Juvenile angiofibromas: changing surgical concept over the last 20 years

OBJECTIVES: Nasopharyngeal angiofibroma is a rare tumor. Several surgical approaches have been established, including transpalatal, lateral rhinotomy, craniofacial, and midface degloving procedures. More recently, less invasive endonasal approaches have been used. In a retrospective study, we analyzed the outcome of surgical treatment for angiofibroma to determine whether an endonasal approach was as effective as other, more invasive techniques for removing the tumors. METHODS: Thirty patients with histologically confirmed angiofibromas were treated by surgical removal at two institutions during a 20-year period. Tumors were staged according to size and extension on the basis of imaging and surgical findings using the Fisch classification. Specific analysis of the operative approaches and recurrence rate by stage were included. Recurrent or residual disease was handled by surgical excision. RESULTS: The number of patients treated increased during the last 10 years in both institutions, but no major changes in distribution of tumor stages were observed. In the most recent years, the endonasal approach has been favored. All 30 patients remain alive and free of disease. CONCLUSIONS: During the last 12 years, we have undergone a marked shift toward endonasal procedures while the tumor stages of the patients treated remained the same. Our results demonstrate that angiofibromas may be managed successfully using less invasive techniques, thereby reducing morbidity, without increasing the chance of recurrence.     

Mental health: integrated network and family-oriented model for co-operation between mental health patients, adult mental health services and social services

Background. Co‐operation between mental health care units and the social services is important in the case of people with social problems who also suffer from mental health problems. However, participation of patients and their families in the treatment process, and co‐operation between them and the professionals, are also important. Communication between the professionals, patients and their family members, and the professionals is a crucial factor for co‐operation. Aims and objectives. The aim of this study was to elucidate the experiences and importance of co‐operation for the patients. The data consisted of interviews with 22 mental health patients who were also clients of municipal social services. Method. The grounded theory approach was used, focusing on the informants’ experiences of the integrated network and family‐oriented model for co‐operation. Results. The findings indicate the importance of the participation of patients and their social networks in psychiatric care or the treatment process. Meetings should be characterized by open and reflexive discussions with all participants’ points of view being included, so that fruitful co‐operation is possible. However, some negative experiences were also reported, all of which were connected with the professionals’ behaviour. Conclusions. Trust and honesty are essential elements in relations between professionals and psychiatric patients, but it cannot be assumed that they will develop naturally. It is the professionals’ responsibility to adjust their behaviour so that these elements can be created in a mutual process between patients and professionals. Multidisciplinary teams are a necessity in family‐oriented co‐operation between psychiatry and social services, and in a satisfactory caring process. Relevance to clinical practice. Nurses’ work is often individually oriented and nurses are ruled by routines in their work. The mental health caring process should be seen as a shared process between the patient, his/her human environment and professionals for which nurses need skills to their interaction with patients and their social network.     

Three part posterior fracture dislocation of the hip without fracture of the femoral head: review of literature and a case report

This case report describes a rare posterior dislocation of the hip with fractures of the ipsilateral femoral neck and greater trochanter, without fracture of the femoral head, in a young adult male following a railway accident. This patient was managed within 6h of injury by open reconstruction. This unusual injury has not been reported previously. Cases of posterior fracture dislocation of the hip with a fracture of the femoral neck without fracture of the femoral head were reviewed from the literature. Mechanism of injury, controversies regarding operative procedures and appropriate surgical approach are discussed. The authors also believe that this injury pattern merits inclusion in the existing classification system of fracture dislocation of hip for management and prediction of outcome.     

Four-triangular-skin-flap approach to umbilical diseases and laparoscopic umbilical port

Background/purpose

Surgery of umbilical pathology requires restoration of a normal umbilical appearance. Also, the umbilicus is used increasingly as the entry site during laparoscopic surgery. However, conventional approaches leave obvious scars. A simple alternative approach that creates a natural-looking umbilicus is described.

