The operative management of osteoporotic fractures of the knee: to fix or replace?

This review considers the surgical treatment of displaced fractures involving the knee in elderly, osteoporotic patients. The goals of treatment include pain control, early mobilisation, avoidance of complications and minimising the need for further surgery. Open reduction and internal fixation (ORIF) frequently results in loss of reduction, which can result in post-traumatic arthritis and the occasional conversion to total knee replacement (TKR). TKR after failed internal fixation is challenging, with modest functional outcomes and high complication rates. TKR undertaken as treatment of the initial fracture has better results to late TKR, but does not match the outcome of primary TKR without complications. Given the relatively infrequent need for late TKR following failed fixation, ORIF is the preferred management for most cases. Early TKR can be considered for those patients with pre-existing arthritis, bicondylar femoral fractures, those who would be unable to comply with weight-bearing restrictions, or where a single definitive procedure is required.     

The intrathoracic kidney: should we fix it?

BackgroundIntrathoracic kidney is a rare congenital anomaly, with only 13 cases reported in the pediatric age group over the past 25 years. The relevant literature is limited to individual case reports or small case series with no follow-up data. Both operative and nonoperative management has been advocated. We report our experience in the management of children with an intrathoracic kidney as well as the efficacy of nonoperative management in select patients.MethodsFive cases of intrathoracic kidney were collected prospectively since 1992 and carefully followed up long term.ResultsTwo children presented with acute respiratory distress and underwent right diaphragmatic hernia repair and nephropexy. Incidental diagnosis of a left intrathoracic kidney was made in 3 children. Long-term follow-up has demonstrated normal function and development of these kidneys in all 5 children with no late bowel herniation in the nonoperative group.ConclusionIntrathoracic kidney associated with bowel in the chest should undergo standard repair and nephropexy. An isolated intrathoracic kidney without evidence of bowel herniation can safely be observed. This is the largest pediatric series of intrathoracic kidney as well as the first to document the efficacy of nonoperative management with long-term follow-up.     

Lateral condylar humerus fractures: which ones should we fix?

Lateral condyle fractures of the distal humerus are problematic whether displaced early or late. Operative intervention with closed reduction and percutaneous pinning or open reduction internal fixation are indicated for a malaligned articular surface and/or an unstable fracture. Intraoperative arthrograms can aid the surgeon in assessing joint reduction.Level of Evidence: Case report.     

Periarticular fractures around the hip and knee: fix or replace?

The number of periarticular fragility fractures around the hip and knee is increasing. If surgical treatment is indicated, open reduction and internal fixation or replacement can often be viable options. In contrast to secondary replacement, the use of replacement in the acute stage might be advantageous because early rehabilitation and weightbearing can be initiated. This article describes the current literature related to internal fixation or primary replacement in periarticular fractures around the hip and knee.     

Ist „fix and flap“ auch im hohen Alter sinnvoll anwendbar?

Die Unfallchirurgie - Die optimale Behandlungsstrategie bei komplexen Knochen-Weichteil-Verletzungen bei alten PatientInnen stellt eine neue Herausforderung dar. Die konkurrierenden Verfahren sind...     

Evaluation of surgical resection of pulmonary metastasis of trophoblastic tumor

Objective: To evaluate the role of the lung lobectomy in gestational trophoblastic tumor patients with lung metastases. Methods: A total of 45 cases of trophoblastic tumor with pulmonary metastases treated by lung lobectomy from 1985~2002 at PUMC hospital were retrospectively analyzed. Seven cases were diagnosed as invasive mole and thirty-eight as choriocarcinoma. Results: Lung lobectomy was performed in all of these patients after several courses of chemotherapy. Seven cases of invasive mole reached complete remission. Eleven cases of choriocarcinoma with stage Ⅲa had received average 13 courses of chemotherapy, 10 of them reached complete remission. Seventeen cases of choriocarcinoma with stage Ⅲb had received average 14.3 courses of chemotherapy, 11 of them reached complete remission. Ten cases of choriocarcinoma with stage Ⅳ had received average 15 courses of chemotherapy, six of them reached complete remission. In the 45 patients, histologic examination disclosed haemorrhagic necrotic tissue in 27 patients, 17 of them reached complete remission(63%). Histologic examination also revealed fibrosis around the focus in 16 patients, 14 of them reached complete remission(88%). Tuberculosis was found in 2 patients.Conclusions: Although the development of effective chemotherapy has resulted in improved survival of patients with gestational trophoblastic tumor, lung lobectomy remains an important adjunct treatment in a selected subset of patients. Pathological examinations can help to estimate the prognosis.     

