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A Blalock-Taussig shunt was performed in a child of 14 months diagnosed with tetralogy of Fallot associated with a complete atrioventricular defect. Seven months later, a balloon dilatation was performed because the shunt was stenosed in the site of the distal anastomosis. Repeat angiography we proved the patency of the shunt without restenosis 4 year later.
Spigelian and Richter's hernias, individually, are both moderately rare. To encounter a patient having both of these surgical diseases as a single entity is indeed unique. Such a patient with an acute partial enterocele of cecum (Richter's hernia) strangulated in a lateral ventral musculoaponeurotic defect (Spigelian hernia) was successfully treated with wedge cecectomy and simple herniorraphy.
OBJECTIVE AND IMPORTANCE: Munchausen's syndrome is a rare psychiatric condition, in which patients seek medical treatment for factitious or self-induced medical problems. Reports in the literature of postoperative Munchausen's syndrome are extremely rare. The major obstacle to improving management of the patients with Munchausen's syndrome is increasing physicians' awareness and recognition of the disease. Although Munchausen's syndrome is rare, physicians probably will encounter at least one such patient at some point during their career and therefore should be aware of this disorder. CLINICAL PRESENTATION: We report two documented cases of postoperative Munchausen's syndrome in patients who underwent cranial neurosurgery. Both patients received complex flaps for closure of their cranial defects. Both patients later admitted to deliberately reopening their cranial wounds because of a psychological desire to continue their illness. INTERVENTION: The primary therapeutic objective is to achieve wound healing and stop the cycle of surgical procedures. Immediate confrontation with the patient often does more harm than good. Instead, psychiatric consultation, with the potential for nonsurgical management and behavior modification, should be obtained. CONCLUSION: Munchausen's syndrome is a rare psychiatric diagnosis, especially in the postoperative patient. The common clues to diagnosis are: 1) a nonhealing wound in the absence of risk factors for wound failure, 2) a history of psychiatric illness, 3) repeated bleeding from the wound site, and 4) a desire to continue the sick role. Early detection will allow proper psychiatric referral to prevent injuries to the patient, abuses to the medical system, and unnecessary operations.
Restoration of form and function after composite oro mandibular resections, especially those of the symphysis, is one of the greatest challenges facing the reconstructive surgeon. Loss of the anterior mandibular arch results in serious impairment of oral competence, speech, deglutition, and mastication producing th~ striking cosmetic disfigurement characterized by the "Andy Gump" caricature of the 1930s (Fig. l)Y The pathomechanics of this deformity are due to anterior and medial deviation of the lateral mandibular segments by the residual mylohyoid muscles and superior displacement by the medial pterygoid, masseter, and temporalis muscles. In comparison, these deforming forces are relatively absent following lateral mandibulectomy. Prevention of the "Andy Gump" deformity and its sequelae is paramount and often mandates composite replacement of bone, skin and mucosa. Additionally, through-and-through lateral or posterior defects requiring trilaminar replacement of skin, bone and mucosa or long bone gaps crossing the midline with massive soft tissue losses pose formidable reconstructive challenges.
A 63-year-old woman developed visual field defects consistent with lateral compression of the optic chiasm. The cause of the compression was found to be a giant venous varix formed by the dilatation of the outflow vein from a dural arteriovenous fistula located in the superior petrosal sinus. After embolization and surgical obliteration of the fistula, the patient's visual function improved markedly.
The effectiveness of using Vicryl mesh (polyglactin 910) in combination with a Brånemark titanium implant is described. A maxillary central incisor with an apical osseous defect resulting from endodontic failure was treated with the Brånemark method of osseointegration for single tooth replacement. Vicryl mesh was used over the osseous defect site and uncovered 5 months later. New bone formation filling the defect and around the implant was observed.
