The diagnosis and treatment of the ‘mixed’ type of depressed fractures of the calcaneum

Summary The mixed type of depressed fractures of the calcaneum is described and a classification proposed. During a six year period, 78 patients with fractures of the calcaneum were seen. Of these 32 were of the mixed type and 23 were treated by sub-talar arthrodesis and restoration of the calcaneal outline. Very good or good results were obtained in all patients subjected to operation.

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Résumé L'auteur décrit un type de fracture du calcanéum par enfoncement «mixte» (i. e. à la fois vertical et horizontal) et il en propose une classification. Sur 78 fractures du calcanéum observées en six ans, 32 étaient de ce type «mixte» et 23 d'entre elles furent traitées par arthrodèse sous-astragalienne avec reconstitution de la forme du calcanéum. D'excellents ou de bons résultats ont été obtenus chez tous les blessés qui ont bénéficié de cette intervention.

     

Surgical treatment of equinus deformity in cerebral palsy by aponeurosis lengthening and Z-lengthening

Abstract Surgical treatment of equines deformity in cerebral palsy can be carried out successfully by Achilles tendon lengthening and gastrocnemius aponeurosis lengthening. From 1993 to 1998, we performed 59 operations in 37 cerebral palsied patients with equinus deformity using Z-lengthening in 30 cases and a modified Bakers procedure in 29 cases. The operations, associated with other hip and knee procedures in 65% of patients, were followed by postoperative use of casts and by a 12-month intensive kinesitherapeutic protocol. On preoperative evaluation, besides pattern deformity and the condition of proximal joints, we considered also age, clinical diagnosis, nature of tone and muscle strength. In most cases, the retrospective analysis showed the correction of deformity and a functional improvement. We observed 9 recurrences in six of the younger patients without relationship with topographic pattern of cerebral palsy. Overcorrection of equines deformity occurred in one diplegic child who had phasic hypertonia and low muscle strength. We believe that the evaluation of patients, the preoperative planning and the effective kinesitherapeutic program are necessary to reduce the risk of complications related to surgery.     

Laparoscopic treatment of enteric fistulas

Background: Elective laparoscopically assisted sigmoid colectomy for diverticular disease and ileocolic resection for terminal ileal Crohns disease are safe and beneficial procedures in many patients. However, few data exist regarding the laparoscopic management of enteric fistulas from diverticular and Crohns disease. Methods: We completed a retrospective chart review of patients who underwent laparoscopic treatment of enteric fistulas complicating diverticular and Crohns disease. Results: During an 8-year period (1994–2002), 72 patients underwent 73 laparoscopically assisted bowel resections for enteric fistulas by one surgeon at the Mount Sinai Medical Center. Ninety percent of patients had Crohns disease, the average age was 39, and the male/female ratio was 38/34. Patients had a history of prior abdominal surgery in 39.7% of cases. Multiple fistulas were present in 30% of patients and 12.3% underwent multiple resections at the time of operation. Mean operating time was 199 min, and the conversion rate was 4.1%. Average length of stay was 5.2 days. There were no mortalities in the series. Overall morbidity was 11%. Conclusions: Laparoscopic management of enteric fistula disease is safe and effective. Low morbidity and short hospital stay demonstrate the safety and benefit of the minimally invasive approach for even complicated fistula disease in patients with history of prior abdominal surgery and multiple fistulas, or in patients requiring multiple resections for fistulas from diverticular and Crohns disease. Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Los Angeles, CA, USA, 12–15 March 2003     

Rectal prolapse: which surgical option is appropriate?

Numerous surgical procedures have been suggested to treat rectal prolapse. In elderly and high-risk patients, perineal approaches such as Delorme’s procedure and perineal rectosigmoidectomy (Altemeier’s procedure) have been preferred, although the incidence of recurrence and the rate of persistent incontinence seem to be high when compared with transabdominal procedures. Functional results of transabdominal procedures, including mesh or suture rectopexy and resection–rectopexy, are thought to be associated with low recurrence rates and improved continence. Transabdominal procedures, however, usually imply rectal mobilization and fixation, colonic resection, or both, and some concern is voiced that morbidity, in terms of infection or leakage, and mortality could be increased. If we focus on surgical outcome, our own experience of laparoscopic resection–rectopexy for rectal prolapse shows that the laparoscopic approach is safe and effective, and functional results with respect to recurrence are favorable. However, the controversy “which operation is appropriate?” cannot be answered definitely, as a clear definition of rectal prolapse, the extent of a standardized diagnostic assessment, and the type of surgical procedure have not been identified in published series. Randomized trials are needed to improve the evidence with which the optimal surgical treatment of rectal prolapse can be defined.     