Methods

The umbilicus is opened by creating 4 isosceles triangular skin flaps. Closure is by suture of the flap apex only, creating scaring that resembles a natural umbilicus.

Results

Between November 1996 and March 2003, this technique was used in 204 children with umbilical hernia, 2 children with a small omphalocele, 1 child with a patent omphalomesenteric duct, 2 children with a urachal abscess, and 7 children with an umbilical granuloma. Five children underwent initial trocar insertion during laparoscopic surgery via this approach. All procedures were performed uneventfully. Transient erythema of one flap occurred in 64 patients (29.2%). Infection developed in 10 patients (5.0%) but was treated with oral antibiotics. The postoperative umbilical appearance was satisfactory in all but 5 patients.

Conclusions

The 4-triangular-skin-flap approach is useful for umbilical diseases and laparoscopic umbilical port access.     

胸顶部肿瘤外科治疗27例临床分析

目的　探讨前径路技术在胸顶部肿瘤手术治疗中的应用及其优势。　方法　从 1995年 1月至 2 0 0 1年 1月 ,手术治疗原发性胸顶部肿瘤患者 2 7例 ,平均年龄 4 9 2岁。病理类型包括非小细胞肺癌、肉瘤、神经纤维瘤、颈段食管癌等。通过对临床表现、肿瘤类型及外侵范围、手术径路及切除程度、并发症、生存期等资料进行分析 ,评估前径路对手术安全性和彻底性的帮助以及对延长生存期的作用。　结果　 6例采用前径路半蛤壳切口 ,全部得到完全切除 ;2 1例采用后径路Paulson切口 ,其中 13例为完全切除 ,8例为姑息性切除。随访 2 3～ 4 6个月 (平均 2 9个月 ) ,总的中位生存期为2 1个月 ,其中完全切除者为 2 9个月 ,姑息切除者为 14个月 ,两者差异有显著意义 (P <0 0 1)。前径路的完全切除率明显高于后径路 (χ2 =1.6 78,P <0 0 1)。　结论　前径路切口可显著改善胸顶结构的暴露 ,尤其对于锁骨下血管、臂丛神经等结构可在直视下予以解剖 ,从而增加了手术的安全性和彻底性。     

Anatomic basis for a minimally invasive approach to the subtalar joint

Introduction An isolated arthrodesis of the talocalcaneonavicular joint is a common indication in cases of pain and post-traumatic arthroses.Materials and methods Because of the high infection rate after surgery with the lateral incision, the authors decided to evaluate an alternative, minimally invasive procedure. Joint destruction was carried out via a posterolateral access after the insertion of two guidewires. For an evaluation of the risk for vessel and nerve structures, 102 ankle joint specimens preserved in formalin/alcohol were examined. Additionally, the minimally invasive access was evaluated in ten ankle joint specimens.Results Neither in the specimen nor during evaluation of the minimally invasive access could injuries of vessels or nerve structures larger than 1 mm in diameter be found. The authors did not encounter any problems when drilling open the articular surface with a destruction of 65% of the overall surface and when performing the following arthrodesis using a plug technique. Using a posterolateral, minimally invasive access between the Achilles tendon and lateral malleolus, it is possible to resect about 65% of the subtalar articular surface for arthrodesis without impact on major vessels and nerves. Postoperative complications such as sensitive and sensory failure as well as wound healing impairment at the lateral side of the foot are not to be expected when choosing the minimally invasive access.Conclusion It has to be said, however, that this technique does not offer the opportunity of performing a corrective arthrodesis as the hindfoot cannot be displayed during surgery. As the result of this study was positive, clinical evaluation was started.     

Limited posterior approach for internal fixation of a glenoid fracture

We present the case of a patient who was treated by open reduction and internal fixation for a displaced glenoid fracture using a limited posterior approach.No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.     

