Replacement of the common carotid artery by a plastic prosthesis. Report of a case with forty years of follow-up.

An 18-year-old man suffered a 38 caliber gunshot wound to the right side of the neck on 25 September 1957. On 16 October 1957, a traumatic arteriovenous aneurysm between the common carotid artery and the internal jugular vein was resected. The jugular vein was ligated and the common carotid was replaced by a nylon prosthesis. On 16 October 1960. the dilated nylon graft was replaced by a dacron prosthesis. The patient has been followed-up during more than 40 years and his condition is normal. To the best of our knowledge, this operation was the first of its kind performed in the world and has the longest follow-up.     

Eleven-year follow-up of cross-leg replantation for traumatic bilateral amputation

The advent of microsurgery has allowed the replantation of traumatically amputated limbs. Replantation of a severed limb to the contralateral stump in bilateral traumatic amputation, however, is rarer, and criticisms include a prolonged hospital stay and complications. A 54-year-old man was caught in a paper-pulping machine and suffered bilateral lower limb amputation rendering his left lower leg unsalvageable. The right lower leg, after debridement however, was suitable for replantation to the left stump. This replantation was performed successfully. The patient was rehabilitated with a contralateral prosthesis and ambulates with a walking stick. At 11-year follow-up the patient has a preference for his replanted leg in contrast to his contralateral prosthesis and has suffered no long-term complications. In addition, from a psychological perspective, he has experienced restoration of perceived body length with the cross-leg replantation.     

Obtaining rigidity in total phalloplasty: experience with 35 patients

PURPOSE: The combination of a neourethra and erection prosthesis in a single neophallus in the female-to-male transsexual remains a challenge. The outcome reported in the literature is disappointing. We report our experience with 35 patients. MATERIALS AND METHODS: Between August 1996 and December 2001, 35 patients underwent implantation surgery. A 1-piece hydraulic Dynaflex prosthesis (American Medical Systems, Minnetonka, Minnesota) was used in 10 patients, while a 3-piece hydraulic CXM and CX (American Medical Systems) prosthesis was placed in 9 and 16, respectively. The 1-piece model was withdrawn from the market in 1997. Thereafter a 3-piece prosthesis was implanted. RESULTS: Of 10 patients in the 1-piece group prosthesis implantation was uneventful in 8. In 2 patients with technical failure the prosthesis was replaced, including 1 in whom the new prosthesis was removed due to infection and successfully replaced by a 3-piece prosthesis. To date at a mean followup of 3.5 years 9 patients have a 1-piece hydraulic prosthesis in place. In the 3-piece prosthesis group of 25 patients implantation was uneventful in 20. In 1 patient infection and partial necrosis of the neophallus developed, 2 had infection, in 1 a cylinder perforated the tip of the phallus and in 1 technical failure occurred. Of the latter 4 patients the prosthesis was replaced successfully in 2 patients, while the other 2 are on the waiting list. The patient with partial necrosis of the phallus is no longer a candidate for an erection prosthesis. To date at a mean followup of 1.8 years 23 patients have a 3-piece hydraulic prosthesis in place. A single patient in the 1-piece group has a 3-piece CX prosthesis. CONCLUSIONS: Good results were observed after implantation of the Dynaflex prosthesis in patients who underwent total phalloplasty. This model is no longer available today. For the more complex 3-piece CX and CXM prostheses implantation results are comparable to those of the 1-piece model.     

Aortic atresia and aortico-left ventricular tunnel: successful surgical management by Konno aortoventriculoplasty in a neonate

A newborn infant with aortic atresia and aortico-left ventricular tunnel was successfully treated by Konno aortoventriculoplasty. A 15 mm Ionescu-Shiley pericardial xenograft was inserted when the patient was 5 days old and it was replaced with a 19 mm St. Jude Medical prosthesis at 2 years of age.     

A New Operation for Far-Advanced Cystic Medial Necrosis of the Aortic Root

Three patients with far-advanced cystic medial necrosis of the aorta, which had produced giant bulbous enlargement of the aortic root and severe aortic regurgitation, were operated on using a procedure not previously described. Measurements of the aortic valve annulus and ascending aorta were made from aortograms. A knitted polyester arterial prosthesis was sewn together to form a circle. This circular prosthesis was sewn to a 31 mm Björk-Shiley aortic valve prosthesis in the way that a tire is fitted onto a wheel. The resulting composite prosthesis, which had the same diameter as the aortic root, was used to replace the excised valve. In all cases a composite prosthesis measuring greater than 50 mm in diameter was used. In 2 of the 3 patients the ascending aorta was replaced with a tubular graft reshaped as a truncated cone. This reshaping was done by inserting multiple gussets into one end of the aortic prosthesis so that the flanged end fit precisely to the enlarged valve prosthesis and the other end fit precisely to the transverse aortic arch. Two patients are asymptomatic more than two years following operation. The third patient died suddenly of a ventricular arrhythmia on the twenty-third postoperative day.     