The tensile strength of Cooper’s ligament suturing: comparison of abdominal and transvaginal techniques

This study was designed to compare the strength and position of sutures anchored into Coopers ligament utilizing a minimally invasive transvaginal suturing technique, versus the open abdominal approach. In 12 fresh cadavers, Coopers ligament was accessed via abdominal and vaginal incisions. After randomization, polytetrafluoroethylene (00) sutures were spaced along one ligament with the transvaginal device (n=36). Contralaterally, sutures were placed abdominally (n=36). Progressive load was applied until suture breakage or dislodgement, and tensile strength was measured using a digital tensiometer. Peak tension averaged 14.5 psi for abdominal and 12.96 psi for vaginal (p=0.28). Suture breakage rather than ligament pullout was more likely for abdominal (95 vs. 56%, p=0.0001). Vaginal and abdominal sutures demonstrated nearly identical mean distances from mid-symphysis (4.62 vs. 4.24 cm, p=0.56). Peak tension was not correlated with suture location (r²=0.17, p=0.28). We conclude that transvaginal suturing, using the minimally invasive device, achieved similar tensile strength and position to the open technique. Transvaginal sutures were associated with greater likelihood of ligament pullout before suture breakage under maximal load; however, the clinical implications of this finding are uncertain.Disclosure: this study utilized no external funding or sponsorship Editorial Comment: In this study, the authors compare sutures anchored to the Coopers ligament utilizing a transvaginal technique with those placed by open abdominal approach. They conclude that transvaginal technique was comparable to the open approach with respect to tensile strength and suture position. Given the well-known advantages of vaginal approach, it is clear that there is a growing need for minimally invasive techniques in pelvic reconstructive surgery. Unfortunately most new surgical techniques are performed in patients without any prior lab evaluation, often with untoward consequences. It is commendable that the authors have tried to evaluate their technique in cadavers to verify their suture placement. While the results of this study are encouraging, we cannot conclude that transvaginal technique can replace abdominal approach. The dynamic forces influencing the surgical sites inside a human body may be very different from the caudally applied force in this biomechanical study. Further research into this interesting question is warranted.     

Squamous carcinoma in a pressure sore with a very short latency period

Malignancy in a chronic pressure sore is rare among Marjolins ulcers. Carcinomas arising in pressure sores are highly aggressive and usually fatal. Although carcinomas in pressure sores are generally well-differentiated squamous carcinomas, they can show quite an aggressive course and do not respond either to chemotherapy or radiotherapy. The mortality rate is high despite wide surgical resection. It must be kept in mind that carcinomas may arise in pressure sores and treatment must be early and aggressive. We report a squamous carcinoma arising in a pressure sore that had a very short latency period. The related literature was reviewed.     

Developmental CSF cysts of the posterior fossa

Summary 20 cases of operated developmental CSF cysts are surveyed: 8 Dandy-Walker syndromes and 12 extraaxial arachnoid cysts. A CSF shunt is the only possible operation for Dandy-Walker syndrome and a single shunt from the cyst is preferable to a double shunt; the success rate is 50%. Congenital extraaxial arachnoid cysts, which arise from a developmental anomaly of the roof of the hindbrain or primitive leptomeningeal spaces, must be differentiated from acquired arachnoid cysts. Those of this series fall into two groups: midline and lateral. Supravermian midline cysts resemble the Dandy-Walker syndrome in several respects, including the frequent recourse to a shunt operation and the uncertain distant prognosis, whilst the other extra-axial cysts usually simulate a cerebellar tumor. Lateral cysts may, however, present peculiar symptoms such as a homolateral motor deficit that does not always respond to surgery, and an oscillating symptomcomplex. Surgical removal is the treatment of choice both for subvermian midline and lateral cysts but subsequent shunting may be necessary to control persisting hydrocephalus. The long term prognosis is generally excellent for subvermian midline cysts but may be only fair for lateral cysts.     

Ultrasound in patients affected with Peyronie’s disease

Peyronies disease (PD, induratio penis plastica) is uncommon. Its etiology is unknown and the incidence is stated to be 1%, although more recent data suggest that it is higher. The symptoms are penile deviation and painful erection in association with penile plaques. The diagnosis is performed by palpation of the penis. X-ray diagnostics are only used to visualize the calcified plaques in soft tissue imaging, and the survey of plaque size and consistence is done by sonography with high reproduction. This enables the exact evaluation of treatment effects. By application of high frequency scanners (7–12 MHz) the extent and depth of the plaques can be estimated non-invasively in high resolution images. Furthermore, color coded duplex sonography and recording of Doppler spectra are used to assess hemo-perfusion in the penile vessels and the analysis of erectile dysfunction, often seen in combination with PD. Sonographic diagnosis appears as a valuable supplement and requirement for a successful therapy of PD.     

The use of the reverse sural neurovenocutaneous flap in distal tibia, ankle and heel reconstruction

The distal third of the tibia, ankle and heel area is difficult to reconstruct. Microsurgery is an option but the time and the complexity of this type of procedure is a disadvantage. For small to medium size defects, local flaps are often an easier alternative. Recent detailed anatomic studies have demonstrated the existence of the perineural vascular plexus. In lower limb surgery, the sural flap is based on this principle and this flap is becoming increasingly popular. Many articles have been written with some contrasting opinions regarding the anatomy, size of flap, location of the skin paddle, mode of transfer and overall survival. The aim of this publication is to present a single surgeons experience in 17 consecutive cases using the reverse sural flap for distal tibia, ankle and heel reconstruction. The location of the defect, the flap dimensions, the results and complications are presented. Some conclusions are drawn and recommendations are made for maximum efficacy when using this flap, especially when used in older patients.     

