Prothèses unicompartimentales — Conclusions de la Table Ronde Réponses aux questions posées

Unicompartmental knee arthroplasty (UKA) is an excellent operation provided the technique is properly applied and the indication is well established. Obesity (weight > 100 kg, or BMI > 32) is a contraindication. The shape of the femoral prosthetic condyle is a cause of loosening in the medium and long term. There is an important difference between medial UKA and lateral UKA. Indications are different and they correspond to different types of patients. UKA is not an alternative to osteotomy; it is in competition with both osteotomy and total knee prostheses and has its own indications. UKA without cement is possible provided sufficient primary stability is achieved. This appears difficult to achieve at the femoral level. The patella poses no problems provided the unicompartmental prosthesis is fitted correctly. The absence of anterior cruciate ligament, together with clinical or radiological anteroposterior laxity, is a contraindication to UKA. The average lifetime of a unicompartmental prosthesis is 8–10 years; lateral prostheses have a longer lifetime. Failure of UKA implies reoperation with conversion to the total knee prosthesis. Hypercorrection by lateral UKA is undesirable. In contrast, there is no objection to hypercorrection of less than 5° by medial UKA. After medial UKA, the recurrence of a varus deformity is possible only if lateral laxity has not been controlled or if one of the prosthetic components is displaced. UKA is not indicated if patellar surgery is required. Hypocorrection by lateral UKA is desirable. Medially, the residual varus should not exceed 5°. In medium and long-term failures, most complications affect the tibia (loosening, polyethylene wear).     

Response of rat testis to localized induced hyperthermia.

A method is presented in which the rat testis is extensively mobilized through a low abdominal incision, but in which its blood supply is carefully preserved. Localized hyperthermia is induced in this mobilized testis by water bath immersion. The tissue temperature is measured during and after immersion by means of a thermocouple inserted into the tissue. The relative sensitivity of spermatogenic tissue to increased temperature is confirmed and the relative resistance of Sertoli and Leydig cells is noted. Minimal or absent inflammatory reaction to thermal destruction of testicular cells is found as long as the tubule is intact. A marked peritesticular inflammatory response is noted when the total testicular tissue is destroyed at the highest temperature tested.     

Focal cirrhosis of the liver

The experience in treatment of 14 patients with focal cirrhosis of the liver is summarized. Clinical and morphological data is presented. It is noted that clinical picture is poor and non-specific. Ultrasonic examination is the main diagnostic tool. It is demonstrated that histological examination of removed specimen is often necessary for final diagnosis. Method of choice in the treatment of patients is surgical one. The scope of surgery depends on intraoperative features, extended hepatic resection is not usually indicated.     

Laparoscopic surgery for early rectal carcinoma

The indications, techniques, and results of laparoscopic surgery for early rectal carcinoma are described in detail. Laparoscopic surgery is indicated when a mucosal tumor is too large to perform endoscopic or transanal resection or the tumor invades the submucosal layer. When the tumor is located in the Rs or Ra region, surgery can be completed laparoscopically. After dissection of the mesenterium and lymphadenectomy are performed, the anal side of the rectum is divided using EndoGIA II. When the tumor is located in the Rb portion, it is impossible to resect the rectum intracorporeally. In this situation, aperi anal maneuver is essential. The rectal mucosa is circumferentially incised just above the dentate line and the internal anal sphincter is dissected. Dissection is advanced to the intersphincteric space. Dissection between the rectum and the levator ani muscle is completed, and the rectum is pulled through the anus. After the oral side of the rectum is divided, a J-pouch is mase and J-pouch-anal anastomosis is performed. Forty-seven patients with rectal carcinoma were operated upon laparoscopically. Postoperative recovery was better than that after open surgery. Serious intraoperative or postoperative complications have not been encountered in this series. In conclusion, laparoscopic surgery is thought to be the procedure of first choice for early rectal carcinoma.     