Early results of subvastus versus medial parapatellar approach in primary total knee arthroplasty

Introduction To evaluate the clinical and radiographic results immediately after total knee arthroplasty, we compared the parapatellar and subvastus approach.Materials and methods Fifty-two patients with osteoarthritis were randomly assigned to two groups. The measurement was based on clinical and radiographic features.Results There was a significant difference in passive range of motion. Patients in the subvastus approach group revealed a full knee extension and flexion of 90° significantly earlier than those in the parapatellar group. However, on the day of discharge, both groups were comparable. Radiological assessment revealed analogous results in both groups. Correction of varus or valgus deformity was required in 48 patients.Conclusion Regardless of the surgical approach, the anteroposterior tibial femoral angle improved significantly in both groups. Concerning pain, operation time, blood loss, blood substitution and complications, no major differences could be seen.     

The transglabellar subcranial approach for nasal dermoids with intracranial extension

OBJECTIVES/HYPOTHESIS: Nasal dermoids are the most common congenital midline nasal lesions. When a midline nasal pit or cyst is identified, scans should be obtained to look for an intracranial connection. The intracranial portion of the lesions has traditionally been approached by the performance of a frontal craniotomy. The transglabellar subcranial approach is a useful technique to resect these lesions and offers several advantages over a traditional craniotomy approach. STUDY DESIGN: Retrospective case review. METHODS: Records of two patients who underwent excision of nasal dermoids by way of a subcranial approach were analyzed. RESULTS: Two patients underwent successful resection of nasal dermoids with intracranial extension by way of a subcranial approach. The patients were 13 months and 19 months old at the time of excision and have been followed for 7 years and 6 years, respectively. There has not been any recurrence of the lesions. There has been no apparent negative impact on facial growth in either of these cases. CONCLUSIONS: The subcranial approach is an effective technique for the resection of nasal dermoids with intracranial extension. These lesions have traditionally been managed with lateral rhinotomy, midface degloving, or external rhinoplasty approaches combined with a frontal craniotomy. The subcranial approach offers excellent exposure, minimizes frontal lobe retraction, reduces the likelihood of cerebrospinal fluid leak, and provides for excellent cosmetic result. This approach was used in two cases with long-term follow-up. The lesions were successfully resected in both cases. Long-term follow-up has shown no recurrence or negative effect on craniofacial growth.     

Learning, Enjoying, Growing, Support model: an innovative collaborative approach to the prevention of conduct disorder in preschoolers in hard to reach rural families

OBJECTIVE: To develop, implement and evaluate a pilot program targeting rural families with preschool aged children at risk of conduct disorder. DESIGN: A prospective single group repeated measures design. SETTING: Communities in four local government areas in the Mid Western Area Health Service, New South Wales. SUBJECTS: A total of 33 families were referred to the program through community services where they were established clients. INTERVENTIONS: The Learning, Enjoying, Growing, Support model comprised a parenting program (Incredible Years; Kids Challenge and Change); a children's social skills program (Playing and learning to Socialise) and a transition to school component. Group programs were run simultaneously over 5-10 weeks. MAIN OUTCOME MEASURES: Measures of positive parenting and child problem behaviour and social skills were conducted on referral, and at completion of the program. RESULTS: There was a self-reported increase in utilisation of all positive parenting skills with significant increases in rewarding (median score on referral: 4 (range: 4-6); at completion of program 6 (4-6); (P = 0.02)) and ignoring (2 (0-6) to 3 (1-8); (P = 0.02)). Children increased their levels of social skills. Significant improvement was reported in cooperation: (median score: 24 (18-33) to 27 (19-33); (P = 0.02)); interaction (24 (6-9) to 26 (11-32); (P = 0.03)) and independence(25 (16-33) to 28 (20-33); (P = 0.008)). There was a downward trend in problem behaviour exhibited with a significant reduction in internalising behaviour (median score 19 (3-30) to 12 (0-32); (P = 0.04)). CONCLUSIONS: The positive impact of the model on parenting skills and child behaviour is promising and communities are continuing to run the programs. We recommend a broader adoption through rural communities.