Quadriceps femoris and hamstring muscle function in a person with an unstable knee

Septal perforation is an avoidable complication of septal surgery, but it can also occur because of a variety of traumatic, iatrogenic, caustic, or inflammatory reasons. Symptoms usually are related to disruption of the normally laminar flow of air through the nasal passages. Crusting, bleeding, parosmia, and neuralgia can develop, leading the patient to seek medical care. When local hygiene and conservative care are unsuccessful in relieving symptoms, closure of the perforation is considered. Repair is often difficult because of the limited exposure and limited amounts of friable mucosa with impaired vascular supply. The failure of attempted closure of septal perforations can be as high as 80 percent. The authors have developed a graduated approach to the closure of septal perforations that tailors the surgical approach to the size and location of the defect. Perforations 0.5 to 2.0 cm in size were closed in 92.9 percent (13 of 14) of patients using an extended external rhinoplasty approach and bilateral posteriorly based mucosal flaps. Larger perforations (2.0 to 4.5 cm) were closed in 81.8 percent (18 of 22) of patients by a two-staged technique, using a midfacial degloving approach to medially advance posteriorly based, expanded mucosal flaps. With careful preoperative management and selection of the appropriate surgical technique, even moderate-to-large perforations can be repaired reliably with limited operative morbidity.     

Upper lateral splay graft

Middle vault collapse narrows the internal nasal valve and impairs airflow through the nose. Loss of structural integrity of the upper lateral cartilaginous vault, the cause of the middle vault collapse, is classically corrected by inserting anterior spreader grafts, resulting in variable success. The desire to reconstruct the natural "T" of the upper lateral and septal cartilages culminated in the development of the upper lateral splay graft. The splay graft spans the dorsal septum but is deep to the left and right upper lateral cartilages. The intrinsic spring in the splay graft elevates each upper lateral cartilage with the septum as the fulcrum, thus correcting the middle vault collapse and opening the internal valve. The procedure, a physiologic substitute for the device "Breathe Right" applied externally, has been performed on nine patients and proved to be a prodigious functional boon to all of them. The powerful splay effect, however, can result in excessive widening of the caudal portion of the dorsum with imprudent use of the technique. Two case reports illustrate the subjective and objective improvement that was shared in all but one patient. Excess widening in one patient resulted in a suboptimal aesthetic improvement, although the functional objectives were met. Identification of suitable patients, preoperative assessment, choice of cartilage donor site, and the surgical technique are discussed. Improved internal valve function, predictability, and reliability are some of the distinct advantages of using a splay graft.     

Elaboration of an alternative, segmental, cartilage-sparing tip graft technique: experience in 405 cases

Despite the value of tip grafting in many rhinoplasty patients, adequate donor cartilage may be unavailable in secondary and even primary patients whose donor sites have been harvested previously or whose septal cartilage is calcified. Furthermore, by enlarging the lobule, tip grafts can create undesirable postoperative disproportions in some patients. These two observations have stimulated the elaboration of a tip graft method (which evolved from the Sheen technique) that uses small amounts of autogenous donor material to augment only those lobular segments that require increased contour or support, without necessarily increasing overall lobular volume. This article reports experience with; the technique in a 405-patient study group. Segmental tip grafting is performed endonasally through access incisions along the caudal edge of one alar cartilage. Grafts augment each third of the tip lobule and anterior columella (corresponding to each of the alar cartilage crura) depending on the aesthetic objective; multiple grafts are always placed. Selective augmentation limits the overall increase in lobular size. The method is not suitable for those patients needing substantial augmentation (58 of 463 tip-grafted patients in the 6-year study period), in which case the author still prefers the Sheen technique. The records of the 405-patient study group (40 percent primary rhinoplasty, 60 percent secondary rhinoplasty) indicate a total nasal revision rate of 14 percent; 6 percent were tip revisions. Tip revisions were more frequent in secondary patients but not in patients with thin skin. Reoperation percentages decreased during the study term, so that the tip revision rate was 12 percent in the first 12 months of study but only 4 percent in the last 12 months (p < 0.0008). The primary indication for tip grafting has evolved since the author's earlier practice experience: in the past 3 years of the study, 77 percent of primary patients and 80 percent of secondary patients underwent grafting principally to improve lobular contour, not tip projection (p < 0.0005). A segmental, cartilage-sparing tip graft technique can provide both projection and contour for primary and secondary rhinoplasty patients. Nevertheless, tip imperfections remain the most common reason for revision in the author's practice.     

