Posterior Wall Defect Research Articles

Telescoping bronchial anastomoses for unilateral or bilateral sequential lung transplantation: CT appearance.

To determine the computed tomographic (CT) appearance of telescoping bronchial anastomoses. CT scans obtained in 36 adult patients with 54 telescoping anastomoses (30 right bronchus, 24 left bronchus) were retrospectively reviewed. Seventeen scans were obtained with 10-mm collimation, one with 5-mm collimation, and 18 with 3-mm collimation. Multiplanar volume reconstruction images were retrospectively generated in 19 patients. CT findings were correlated with fiberoptic bronchoscopic findings and clinical records. Smooth, spherical air collections caused by diverticula of redundant mucosa were seen at the inferior or medial aspect of 22 anastomoses (41%). Endoluminal flaps and linear air collections caused by separation of the invaginated bronchus from the recipient bronchus were seen in 16 anastomoses (30%). Flaps and linear air collections were seen only at the anterior, superior, or inferior aspects of the anastomosis. Flaps and diverticula were more common at right anastomoses than at left anastomoses. No patient with an endoluminal flap or diverticulum at CT had dehiscence at bronchoscopy. Irregular air collections or posterior wall defects were suggestive of dehiscence at four anastomoses (7%). Dehiscence was confirmed bronchoscopically at two of these four anastomoses. Endoluminal flaps and linear or spherical air collections can be a normal feature of the telescoping anastomosis and should not necessarily be interpreted as dehiscence.

The effect of variable size posterior wall acetabular fractures on contact characteristics of the hip joint.

The indications for open reduction and internal fixation of posterior wall acetabular fractures associated with a clinically stable hip joint are unclear. In previous work a large posterior wall defect (27% articular surface area) resulted in significant alteration of load transmission across the hip; specifically, there was a transition from evenly distributed loading along the acetabular articular surface to loading concentrated mainly in the superior portion of the articular surface during simulated single leg stance. However, the majority of posterior wall fractures involve a smaller amount of the articular surface. Posterior wall acetabular fractures not associated with instability of the hip are commonly treated nonoperatively. This practice does not account for the size of the posterior wall fracture. To study the biomechanical consequences of variably sized articular defects, a laboratory experiment was conducted evaluating three progressively larger posterior wall defects of the acetabulum during simulated single leg stance using superlow Fuji prescale film (Itochu International, New York): (a) 1/3 articular surface width through a 50 degrees arc along the posterior wall of the acetabulum, (b) 2/3, and (c) 3/3 articular width defects through the same 50 degrees arc along the posterior wall of the acetabulum. In the intact acetabulum, 48% of the total articular contact was located in the superior acetabulum. Twenty-eight percent of articular contact was in the anterior wall region of the acetabulum and 24% in the posterior wall region. After the 1/3 width posterior wall defect, 64% of the articular contact was located in the superior acetabulum (p = 0.0011). The 2/3 width posterior wall defect resulted in 71% of articular contact area being located in the superior acetabulum (p = 0.0006). After the 3/3 width posterior wall defect, 77% of articular contact was located in the superior acetabulum, significantly greater than the intact condition (p < 0.0001) and 1/3 width defect (p = 0.0222). The total absolute contact areas for all defect conditions were significantly less than the intact conditions. The results of this study reconfirm the observation that posterior wall fractures of the acetabulum significantly alter the articular contact characteristics in the hip during single leg stance. The relationship between defect size and changes in joint contact showed that the smallest defect resulted in the greatest alteration in joint contact areas, whereas larger defects resulted in minor increments of change in contact area. This finding is of concern because the clinical practice of managing acetabular fractures nonoperatively if the hip joint is stable is based on the supposition that the joint retains enough integrity to function without undue risk of late posttraumatic osteoarthritis. A better understanding of the natural history of stable posterior wall acetabular fractures is needed to ascertain whether some of these fractures merit operative repair.