应用肿胀吸脂器进行皮下超量灌注吸脂术

目的为减轻皮下超量吸脂术中注射肿胀液时的劳动强度,提高工作效率。方法在25例皮下超量吸脂术使用肿胀吸脂器,其中的连续注液器注射肿胀液,负压泵进行抽吸。结果注液过程缩短,肿胀液充分、均匀,麻醉效果肯定,负压泵吸力大,抽脂量多,术后效果肯定。结论肿胀吸脂器可以连续注液,提高肿胀麻醉工作过程的效率;同时可以负压抽吸,加快了手术过程,是一种全新的吸脂设备。     

Pubertas praecox and hypothalamic hamartoma

Summary Precocious puberty of cerebral origin is classified into pseudoprecocious puberty and true precocious puberty. Pseudoprecocious puberty is caused by HCG secreting tumours. True precocious puberty is caused by various hypothalamic diseases. Among them, hypothalamic hamartoma is the most common cause. Precocious puberty is caused by elevated blood pituitary gonadotropin concentration, secondary to the elevated hypothalamic LHRH secretion. The hypothalamic hamartoma is not infrequently associated with laughing (gelastic) seizures as well as convulsions. Diagnosis of a hypothalamic hamartoma is easily made by CT. Although the hypothalamic hamartoma is difficult to operate on, the value of surgery is stressed for treatment of precocious puberty. This is also confirmed by recent reports.     

Subcutaneous transposition of the proximal oesophagus in oesophagoplasty.

Experience with a new technique of oesophagoplasty is presented, in which the proximal part of the oesophagus is transposed to the subcutaneous space in front of the sternum and anastomosed to the organ replacing the oesophagus. This kind of operation has been performed successfully in five cases. The advantages are: thoracotomy is avoided; oesophageal anastomosis is easily performed; anastomotic failure in the subcutaneous space is not a serious problem; revision of the anastomosis is easily performed under local anaesthesia; and the mortality rate due to oesophageal anastomotic failure is diminished. The procedure is indicated in cases where a long graft for oesophagoplasty is not available and intrathoracic anastomosis is not desirable. It may also be used after oesophagogastrectomy or total gastrectomy. The most common complication is the development of a salivary fistula that heals spontaneously in a few days.     

Construction of penis with two free flaps

A case of penis construction using two free flaps is presented. The urethra is constructed with an ulnar forearm flap and external coverage is provided with deltoid flap. The biggest disadvantage with radial forearm flap, which is considered to be the most ideal donor flap for penile construction, is its large and unsightly donor scar. The authors have been using deltoid flap for penile construction because its donor scar is concealed under the half-sleeve shirt; however, its biggest disadvantage is its thickness. With the method presented here, an appropriate-size penis can be constructed even in an obese individual whose deltoid flap is thick. Donor scar is almost inconspicuous when the patient is wearing a half-sleeve shirt, because the donor scar on the forearm is 3-cm wide and located on the ulnar side.     

Review of the free scapular flap: a versatile flap for most osteocutaneous tissue defects

Although there is little doubt that the scapular flap is a versatile flap that is suitable for most tissue defects, it has failed to gain its proper place in the reconstructive armamentarium. This may be due to the perceived donor site morbidity. However, many published articles have shown that the donor site morbidity is limited and acceptable. The scapular free flap is accessible, relatively easy to dissect and has a long vascular pedicle with a constant position of artery and veins. The donor site may be closed primarily for flaps that do not exceed 10 cm in width. It is usually hairless, and is ideal for intermediate-sized defects. There is no functional donor site deficit and the resulting scar is acceptable. No major artery is sacrificed. The independent arc of skin flap rotation relative to the bone component is another major advantage over other flaps. Therefore, I believe that the scapular free flap is a superior and adaptable flap in most skin and/or bone defect reconstructions.     

Caecal Perforation in Large-Bowel Obstruction1

Reports of two unusual cases of obstructive caecal perforation are presented, and the relevant literature is reviewed. It is suggested that the prime factor in obstructive caecal perforation is ischtemia. The importance of recognizing and treating impending perforation of the caecum in large-bowel obstruction is emphasised. Caecostomy is recommended for small perforations, but resection is indicated if more extensive ischcemia is present.     