Anatomically sound, simplified approach to repair of "complete" atrioventricular septal defect

BACKGROUND: There are few congenital anomalies of the heart that have benefited more from thorough anatomic analysis than the complex anomaly known as atrioventricular septal defect in the setting of common atrioventricular junction. Recent advances in understanding the anatomy of this lesion have led to alternative methods of repairing these defects. METHODS: The medical records of 21 consecutive patients undergoing repair of complete atrioventricular septal defect have been reviewed. Nine of these patients had a standard one- or two-patch repair, and 12 had direct closure of the ventricular element of the defect. RESULTS: Direct closure resulted in significantly shorter pump and cross-clamp times. Follow-up for an average of 34 months suggests that when direct closure can be performed, the results are comparable with those of the more standard technique. CONCLUSIONS: Our initial success with this approach is encouraging; however, longer follow-up is required to establish whether it will be broadly applicable.     

Transvasal closure of interatrial defects using the Babic double-umbrella occluder system

The purpose of the study was to assess the feasibility and safety of closure of atrial septal defects and patent foramen ovale by means of a new interventional technique. Transvasal closure of ostium secundum atrial septal defect and patent foramen ovale was performed in 18 patients using an occluder system for atrial septal defects. Two patients had undergone unsuccessful direct surgical closure years before. Implantation and follow-up were controlled using radiographic views both with and without contrast injection, transthoracic and multiplane transesophageal echocardiographic imaging, color Doppler sonography, and computed tomography. The defect was closed in 16 patients using 19 procedures. Removal of the devices through the sheath was indicated in 4 patients because of placement failure. Intraprocedural complications were ventricular fibrillation in one patient and fixation of the device in Chiari's network in an additional one. During 7-26 months follow-up occluder damage was seen in two patients and perforation of the left atrium in one patient. Thickening on the occluder surface was observed in two patients. There was no death. The system for closure of atrial septal defect is feasible and safe in patients with defects < or = 27 mm in diameter. Long-term observation of outcome is limited yet.     

Transcatheter closure of atrial septal defects within the oval fossa: medium-term results in children using the 'ASDOS'-technique

OBJECTIVES: The purpose of this study was to evaluate the safety and efficacy of the ASDOS-technique (Sulzer-Osypka GmbH, Germany) for transcatheter closure of atrial septal defects within the oval fossa. BACKGROUND: Although several attempts have been made to occlude defects within the oval fossa by transcatheter techniques, none of these has gained general acceptance. METHODS: Patients with a defect in the oval fossa measuring equal to or less than 20 mm diameter, with a residual septal rim of 5 mm or greater, body weight greater than 10 kg, with clinical indications for surgical closure were considered for transcatheter closure. Follow-up investigations were performed at discharge, after 1, 3, 6 and 9 months, as well as after 1 and 2 years. RESULTS: Of 78 patients considered for closure, a device was inserted in 41 patients (53%), with success being achieved in 40 patients (98%). The ages ranged from 1.1 to 15 years (7.8 +/- 1.92 years), the 'stretched' diameter of the defect from 10 to 20 mm (14.7 +/- 2.60 mm), and the diameters of the inserted devices from 25 to 45 mm (33.2 +/- 5.43 mm). Transient impairment of atrioventricular conduction occured in 4 patients. During the follow-up of 23.0 +/- 5.6 months elective surgical closure of a residual shunt was performed 26 months after insertion of the device in one patient. None of the other patients required surgery, hospitalisation or medical treatment, and none is requiring further treatment of the defect within the oval fossa. Fracture of one arm of the device occurred in 4 patients, but the fractured arms are in an unchanged and stable position after a period of at least 19 months. CONCLUSIONS: Our medium-term data show that transcatheter closure in children of defects within the oval fossa can be performed with a high efficacy and safety using the ASDOS-device.     