Function of Fifty-Seven Septic,Revised and Healed Total hip Arthroplasties

An evaluation of hip function was made 2–5 years postoperatively in 57 patients reoperated using gentamicin—containing bone cement because of deep infection after total hip arthroplasty. Forty patients were completely free from pain and 17 had slight intermittent pain. Fifty—one had normal or nearly normal walking ability. Most patients managed dressing and getting in and out of a bath without help. It is concluded that revision in most cases offers a satisfactory solution for the patient and gives a better functional result than simple removal of the prosthesis.     

Surgical treatment of thrombosed Bj?rk-Shiley aortic valve prosthesis.

Massive thrombosis of a Bj?rk-Shiley aortic valve prosthesis occurs with significant frequency when adequate anticoagulation has not been attained. The converse is also true: This complication is extremely rare in patients receiving anticoagulant therapy. Therefore, we recommend anticoagulants for all patients with Bj?rk-Shiley aortic valve prostheses. Once a diagnosis of a thrombosed prothesis is made, however, immediate operation is indicated. Declotting of the valve without removal of the disc is adequate treatment. After thrombectomy, it is extremely important to evaluate the entire prosthesis critically, with particular attention to the area of the hinge and the occluder. If any wear is observed, the entire prosthesis should be replaced. Excellent long-term results can be expected if the patient is maintained on adequate anticoagulation postoperatively.     

Unoperated bilateral cleft lip and palate in a young adult: a thirty three year follow-up

A 15-year-old patient with an unoperated complete bilateral cleft of the lip and palate was operated in 1955. The premaxilla was sacrificed and replaced with a prosthesis. The prolabium was hypoplastic and was used to reconstruct the columella. A follow-up of 33 years is presented.     

%VO2max as an indicator of prosthetic rehabilitation outcome after dysvascular amputation

In this study, independent ambulation of at least 100 metres with/without a cane was regarded as successful prosthetic rehabilitation. The subjects were classified into two groups according to this criterion at the time of discharge. The successful group attained this performance, the other group failed to reach this level. The successful group included 8 unilateral trans-femoral amputees aged 72.2 +/- 2.1 years who underwent amputation at more than 70 years, and succeeded in walking with a prosthesis. The group which failed included 9 unilateral trans-femoral amputees aged 63.2 +/- 2.1 years who underwent amputation between the ages of 60-65 years, and had great difficulty in walking with a prosthesis. The purpose of this research was to investigate whether or not %VO2max as an indicator of physical fitness is useful in predicting prosthetic rehabilitation outcome after dysvascular amputation by comparing these two groups. Evaluation of physical fitness was conducted before the subjects began prosthetic rehabilitation. Information about each subject before fitting with a prosthesis was collected retrospectively from clinical charts made during admission. The successful group were capable of strenuous exercise, reaching the intensity of 50% VO2max or more. In the group which failed only one reached the intensity of 50% VO2max. The working capacity of 50% VO2max or greater would appear to be a valid initial guideline level of physical fitness at which an amputee can expect to succeed in walking with a prosthesis. Apart from physical fitness, a lesser number of comorbidity, good ability to stand on the remaining leg, and a strong will to walk were found to be important factors contributing to successful prosthetic rehabilitation. This study also showed that age alone was not an important factor.     

An unusual complication of penile prosthesis following urethroplasty

We report a case of an adult who had undergone transpubic urethroplasty for a 5-cm long posterior urethral stricture. A malleable penile prosthesis (AMS 600R) was implanted 19 months later for the trauma-related impotence. The patient was discovered to develop a complete obliteration of the urethra after removal of infected penile prosthesis 18 months later. Perineal urethroplasty cured his restricture. Suggestions are made to prevent urethral restricture if penile prosthesis is required after urethroplasty.     

Total prosthesis arthroplasty in femur head necrosis

In young patients with advanced necrosis of the femoral head, the short- and medium-term results of total prosthesis arthroplasty are the most satisfactory. However, the prospect of aseptic loosening hangs over such arthroplasties like Damocles' sword. Reports from the literature suggest that, in addition to the age of the patient, there is also an endogenous factor that can be responsible not only for the etiology and pathogenesis of the necrosis, but also for the early loosening of the prosthesis. We have followed up 54 patients (73 hip joints) who had total hip replacement as a result of necrosis of the femoral head between 1976 and 1988. Altogether, 3 acetabular and 5 femoral shafts had to be replaced (7 patients). This corresponds to a loosening rate of 10% after an average of 4.9 years. Hence, the prosthesis changing rate is lower than that reported by other authors, but is still higher than in patients with coxarthrosis. Only 2 of 52 cemented shaft prostheses had to be replaced; the average age of these patients was 61.4 years. Of the 21 cement-free shaft implantations, 3 had to be replaced, the average age of these patients being 42.9 years. The fact that the average age of the latter patients was lower may be the reason for the revision rate not being significantly higher for the non-cemented shafts. In view of the fact that necrosis of the femoral head can rapidly result in the patient becoming an invalid if it is allowed to follow its natural course, hip joint prostheses should also be offered to younger patients.     

