Nonunion of fractures of the subtrochanteric region of the femur

There are no large clinical series to guide the clinician treating a subtrochanteric nonunion. Deformity, bone loss from previous hardware, and the high stresses in the subtrochanteric region all pose challenges to achieving successful bony union with reoperation. The purpose of this study was to retrospectively review a consecutive series of patients treated with reoperation using contemporary techniques for subtrochanteric nonunion. Between 1992 and 2002, 23 patients with a mean age of 55 years (range, 16-88 years) with 23 subtrochanteric nonunions were treated with additional attempts to achieve union. Two patients were lost to followup. The remaining 21 patients were followed up for a mean of 12 months (range, 6-39 months). Implants used for revision internal fixation were as follows: eight patients were treated with a cephalomedullary nail, seven patients were treated with a standard antegrade femoral nail, five patients were treated with a 95 degree angled blade plate, one patient was treated with a sliding hip screw, one patient was treated with a 95 degree dynamic condylar screw, and one patient was treated with dual large fragment plates. Eighteen of 23 patients had bone grafting: eight had autograft, six had allograft, and both were used in three patients. One patient had free vascularized fibular transfer. Twenty of 21 nonunions healed (95%). At last followup, all patients with healed fractures had no or minimal pain. All were ambulatory. There were no intraoperative complications. There was one postoperative complication (4%), an adynamic ileus that was treated medically. Revision internal fixation and selected bone grafting for subtrochanteric nonunion led to a high rate of fracture union and functional improvement. Intramedullary devices with fixation into the femoral head and neck and fixed angled devices were effective in achieving stable fixation of the proximal bony fragment.     

Results of total endoprosthetic treatment of dysplasia coxarthrosis with additional autologous acetabuloplasty of the roof of the acetabulum

With reference to the different operative treatments of dysplasia coxarthroses with a total hip endoprosthesis, 43 operations on the hip joint performed from 1975 to 1979 with a filling up to the acetabular roof defect with an autogenous bone graft had a clinical and roentgenological follow-up. The results were evaluated by means of a standardised procedure, and it was demonstrated with the help of clear successes that also anatomopathologically complicated cases can be provided with a suitable total endoprosthesis.     

Sonographic evaluation of hypertrophy of septum of Bertin

Sonography was utilized to evaluate 12 patients with hypertrophy of the septum of Bertin. To confirm the diagnosis, angiography was used in 7 patients and radionuclide imaging in 2. Three sonographic characteristics were found: (1) an isoechogenic, ellipsoid mass with an echogenic linear rim of renal sinus fat; (2) contiguity of the mass with a normal-placed septum of Bertin; and (3) the occurrence of the mass effect always at the level of the emergence of the renal vein. The sonographic findings could be divided into two definite types. Type I showed moderate hypertrophy with a mass effect ranging from 1.1 by 2.3 cm to 2.0 by 3.2 cm in diameter, usually presenting with a smooth contour and discrete mass effect on the intravenous pyelogram (IVP). Type II showed severe hypertrophy with a mass effect ranging from 3.2 by 4.0 cm to 3.5 by 4.5 cm in diameter, usually presenting with a lobulated contour and irregular stretching of the calyceal system on IVP. The differential diagnosis is discussed. In conclusion, we found that sonography associated with excretory urography is an accurate method for the diagnosis of hypertrophy of the septum of Bertin.     

Kinematics of three variations of the Freeman-Samuelson total knee prosthesis

The effect of changes in the articulating surfaces on the kinematics of the Freeman-Samuelson total knee replacement was evaluated. Twenty-two patients (22 knees) (median age, 69 years) were randomized to a standard design with a fixed polyethylene bearing, a design with a mobile bearing, or a new design with a spherical medial femoral condyle with a fixed bearing. The patients were studied with radiostereometry and film-exchangers at 0 degrees nonweightbearing and during active weightbearing extension from 45 degrees to 15 degrees. The center of the tibial tray with a mobile-bearing prosthesis occupied a more anterior position than observed in the designs with a fixed bearing. The medial femoral condyle center had a more posterior position in the standard design than in the design with a spherical medial condyle. From a distally displaced position at 45 degrees, the medial condylar center displaced a mean of 1.8 mm proximally during extension in the standard design and had a constant position in the meniscal design. In the spherical design the medial condyle was displaced proximally at 45 degrees and displaced a mean of 1.6 mm distally during extension. The reduced anteroposterior and proximodistal translations in the meniscal design are compatible with improved congruency between the components. The design with a spherical medial condyle stabilized anteroposterior motions, but showed more pronounced proximodistal displacement medially than did the other two designs.     