Esophageal perforation: emphasis on management

BACKGROUND: Perforation of the esophagus is a deadly injury that requires expert management for survival. METHODS: We performed a retrospective clinical review of 66 patients treated at Emory University affiliated hospitals for esophageal perforation between 1973 and 1993. RESULTS: Iatrogenic perforations accounted for 48 injuries (73%), barogenic perforations occurred in 12 patients (17%), trauma was causative in 3 (5%), and 3 patients had esophageal infection and other causes. Lower-third injuries occurred in 43 cases (65%), middle third in 14 (21%), and upper third in 9 (14%). Early contained perforations were managed successfully by limiting oral intake and giving parenteral antibiotics in 12 patients. Cervical perforations were drained without attempt at closure of the leak. Perforations with mediastinal or pleural contamination recognized early were managed by primary closure and drainage in 28 patients. Reinforcement of the primary closure using stomach fundus, pleural, diaphragmatic, or pericardial flap was performed in 16 patients. Those perforations that escaped early recognition required thoughtful management, using generous debridement and drainage and sometimes esophageal resection. The esophageal T tube provided control of leaks in 3 of these patients and was a useful adjunct. Using these management principles, we achieved a 76% survival rate for all patients. Six patients with perforations complicating endoesophageal management of esophageal varices were a high-risk subset with an 83% mortality rate. CONCLUSIONS: Esophageal perforation remains an important thoracic emergency. Aggressive operative therapy remains the mainstay for treatment; however, conservative management may be preferred for contained perforations and the esophageal T tube may be used for late perforations.     

Alveolar bone grafting in unilateral complete cleft lip and palate patients

Autogenous bone graft of an alveolar cleft area has the following advantages: (1) assistance in the closure of buccoalveolar oronasal fistula; (2) provision of bony support for unerupted teeth and teeth adjacent to the cleft; (3) formation of a continuous alveolar ridge to facilitate orthodontic correction of malocclusion; (4) supporting the nostril floor and alar base to improve nasal aesthetics. It has been well accepted in most craniofacial centers as routine procedure in cleft lip and palate rehabilitation. A new surgical technique for alveolar bone grafting has been introduced to the Chang Gung Craniofacial Center since July 1991. It provided a good exposure of the alveolar cleft, primary closure of the fistula and adequate volume of bone graft. A review of 27 consecutive alveolar bone grafting procedures performed in unilateral cleft lip and palate patients from July 1991 to June 1992 was presented. Patients have been followed up for at least 6 months. The alveolar bone graft was evaluated clinically and radiologically at one week, six months and one year after the surgery. The preliminary results indicated that the new surgical technique produced less chance of recurrent fistula, good postoperative gingival height, and improvement of nasal aesthetics. Based on the results of this new study we strongly advocate the use of this new surgical technique.     

Evaluation of laser sclerostomy fistulas using ultrasound biomicroscopy

OBJECTIVE: To study the learning risk of a new surgical technique, the deep sclerectomy (DS), which may be complicated with a perforation of the trabeculodescemetic membrane. To do so, we compared the results and the complications of patients who underwent DS transformed in trabeculectomy (DSt) and those of patients who underwent trabeculectomy (TE). MATERIALS AND METHODS: Between june 1994 and june 1996, we performed 234 DS, 19 of them had to be transformed into a TE, because of a perforation of the trabeculodescemetic membrane during the deep sclerocorneal dissection. Two matched groups of patients were prospectively followed, one group including 19 DSt and a control group including 19 TE. RESULTS: The IOP decrease on the first postoperative day was greater in the DSt-group compared to the TE-group (2.32 +/- 3.89 vs 6.73 +/- 4.31, p = 0.004). Scleral perforations occurred mainly during the learning phase of this new surgical technique. Postoperative complications were similar in both groups, except for hypotony and hyphema which were more frequent in the DSt-group (hypotony: 90% vs 37%, p = 0.0019; hyphema: 68% vs 16%, p = 0.017). The long term success rate with or without medication were comparable in both groups. CONCLUSION: This study shows that, when a DS is complicated with a perforation of the trabeculodescemetic membrane, the long term success rate of the surgery is similar to that of trabeculectomy. However, immediate postoperative complications such as hypotony and hyphema are increased. These results should encourage surgeons to learn this new non perforating filtration surgery.     