Based on our experience with 12 patients who underwent wide anterior chest wall resection in our institute, we attempt to define the indication of the different techniques for reconstruction by musculo-cutaneous flaps according to the extent of resection and location in the chest wall. The pectoralis major flaps are simple and important in the reconstruction of sternal defects; especially when dense retrosternal fibrosis has already developed after radiotherapy. The latissimus dorsi flaps are reliable and thick and suitable for coverage of major tissue loss. A new technique is also described for reconstruction of major anterolateral chest wall defects as well as sternal defects by a latissimus dorsi osteo-muscular flap. The external oblique musculo-cutaneous flaps are used to cover defects in the lateral chest wall below the 5th rib. Pedicled omental flaps are complementary flaps and can be used when muscle flaps are insufficient to replace significant tissue loss. Respiratory problems arising from paradoxical chest wall movement are temporary and may be encountered in the immediate post-operative period. Because of the development of fibrosis and of a better adaptation of the patient, this condition is well tolerated during the month following operation.
A new animal model for examining the intramedullary bone response to various implant materials and surfaces is presented, utilizing an implantable chamber with multiple bone ingrowth channels placed through a cortical defect in the lateral aspect of the distal femur. Twelve adult mongrel dogs received bilateral implants containing channels lined by smooth-surfaced coupons of titanium, titanium alloy, sputter-hydroxyapatite-coated titanium alloy, and UHMW polyethylene. A pattern was detected for all test groups of early initial bone ingrowth by two weeks, which became maximal at six to twelve weeks, followed by remodelling to a more mature lamellar bone and later resorption by 24 weeks, with fibrous tissue interfaces covering the smooth test coupons of all groups at all times. Significantly increased bone ingrowth in the sputter-HA coated group was found only at six weeks.
The authors report a case of suppurative hidradenitis of unusual severity affecting the axillary, inguinal, perianal, genital and sacral areas. The surgical treatment consisted initially of large excision of the axillary areas. A musculo-cutaneous latissimus dorsi island flap was then used to cover the defect. 45 days later, a complete excision, in only one operative session, of the inguinal, perianal, genital and sacral area was performed, associate durth colostomy. A mesh graft was performed 15 days after the excision. This procedure allowed an early scar.
Loosening of the implant is one of the most serious complication in case of total hip replacement. It is caused by the growth of a secondary cancellous channel and in destroyed bone cement. From 1981 to 1986 we operated 63 patients to exchange a loosened hip prosthesis. With 15 patients we have seen a severe damage of the femur shaft. Big parts of the bone tube were missed. To insert the new stem we had to reconstruct the proximal femur and the calcar region by autogenous cortico-cancellous bone grafts in seven cases. In three cases a large defect of the lateral femur cortex was reconstructed by extended cancellous bone graft. In five cases we found a cominuted fracture of the femur shaft. The osteosynthesis was performed by plating. The screws were inserted through the bone into the stem. They find a very strong grip in the polyacetal material. 14 of 15 patients operated in this manner could achieve a walking ability. Most of them improved one step higher in the evaluation scheme according to Merle d'Aubigne. One patient suffering from a septic loosening showed a severe exacerbation with septicemia and ended in a disarticulation of the hip joint. The so called isoelastic prosthesis gives a chance to reconstruct the femur tube. It allows unhindered calcification of bone graft and acts as a forming model for new bone. With this we are able to restore the movement of hip joint as well as weight bearing and working ability of the limb. Additional osteosynthesis is possible to perform.(ABSTRACT TRUNCATED AT 250 WORDS)
Evaluation of 87 fixations of the lower leg revealed that standard x-ray film safely enables accurate determination of defective axial and lateral positioning. Assessment of rotatory malpositioning is unsafe and not likely to yield accurate results. The only possibility is to take the x-ray film of the fixed foot; this enables conclusions from measurements performed on the x-ray film with the metal still implanted and the fixation still in place, as reference parameters. Detailed analysis of the x-ray films, however, revealed even further results: delayed and disturbed healing of bone fractures can be detected early from the mechanical measurement data on the x-ray film, so that correction of the fixation nail can be made well in time. Cases treated in this way healed properly and in a well-adjusted manner. Corrections performed with the fixation nail were pseudoarthroses (5 cases), 4 of which healed without complications whereas one healed after removal of the nail and conservative aftercare. Fractures in the distal part of the lower leg seem to be particularly critical. Because of the close proximity of the ankle joint, unsatisfactory stability will result if the nail end is too short.