Carcinoma of the urachus--report of 4 cases

Four cases of urachal carcinoma are presented. The first case was a 36-year-old man who was admitted with the chief complaint of macrohematuria with mucinous debris. Cystoscopic examination revealed a single tumor at the dome of the bladder. Partial cystectomy and postoperative radiation therapy were performed. Histological findings showed a well differentiated adenocarcinoma. He has been well for twelve years postoperatively. The second case was a 52-year-old man who was admitted with the chief complaint of macrohematuria with mucinous debris. Cystoscopic examination revealed a single tumor at the dome of the bladder. Partial cystectomy and postoperative radiochemotherapy were performed. Histological findings showed a moderately differentiated adenocarcinoma. He died of a recurrent tumor 30 months after operation. The third case was 70-year-old man who was admitted with the chief complaint of macrohematuria with mucinous debris. Cystoscopic examination revealed multiple tumors at the dome of the bladder, internal urethral orifice and right lateral wall. Total cystectomy, ureterocutaneostomy and postoperative chemotherapy were performed. Histological findings showed a poorly differentiated adenocarcinoma. He died of a recurrent tumor 30 months after operation. The fourth case was a 68-year-old woman who was admitted with the chief complaint of macrohematuria with mucinous debris. Cystoscopic examination revealed a single tumor at the dome of the bladder. CT scan demonstrated a mass with calcification extending from the bladder dome superiorly. Partial cystectomy and postoperative chemotherapy were performed. Histological findings showed a well differentiated adenocarcinoma. She has been well for three months postoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)     

Laparoscopic transabdominal repair of hernia of Morgagni-Larrey

A patient with symptomatic gall stones was found to have a hernia of Morgagni. The patient complained of upper abdominal symptoms along with heaviness in the chest and mild dyspnea. A complete diagnosis was possible with a chest X ray and a CT scan, which revealed a right-sided Morgagni hernia containing omentum and some bowel loops. It was decided to laparoscopically deal with both lesions at the same sitting. Initially, a laparoscopic cholecystectomy was accomplished. The hernial contents were then reduced and an 8 cm x 5 cm defect was closed with a tailored mesh sutured in place with a hernia stapler. Follow up after one month showed an asymptomatic patient confirmed by CT scan. Morgagni hernia is eminently treatable laparoscopically and must be considered as a first line approach to this problem. It can safely be combined with other laparoscopic procedures.     

Biomechanical analysis of tension band wiring (TBW) of transverse fractures of patella

Purpose: Tension band wiring is commonly used for fixation of simple transverse fractures. The popular configuration is parallel Kirschner wires (K-wires) and a stainless steel wire loop placed in a vertically oriented figure-of-8. Methods: We used a wooden model of a patella with a midway transverse fracture and compared four different types of fixation. The first construct had a vertical figure-of-8 with one twist of wire. The second contained a vertical figure-of-8 with two twists of wire. The third was a vertical figure-of-8 with two twists of wire placed at adjacent corners while the last one had a horizontal figure-of-8 with two twists of wire placed at adjacent corners. Interfragmentary compression at the point of wire breakage was measured for each construct as well as permanent displacement on cyclic loading. Results: Placement of the figure-of-eight in a horizontal orientation with two wire twists at the corner improved interfragmentary compression by 63% (p < 0.05, Tukey post hoc test). On cyclic loading, all the constructs with vertical figure-of-eight but none with a horizontal construct failed (p ¼ 0.01; Fisher''s exact test). Permanent fracture displacement after cyclic loading was 67% lower with horizontal figureof-eight constructs (p < 0.05; t test). Conclusion: Placing wire twists at the corner and a horizontal placement of figure-of-8 improves stability of the construct.     

