. All patients were asymptomatic and the follow-up urethrocystography showed no diverticular recurrence.     

Termination of pregnancy at 9-13 weeks' amenorrhoea with mifepristone and misoprostol

The effectiveness of a combined regimen of mifepristone and vaginal misoprostol for termination of pregnancies of 9-13 weeks of gestation was investigated in 120 UK abortion patients (median age, 22.1 years; median duration of amenorrhea, 10.3 weeks). Each woman received a single oral dose of 200 mg of mifepristone 36-48 hours before admission, at which time 800 mcg of misoprostol was administered vaginally. Where indicated, a further two doses of 400 mcg of misoprostol (vaginal or oral) were provided every 3 hours. All 120 women aborted on the day of prostaglandin administration; however, 6 women (5%) required exploratory curettage after the procedure for retained placenta. The median prostaglandin dose was 1200 mcg (range, 800-1600 mcg). The median time from misoprostol administration to abortion was 4.33 hours (range, 1.3-16.0 hours). 60 women (50%) required oral analgesics and 26 (22%) received parenteral analgesia. Diarrhea occurred in 38 women (32%). The median duration of bleeding after abortion was 12.5 days (range, 3-43 days). In questionnaires administered to 73 women, only 3 (4%) expressed dissatisfaction with medical abortion, because of pain or prolonged bleeding. The relatively high dose of misoprostol used in this study and the vaginal route of administration are presumed to account for the 95% success rate. Extension of medical abortion to later gestation times would decrease the need for surgery and expand women's choice of methods of pregnancy termination.     

Ecological treatment of bacterial vaginosis

Ecological treatment of bacterial vaginosis with a Lactobacillus (yoghurt) was studied, and the following results were obtained. 1. A total of 11 women aged 20 to 60 with bacterial vaginosis were treated with intravaginal application of 5 ml of commercial yoghurt (pH 4.3 +/- 0.2). The effect of the treatment was evaluated 3 days after administration by monitoring the vaginal discharge and bacteriological assessment. 2. The clinical improvement was evaluated and the decreases of vaginal discharge and vaginal redness were significant and vaginal pH was lowered significantly also (P < 0.05). In the vaginal discharge 29 strains of bacteria were detected, but 3 days after administration, all 14 strains of Gram-negative bacteria disappeared. As for the overall bacteriological effects, 6/11 cases (54.5%) were eradicated. 3 cases were partly eradicated, 2 cases were replaced. These findings indicated that the Lactobacillus therapy was effective in both clinical and bacteriological responses.     

The epidemiology of genitourinary fistulae in Kumasi, Ghana, 1977-1992

The aim of the study was to determine the clinical epidemiology of genitourinary fistulae as seen at Komfo Anokye Teaching Hospital in Kumasi, Ghana. A retrospective study was carried out from the hospital records and operative reports of all patients with genitourinary fistulae seen at Komfo Anokye Teaching Hospital between January 1977 and December 1992. Patient age, parity, type of fistula and cause of fistula were abstracted from the medical records. There were 164 cases of genitourinary fistula managed during the study period. There were 150 fistulae due to obstetric causes (91, 5%), the vast majority of which were due to prolonged obstructed labor (121 cases, 73.8% of all fistulae), with a minority related to complications of lower-segment cesarean section (14 cases, 8.5% of all fistulae). In 5 cases (3.1%) patients developed a rectovaginal fistula owing to perineal tears and prolonged obstructed labor. During this time period there were 157,449 deliveries, giving an obstetric fistula rate of 1 fistula per 1000 deliveries. Obstetric fistulae were most common at the extremes of reproductive age and parity Fourteen additional fistulae (8.5% of all cases) were due to gynecologic causes, most commonly from surgical injury occurring at the time of abdominal hysterectomy for leiomyomata uteri (12 cases, 7.3% of all fistulae). It was concluded that in Kumasi, Ghana, obstetric trauma from prolonged obstructed labor is the most common cause of genitourinary fistula formation. Such fistulae occur in older multiparous women as well in young primigravidae. Obstructed labour can, and does, occur in women who have previously undergone uneventful vaginal delivery. Birth attendants should be aware of that fact. Prompt referral for obstetric intervention should be made in obstructed labor, irrespective of the age and parity of the patient.     