Alveolar carcinoma of the lung. Anatomo-clinical considerations and presentation of 4 cases

Alveolar carcinoma of the lung is a rare form that is often discovered casually, and may well be asymptomatic. Four personal cases are presented. The view is advanced that this is a distinct form that is clearly distinguishable from bronchogenic adenocarcinoma. It has a single site and is derived from the type II pneumocyte. Particular attention is given to the clinical and diagnostic features of alveolar carcinoma. It is felt that early diagnosis followed by radical surgery leads to a marked improvement in prognosis.     

Insertion of a chest tube to drain pneumothorax

Intercostal chest tube drainage with an underwater seal is a simple and effective method to eliminate air in the pleural space. The patient is then positioned lying, shoulder elevated and undressed to the waist with the arm abducted at 90°. The fourth intercostal space just anterior to the midaxillary line is usually chosen. The surgical field is prepared with antiseptic solution, and lidocaine is injected to create a transverse wheal to demarcate the length and position of the skin incision. The tip of the scalpel blade is used to make an incision large enough to admit the index finger comfortably. Blunt dissection is undertaken using a Roberts clamp. Once the deep fascia is reached, the intercostals space becomes distinctive. Further lidocaine is used to create a field block by injecting multiple intercostal nerves. After leaving adequate time for the intercostal block to work, the Roberts clamp is then used with gentle but firm pressure, spreading the intercostals muscles apart. When the Roberts clamp enters the pleural cavity, a gush of air is normally audible. The jaw of the Roberts is opened to dilate the puncture site, and then followed by the index finger to dilate a tract into the pleural space. Once satisfied that there is no adherent lung tissue to the chest wall, a 28 F drain is introduced into the pleural space without a trocar. Once the drain is sited, it is attached to an underwater seal, and the drain is then secured with a silk suture.     

A new method of autotomography in cerebral angiography (author's transl)]

Acompanied with the recent advances of various techniques of cerebral angiography, the angio-tomography is now going to be recognized as one the significant techniques. But, this angio-tomography requires a special work place with tomographic equipment. Thus the applicability of the method is now limited as far as the routine use is concerned. So, the technique of autotomography is often tried as a convenient substitute for the angiotomography, because this technique is very simple and does not need any special facilities. But, as the autotomography is only possible to take the midline tomogram, it's application is strictly limited. So, we have invented a new method of the autotomography using a simple device. This device is constituted of two portions; one is a plate of rotation, and the other is a box to fasten a patient's head. By sliding the box on the plate, it is possible to move the rotatory axis to the aimed portion of the head. In this way, it is possible to take an arbitrary tomographic plane. As our device is simple and it's use is very easy, this method of the autotomography is possible to apply in a routine examination. This report describes the principle and the method of the use of our new device and demonstrates several films taken by this method.     

Anesthésie pour chirurgie carotidienne avec clampage sous contrôle de la pression résiduelle carotidienne

Carotid endarterectomy with clamping is performed in 50 patients. Internal carotid artery stump pressure is measured in all cases after clamping at the beginning of the operation. In 35 patients, an increase of systolic pressure is observed which allows a stump pressure more than 70 mmHg in 29 patients. In 15 patients, systolic pressure decreases and a stump pressure more thant 70 mmHg is observed in two patients. When the stump pressure is more thant 70 mmHg, the clamping is maintained. When the stump pressure is low, the clamping is stopped. A perfusion of Metaraminol increases systolic pressure in all cases : stump pressure is measured again after a second clamping. In 17 cases out of 19, stump pressure increases more than 70 mmHg and the clamping is maintained. In the two cases with a low stump pressure, a shunt is used during intervention.     

Risk Factors for Fractures Identified in the Algorithm Developed in 5-Year Follow-Up of Postmenopausal Women From RAC-OST-POL Study