Use of acetabular models in planning complex acetabular reconstructions

The number of patients requiring revision total hip arthroplasty continues to increase each year. Accurate preoperative planning is a key factor in obtaining a good result. Radiographis provide little information concerning the actual extent of the acetabular defects. Computed tomography-generated models ofthe acetabulium can provide the surgeon with accurate information concerning the size and location of the defects. Evaluation of radiographs and models in 24 cases showed that radiographs alone failed to detect all 13 anterior wall defects ( P < .001), 8 of 18 posterior wall defects (44.4%, P < .001), and 8 of 19 segmental central defects (42%, P < .001), all of which were easily identified with the models. This study showed that preoperative planning based on the foam models accurately predicted the actual implant used in 22 of 24 cases (92%).

Simultaneous Interstitial Radiotherapy With Regional or Free-Flap Reconstruction, Following Salvage Surgery of Recurrent Head and Neck Carcinoma: Analysis of Complications

Reports on complications following brachytherapy offer conflicting views on the benefit of locoregional flap coverage of the implanted tumor bed. This study reviews complications following pedicled and free-flap coverage of brachytherapy sources after salvage surgery for recurrent head and neck carcinoma. Retrospective chart review. Academic tertiary referral center. Fifteen patients with advanced, radiorecurrent carcinomas of the head and neck, treated between 1988 and 1992. All patients underwent surgical resection and implantation of the tumor bed with iridium 192 after-loading catheters (13 patients) or iodine 125 seeds (two patients). The average dose of interstitial radiotherapy supplied was 50.24 +/- 45.19 Gy (mean +/- SD). Coverage of the implanted tumor bed was achieved with regional myocutaneous flaps in 10 patients and microvascular free flaps in five patients. All wound and healing complications were identified. Patients were followed up for a minimum of 3 months. No significant complications were encountered. No flap, pedicled or free, demonstrated any degree of necrosis. Four minor complications developed in the group of patients who underwent reconstruction with pedicled myocutaneous flaps. One orocutaneous fistula developed in a patient in whom a radial forearm was used to reconstruct a posterior pharyngeal wall defect. An expectation of increased postoperative morbidity should not interfere with the decision to proceed with multimodality salvage therapy of patients with advanced, recurrent head and neck tumors. The advantages of free tissue transfer in the reconstruction of head and neck defects are not compromised when the flaps are simultaneously utilized to provide coverage for brachytherapy sites.