Intra-arterial preventive chemotherapy for residual liver after resection of hepatic metastasis from colorectal cancer

We treated 18 cases with intra-hepatic arterial infusion chemotherapy after resection of hepatic metastasis from colorectal cancer (June 1991-September 1997). Eight cases were H1, 7 were H2, and 3 were H3. Hepatic lobectomy was done in 3 cases, lobectomy + partial resection in 2 cases, and partial resection in 13 cases. All cases received high-dose intermittent 5-FU infusion (WHF = 5-FU 1,000 mg/m2/5 hrs/w) on an outpatient basis. The total frequency of WHF was 4-54 times (average 29), and total 5-FU doses ranged from 6.0 to 81.0 g (average 40 g). The 1- and 5-year cumulative survival rates were 100% and 77.5% in all patients 100% and 87.5% in H1 group and 100% and 64.3% in H2 + H3 group, respectively. There was no significant difference of survival between the H1 and H1 + H3 groups. The 1- and 5-year recurrence rates in residual liver were 5.9% and 14.4%, respectively. One of 2 cases with residual liver recurrence was resected for metastasis again, and the patient is now in a disease-free state. WHF after resection of hepatic metastasis from colorectal cancer has a preventive effect for their survival, not only in H1 group but also in H2 + H3 group.     

Determination of DMPC hydration in the L(alpha) and L(beta'') phases by 2H solid state NMR of D2O

OBJECTIVE: To compare the effect of vaginal misoprostol with that of placebo when used prior to dilation and aspiration in women with a missed abortion. METHOD: Eighty-four pregnant women with a missed abortion were randomized to receive either vaginal misoprostol (200 micrograms) or placebo the day before the planned dilatation and aspiration under inhalation anesthesia. RESULT: Thirty-five women (83.33%) in the misoprostol group and 6 women (17.14%) in the placebo group aborted spontaneously prior to the scheduled dilatation and aspiration, P < 0.0001. The mean insertion to spontaneous expulsion time was 11.63 +/- 6.14 h in the misoprostol group compared to 11.95 +/- 5.43 h in placebo. In the misoprostol group two women required intramuscular pethidine for analgesia. In the placebo group there were two cases of blood loss in excess of 500 ml and one woman with a uterine perforation. CONCLUSION: Vaginal administration of misoprostol to women with a missed abortion produced spontaneous expulsion of the pregnancy and reduced the need for surgical treatment.     

Lithostar Multiline. A multi-function lithotripter for ESWL and endourology: initial clinical experiences

After > 10,000 treatments-our HM3/4 and MPL 9000 have been replaced by the Siemens Lithostar multiline. As a ESWL center with ESWL as the primary treatment indication for all types of stones in kidney and ureter we report our initial experience with this new multifunctional lithotripter. The system consists of an electromagnetic shock-wave emitter (Focus 80 x 5 mm) and a digital fluoroscopy unit. Stone localization is achieved in a - 10 degrees and + 30 degrees position without movement of the patient. The treatment table itself allows most endourologic and percutaneous auxiliary procedures. Additionally, an intergrated inline ultrasound is available. From 10/94 to 08/95, 204 male and 96 female patients with a mean age of 50.7 (4-92) years underwent ESWL with the Lithostar multiline. The mean stone diameter was 10.3 (2-20) mm with 53% ureteral and 47% renal stones. 300 patients underwent 480 treatments (average shocks 3673, range 793-8000; mean energy level 5.5, range 1-9). Stone localization was achieved after 5 (1-39) min (mean fluoroscopy time 3.1 (0.5-16.2) min). In 92.7% no analgesic premedication was done, 56% of the patients needed no analgesics at all during ESWL. 44% received 8.1 (2-15) mg Piritramid intravenously. Epidural anesthesia was performed in only 2.3% for a second treatment. 95% of the patients had complete stone disintegration. In 68% disintegration was achieved in one session. ESWL was repeated for further disintegration in 18.5%, because of an unsuccessful treatment in 11.5% and because of technical interruption of the previous session in 2.5%. We saw subkapsular haematomas in 2%. Auxiliary procedures following ESWL were necessary in only 9.2% of the patients. In situ ESWL with the new Lithostar Multiline seems to be effective as the Domler HM3/4. Analgesia-free treatment was performed in more than 50% of the patients. Auxiliary procedures were less frequently necessary as compared to our previous experience with in situ ESWL.     