Comparison of costs of different anaesthetic techniques

The costs of anaesthetic drugs, intravenous agents as well as gases, were studied for different anaesthetic techniques in a medium-sized operative procedure, cholecystectomy. Three anaesthetic breathing systems were used: a non-rebreathing system, a circle absorber system with medium fresh gas flows of 3-6 l/min, and a low-flow circle system. Anaesthesia without volatile inhalation agents used with a low-flow technique was the least expensive, and anaesthesia with isoflurane in a non-rebreathing system was the most expensive. The costs of anaesthesia without volatile inhalation agents in a non-rebreathing system, enflurane anaesthesia in a circle system with medium fresh gas flows, and isoflurane anaesthesia with low-flow technique were similar.     

Relevance of history of injury to the diagnosis of meniscal tears.

A consecutive series of 217 arthroscopic meniscectomies has been reviewed in order to investigate the incidence of significant meniscal lesions without obvious precipitating injury. There were 10 bucket handle tears out of 117 (9%) with a mean age of 32 years with no significant injury; 18 flap tears out of 69 (26%) with a mean age of 40 years; and 7 out of 19 (37%) radial tears with a mean age of 36 years also had no significant injury. This study indicates that the absence of a history of injury in the young patient with a symptomatic knee does not exclude significant meniscal tears, such as a bucket handle, and therefore has implications for history taking and diagnosis.     

Characteristics of surgical treatment of benign bifurcation strictures of the hepatic ducts

Experience in the treatment of 195 patients with benign bifurcation stricture of the hepatic ducts is discussed. This group was made up of patients with the cicatricial process involving the region of the bifurcation or continuing to one or both lobar hepatic ducts. Two basic methods of bile--diverting operations were used: with carcass drainage (mono- and bilateral) of the anastomosis and hepatic ducts (n-155) and without a carcass drainage with the formation of a widecholecysto- intestinal anastomosis (through inclusion of the left lobar hepatic duct) by means of interrupted sutures without grasping the mucous membranes of the hepatic ducts and intestine (h-36). A combined method was used in 4 patients with an isolated stenosis of the right hepatic duct and an intact left hepatic duct. Intubation of both lobar hepatic ducts is considered necessary in patients with a bifurcation stricture in the existence of indications for carcass drainage of the bile-diverting anastomosis. Analysis of the immediate and late--term results showed that the postoperative period was more favourable in patients with bilateral carcass drainage of the bile-diverting anastomosis and in those with a precision anastomosis that in patients with monolateral drainage (complications occurred, respectively, in 16.3% and 46.6% of patients, and a good late-term results was encountered, respectively, in 78.5% and 55% of patients). The stricture did not recur in patients with a precision anastomosis and in those with bilateral carcass drainage.     

Carcinoma of the junction of the main hepatic ducts

Patients with carcinoma of the hepatic duct junction often present the surgeon with a difficult problem. If at all possible radical surgery may be performed either as a resection of the tumour and an anastomosis according to Roux-en-Y or a resection of the left or right hepatic lobe together with the obliterated hepatic duct or ducts. The present series consists of 17 patients treated for cancer of the hepatic duct junction during the period 1965-1974 with a follow-up period of at least five years. The surgical treatment given included a radical procedure in 8 cases, a palliative procedure in 7 cases and in 2 cases surgery of the hepatic ducts was not possible. Radical procedures included 4 patients with a resection of the left hepatic lobe and 4 patients with resection of the left and right hepatic ducts and anastomosis according to Roux. A mean survival time of 22.8 months was reached when a radical operation was attempted with a longest survival time of 8 years. A palliative procedure gave a mean survival time of 2.0 months. These figures indicate that a careful selection of patients for an attempt of radical surgery could be made since removal of the tumour gives a more effective palliation, often a longer survival time and an improvement of quality of life.     

Flow cytometric analysis of the DNA content of thymomas

In this study, the prognostic value of determining the nuclear DNA content of thymomas by flow cytometry was evaluated. Of a total 31 resected thymomas, 10 (32%) showed DNA aneuploidy, the presence of which was significantly correlated with an advanced clinical stage of disease. The patients with an aneuploid tumor had a poorer prognosis than those with a diploid tumor, demonstrating a survival rate of 50% at 7 postoperative years, which was considerably less favorable than that of the patients with a diploid tumor, being 100% in the same period (p<0.05). Moreover, patients with a high DNA index (DI), i.e., a DI1.5, tended to have a poorer prognosis than those with a low DI. These findings indicated that the DNA content can be an important prognostic index in patients with thymomas.     