Vascularization of the fusion mass in a posterolateral intertransverse process fusion

STUDY DESIGN: A previously characterized rabbit model was used to study vascularization of the fusion mass in a posterolateral intertransverse process fusion. OBJECTIVES: To determine the interosseus origin of the new blood vessels in a posterolateral intertransverse process fusion mass and to test the hypothesis that bone incorporation and the extent of vascularization are closely related. SUMMARY OF BACKGROUND DATA: It has been reported that vascularization is essential for bone graft incorporation. There are, however, few reports dealing with vascularization of the spinal arthrodesis. METHODS: Thirty-one adult New Zealand White rabbits underwent bilateral intertransverse process fusion, using autogenous iliac crest bone graft. The rabbits were killed at 3 weeks (n = 6) and 6 weeks (n = 25) after surgery, and colored silicone was injected to fix the vasculature. A semiautomated image analysis system was used to assess the percentage of the area of vascularization in the fusion mass and the transverse processes. RESULTS: The major interosseus blood supply for vascularization of the autogenous bone graft came from upper and lower transverse processes. There were three types of fusion mass observed at 6 weeks after surgery: solid type, solid type with cartilaginous cleft, and nonunion type. There was significantly less vascularization of the fusion mass and of the transverse processes in the nonunion type compared with that in the solid type and with that in the cartilaginous cleft type. CONCLUSIONS: There is a close correlation between bone incorporation and the extent of vascularization in a posterolateral intertransverse process fusion.     

Pediatric lung transplantation. Indications, techniques, and early results

From July 1990 to April 1993, 36 lung transplantations in 33 patients were performed in our pediatric transplant program (0.25 to 23 years, mean age 10.3 years). Eight children had been continuously supported with a ventilator for 3 days to 4.5 years before transplantation and three were supported by extracorporeal membrane oxygenation. Indications for lung transplantation in this pediatric population included the following: cystic fibrosis (n = 13), pulmonary hypertension, and associated congenital heart disease (n = 10), pulmonary atresia, ventricular septal defect and nonconfluent pulmonary arteries (n = 3), pulmonary fibrosis (n = 6), and acute respiratory distress syndrome (n = 1). Three children underwent retransplantation for acute graft failure (n = 2) or chronic rejection (n = 1). Pulmonary fibrosis was related to complications of treatment of acute of myelogenous leukemia with bone marrow transplantation in two children and to bronchiolitis obliterans, bronchopulmonary dysplasia, interstitial pneumonitis, and Langerhans cell histiocytosis in four others. Thirteen children underwent lung transplantation and concomitant cardiac repair. Bilateral lung transplantation, ventricular septal defect closure and pulmonary homograft reconstruction of the right ventricular outflow tract to the transplanted lungs was performed in three children by means of a new technique that avoids the need for combined heart-lung transplantation. Two patients had ventricular septal defect closure and single lung transplant for Eisenmenger's syndrome, two had ligation of a patent ductus arteriosus and transplantation, three additional children underwent atrial septal defect closure and lung transplantation, and two underwent lung transplantation for congenital pulmonary vein stenosis. Eight early deaths and three late deaths occurred (actuarial 1-year survival 62%). Lung transplantation in children has been associated with acceptable early results, although modification of the adult implantation technique has been necessary. Lung transplantation and repair of complex congenital heart defects is possible; heart-lung transplantation may only be required for patients with severe left heart dysfunction and associated pulmonary vascular disease. Bronchiolitis obliterans remains a major concern for long-term graft function in pediatric lung transplant recipients.     

CYP2D6 genotype and smoking behaviour in cigarette smokers

BACKGROUND: Esophageal perforation is one of the most dreaded complications in therapeutic gastrointestinal endoscopy. We assessed the frequency of esophageal perforation after endoscopic procedures in a highly specialized endoscopy unit and compared clinical outcomes in patients undergoing either surgical or conservative management. METHODS: From January 1985 to June 1996, 1011 instrumental endoscopic procedures (dilatation and bougienage) were performed in our department. The computerized complication database was searched to identify all patients with esophageal perforation during this same period, and their records were reviewed. RESULTS: Seventeen esophageal perforations (1.7%) occurred in the course of 1011 procedures. Four perforations resulted from balloon dilatation, and 13 were secondary to bougienage. Six patients were managed surgically (35%), all of them recovering uneventfully. Eleven patients were managed conservatively, mainly because they were unfit for surgery. Survival rate in this group was 82%; only two patients died, both of whom had underlying malignant disease. CONCLUSIONS: The current concept in management of esophageal perforations comprises surgical as well as medical treatment. In well-selected cases, non-operative treatment can be considered with favorable results.     

