Supracondylar process of the humerus

Four cases of supracondylar process of the humerus in three patients are presented. The main features of a supracondylar process as compared with an osteochondroma are reviewed. The three patients had pain and one had signs indicating median nerve compression. One had a supracondylar process together with an osteochondroma in the contralateral supracondylar region. One patient with a bilateral supracondylar process refused an operation. The other two patients underwent surgical treatment. The symptoms disappeared in the two patients who were operated.     

Parkinsonism and rest tremor secondary to supratentorial tumours sparing the basal ganglia

Summary Intracranial neoplasms are an uncommon cause of symptomatic Parkinsonism and rest tremor. We found an incidence of 0.3% in a prospective evaluation of 907 patients with supratentorial tumours. Eight patients with Parkinsonism and rest tremor secondary to supratentorial tumours sparing the basal ganglia are reported.Neuro-imaging revealed compression and distortion of the basal ganglia by large tumours which were identified histopathologically as meningiomas in four patients and as an epidermoid, a fibrillary astrocytoma, an anaplastic oligodendroglioma and a glioblastoma.Six patients underwent tumour removal by craniotomy, in two the histopathology was obtained by stereotactic biopsy. Four patients were free of Parkinsonian symptoms and signs on long-term follow-up.The possible pathophysiological mechanisms involved are discussed. Since some of these patients closely resemble cases of idiopathic Parkinson's disease, and the movement disorder can precede other symptoms and signs or will remain isolated in the further course, the diagnosis of an intracranial neoplasm was generally delayed in these patients. Increased awareness of this rare entity may lead to an earlier diagnosis. Early computed tomography in patients with Parkinsonism might help to detect these patients with a potentially curable cause of their condition.     

Complex vesicovaginal fistula. Report of 55 cases]

OBJECTIVE: To specify the clinical and therapeutic peculiarities of complex vesico-vaginal fistulas. MATERIAL AND METHODS: 55 cases of complex vesico-vaginal fistulas are reported. After the clinical diagnostic all the patients had an intravenous excretory urogram. The fistulas were classified according to the Benchekroun classification. RESULTS: The mean age was 34 years (17-70 years). The diagnostic was made clinically in all the patients. Thirteen patients had an abnormal intravenous excretory urogram. The treatment was made by a vaginal way in 45 patients, by an abdominal way in three patients and by a mixed way in two patients. Four patients had an urinary diversion and one refused the treatment. Among the 50 patients whose fistula was treated, 44 (88%) were continent whom 26 (52%) after one operation, 15 (30%) after two operations and three (6%) after three operations. CONCLUSION: The complex vesico-vaginal fistulas as all the vesico-vaginal fistulas are diagnosed clinically. The intravenous excretory urogram is indispensable to search an associated ureteral lesion. The treatment is surgical and usually needs the interposition of a vascularised graft.     

Gastrointestinal complications after cardiac surgery.

Gastrointestinal complications after cardiac surgery are uncommon, but are associated with a high morbidity and mortality. Over 11 years 8559 procedures requiring cardiopulmonary bypass were performed in this unit and 35 patients were identified who developed gastrointestinal complications after surgery, an incidence of 0.41%. There were nine deaths in this group, a mortality of 25.7% compared with an overall mortality after cardiac surgery in Ireland ranging from 3.24% to 4.81%. These complications required surgery in 21 patients. The most common indication for surgical intervention was upper gastrointestinal bleeding in 10 patients, three patients had acute pancreatitis, two patients had perforated peptic ulcer; two patients had intestinal ischaemia, with five cases of colon pathology. The difficulties of making an early diagnosis are outlined and a low threshold to exploratory laparotomy is recommended.     

Carotid bruit: a follow-up report on its significance in patients undergoing an abdominal aortic operation.