The important role of biotin in human physiology has been highlighted by the recognition of two newly discovered human inborn errors of the metabolism of biotin. The molecular defect in the neonatal-onset disease is in the enzyme holocarboxylase synthetase. The defect in the later infantile-onset disease is in the enzyme biotinidase. Both disorders present with impressive clinical manifestations involving the skin and hair. In the neonatal disease, alopecia totalis is associated with a bright red scaly total body eruption. In biotinidase deficiency, the alopecia is more patchy and the skin lesions resemble acrodermatitis enteropathica. Both disorders are complicated by recurrent episodes of life-threatening acidosis and massive ketosis.
The authors have studied 30 patients with torpid schizophrenia associated with unfavourable changes of the 'verschroben' type. Only those cases are considered in which manifestations of this defect almost completely determined the clinical picture of the disease. A detailed psychopathological analysis has demonstrated that in patients presenting unfavourable changes of the 'verschroben' type all features characteristic of a mild typical schizophrenic defect or a defect of schizoid structure (autism, emotional changes, bizarre behaviour, paradoxic features in thinking and behaviour, motor peculiarities, disturbances in the sphere of instincts and inclinations) become most expressed. It has also been established that a 'verschroben' type defect forms at later stages of the disease taking a form of evolutional schizophrenia.
261 children with 281 cholesteatoma operations performed between 1970 and 1982 in the ENT-Clinic of the University of Tübingen were followed-up. In 77 ears an open technique (attico-antrotomy with removal of the posterior canal wall) was employed. In 103 ears a combined approach with posterior tympanotomy and preservation of the posterior canal wall was performed. In 47 ears an atticotomy with reconstruction of the lateral attix wall defect with tragal cartilage and perichondrium was done. The cholesteatoma was limited to the middle ear in 54 patients; treatment consisted of a transcanal tympanoplasty. 36.3% of the children had a residual or a recurrent cholesteatoma, 19.5% after open technique, 61.2% after a combined approach operation, 17% after atticoantrotomy and reconstruction of the scutum and 29.6% after a transcanal tympanoplasty. We therefore conclude that a second look operation is necessary especially after closed technique surgery.
A 25-year-old woman presented in 1973 with the complaint of proptosis of the left eye with mastication. A firm retrobulbar orbital mass was detected, and diagnosis of possible dermoid cyst was made. She was subsequently lost to follow-up. Computed tomographic (CT) scanning and surgical excision done in 1984 confirmed the presence of an orbital dermoid cyst communicating with the temporal fossa through a bony defect in the lateral orbital wall. We suspect that pressure by the temporalis muscle on the dumbbell-shaped cyst caused the proptosis with mastication.
The association of pituitary adenoma and adjacent cerebral aneurysm is not uncommon and acute hemorrhage into a pituitary adenoma is also a well recognized condition. However, the simultaneous occurrence of pituitary apoplexy with intracranial aneurysm is very rare. Such a case demonstrates the diagnostic difficulty in distinguishing between pituitary apoplexy and rupture of an aneurysm. We reported a patient with subarachnoid hemorrhage in whom a hemorrhage into the pituitary adenoma and a carotid-ophthalmic aneurysm was proven, and discussed the differential diagnosis and treatment. A 41-year-old man, who developed sudden severe headache with nausea and vomiting, was admitted to our hospital. Examination disclosed a mildly stuporous man with bilateral defects of upper lateral visual fields and lumbar puncture revealed subarachnoid hemorrhage. Plain radiographs of the skull showed an enlarged and eroded sella turcica. Carotid angiography revealed a left carotid-ophthalmic aneurysm. A plain CT scan demonstrated an acute suprasellar hematoma. A transsphenoidal operation was performed and postoperative course was uneventful.
An unconventional method of managing infection of the interventricular Teflon patch in a patient with tetralogy of Fallot is reported. The patch was initially replaced by a new patch. After reinfection, however, removal of the patch and pulmonary banding eradicated the infection, and at a later stage the defect was re-repaired successfully.
Report of three patients with small bony defects on the lateral bony wall or the bridge of the nose. Reconstruction was performed with a combined cushion like implant of lyodura polsted with merthiolate preserved allongene crashed cartilage. Over a follow up time period of two years the cosmetic results are good. The histological behavior of these implants was studied in animals.