The aim of the study was to establish factors with an impact on fracture risk and to develop an algorithm to predict osteoporotic fracture. A total of 978 postmenopausal women from the epidemiological, population-based RAC-OST-POL study with a mean age of 65.7?±?7.3 years were enrolled. At baseline, bone mineral density at hip and clinical risk factors for fracture were collected. Afterward, each person was asked annually on fracture incidence in the 5-year follow-up. Finally, data for complete 5-year observation were gathered for the group of 802 patients. During the follow-up, 92 osteoporotic fractures occurred in 78 women. The most common fracture site was the forearm (n?=?45). The following baseline factors were found as significant for fracture incidence: femoral neck bone mineral density, prior fractures, steroid use, falls within previous 12 months, and height. Fracture risk was predicted by the following formula: $\mathit{Risk}of\mathit{fracture}\mathit{incidence}=\frac{1}{1+e^{?\left(\begin{array}{l}?9.899+1.0771\mathit{STEROIDS}+0.681\\ 1\mathit{PRIORFALLS}+0.6111\mathit{PRIORFRACTURES}\\ ?0.4831FN\mathit{Tscore}+0.0421\mathit{HEIGHT}\end{array}\right)}}$. In our current longitudinal study, an algorithm predicting fracture occurrence over a period of 5 years was developed. It may find application in daily medical practice.     

Substance abuse and dependence in anaesthetists

The incidence of substance abuse amongst anaesthetists in the United Kingdom is unknown. In the interests of patient safety, it is essential that the dependent doctor is identified and entered into a treatment regime. No national strategy is in place to treat and, where possible, return the anaesthetist in recovery to work. It is important therefore, that individual employers have a standing operating procedure to deal with the addicted doctor. It is essential that the initial approach is made by a competent panel, each of whom has experience of dealing with dependent doctors. This is an extremely stressful time for the doctor involved; it is therefore essential that active support is given. It is not always necessary to suspend the doctor from work whilst treatment is undertaken. In the dependent doctor sudden withdrawal of the substance of addiction can be life-threatening. It is therefore essential that the supervising physician has specialist knowledge of the treatment of addiction. Residential care probably provides the greatest hope of success. In the United States, Canada, Australia and New Zealand 'impaired physician' programmes are in place which allow some doctors to return to work, initially under strict supervision. Registration with a self-help organisation is essential; a list of such groups in the United Kingdom is appended.     

The role of neck dissection in head and neck mucosal squamous cancer

The most clinically useful system of classification of neck lymph nodes is grouping into levels I-V. Anatomical, clinical and pathological studies demonstrate that although generally lymphatic flow is from above downwards, level I is often bypassed and level V is seldom involved. Neck dissection is classified into radical, modified radical, selective and extended radical neck dissections. Recent studies demonstrate that elective neck dissection is beneficial to the outcome of oral cancer patients, but not necessarily to laryngeal and pharyngeal cancer patients. Modified radical neck dissection is as effective as radical neck dissection when performed in the elective situation. Selective neck dissection in the form of supra-omohyoid neck dissection is useful as a staging procedure. Modified radical neck dissection is acceptable for the N1 neck provided postoperative radiotherapy is given.     

Antegrade and retrograde endoscopy for treatment of esophageal stricture

Total or near-total esophageal stricture results from multiple processes. Traditional treatment with wire cannulation followed by serial dilation is often contraindicated due to poor visualization and the risk of perforation. We seek to demonstrate that combined antegrade and retrograde endoscopy are useful for treatment of total or near-total esophageal strictures. The gastrostomy tube is removed and the tract dilated. A standard endoscope is passed retrograde to the stricture. An antegrade endoscope is advanced until transillumination across the stricture is visualized. A biopsy forceps or needle is used to traverse the stricture in an antegrade fashion. The tract is cannulated with a stiff wire that is then brought out through the gastrostomy site. The stricture is serially dilated. The gastrostomy tube is replaced, and a nasogastric tube is left across the stricture for 3 to 4 weeks. The endoscope is withdrawn and an 18 or 20 Fr gastrostomy tube is left in place. A total of three patients with total esophageal strictures were treated using combined antegrade and retrograde esophagoscopy. All three patients regained the ability to swallow secretions. Importantly, there were no instances of esophageal perforation. This technique has broader application, including combination with minilaparotomy for patients without retrograde access. Further research is needed to determine durability of stricture dilation.     

Vertebra plana and eosinophilic granuloma of the cervical spine in children

Eosinophilic granuloma of the cervical spine in children is a rare lesion which presents both diagnostic and therapeutic problems. The report describes three additional cases. Open biopsy is recommended instead of attempted needle aspiration in children. Laminectomy is likely to result in spinal deformity, and is not advised unless a second stage fusion is planned. Radiotherapy is effective in controlling the lesion. The ultimate outcome is usually good.