Hemi-replacement arthroplasty of the proximal humerus. A case report

A ten-year-old girl underwent excision of a chondrosarcoma of the right proximal humerus with subsequent insertion of a prosthesis. Failure of the device occurred six years after operation, requiring revision to an identical but shorter prosthesis. This device failed 1 1/2 years later and was replaced by a fibular graft inserted in the humeral medullary canal. The fibular graft was removed 18 months later, resulting in a flail right shoulder. The mode of failure in each instance was anterior and superior dislocation of the hemiarthroplasties. Currently, ten years after the initial procedure, the patient is tumor free with a shortened functional right upper extremity.     

Post-traumatic tricuspid insufficiency: a case report

Post-traumatic tricuspid insufficiency is a rare complication of chest trauma. An 18-year-old male patient was injured in a bicycle accident from his abdominal and anterior chest wall. The tear on the inferior diaphragmatic surface of the heart was repaired with primary sutures by the attending surgeon. Eighteen years later, he was admitted to the hospital with severe tricuspid regurgitation (3+/4+). During the operation, the valve was determined unsuitable for repair and was replaced with a bioprosthesis. The hemodynamic aberrations relevant to an isolated tricuspid valve injury are very often well-tolerated. Reconstructive surgery may be possible in the early period. In the late cases, repair is sometimes not feasible due to degeneration of the valvular apparatus. Replacement with a biological prosthesis may give the best long-term results in longstanding cases.     

定制肿瘤型关节假体髓外柄断裂的有限翻修技术

 目的 介绍定制肿瘤型关节假体髓外柄断裂的有限翻修方法,并评价其临床应用效果。方法 3例患者行定制肿瘤型关节假体置换术后发生假体髓外柄断裂,男2例,女1例;年龄分别为25岁、51岁和52岁。原发肿瘤部位及病理组织学类型分别为股骨远端骨肉瘤、股骨远端复发性骨巨细胞瘤及股骨近端软骨肉瘤。假体髓外柄断裂分别发生于术后11个月、34个月和28个月,均无明显外伤史,为行走时发生假体断裂。假体断裂处位于股骨远端假体髓外柄结合部和股骨近端假体的股骨颈基底部。依据假体断裂后髓内柄固定牢固及髓外柄残留足够长度的情况,为避免常规翻修手术中较困难的原假体髓内柄及骨水泥取出,设计了股骨近端和远端翻修假体进行有限翻修,该翻修假体由套筒部和关节部组成,材质及关节部外形与原假体相同,翻修时保留原假体髓内柄,将翻修假体套接于残留的髓外柄,骨水泥及挤压螺钉固定,同时更换磨损的配件,从而完成有限翻修。术后常规功能锻炼,定期随访观察翻修假体稳定性及肢体功能恢复情况。结果 3例患者假体断裂原因为股骨远端假体髓外柄结合部、股骨近端假体股骨颈基底部疲劳断裂各1例,股骨远端假体髓外柄结合部松动、锁钉断裂1例。翻修术后分别随访1个月、103个月和110个月,1例骨巨细胞瘤患者发生软组织内肿瘤复发而再行肿瘤切除术。至末次随访时,3例患者翻修假体固定牢固、无松动。MSTS评分肢体功能评分分别为66.7%、86.7%和83.3%。结论 定制肿瘤型关节假体由于疲劳或结构失效可发生断裂,套接式翻修假体可保留固定牢固的原假体髓内柄而行有限翻修,降低了手术难度,有利于肢体功能的尽快恢复。     

Relapsing seroma in a uremic patient bearing a PTFE graft as vascular access

Seroma is one of the most frequent complications of PTFE vascular grafts and its etiology is still unclear. Case report: A 51 year-old male on regular dialytic treatment for seven years underwent the surgical implantation of a vascular prosthesis of homologous safena due to the thrombosis of his native artero-venous fistula. Several years earlier the patient had suffered the amputation of the left forearm because of electric shock. A few months later the vascular prosthesis was replaced with a PTFE vascular graft as a result of aneurysm formation and thrombosis. During the following days a non pulsating swelling occurred near the arterial anasto-mosis. Ultrasonography, doppler sonography and aspiration confirmed the diagnosis of seroma and it was surgically removed. Some weeks later a new seroma was observed in the same site and associated with a skin ulcer. A new surgical removal had no benefit and about one month later a perigraft collection was found along with signs of bacterial infection. For this reason the patient underwent the surgical excision of the PTFE graft and a vascular access was warranted by placing a Tesio TM catheter. Usually surgery is considered mandatory in seromas larger than 2 cm in diameter and showing continuous growth. In our patient the poor vascular status might have suggested a more conservative management even with a seroma diameter of about 7 cm. Nevertheless the high risk of systemic infection prompted us to remove the PTFE graft.     