Transxiphoid approach without median sternotomy for the repair of atrial septal defects

BACKGROUND: Interest in minimally invasive procedures has recently increased because it results in less surgical trauma, decreased patient discomfort, short hospital stay, reduced costs, and better cosmetic appearance. Based on these facts, we have been using the transxiphoid process approach without sternotomy for the correction of atrial septal defects. METHODS: From July 1996 to January 1997, the xiphoid process window approach was performed in 10 patients with ostium secundum atrial septal defect. Ages ranged from 6 months to 14 years (mean, 5.3 years). In all patients, extracorporeal circulation was carried out by means of cannulation of the femoral artery and both caval veins and of aortic cross-clamping. Videothoracoscopy was used to improve visualization of the aorta. RESULTS: There were no intraoperative or postoperative complications, and in all but 1 patient, extubation was possible while in the operating room. CONCLUSIONS: The xiphoid process window, with no median sternotomy, permitted closure of the atrial septal defects with good results and could be used as a less invasive technique for their correction.     

Purification and characterization of a cytotoxin from Enterobacter cloacae

OBJECTIVE: To document our evolving surgical management of colonoscopic perforation and examine factors crucial to the improvement of patient care. DESIGN: We conducted a computer-based retrospective analysis of medical records (1980 through 1995). MATERIAL AND METHODS: Among 57,028 colonoscopic procedures performed, 43 patients (0.075%, or 1 perforation in 1,333 procedures) had a colonic perforation. Two additional patients were treated after colonoscopy performed elsewhere. The outcomes analyzed included surgical morbidity and mortality. RESULTS: Twenty-six women and 19 men who ranged in age from 28 to 85 years (median, 69) were treated for colonic perforation. More than 80% of perforations occurred during the latter half of the study period because of the increased volume of colonoscopic procedures (8 perforations among 12,581 examinations from 1980 through 1987 versus 35 perforations among 44,447 colonoscopies from 1988 through 1995). Emergency laparotomy was performed in 42 patients (93%). Perforations occurred throughout the colon: right side = 10; transverse = 9; and left side = 23. Three patients without evidence of peritoneal irritation fared well with nonoperative management. Most patients underwent primary repair or limited resection in conjunction with end-to-end anastomosis. In 14 patients (33%), an ostomy was created. One patient underwent laparotomy without further treatment. Intra-abdominal contamination ranged from none (31%) to local soiling (48%) to diffusely feculent (21%). Postoperative complications occurred in 12 patients and were associated with older age (P = 0.01), large perforations (P = 0.03), and prior hospitalization (P = 0.04). No postoperative deaths occurred. CONCLUSION: Despite a consistently low risk of colonic perforation, the increasing use of colonoscopy in our practice has resulted in an increased number of iatrogenic colonic perforations. In order to minimize morbidity and mortality, prompt operative intervention is the best strategy in most patients. Non-operative management is warranted in carefully selected patients without peritoneal irritation.     

Surgical closure of persisting failed tracheoesophageal voice fistula

Tracheoesophageal puncture (TEP) is a highly successful procedure for voice restoration. Occasionally, however, patients fail to achieve satisfactory voice or develop salivary leakage through the fistula into the trachea. Closure of the TEP is then necessary. In most cases, spontaneous closure occurs once the prosthesis has been removed. When the fistula does not close spontaneously, surgical closure is indicated to prevent aspiration and pulmonary complications. We describe a three-layer technique that employs interposition of dermal graft. The technique was used on 14 patients over a 7-year period. Most patients received irradiation to the neck. Complete closure was achieved in 13 of 14 cases; 1 patient developed partial breakdown of the closure. Our technique is relatively easy to perform and has a high success rate (92%). Irradiation did not adversely affect the closure rate.     