Closed humeral shaft fractures: a prospective evaluation of surgical treatment

OBJECTIVE: We tried to define the roles of the rigid dynamic compression plate (DCP) and the semi-rigid Ender nail (EN) in the treatment of closed humeral shaft fractures. DESIGN: A prospective, randomized clinical study was performed with detailed comparison parameters. MATERIALS AND METHODS: Ninety-one closed humeral shaft fractures were treated. Randomly, 30 humeri were treated with open reduction and internal fixation with DCP and no bone grafting (BG), 29 were treated with the same procedure but with BG, and 32 were treated with closed reduction and internal fixation with Ender nails. The average follow-up period was 32 months (range, 13-54 months). MEASUREMENTS AND MAIN RESULTS: In the group with DCP without BG, the average blood loss was 270 mL, operation time was 92 minutes, hospital length of stay was 6.5 days, and union time was 12.5 weeks. In the group with DCP with BG, the average blood loss was 325 mL, operation time was 108 minutes, hospital length of stay was 6.9 days, and union time was 9.4 weeks. In the EN group, the average blood loss was 114 mL, operation time was 54 minutes, hospital length of stay was 5.6 days, and union time was 9.9 weeks. Analysis of variance and Fisher's exact test were used to evaluate the statistical significance. CONCLUSION: In our experience, for humeral shaft fractures fixed surgically, EN is better than DCP without BG. When DCP is chosen for the means of fixation, prophylactic BG is recommended, especially in cases with more comminution.     

Total colpocleisis for vaginal eversion

OBJECTIVE: This report describes a technique for total colpocleisis performed on women with posthysterectomy vaginal eversion and presents the outcome of this surgery. STUDY DESIGN: Thirty-three women, aged 51 to 94 years (78.1 +/- 8.8, average +/- SD) with vaginal eversion were treated with total colpocleisis. Twenty-four women had previously undergone a total of 40 operations for prolapse, and many had a massive prolapse with scarring and ulceration. Five women had stress incontinence, and an additional 12 had poor urethral support without stress incontinence. In association with colpocleisis, 14 had suburethral plication of the endopelvic fascia; two, needle suspensions; and one, a pubovaginal sling. Three had a perineorrhaphy. RESULTS: Operations lasted from 30 to 205 minutes (101 +/- 33.4, average +/- SD), and the estimated blood loss ranged from 20 to 750 ml (206 +/- 171, average +/- SD). No operative complications occurred. Postoperatively, congestive heart failure developed in two women and one had pneumonia; all illnesses resolved with appropriate therapy. There were no complications at the operative site. Average follow-up was 35 (+/-48) months. All women were initially cured of the vaginal eversion. Recurrent eversion developed in one woman 1 year after surgery and was successfully treated with repeat colpocleisis. Of five women with preoperative stress incontinence, four were cured and one lost to follow-up. No new stress incontinence occurred. CONCLUSION: Total colpocleisis is an effective operation for the treatment of vaginal eversion in selected situations. When defective urethral support is corrected at the time of the operation, postoperative incontinence is not usually a problem.