Presence Of Associated Lesions Research Articles

Mortality And Prognostic Factors In Patients Operated For Acute Epidural Hematoma.

Epidural hematoma is one of the most common surgical emergencies encountered in neurosurgery. This study was conducted to determine the mortality and prognostic factors in patients operated for traumatic intracranial epidural hematoma in a resource-constrained setting from a developing country. This retrospective study was conducted in the Department of Neurosurgery at Ayub Teaching Hospital Abbottabad from 1st January 2019 to 31st Dec 2021. Inclusion and exclusion criteria were created. The medical record of 116 patients admitted and operated on for traumatic extradural hematoma was retrospectively reviewed. Information was recorded using a standardized structured questionnaire. The outcome was measured in terms of the Glasgow coma outcome score. Out of 116 patients, 93 were male and 23 were female.19 (16.4%) patients were in the age range 0-5 years, 42 (36.2%) were in the age range 6-15, 35(31.0%) were in the age range 16-30, 11 (9.5%) were in the age range 31-45 years, 7 (6.0%) were in the age range 46-60 years while only one patient included in this study was above 60 years. Overall mortality was 4.3%. Mortality was higher in females and in those aged less than 5 years (3.4%). 4 out of 16 patients died with GCS less than 8, while none of the patients died when GCS was above 12. Mortality was significantly higher in the presence of associated lesions (4.4% vs. 0%) and anisocoria (2.6% vs.1.7%). Patients who operated within 6 hours of trauma resulted in better outcomes with a mortality rate of 0.0% and functional recovery of 57.8 % while for those who operated after 6 hours, mortality was significantly higher (4.3%) and functional recovery was significantly low (15.5%). Good surgical outcomes can be achieved with early operative intervention if indicated. Female gender, low preoperative GCS score, presence of pupillary dilatation, presence of associated lesions, delayed surgical intervention and age less than 5 years are significant predictors for poor outcomes.

Computerized Tomography Scans for Ankle Fracture: Diagnosis, Management and Surgical Plan Modifier

Category:Trauma; AnkleIntroduction/Purpose:Ankle fractures are one of the most operated injuries in orthopedic practice. The decision upon the best management is based on the displacement of the bone fragments and the presence of associated lesions (osseous and/or soft tissues). The therapeutic decision is classically established upon plain radiographs, which might be temerarious due to the usual difficulty in analyzing those exams. In recent years, some authors have advocated that computed tomography could be used as an assistant instrument on the decision-making. Our study aims to demonstrate the superiority of the association between both methods on diagnosis, therapeutic decision, and surgical plan for these injuries.Methods:Patients diagnosed with an ankle fracture, between 2011 and 2016, and assessed with CT and X-ray were included in our investigation. Seven examiners with different degrees of experience analyzed the exams, determined the injuries, chose how they would treat, and the defined surgical strategy when applicable. This was done, at first, only with radiographs and after with the combination of CT and radiographs. The data were statistically compared.Results:Fifty-three patients were included. The medial malleolus fractures characteristics (posteromedial fragment and anterior colliculus), the presence of posterior malleolus fracture and its characteristics (displacement, bone fragment greater than 25%, posteromedial or posterolateral segment), syndesmosis injury, and the absence of deltoid ligament lesion were more noticeable from the combination of CT and radiography. Concerning surgical treatment, the prone position, the posterolateral surgical approach (rather than anterolateral) on lateral malleolus osteosynthesis, the decision to surgically treat the posterior malleolus fracture (through posterolateral approach with posterolateral plate), the option to include the syndesmosis approach in the treatment, and not to include deltoid ligament repair were more noticeable from the combination of CT and radiography, among all groups of expertise, with high inter-observer reliability.Conclusion:The usual radiographs may fail to demonstrate subtle lesions, as posterior malleolus fractures and syndesmotic injuries. The tomographic evaluation increases the precision of diagnosis and improves the quality of information that the surgeon receives, providing data that can positively affect patient care.

