Etiology and assessment of hypercoagulability with lessons from heparin-induced thrombocytopenia

Hypercoagulability, or thrombophilia, is a condition associated with an abnormally increased tendency toward blood clotting. Affected individuals are prone to developing venous or arterial thrombosis and often require thromboprophylaxis. Hypercoagulability can be generally classified as either an inherited or acquired condition. Patients with an inherited thrombophilia have genetic variances that alter the quality or quantity of proteins involved with hemostasis. Hypercoagulability may also be acquired and develop as an exaggeration of normal physiologic responses to major tissue injury, or an abnormal response to various prothrombotic clinical factors. Careful assessment for hypercoagulability is important because effective management strategies, often involving anticoagulation, may be available. Heparin-induced thrombocytopenia is an example of an acquired hypercoagulable state that has been well studied and, when recognized, responds to appropriate therapy. In this article, we review the etiology, risks, and assessment of thrombophilia, with emphasis on the clinical lessons learned from heparin-induced thrombocytopenia.     

Extraanatomic bypass for peripheral arterial injuries

Over an 8-year period, extraanatomic bypass grafting was performed for peripheral arterial injuries or infections in 12 patients. The indications for use of the technique were as follows: (1) extensive loss of soft tissue over arterial injury or avulsion; (2) wound infection with rupture of a previous arterial repair; or (3) combined infections in soft tissue and the underlying artery due to illicit drug injection. The technique involved excision of the injured or infected artery beyond the margins of the debrided wound and insertion of an autogenous saphenous vein as an extraanatomic bypass graft in a medial or lateral position around the wound. Shotgun wounds were the mechanism of injury in six patients, whereas an extensive injury or infection in the brachial artery was present in eight patients. Successful wound coverage or closure was accomplished and distal arterial flow preserved in 11 patients, 5 of whom had residual neuromuscular or bony defects related to the magnitude of the original injury.     

Rupture of intracranial aneurysm after partial clipping due to aspiration drainage system--a case report

In neurosurgical practice, extradural or subgaleal drains are commonly placed and connected to a vacuum system. Several reports have described severe bradycardia or arterial hypotension, or both, after connection of negative suction pressure to the extradural or epicranial drains following craniotomy. We encountered an unusual complication with the use of the vacuum drain after an elective aneurysmal clipping surgery. Our case is an iatrogenic intracranial hypotension leading to a clinically significant and potentially fatal complication.     

Effect of venous retroperfusion on experimental myocardial ischemia in the open-chest pig

Venous retroperfusion, by arterialization of the coronary sinus or the vein accompanying an ischemic artery, has been suggested as an alternative method of myocardial revascularization in patients with severe coronary disease in whom direct revascularization would be an unacceptable risk or technically impossible. This study was carried out to assess whether or not venous retroperfusion can increase myocardial blood flow in the area of ischemia after sudden occlusion of a normal coronary artery in an animal, the pig, with a coronary vasculature similar to that of humans. It was found that net flow measured with an electromagnetic flowmeter through either an aorta-to-coronary sinus shunt or an aorta-to-left anterior descending coronary vein shunt after occlusion of the left anterior descending artery was at first high but rapidly decreased toward zero flow within 1 hr. Blood flow in the ischemic region measured by the microsphere method 20 min after coronary occlusion did not increase. This disparity between electromagnetic flow and regional flow suggests that there are venous-to-thebesian or venous-to-venous shunts into the systemic and pulmonary circulation through vessels greater than 14 micron. It is unlikely that effective oxygen or metabolite exchange would occur in vessels this size.     

Orthopaedic surgery and Food and Drug Administration off-label uses

The use of a drug or device for a purpose other than that for which it was approved by the Food and Drug Administration has become an important method by which medical knowledge is expanded. Ethical and moral issues are raised whenever a drug or device is used in an unapproved manner. Physicians using devices in an off-label fashion must be aware of these issues and how they affect their patients. Reviewing an ethical checklist before embarking on the use of a device or drug in an off-label fashion can alert the physician to potential ethical and moral conflicts. The ethical physician always will place his or her patient's well-being and best interests above all else. Using this pledge as the cornerstone of all clinical decisions, the virtuous physician is able to offer the most innovative and new procedures without compromising his or her ethical or moral obligations to their patients.     