上顎洞後壁部骨欠損の検出に関する実験的研究 : パノラマ X 線撮影と X 線 CT の比較

An experimental comparison in the detection of bony defects in the maxillary sinus posterior wall and the zygomatico-alveolar region of dry human skulls was made using panoramic radiography and computed tomography (CT). Locations in the posterior wall where the bony defects were experimentally created were in the center, facing the pterygopalatine fossa, above the maxillary tuberosity, and adjacent to the zygomatic process of the posterior wall of the maxillary sinus. Also, defect was created in the zygomatico-alveolar region of the maxilla. In this study, bony defects with diameters of 5 mm, 7 mm, and 10 mm were used to simulate bony destruction. The Frankfort horizontal plane of the dry skull was kept horizontally in panoramic radiography. The 2 mm thick scans were exposed parallel to the Frankfort horizontal plane of the dry skull in CT. The results obtained are as follows : 1. Bony defects, with diameters of 5 mm, 7 mm, and 10 mm in the center of the maxillary sinus posterior wall, were not detected by panoramic radiography. With CT, bony defects with diameters of 5 mm, 7 mm, and 10 mm were detected respectively by 4 slices, 6 slices, and 7 slices of the image. 2. A bony defect with a diameter of 5 mm in the posterior wall, facing the pterygopalatine fossa, was not detected by panoramic radiography and CT. However, bony defects with diameters of 7 mm and 10 mm were detected by both examinations. With CT, bony defects with diameters of 7 mm and 10 mm were detected respectively by 6 slices and 7 slices of the image. 3. A bony defect with a diameter of 5 mm in the posterior wall, above the maxillary tuberosity, was not detected by panoramic radiography. However, bony defects with diameters of 7 mm and 10 mm were detected by panoramic radiography. With CT, bony defects with diameters of 5 mm, 7 mm, and 10 mm were detected respectively by 4 slices, 7 slices, and 8 slices of the image. 4. Bony defects, with diameters of 5 mm, 7 mm, and 10 mm in the posterior wall adjacent to the zygomatic process of the maxilla, were not detected by panoramic radiography. With CT, bony defects with diameters of 5 mm, 7 mm, and 10 mm were detected respectively by 4 slices, 7 slices, and 8 slices of the image. 5. Bony defects, with diameters of 5 mm, 7 mm, and 10 mm in the zygomatico-alveolar region of the maxilla, were detected by panoramic radiography and CT. With CT, bony defects with diameters of 5 mm, 7 mm, and 10 mm were detected respectively by 3 slices, 5 slices, and 6 slices of the image. Noting above findings, it is clear that bony defects with a larger diameter than 7 mm in the posterior wall, facing the pterygopalatine fossa and above the maxillary tuberosity and bony defects with a larger diameter than 5 mm in the zygomatico-alveolar region of the maxilla may be better detected using panoramic radiography. However, panoramic radiography has limitations in the ability to diagnose maxillary sinus disease because the anterior and posterior walls of the maxillary sinus are superimposed on the medial wall. The findings of the study indicate that when CT is used as a follow-up to panoramic radiography in examination of maxillary sinus disease, the results from the panoramic radiography should be consulted.

外耳道保存鼓室形成術後の外耳道後壁骨欠損 段階手術所見からの検討

The incidence and location of the posterior canal wall defect were studied in 175 ears of 167 patients who underwent planned two-stage tympanoplasty by the intact canal wall technique during the last ten years. Of the 84 ears with intact scutum, the bony defect was present in 14 ears at the first operation, and in 12 of these at the second operation. Ten ears developed bony defects between the first and second operations, although the canal wall had been primarily preserved. This was ascribed to atrophy of the posterior canal wall. Of the 91 ears with destruction of the scutum, bony defects other than of the scutum were present in 12 ears at both operations. Canal wall atrophy was present in 16 of the 91 ears. Canal wall defects were listed according to Weinberg's classification. In the canal wall atrophy group, Type A lesions (a round hole in the middle of the canal wall) were seen in 20 ears; Type B lesions (a semicircular defect in the interior wall) in 3 ears; Type C lesions (a semicircular defect in the exterior wall) in 3 ears. Type D lesions (bony destruction along the entire length of the posterior wall) were not seen.

Surgical Treatment of Orbital Dysplasia associated with von Recklinghausen's Disease

A 41-year-old woman had had slowly progressive loss of vision and exophthalmos of the left eye from the age of 35 years. Multiple cafe-au-lait spots and subcutaneous neurofibromatous masses were noted. Plain skull X-rays revealed a defect of the posterior wall of the left orbit and bulging of the left frontotemporal bone. There was also a small bony defect in the occipital bone adjacent to the left lambdoid suture. Computed tomography (CT) disclosed a marked deformity of the left middle cranial fossa and a bony defect in the posterior wall of the left orbit. Three-dimensional CT was extremely useful in the planning of the surgical repair. The posterior orbital wall defect, which was approached through a left frontotemporal craniotomy, was covered with a resin plate, and the exophthalmos was corrected under direct vision. The bulging frontotemporal bone was resected and replaced by a resin plate. Postoperatively, the exophthalmos was markedly reduced and the patient regained light perception in the left eye.