Endoscopic management of milk of calcium-filled ureterocele stump

A 38-year-old woman with a duplicated right collecting system and a history of right upper-pole heminephrectomy was referred for persistent dysuria and right lower-quadrant abdominal discomfort. Imaging identified a remnant ureter and a ureterocele filled with what appeared to be a large homogenous stone. At cystoscopy, the ureterocele was incised with a holmium:YAG laser, releasing a large quantity of white milky fluid (milk of calcium). There was no evidence of any solid material. Endoscopic evaluation should be the first step in patients with stones in a ureteral stump because milk of calcium may be the etiology of what appears to be a large stone burden in an obstructed system.     

Anxiolytics and Sedatives and Risk of Fractures: Effects of Half-life

To study the risk of fractures associated with anxiolytics, sedatives, and hypnotics, we conducted a case-control study. Cases were all subjects with any fracture during the year 2000 (n = 124,655). For each case, three controls (n = 373,962) matched on age and gender were randomly drawn from the background population. The exposure was use of any anxiolytic, sedative, or hypnotics. Adjustments were made for a number of potential confounders. Most anxiolytics, sedatives, and hypnotics were associated with a limited increase in the risk of fractures. There was a dose-response relationship, and drugs with a half-life longer than 24 h were associated with a trend toward a higher relative risk of fractures than drugs with a shorter half-life. Both current use (last use <1 year ago) and past use (last use more than one year ago) were associated with an increased risk of fractures. We conclude that anxiolytics, sedatives, and hypnotics are associated with a limited increase in the risk of fractures. For most drugs a dose-response relationship was present, and drugs with a half-life >24 h tended to be associated with a higher risk of fractures than drugs with a shorter half-life. This points to a dose-dependent risk of, for example, falls leading to fractures. However, the increased risk of fractures with past use may suggest an effect of the condition for which the drug was prescribed rather than the drug per se (confounding by indication).     

Use of thermography in the differential diagnosis of phylloides tumour

Thermography can be used as a method of diagnosing breast masses. We report our results of its use in the differential diagnosis of fibroadenoma from phylloides tumours (n = 47 and 20 respectively). Thermographic resolution (Th) and the difference in temperature between the tumour and a similar zone in the contralateral breast (delta 2) were compared. Thermograms were class Th1 (with a similar thermal pattern in both breasts without hypervascularization or hot points) and Th2 (with hypervascularization or a hot area with a thermal difference with the same area in the opposite breast (delta 2) of less than 2 degrees C) in most (95.7 per cent) of the patients with fibroadenoma and were class Th5 (having one or more pathological sign) in 85 per cent of the patients with phylloides tumours. Patients with phylloides tumours had a mean delta 2 of 2.99 degrees C whereas most of the patients with a fibroadenoma showed no difference in temperature. Their mean delta 2 was 0.2 degrees C (P less than 0.0005). We conclude that thermography helps in differential diagnosis between a fibroadenoma and a phylloides tumour.     

Evaluation of the efficacy of a new graduated anal dilator in the treatment of acute anal fissures

Dilatation of the anal sphincter with anal dilators for the treatment of acute anal fissure is efficacious, economic and safe but not always correctly executed with a negative repercussions on the technical results. Our study was aimed at comparing the efficacy of new graduated dilator with a progressively graduated diameter, using a standard treatment schedule, or a free schedule in comparison with the use of multiple classic dilators currently available for the resolution of anal fissures. A series of 60 patients, 35 female and 25 male, with a clinical diagnosis of acute anal fissure in the absence of a hypotonic anal sphincter, abscess or perianal fistula, hemorrhoidal thrombosis, chronic inflammatory bowel diseases or lower gastrointestinal neoplasms were preliminarily evaluated with the solid sphere test and randomly divided into three groups: the first was treated with the new graduated dilator with a standard treatment schedule (20 patients); the second was treated with multiple anal dilators (20, 23, 27 mm) (20 patients) using a standard treatment schedule, and the third group (20 patients) was treated with the new graduated dilator according to a free treatment schedule. After four weeks of treatment, 91% of all patients showed resolution of the anal fissure. Patients treated with new graduated dilator and those treated with multiple dilators according to the standard schedule showed similar 90% rates of fissure healing in comparison to the 92% treated with the graduated dilator according to the free schedule. The tolerability and manageability of the new single graduated dilator was judged positively by all patients in the treated groups. The use of the graduated anal dilator according to a free treatment schedule seems to induce lasting resolution of acute anal fissures with similar results to those achieved using traditional multiple dilators, while proving better tolerated by the patients.     