Spectrum of ocular injuries in children with major trauma

BACKGROUND: Few studies document the variety of ocular injuries encountered in children after major trauma. This study was performed to determine the type and frequency of ocular injuries in a large population of children with major trauma. METHODS: All children with ocular and adnexal injuries (n = 7497) among 96,879 children registered in the National Pediatric Trauma Registry (NPTR) were analyzed. Children were stratified for Injury Severity Score (ISS is a method for categorizing patients with multiple injuries in which an ISS > 15 is considered major trauma), age, sex, injury, protective restraint, vision threatening injury, and basilar skull fracture. RESULTS: Nearly 8% of the children in the NPTR sustained an ocular injury. These children had one or more injuries to one or both eyes and/or the ocular adnexa for an average of 1.3 ocular injuries per child. Three-fourths (75%) of the children with an ocular injury had an ISS < or = 15 and one-fourth (25%) had an ISS > 15. Among children with an ISS > 15 the most common injuries were orbital wall fracture (59%) and contusion of the eye and ocular adnexa (18%). Among these same children with an ISS > 15, the percent of orbital wall fractures, injuries to the optic nerve, and injuries to the other ocular cranial nerves doubled while the percent of basilar skull fractures tripled when compared with children with an ISS < or = 15. Penetrating injuries of the globe were significantly lower in children with an ISS > 15 than in children with an ISS < or = 15. Over 70% of the children with an eye injury and an ISS > 15 sustained injury in an accident involving a motorized or non motorized vehicle, and over 75% of those who could have been restrained, were not restrained. CONCLUSIONS: Children with an ocular injury sustained during major trauma (ISS > 15) are more likely to have a basilar skull fracture, orbital wall fracture, and a contusion of the eye and/or the ocular adnexa as compared with children with ISS < or = 15. Children with any of these injuries sustained during major trauma should be afforded prompt ophthalmologic evaluation to uncover injury to components of the visual system.     

Large Vessel Injury following Operation for a Herniated Lumbar Disc

Major vascular injury can occur during an operation for a herniated lumbar disc due to the intimate anatomical relation between the lumbar vertebrae and major vessels. Although occurrence is infrequent, it is associated with high morbidity and mortality. Diagnosis is suspected when early signs of retroperitoneal hemorrhage appear, but may often be delayed for weeks or years. Formation of a pseudoaneurysm or an arteriovenous (A-V) fistula may be of gradual onset and produce initially only a few symptoms. We report here six cases of large vessel injury, which consisted of active bleeding from an injured common iliac artery, or a pseudoaneurysm of the common iliac artery with or without an A-V fistula that occurred following an operation for a herniated lumbar disc and was successfully treated by radiologic intervention and/or surgery. Angiography with the intention of intervention is considered the first step of treatment for a large vessel injury following an operation for a herniated lumbar disc at the level between fourth and fifth lumbar or between fifth lumbar and first sacral intervertebral space.     

Caliceal diverticulum and hydrocalyx. Laparoscopic management

Laparoscopic treatment of caliceal diverticula or hydrocalyces is an excellent choice for anterior cavities without significant overlying renal parenchyma that are large or that have an endoscopically inaccessible neck and either a narrow neck or large stone burden.     

Variations of the extensor indicis muscle and tendon

Variations of the extensor indicis muscle were examined in 164 hands from 86 Japanese cadavers. Anomalous cases exhibiting supernumerary muscles or tendons were found in 22 hands. These variations were classified into four types: type 1, an additional tendon slip from the extensor indicis tendon; type 2, an extensor indicis radialis or extensor pollicis et indicis accessorius; type 3, an extensor medii proprius with or without extensor medii brevis; and type 4, an extensor indicis radialis and extensor medii proprius. The extensor medii proprius was the most common variation, followed by extensor indicis radialis. There were no clear differences in incidence of variations between men and women or between right and left hands. When variations were bilateral, both sides were identical or similar in type.     