Transcatheter closure of residual atrial septal defect following implantation of buttoned device

We report a case in which residual shunting after a buttoned device occlusion of atrial septal defect (ASD) was eliminated by transcatheter retrieval of a portion of the device, followed by implantation of a second device. This method may be helpful for those patients with residual ASDs who decline surgical device retrieval and defect closure.     

Spontaneous corneal perforation in pellucid marginal degeneration

PURPOSE: We present a report of a spontaneous corneal perforation in a patient with pellucid marginal corneal degeneration. METHODS: We describe the presentation and management of a 74 year old male with spontaneous corneal perforation related to pellucid marginal corneal degeneration. RESULTS: The corneal perforation was repaired with a 3 mm penetrating patch graft. The cornea has remained stable for 7 years with no further progression of corneal ectasia in either eye. CONCLUSIONS: Although rare, spontaneous corneal perforations in patients with pellucid marginal corneal degeneration can occur, and patients should be cautioned about this possibility.     

Nasal fractures--indications for open reposition

BACKGROUND: Many septoplasties and septorhinoplasties are indicated due to previous traumatic etiologies, and the typical treatment of these septal and/or bone fractures has been closed reduction. Review of the literature reveals a success rate of only between 30-82%. One of the reasons for these poor outcomes is the influence of tension and pressure stress vectors due to hidden cartilage fractures behind intact septal mucosa. This is the main indication for open reduction of nasal trauma. The present study analyses the results of our experience with the open reduction of nasal fractures. METHODS: In a six-year period between 1991 and 1996, a total of 34 open reductions were performed out of 155 nasal fractures. This series was analysed clinically and with the aid of computer tomograms. Postoperative follow-up involved a combination of clinical evaluation, nasal endoscopy, and photography. The indication for open reposition was based on analysis of force of impact and suspicion of cartilage damage. The goal of the procedures was to incise partial-thickness fractures to make them full-thickness, thereby relieving the inherent tension in the cartilage, and to mobilize impacted bone fragments with microosteotomies so they could be properly reduced. At the same time, any previously existing anatomical abnormalities with functional impact were also corrected. RESULTS: The rate of patient satisfaction based on postoperative cosmesis and function was 88%. The group in which open reduction was most commonly indicated was the frontal impact cohort (n = 18.53% of open reductions). This was followed by the frontolateral impact cohort (n = 8.23%). In only one (1/155) open reduction was it not possible to find a cartilage fracture on exploration. Revision surgery was required in 2 cases due to nasal obstruction from synechiae between the septum and the anterior aspect of the inferior turbinate. Reoperation was necessary in a third patient due to airway obstruction from septal deviation. In a final case the patient was dissatisfied with the postoperative nasal appearance but declined revision surgery. Analysis of computer tomograms gave no additional information, though three-dimensional CT can aid in preoperative assessment of fragment position in those cases with severe edema and hematoma. CONCLUSION: Due to the high rate of subjective and objective success in postoperative nasal function and appearance, we suggest that consideration be given to widening the current indications for open reduction of nasal fractures. It is important to maintain a high degree of suspicion and explore the septum for subclinical fractures and be aware of the pattern of damage that can be anticipated based on classification of impact as described herein. The importance of precise clinical evaluation by inspection, palpation, and endoscopy cannot be overemphasized, and may not be replaced by radiographic imaging.     

Management of mucosal perforation during pyloromyotomy for infantile pyloric stenosis

Mucosal perforation during Fredet-Ramstedt pyloromyotomy is the cause of unnecessary morbidity and death if unrecognized. Previously, a variety of closure have been advocated. In 1,777 cases there has been 42 (2.3%) intraoperative perforations. One unrecognized perforation led to a postoperative death. Closure of a mucosal tear is accomplished safely by a simplified suture technique without prolonged convalescence or death.     

Per-catheter ASD closure

Per-catheter devices for atrial septal defect (ASD) closure have been evolving since 1974. The four major devices available for use on a limited basis in early 1997 are reviewed. These include (in alphabetical order) the Angel Wing device, the ASDOS device, the Buttoned device, and the CardioSeal device (successor to the Clamshell). Sufficient data have been collected to indicate that transcatheter ASD closure is a viable alternative to surgery in selected patients. The advantages of the concept of per-catheter closure over surgical closure should lead to the continued development of devices and techniques for per-catheter treatment of ASD and other septal defects in the years to come.