The records of 516 patients who underwent an elective abdominal aortic operation for aneurysmal or occlusive disease are reviewed. Four patients operated on twice are considered an individual patient for each operation. Excluding 27 patients who had a prior carotid endarterectomy, there were 84 with a carotid bruit. Thirty-six patients without a carotid bruit had experienced an episode of cerebral ischemia. Four patients had a postoperative stroke. There was no correlation between the stroke and presence of a carotid bruit or history of cerebral ischemic symptoms. We do not challenge the validity of prophylactic carotid endarterectomy but question if the need for an abdominal aortic operation should be considered indication for carotid angiography and surgery in patients with a carotid bruit.     

Neurogenic bladder dysfunction in lumbar intervertebral disc prolapse.

Lumbar disc prolapse with urinary dysfunction is an uncommon condition. The clinical, pathological and follow-up details of 30 patients are presented. Detrusor recovery is rare and most patients are left with an areflexic bladder. Female patients with lumbar disc prolapse and an areflexic detrusor who strain to empty their bladders are likely to develop genuine stress incontinence. This may be managed by the early institution of intermittent self-catheterisation, which may reduce the need for incontinence surgery.     

Detection and management of the unstable patient

The vast majority of doctor-patient interactions in the field of facial plastic surgery are mutually rewarding. Unstable patients will be encountered, however, because of the psychological components of cosmetic surgery. The harm or chaos such patients cause can be minimized by an awareness of unstable patient characteristics, an effort to screen for unstable behavior potential, and development of plans and protocols to manage such patients when they are encountered.     

Minimum Excess Weight Required for Obesity Surgery: how far can we go?

The classical indication for obesity surgery, in terms of excess weight, included only patients with an excess weight of 100% or 45 kg. This review challenges this classic indication. Sixty-four out of 170 patients treated with a biliopancreatic diversion had an excess weight below 80%. The specific weight-related complications, reoperations and results are compared with patients above 80% excess weight. The different groups are comparable in complications and results.     

Urgent endovascular treatment of acute symptomatic occlusion of the cervical internal carotid artery

OBJECT: The prognosis of patients with acute symptomatic cervical internal carotid artery (ICA) occlusion is generally considered to be poor. Traditionally, such patients are not considered eligible for urgent thrombolytic/endovascular treatment. Since 1998, an aggressive therapeutic approach with endovascular treatment has been adopted at the authors' institution. In this report they assess whether aggressive treatment of ICA occlusion is appropriate. METHODS: The clinical characteristics and outcome of six consecutive patients treated urgently with an endovascular approach between 1998 and 2001 are reviewed and summarized. Recanalization was accomplished in all patients. At a mean follow-up period of 8 months (range 2-14 months), five of six patients had good or excellent outcomes (modified Rankin Scale [mRS] Score 0-1) and one had a poor outcome (mRS Score 4). CONCLUSIONS: With recent advancements in thrombolytic and endovascular treatments, an aggressive endovascular approach in patients with acute symptomatic cervical ICA occlusion may be successful. Further clinical data are required to determine the optimal endovascular approach in these patients.     

Shoulder arthroplasty - Clinical results in 171 patients

AIM: Review and critical evaluation of 181 shoulder arthroplasties performed on 171 patients between December 1992 and January 1997. METHOD: We performed 118 hemiarthroplasties and 63 total shoulder replacements in 171 patients with an average age of 56.5 years. The patients were examined clinically and radiologically before surgery and followed-up for an average of two years. The Constant score was used for postoperative functional assessment. RESULTS: 46 % of the patients were very satisfied and 31 % were satisfied with the outcome. We found a significant pain reduction and an improvement of active joint function. The average Constant score was 34.9 preoperatively and 65.2 postoperatively. Overall, we found the best results after joint replacement in patients treated for avascular necrosis or fracture sequelae of the humeral head. A revision surgery had to be performed in 16 patients (8.8 %). CONCLUSION: The results of this study are encouraging and underline the growing importance of shoulder arthroplasty. The preoperative limited range of motion, previous surgeries, and the status of the rotator cuff are preoperative indicators for a favourable postoperative outcome. Preoperative planning, anatomical reconstruction, and an optimal rehabilitation programme are the keys for successful shoulder arthroplasty.     