Girdlestone's hip resection. Clinical and electromyocinesigraphic study

Forty-five patients with unilateral excision of the femoral head and neck and 2 patients with bilateral excision were studied with a follow-up of 6 months to 6 years. In 36 cases the hip excision was performed after a total hip prosthesis. We have personally monitored 22 patients. The others either died or suffered from other general diseases not related to the operation, making it impossible to check their locomotor apparatus. Two criteria were studied in particular: walking and pain. Fifty-five percent of the patients can walk well with one cane, 31% with two canes, and 14% require assistance to walk. Thirty-one can stand and walk without pain, 55% have some discomfort when fatigued, and 14% have constant pain. Electromyocinesigraphic examination was performed in 6 patients in order to study the automatic function of the muscles when the patient was standing and walking. We found the following: (1) no innervation of the hip abducters with high activity of the rectus anterior during the standing phase of the leg operated upon; (2) abnormal symmetrical and permanent activity of the erectores trunci during the usual standing posture and during walking; (3) increased activity of the hip abductors of the nonoperated leg when standing and walking.     

Total hip replacement comparison between the McKee-Farrar and Charnley prostheses in a 5-year follow-up study

In a prospective study, 177 patients who underwent total hip replacement by the McKee-Farrar or Charnley techniques were followed up for 5 years with yearly clinical examinations, walking tests, and X-rays. The findings concerning pain, walking ability, and complications were satisfactory and similar to the inventors' own 5-year results. Comparison between the two techniques disclosed no major differences. Over 90% of the patients were free from pain; the infection rate was 3.4% and the loosening rate 6%. A walking test showed marked increase in speed over the first few years and a slight decrease after the third year. Our findings do not support the hypothesis that the metal-on-metal prosthesis is clinically inferior to the metal-on-polyethylene prosthesis.     

Total hip replacement comparison between the McKee-Farrar and Charnley prostheses in a 5-year follow-up study

Summary In a prospective study, 177 patients who underwent total hip replacement by the McKee-Farrar or Charnley techniques were followed up for 5 years with yearly clinical examinations, walking tests, and X-rays. The findings concerning pain, walking ability, and complications were satisfactory and similar to the inventors' own 5-year results. Comparison between the two techniques disclosed no major differences. Over 90% of the patients were free from pain; the infection rate was 3.4% and the loosening rate 6%. A walking test showed marked increase in speed over the first few years and a slight decrease after the third year. Our findings do not support the hypothesis that the metal-on-metal prosthesis is clinically inferior to the metal-on-polyethylene prosthesis.     

Prosthetic valve replacement in Ebstein's malformation: 30-year follow-up.

This report addresses a 42-year-old asymptomatic patient who underwent prosthetic replacement of his tricuspid valve 31 years previously for Ebstein's malformation. A ball valve prosthesis was implanted to replace the abnormal valve. Furthermore, he had concomitant closure of a large atrial septal defect with a perforated patch together with plication of the atrialized ventricular segment. The patient is asymptomatic, and it remains noteworthy that he has not been on coumadin for about 30 years.     

Neglected Irreducible Dislocation of the Interphalangeal Joint of the Great Toe: A Case Report

Irreducible dorsal dislocation of the interphalangeal joint of the great toe is rare. We report a case of a 58-year-old man with an irreducible interphalangeal joint of the great toe that had been untreated for 4 years. The mechanism of this injury was thought to be a combination of axial loading with a hyperextension force when the patient hit his great toe against a pipe. Invagination of the sesamoid became a barrier for manual reduction attempted after the initial injury. The patient did not seek treatment because of the minor deformity of the affected great toe and lack of severe symptoms. One year later, symptoms eventually developed on the plantar aspect of the great toe, particularly when the patient was walking upstairs. He decided to seek treatment as pain worsened and he became more active when he changed occupations 4 years later. Manual reduction was impossible. The patient was treated with operative exploration of the joint and arthrodesis of the great toe. The operative course was uneventful. At 4 years after surgery, the patient could walk, run, and walk up and down stairs without discomfort.