Management of sacrococcygeal teratoma of the fetus

We present a case of a 22 year pregnant lady with a fetus having sacrococcygeal teratoma. The patient presented at 35 weeks of gestation with an ultrasound report showing growth at the sacral region. Emergency caesarean section was performed at 36 week and a baby girl with a huge mass on her sacral region was delivered. She was operated upon by the pediatric surgeons on the same day and the mass was excised. Histopathology of the mass confirmed the diagnosis of sacrococcygeal teratoma with an immature component. The infant is now 6 months old and there is no sign of recurrence.     

Surgical treatment of non-unions of the clavicle

Surgical Principles A non-union of the clavicle can develop following a fracture, which is conservatively treated with insufficient reduction or inadequate immobilisation, as well as after an open reduction and internal fixation in cases with severe soft tissue injury or with poor osseous stabilization. Dynamic compression plating of a non-union of the clavicle provides the mechanical stability required for bone healing; in cases of atrophic non-union or pseudarthrosis with loss of bone, the procedure is supplemented with an autogenous cancellous bone graft, whereas those with associated shortening are treated with the interposition of a cortico-cancellous block. The (rare) post-traumatic thoracic outlet syndrome can frequently be treated successfully through a stable internal fixation of the pseudarthrosis. First published in: Operat. Orthop. Traumatol. 1 (1989), 139–144 (German Edition).     

Management of infections of polytetrafluoroethylene-based mesh

BACKGROUND: Mandatory removal of infected expanded polytetrafluoroethylene (ePTFE) mesh has been advocated, leading to a high rate of hernia recurrence. Although salvage of infected mesh has been reported, the feasibility, efficacy, and long-term outcomes of this practice remain unclear. The purpose of this study was to delineate a protocol for salvaging infected ePTFE mesh. METHODS: We reviewed retrospectively the records of patients with infections of ePTFE-based mesh placed for complex abdominal hernias at a tertiary referral center from October 1997 to September 2005. RESULTS: Twenty-two patients were treated for ePTFE-based mesh infections. Fifteen patients had undergone laparoscopic repair, and seven patients had undergone open repair. The median time of presentation after repair was 70 days (range 10-480 days). Fourteen patients had an extensive mesh infection and underwent mesh excision, with twelve patients having attempted fascial closure; hernias recurred in all twelve patients. Two patients underwent mesh excision and repair with a biologic mesh. Eight patients had a limited area of mesh involvement; six of these patients underwent surgical debridement, partial excision of the mesh, re-approximation of the remaining mesh with non-absorbable suture and drains, and application of a vacuum-assisted closure system to the open portion of the wound. These patients received four weeks of antibiotics with delayed wound closure. Two patients underwent percutaneous drainage of a perigraft abscess. There was no hernia recurrence in seven patients with a mean follow-up of approximately three years. CONCLUSIONS: Infections of ePTFE-based mesh can present in early or delayed fashion. Although mesh with extensive infection could not be salvaged, limited mesh infections could be managed successfully with percutaneous or open drainage and prolonged antibiotic courses.     

Incidental carcinoma of the prostate: an analysis of the predictors of progression

Incidentally discovered prostatic cancer can pursue a benign clinical course or it can rapidly progress. Differentiating those tumors with low biological potential from more aggressive lesions has been the focus of many reports. To define more completely the variables that can be used to predict those patients with low biological potential requiring limited treatment from those needing more extensive therapy, a retrospective study of 232 patients with incidentally discovered cancer was undertaken. Progressive disease was used as an endpoint for statistical analysis with the Kaplan-Meier technique and Cox's multiple hazard regression mode. This extensive analysis of multiple parameters demonstrated a significant advantage of survival free of disease for patients presenting with tumors manifesting a lower Gleason score and volume extent. Probability tables were constructed to allow for prediction of the probability of progression for a given patient with incidentally discovered prostate cancer directly related to patient age at diagnosis, Gleason score, and initial volume extent of the tumor. With these tables a logical therapeutic approach can be derived for each patient in an attempt to maximize survival free of disease with minimal intervention.