The Use of Preoperative Computed Tomography Scanning in Total Hip Arthroplasty

Computed tomography (CT) scanning is a useful tool in many areas of orthopedics. This prospective study reviews the authors' experience with CT scans in 73 patients studied prior to total hip arthroplasty. The CT scan is valuable in the primary total hip arthroplasty if the radiograph suggests medial, posterior, or superior acetabular wall defects. In some instances, bone grafting or other special procedures are required for the reconstruction of these defects. In the present study, preoperative CT identified an abnormality in 18 cases with deficient acetabular walls, while plain radiographs identified only six of these difficulties. Although important information for planning revision total hip arthroplasties was noted in this series, CT scans are indicated primarily in instances of suspected acetabular wall defects.

Tympanoplasty with calcium phosphate.

In 35 patients, with an average follow-up period of 2 1/2 years, the middle ear was reconstructed with prostheses of hydroxyapatite, which is the main substance of living bone tissue. In case of a missing incus, an interposition prosthesis of dense hydroxyapatite was used. Defects in the bony posterior canal wall were reconstructed with a canal wall prosthesis of porous hydroxyapatite and cavities with a barefoot plate were reconstructed with a total alloplastic middle-ear implant, consisting of a canal wall of porous hydroxyapatite and a chain of wire and dense hydroxyapatite. With these prostheses, radical surgery of the middle ear can be combined with a physiological reconstruction.

Improved results of surgical management of postinfarction ventricular septal rupture.

Fifty-five patients had surgical repair of postinfarction ventricular septal rupture in Massachusetts General Hospital from 1968 through 1981. In patients operated more than three weeks after infarction, hospital survival has been 93% (14/15). Before 1975 in patients operated less than three weeks after infarction, hospital survival was 41% (7/17). In this same era patents operated for septal rupture with cardiogenic shock present before operation had a hospital survival rate of only 27% (3/11). Before 1975 patients with cardiogenic shock were supported with intra-aortic balloon pumping (IABP) and vasopressors, and operation deferred pending hemodynamic stabilization. Before 1975 patients with anterior septal rupture had a hospital survival rate of 64% (9/14), while patients with posterior septal rupture had a hospital survival rate of only 38% (5/13). This difference in survival according to the location of septal rupture occurred despite comparable numbers of patients in each group requiring early operation, as well as incidence of cardiogenic shock. Since January 1, 1975 patients operated less than three weeks after infarction have had an overall hospital survival rate of 70% (16/23). Of the 10 most recent patients operated early, nine are survivors. In patients with anterior defects 85% (11/13) survived, while in patients with posterior defects 67% survived (10/15). In patients operated with cardiogenic shock present before operation, survival has been 67% (10/15). Changes in management leading to improved results include (1) immediate operation for patients with cardiogenic shock, (2) cold cardioplegic protection of the myocardium, and (3) prosthetic replacement of posterior left ventricular free wall defect, after infarctectomy and septal repair, in patients with posterior septal rupture.

Die Anwendung eines Fibrinklebers in der Ohrchirurgie

In 40 cases of tympanomeatoplastic a special glue, consisting of fibrinogen and thrombin, was used to glue grafts of homologous cartilage into the defect of the posterior wall. In 39 of 40 cases the result was satisfactory. In 9 of 10 cases we had successful results in closing traumatic perforations of the tympanic membrane. In 12 cases recidiv perforations after tympanoplastics were clottid without any other manipulation. Since 1978 we used the new glue in 70 cases to fix bone transplants on to the stapes. The audiological results are 5–6 dB better as in usual techniques.

Tragal perichondrium and cartilage in reconstructive ear surgery.