Determination of the optimal frequency of injection of triamcinolone: monitoring change in volume of keloid lesions following injection of 40 mg of triamcinolone

Background

Different dosage protocols may be advocated by different clinicians for the same keloid lesion. The aim of this study was to determine the optimal frequency of injection of triamcinolone for the purpose of reducing the size of keloid, by monitoring volume change in lesions.

Methods

Volume of all lesions was measured, and 40 mg of triamcinolone was injected once. Lesion volume was thereafter monitored weekly for 6 weeks.

Results

Mean pretreatment volume was 6.4 ml. Following triamcinolone injection, mean lesion volume became 5.1, 3.7, 3.6, and 3.6 ml at 1, 2, 3, and 4 weeks postinjection, respectively. The mean lesion volume was 3.7 and 3.9 ml at 5 and 6 weeks postinjection. Mean lesion volume was 1.29 ml lower at 1 week than at pretreatment stage (SD?±?0.8797), 1.35 ml lower in volume at 2 weeks than 1 week (SD?±?1.0386), and 0.138 ml lower in volume at 3 weeks than 2 weeks (SD?±?0.159). Mean lesion volume was 0.0250 ml lower at 4 weeks than at 3 weeks (SD?±?0.3215), 0.1000 ml greater in volume at 5 weeks than 4 weeks (SD?±?0.1713), and 0.2000 ml greater in volume at 3 weeks than 2 weeks (SD?±?0.0418). There is a statistically significant difference between the mean volume at 1 week postinjection and that at pretreatment stage, between 2 and 1 week, and between 3 and 2 weeks (p?≤?0.05). Reduction in volume was found to be most profound and statistically significant within the first 2 weeks postinjection.

Conclusions

This study finds that the optimal frequency of intralesional injection of triamcinolone involves a 2-week injection interval.Level of Evidence: Level IV, therapeutic study

     

Treatment of 209 cases of liver injury

Objective: To summarize the experience of the treatment of traumatic hepatorrhexis. Methods: The clinical data of 209 cases of liver trauma treated in the three affiliated hospitals of the Third Military Medical University from 1989 to 1999 were retrospectively analyzed. Among the 209 patients, 108 (51.7%) had Grade Ⅲ or more severe liver injury. Operative treatment was performed in 186 cases and preservative treatment in 23. Results: In the operated group, 169 patients were cured. The eomplications occurred in 18 patients and 17 of them died. In the non-operated group, the complications occurred in 22 patients and only 1 of them died. Conclusions： Severe injury and delayed treatment are two major factors leading to death from liver injuries.Surgical intervention is still the principal measure to treat traumatic hepatorrhexis. The indications for non-operative treatment should be carefully selected.     

Analysis of urgent reconstruction of electrical injuries

Objective:To summarize the reconstruction experience of the electrical injuries in emergency.Methods:All 309 wounds in 105 patients who suffered from electrical injuries were reviewed during a 10year period from Jan.1st 1986 to Dec.31st,1996.Treatment method,patient data and results were compared and analyzed.A comprehensive urgent reconstruction alternative used in all cases included the followings,1)debriding the wound in emergency,2)preserving the vital tissues as much as possible,even devitalized tissues or local necrosis,3) transplanting these vital tissues during the first surgery if the functional reconstruction required,4) nourishing the wound bed by tissue flaps covering with rich blood supply,5)improving flap survival by continuous irrigation for 24-720 hours beneath the flaps with a compound medicine after surgery.Results:Satisfactory results were obtained with the extremity loss ratio of less than 7% in this group compared with 42.5% which was 10 years before 1984 in the same hospital.Conclusions:This urgent comprehensive reconstruction alternative is an effective and workable method for reducing extremity loss of electrical injuries.