Biliary pancreatitis.

Seventy-one patients with acute pancreatitis are reviewed. Biliary disease was incriminated as an aetiological factor in 17 of these patients. During the period under review, 141 patients with acute cholecystitis were treated. The age and sex incidence in these 3 groups are compared, and some diagnostic problems are discussed.     

Disparities in access to liver transplantation in Spain

BACKGROUND: The maintenance of an equitable system for access to transplantation is a matter of concern to all professionals involved in this field. Any national system must ensure equity. METHODS: The rates of indication for liver transplantation have been reviewed for all Spanish regions. The time to transplantation was evaluated with respect to different recipient characteristics and donor rates. The indication rates for liver transplantation are similar in the different countries with liver transplant programs but are far from similar among different regions in Spain. This suggests that there is not equity in the access to liver transplantation. RESULTS: A review of the factors affecting the waiting times to transplantation after being registered for the waiting list shows that some groups of patients are currently waiting less time than others. Shorter waiting times occur in patients of the AB group, children, patients with hepatocarcinoma, and patients living in the zone of Valencia, despite similar organ donation rates in all transplant zones. CONCLUSION: Neither the rate nor the probability of liver transplantation is affected exclusively by the organ donation rate in Spain but also depends on the number of patients admitted to the waiting list. Despite the existence of an organ allocation system that is center-oriented, liver patients are receiving grafts mainly based on the severity of the illness, because clearance rates from the waiting list of both dead patients and grafted patients are the same.     

Anaesthesia for children with osteogenesis imperfecta – a review covering 30 years and 266 anaesthetics

Osteogenesis imperfecta is an uncommon condition which presents in a variety of forms which are reviewed. Many of the problems, particularly in the more severe cases, are related to fractures and deformities which require anaesthesia for correction. This paper reviews 266 anaesthetics for 63 patients. The concept that malignant hyperpyrexia is an associated condition is refuted although these patients may have an increased metabolic rate and a tendency to pyrexia. The care of these patients during anaesthesia is discussed particularly in relation to transfer, positioning, temperature and airway problems.     

The mechanism of an osteoporosis center

The cost of osteoporosis to the quality of human life and well-being are immeasurable; its costs to society are significant. Osteoporosis affects approximately 20 million Americans and has been estimated by the National Osteoporosis Foundation to equal $7 to $10 billion in health care costs and productivity annually. Osteoporosis represents a major health problem. Clearly, a screening and bone maintenance program can be managed by nurses in a cost-effective manner and serves as an efficient facilitator in the education and care of patients. Furthermore, an osteoporosis center can provide invaluable support for professionals in various disciplines of medicine. In our experience at The Hospital for Special Surgery most of our patients come to our center as a result of a physician referral. An average of 600 to 800 patients are seen annually and about 15 per cent of these patients are referred from the screening program to a metabolic bone treatment source. Approximately 5 per cent of patients referred for treatment are hospitalized for an extensive evaluation which includes an iliac crest-bone biopsy. As the patient population in the Osteoporosis Center has grown there has been a recognition of special patient groups who have specific needs. This has resulted in the establishment of clinics which address the problems associated with patients who are renal stone formers, anorexic, and amenorheic (many of this latter group are athletes or dancers).(ABSTRACT TRUNCATED AT 250 WORDS)     

Results of artificial sphincter in a case of sphincter incontinence in the multiple surgery patient

Stress incontinence represents 77 to 91% of female urinary incontinence, 10% of witch are sphincterial incontinence. The specific treatment of sphincterial incontinence is of periuretral injections or calls for an artificial sphincter. We present the retrospect of 12 patients having undergone several surgical treatments and having at last the benefit of an artificial sphincter since 1990. In majority, these patients had been operated for bladder neck hypermobility. The indication, preoperatory evaluations, surgical technics and results are discussed. During the mean follow-up of 40.5 months, 91.7% of patients are perfectly continent. The results are equal to those of other publications.     