Surgical remodeling of the silhouette by aspiration lipolysis or selective lipectomy

The author, a pioneer in originating the technique of suction lipectomy, discusses in detail the pathophysiology of the fat cell and fat metabolism. In addition, he describes the surgical means by which, since 1977, he has popularized this innovative new approach to the treatment of unsightly fat deposits in many sites in the body, including the thighs, buttocks, abdomen, hips, arms, ankles, breasts, and submental regions.     

Frey’s Procedure Using the Harmonic Scalpel

Freys procedure, which is performed for chronic pancreatitis, principally involves coring of the head of the pancreas and pancreaticojejunostomy. The coring of the inflamed and enlarged pancreatic head is the most difficult and time-consuming part of this operation and is often associated with considerable bleeding. We used the harmonic scalpel to perform Freys procedure in six consecutive patients, which reduced intraoperative bleeding and made the operation technically easier.     

Mesenteric Involvement of Acute-Stage Buerger’s Disease as the Initial Clinical Manifestation: Report of a Case

Buergers disease is almost always a disease of the blood vessels in the extremities. Conversely, mesenteric involvement of Buergers disease is rare, and no true series have been reported. We report the case of a 37-year-old man with clinical symptoms of upper extremity Buergers disease, who underwent surgery for extensive small bowel infarction. Histopathologic findings revealed that the mesenteric arteries were swollen and infiltrated with neutrophils, but not associated with fibrinoid necrosis. The lumen was occluded by a highly cellular thrombus with the appearance of a microabscess. These findings were compatible with acute-stage mesenteric Buergers disease and postoperative studies revealed multiple occluded segments in the small and medium-sized arteries of both legs and the left arm, suggestive of Buergers disease in the extremities.     

Benign Symmetric Lipomatosis (Madelung’s Disease): Case Reports and Current Management

Benign symmetrical lipomatosis (BSL) is a rare disorder characterized by the presence of multiple, symmetric, nonencapsulated fat masses in the face, neck, and other areas. Typically, this entity has been related to the presence of three anterior bulges in the neck. The disorder was first described by Brodie in 1846. After that, Madelung in 1888 and Launois and Bensaude in 1898 characterized the disease. There are multiple synonyms for this disorder, such as Madelungs disease, Launois–Bensaude syndrome, and multiple symmetrical lipomatosis. Benign symmetric lipomatosis is usually described in adults from 30 to 60 years old, with an incidence of about 1 in 25,000 and a male-to-female ratio of 15:1 to 30:1. Most cases have no hereditary pattern. More than 90% of the patients have associated alcoholism. The ethiology of benign symmetric lipomatosis remains unknown, but an abnormal lipogenesis induced by catecholamines has been observed. The transformation of BSL to a malignant tumor is extremely rare. In the current report, the authors describe two cases of benign symmetric lipomatosis treated in their department and a review of the literature.     

Laparoscopic management of Chilaiditi's syndrome

Chilaiditis syndrome refers to the symptoms of abdominal pain, distention, vomiting, anorexia, and constipation caused by hepatodiaphragmatic interposition of the intestine. Although patients with this radiographic finding are commonly asymptomatic, presentation with symptoms is rare and accurately refers to this syndrome. There is an increased incidence of Chilaiditis syndrome among mentally ill adults. Traditionally, Chilaiditis syndrome is managed medically by discontinuing causative medicines. However, among the mentally ill population whose psychotropic medications precipitate the interposition of the colon, ceasing these psychotropic medications is not an appropriate option. The case presented involves a mentally ill patient with Chilaiditis syndrome who was successfully managed with laparoscopic colopexy. At follow-up, the patient reported marked improvement of abdominal symptoms.     

Immunohistochemical and immunocytochemical findings in Blount’s disease

Abstract Tissue specimens from patients with Blounts disease were used to examine some biological and morphological aspects of the disease. In particular, we investigated the immunohistochemical characteristics of Blount patients cartilage as regards the extracellular matrix components. Some unexpected findings regarding the presence of bone sialoprotein, osteonectin, osteopontin, tenascin and fibronectin, in addition to the presence of various collagen types, led us to hypothesize an early ageing process in Blount patients cartilage with an abnormal tendency to mineralization. We made primary cultures of chondrocytes from patients to test if the reversion of mechanical in vivo conditions could normalize the cell proliferation and extracellular matrix deposition. Cell cultures failed to reverse the older phenotype that appears to be characteristic of Blount cell populations and confirmed their activity of synthesis of collagenic and non-collagenic proteins. In conclusion, some immunohistochemical and immunocytochemical aspects of Blount cartilage cells suggest an early tendency to mineralization of the extracellular matrix as compared with normal tissue.     

Primary Ewing’s sarcoma of the maxilla: a patient report

Primary Ewings sarcoma rarely arises in the facial skeleton and only occasionally in the maxilla. To date, there have been 22 cases of maxillary Ewings sarcoma reported in the English-language literature. We report a case arising in the maxilla, successfully treated by wide resection, followed by adjuvant radiotherapy and systemic chemotherapy.