Two hundred and fifty-five ear operations using tragal perichondrium and cartilage for reconstruction are presented. Of these, 108 were myringoplasties, 137 were tympanoplasties with ossicular reconstruction performed by nine different methods, and 10 were tympanoplasties with reconstruction of posterior canal wall defects left by radical mastoid surgery. The method presented in this study of using the tragal perichondrial graft is well suited for myringoplasty and can be used where the drum remnant is very small or the anulus is missing. The natural angle of the tragal perichondrium can take the place of the missing anulus anteriorly, inferiorly or posteriorly. Myringoplasty graft survival at one year follow-up was 92%, and 76% had hearing within 10 db of bone conduction. In tympanoplasty, the tragal perichondrium was used en bloc with its cartilage for reconstruction of the ossicular chain where suited. The malleus was used to reconstruct the ossicular chain in different variations. Other methods used are fully described. At one year follow-up the rate of grafting success for tympanoplasties was 91%, and 78% had hearing within 10 db of bone conduction. A method for reconstruction of the posterior canal wall and tympanoplasty after radical mastoidectomy is presented. It uses tragal cartilage and perichondrium en bloc. At one year follow-up, eight of ten cases operated on by this method had an intact drum and posterior canal wall, one had an intact drum but the posterior canal collapsed into the mastoid, and one had an intact canal wall but the eardrum re-perforated. Nine had postoperative hearing within 10 db of bone conduction. A randomly selected group of 100 tympanoplasties was examined for postoperative gain in hearing according to the speech reception threshold, a more practical criterion of surgical success than 10 db air-bone gap. Although the total number showing improvement was similar to the number gaining hearing within 10 db of pure tone bone conduction (76% vs. 78%), when changes of 5 db were discounted, only 56% were improved (and 33% had a significant gain in hearing).

Preperitoneal approach in the repair of inguinal hernias

T HE SEARCH for the elusive solution to the problem of inguinal hernia has stimulated surgeons since the days of Sir Astley Cooper [I ] to devise new and more effective technics for the permanent repair of this anatomic defect. The scholarly studies of McVay and Anson [2,3] in the early 1940’s has undoubtedly exerted a most powerful influence on the thinking of the surgical community in this matter. Their compelling logic in insisting upon the use of the transversus layers and Cooper’s ligament in the repair of posterior inguinal wall defects cannot be denied. Volumes have been written by hosts of surgeons attesting to the efficacy of this method since McVay’s initial report on the clinical application of the anatomic study by himself and Anson. Happily, it is now the rare surgeon who persists in suturing the conjoined tendon to the inguinal ligament to repair a direct hernia. The respectably low recurrence rate after inguinal herniorrhaphy when the transversus layers and Cooper’s ligament have been utilized has unfortunately led to some degree of complacency in calculating this problem. The high incidence of small indirect hernia, effectively treated by high ligation of the sac and minimal repair of the posterior inguinal wall, has contributed to the general feeling of well-being. The patient with recurrence is too often relegated to the scrap pile of causes such as poor tissues, faulty suture material, or the “elsewhere” surgeon. Recurrence rates are in fact hard to measure since the patient may actually be unaware of a small recurrent hernia, he may not report a recurrent hernia of any size, or he may seek another surgeon. Thus, both the cause and incidence of recurrent hernia remain something of a mystery. Cheatle [P] in 1920 and Henry [5] in 1936 separately reported an approach to the inguinal canal for the cure of hernia that was different from the conventional anterior approach. Both described an incision above the inguinal canal approaching the posterior inguinal wall in the preperitoneal plane. Nyhus and Harkins [6] have reported their experience with over 800 hernia repairs utilizing their own version of the Cheatle-Henry approach. More recently, Dyson and Pierce [7] have reported 192 hernia repairs using a similar route. Nyhus [8] has clearly and convincingly redescribed inguinal anatomy based on his experience in the dissection of fresh cadavers, placing particular emphasis on the anatomy of the posterior inguinal wall. His clinical application, utilizing the information gained from his dissections, and his highly respectable recurrence rates deserve our serious consideration. His anatomic reappraisal of the posterior inguinal wall vividly describes hernial defects from the preperitoneal view, and although the structures which he uses for repair are fundamentally the same structures which are used in the McVay approach from the front, they take on a curiously logical appearance. This paper is not intended to redescribe all inguinal anatomy, but in order to focus attention on the posterior inguinal wall it is necessary to point again to this layer as it relates to preperitoneal inguinal herniorrhaphy. Vital to the dis-