Ostomy Prolapse in Paraplegic Patients: Etiology,Prevention, and Treatment

Abstract

Colostomies are sometimes used to manage those SCI patients who have large pressure sores that are frequently soiled by stool. Seventeen such patients in an Acute Spinal Cord Injury Unit were reviewed to define the problem of ostomy prolapse in paraplegic patients. It was concluded that prolapse is more likely in those patients with an injury at or above the T-10 level. The two patients who had loop colostomies developed prolapse. Those ostomies that were end-sigmoid and exteriorized into an area where there was sensation and abdominal wall muscular integrity were the most successful. (J Am Paraplegia Soc 1990; 13: 7–9)     

Mechanical support for high-risk coronary artery bypass grafting

Mechanical circulatory support devices are being used to an increasing extent. The use of these devices as an adjunct to cardiac surgery to support ventricular function has contributed to improved outcomes for the highest risk patients. In the context of patients undergoing coronary artery bypass grafting, there are several potential indications for mechanical circulatory support: preoperatively in the setting of acute cardiogenic shock, or in patients with intractable angina with or without haemodynamic compromise; at induction of anaesthesia prophylactically in patients with critical coronary anatomy and/or severely impaired left ventricular function; intraoperatively in the setting of failure to wean from cardiopulmonary bypass; or postoperatively in patients who develop an intractable low cardiac output state. The use of the intra-aortic balloon pump, veno-arterial extracorporeal membrane oxygenation, TandemHeart, Impella and central ventricular assist devices will be considered in the setting of high-risk patients undergoing coronary artery bypass grafting.     

An anatomic reconstruction of the distal radioulnar ligaments for posttraumatic distal radioulnar joint instability

Fourteen patients with posttraumatic distal radioulnar joint instability were treated with a reconstruction of the distal radioulnar ligaments. The technique is anatomically accurate, is reproducible, and requires less dissection than previously described techniques. Candidates for the procedure had joint instability and an irreparable triangular fibrocartilage complex. Ten patients had bidirectional instability. Two patients had a concurrent corrective osteotomy of the distal radius for a malunion. The procedure restored stability and relieved symptoms in 12 of 14 patients at 1 to 4 years' follow-up evaluation. One patient with a deficient sigmoid notch and one with ulnocarpal ligament injury did not achieve full stability. All patients attained near full pronation and supination. The procedure is an effective treatment for an unstable distal radioulnar joint when its articular surfaces are intact and the other wrist ligaments are functional, and it can be used in combination with a distal radius corrective osteotomy.     

Traumatic atlanto-occipital dislocation. Case report

Traumatic atlanto-occipital dislocation is a serious injury that is usually fatal. The number of patients surviving this injury, however, appears to be increasing, and most of these survivors are children. This may reflect an improvement in emergency transport services. Seventeen previously reported cases of patients surviving atlanto-occipital dislocation for more than 48 hours are reviewed and an additional case is presented. Many of these patients had an excellent neurological outcome. The radiographic criteria necessary for the diagnosis of atlanto-occipital dislocation are discussed. Cervical computerized tomography may confirm the diagnosis when necessary. It is suggested that there are three types of atlanto-occipital dislocation; utilizing this new classification, a rationale for treatment is described. Fusion is favored for long-term stability.     

Conversion of supravesical urinary diversion to an ileal neobladder. Indications, results, problems

The creation of an ileal neobladder or another continent bladder substitute can improve the psychological well-being of patients who need cystectomy. The excellent surgical outcome and continence that can be obtained with an ileal neobladder mean it can be constructed for reversal of diversion even in cystectomized male patients. Selection, indications and results in five patients with reversal of diversion are presented.