Gutachterliche Probleme nach Beschleunigungsverletzungen der Halswirbelsäule

Reasons for problems in stating an expert opinion on acceleration injuries of the cervical spine are numerous. The presence of unexpected or the absence of expected symptoms, the lack of objective proof for alterations or the presence of complaints that are difficult to prove, the discrepancy between recognizable force of the impact versus the resulting damage to the injured as well as the chance of being completely incapable of rendering proof that unquestionably a potentially damage-causing event is--beyond any reasonable doubt--the origin of an observed alteration in an injured individual are some of the problems a medical expert has to face when dealing with the analysis of injuries of the cervical spine. Unsatisfactory documentation in the patient's records, discussions about the reliability of diagnostic means or the interpretation of their results, difficult to procure evidence of accident-specific biomechanics and their direct or indirect impact on the body or neck of the injured person as well as distinguishing cervical sprain from mild brain damage, post-traumatic distress syndrome, cognitive disorder, psychiatric disease, aggravation, or malingering makes it hard for an expert to state an expert opinion.     

Orbital hematic cyst: case report and clarification of terms

We present a case of a hematic cyst and review the literature in order to clarify nomenclature discrepancies regarding terms used to describe cysts containing blood and blood breakdown products in and around the orbit. We believe orbital cysts containing blood and blood breakdown products should be separated into two major categories depending on the presence or absence of an epithelial or endothelial lining. A hemorrhage into a preexisting lesion such as a dermoid, on lymphangioma, which contains blood breakdown products lined by an endothelial or epithelial lining, should be referred to as an acute or chronic hematoma in a dermoid or lymphangioma. In contrast, a hematic cyst contains blood breakdown products and has no epithelial or endothelial lining but rather a fibrous pseudocapsule.     

HTLV-1-associated arthropathy treated with anti-TNF-alpha agent

Human T cell leukemia virus type 1 or HTLV-1 infection is a public health problem in endemic regions like Japan, Central America or Africa. Although the majority of HTLV-1 carriers remain asymptomatic throughout their lives, some patients could develop neurological disorder, inflammatory arthropathy also called HTLV-1-associated arthropathy or T-cell malignancy, the adult T-cell leukemia/lymphoma or ATL with a very poor prognosis. Described to be very close to rheumatoid arthritis, HTLV-1-associated arthropathy patients have few or no response to the first line therapy with corticosteroids and disease modifying antirheumatic drugs or DMARDs. The use of anti-TNF-α agents in these patients is an interesting alternative but asks the question of risk of developing an adult T-Cell leukemia/lymphoma. We reported an exceptional case of a smoldering ATL patient with an HTLV-1-associated arthropathy, refractory to corticosteroid, DMARDs and rituximab therapy, treated successfully with etanercept, without progression to aggressive ATL after 5 years.     

Lesions of Cowper's ducts and glands in infants and children.

Lesions of Cowper's duct and gland are more common than previously reported. They may be asymptomatic or may cause micturition difficulties or urinary retention. They may be congenital or acquired (usually inflammatory). Radiographic findings are either a rounded filling defect arising from the floor of the bulbous urethra or reflux into a dilated duct which parallels the bulbomembranous urethra. Panendoscopic fulguration is a simple and effective method of treatment for symptomatic patients with retention cysts. Asymptomatic patients do not need any therapy. A dilated duct should not be confused with partial urethral duplication, a urethral diverticulum, or an ectopic ureter since such an error may lead to an unnecessary operation.     

Orbital Hematic Cyst: Case Report and Clarification of Terms

We present a case of a hematic cyst and review the literature in order to clarify nomenclature discrepancies regarding terms used to describe cysts containing blood and blood breakdown products in and around the orbit. We believe orbital cysts containing blood and blood breakdown products should be separated into two major categories depending on the presence or absence of an epithelial or endothelial lining. A hemorrhage into a preexisting lesion such as a dermoid, on lymphangioma, which contains blood breakdown products lined by an endothelial or epithelial lining, should be referred to as an acute or chronic hematoma in a dermoid or lymphangioma. In contrast, a hematic cyst contains blood breakdown products and has no epithelial or endothelial lining but rather a fibrous pseudocapsule.     

Surgical treatment of aseptic forearm shaft pseudarthrosis

Non union of a lower arm fracture (without infection) is the result of inadequate immobilization or of too extensive devastation of the bone. Within 1975 to 1985 in the accident-hospital of Tübingen we saw 131 pseudarthroses of the ulnar or radius shaft in 111 patients. Among these a hypertrophic pseudarthrosis is mostly seen after conservative treatment or operative treatment with intramedullary nailing. Atrophic pseudarthroses or defect pseudarthroses mostly occur after open fractures, comminuted fractures or insufficient plate osteosynthesis. The operative treatment was regularly a plating of radius and/or ulna (mostly with the 3.5 mm AO-DC-plate) combined with correction of axis or rotation deformity. Depending on the type of the pseudarthrosis, decortication was also performed as well as an autogenous bone-grafting or an interposition of a cortical-cancellous-block. All but one of the pseudarthroses each of the ulna and radius, healed completely. Most patients had a reduction of pain, improvement of mobility of the elbow or wrist joint, especially an improvement of supination/pronation, regarded as an index of correction of a malrotation. Postoperative physiotherapy has to be most careful; the best physiotherapy is the everyday active use of the arm by the patient himself.     

Chest tube perforation of esophagus following repair of esophageal atresia

The two major acute thoracic complications of closed chest tube thoracostomy are pulmonary laceration and vascular compression. We have noted that closed chest tube thoracostomy can also perforate an esophageal anastomosis or myotomy site. Clinically, such a perforation produces a profuse discharge of gas and/or fluid through a chest tube positioned at the level of the anastomosis or myotomy site. Plain films demonstrate an accumulation of extrapleural gas and/or fluid adjacent to the distal portion of the chest tube. If untreated, these accumulations may form into an extrapleural abscess.     

ENDOSURGICAL TREATMENT FOR SPONTANEOUS PNEUMOTHORAX

When spontaneous pneumothorax is recurrent or persistent, an open pleurodesis with excision or ligation of the bullae is the procedure of choice but can lead to significant morbidity. Thorascopic surgery for the management of spontaneous pneumothorax was first introduced in 1937 but this has become a useful technique only since the introduction of video-controlled thorascopic surgery and the availability of suitable endothoracic instrumentation. A review was made of nine patients having endosurgery for recurrent (six) or persistent (three) pneumothorax. At surgery the bullae were ligated with an endoloop (four) or excluded with an endostapler (five). Pleurodesis was obtained by a combination of strip pleurectomy, diathermy and installation of an alcohol iodine solution. The early results are similar to those following an open operation with considerably reduced hospital stay and morbidity.     

Wrist deformities after fracture

Wrist deformities can occur after fracture because of malunion of the fracture or injury to the growth plate leading to imbalance of growth. Prevention of malunion is paramount by early recognition with proper reduction and casting or fixation with casting. If a mal-union occurs, an osteotomy may be necessary if anticipated growth will not correct the deformity. Injury of the growth plate may lead to wrist deformity in two ways: angular growth or growth arrest. Angular growth deformities are corrected most commonly by osteotomy. Growth arrest of the radius or the ulna leads to an ulnar-positive or an ulnar-negative variance at the wrist. If the ulnar variance is symptomatic, treatment is centered on achieving a level joint. Options for joint leveling procedures include epiphysiodesis or physeal stapling of the longer bone, lengthening osteotomy of the shorter bone, or shortening osteotomy of the longer bone.     

Fractures and fracture-dislocations of the tarsometatarsal joint

We are reporting the results in a consecutive series of forty adults in whom, between 1978 and 1984, forty-one tarsometatarsal fracture-dislocations were treated with open reduction followed by temporary internal fixation with AO screws. Ninety per cent of the patients had an intra-articular or a periarticular fracture. An anatomical or nearly anatomical reduction was achieved in all but a few patients, and there was no loss of fixation or displacement. For thirty-four patients (thirty-five injuries), the length of follow-up averaged 3.4 years, and a good or excellent functional result was obtained in all but two of the thirty in whom an anatomical reduction had been achieved. Of the six patients who had a fair or a poor result, five had an associated grade-II or grade-III open injury. The development of post-traumatic arthritis was directly related to damage to the articular surfaces or to inadequate reduction, or to both.