Role of magnetic resonance imaging on fingers in diagnosis of post-traumatic tendon and ligament injuries

BackgroundMagnetic resonance (MR) imaging is a powerful method for evaluating acute and chronic lesions of the stabilizing articular elements (volar plate and collateral ligaments) of the fingers and thumbs, the condition of tendons, the presence of a tear, the number of affected tendons, the extent of tendon retraction, and the presence of associated lesions. This study was done to clarify the value of magnetic resonance imaging (MRI) in assessment of trauma-related injuries of the tendons and ligaments of the fingers and subsequently positively affect the surgical decisions in such cases.ResultsThis study included 42 patients (33 males and 9 females) with a mean age of 35 years. All of them had history of trauma. Male affection was 78.5%, while females constituted only 21.5%, striking right-sided-hand affection (92.9%). The most affected finger was the thumb. The most common affected sites were extending from the metacarpophalangeal (MCP) till the proximal interphalangeal (PIP). The tendons were affected in 42.9%; meanwhile, ligamentous affection represented 57.2%. The flexor tendon tear represented by 28.6%%, while extensor tendon tear occurred in 14.3%. The study also showed that partial thickness tear is represented by 66.7%, while complete thickness tear occurred in about 33.3%. Bone marrow edema and post-traumatic tenosynovitis occurred in about 14% of cases.ConclusionsMagnetic resonance imaging is an essential technique to obtain a correct pre-surgical diagnosis. It is of utmost importance to possess an in-depth knowledge of finger radiological anatomy in detail, as well as the appearance of the different pathologic entities on MRI. It provides a great assessment of the tendons and ligaments tear by whether partial or complete, any associated marrow edema or bony fragment avulsion and the extent of retraction in cases of complete tear.

Analysis of the nature and severity of injuries in patients with traumatic lesions of the brachial plexus

Brachial plexus lesions (BPL) is a severe, disabling pathology is mostly occur in young patients of working age. Often, BPL is combined with other injuries, which significantly aggravate the diagnosis, and therefore delay the start of treatment. Objective: to analyze the characteristics of injuries in patients with traumatic BPI, that has been surgically treated at our center. Methods: retrospective analysis of 237 patients was performed, study included only patients with traumatic brachial plexus injuries, that has been surgically treated at our center, from 2000 to 2019. All patients underwent a thorough anamnesis, orthopedic-neurological examination, radiography, ultrasound, CT, MRI, NCS, ENMG. Particular attention was paid to the etiology, anatomical localization of the lesion, and presence of associated lesions. Results: 84.4 % of patients with BPL had other injuries. In patients of the younger age group (up to 50 y. o.) among the causes of this injury prevailed motorcycle road-traffic accident with root lesions, while in patients after the age of 50 y. o. — fell with injury at the level of cords. Root avulsions are characterized by high energy trauma, while lesions of the brachial plexus cords result from low-energy trauma. Most characteristic of the preganglionic injuries of the brachial plexus were their combination with traumatic brain injury and chest injuries, while for the injury at the level of cords were humerus fractures. Retroclavicular injuries (injury at the devisions level) were characterized by both combination of closed traumatic brain injury and fractures of clavicle and humerus. Conclusions: Most common BPL occur in three critical zones: preganglionic — 36.3 %, subclavicular — 35.4 %, and retroclavicular — 20.3 %. Risk group of patients with BPL should include patients with polytrauma, patients who had injuries traffic accident, falling or significant upper extremity traction.

Experimental Study Upon the Virulence of Infectious Microbial Agents Involved in Violent Deaths Presenting Septic States

The study of bacterial pathogeny represents a very important issue for the forensic specialists, clinicians, managers and healthcare policymakers. The purpose of this experimental research is to study the virulence of some infectious microbial agents (Pseudomonas Aeruginosa, Staphylococcus Aureus, Escherichia Coli, Proteus Mirabilis, Erysipelothrix Rhusiopathiae), some of them frequently involved in violent deaths presenting septic states, by inoculating them in white mice Mus Musculus (MMs), in the presence of competing factors of death, reproducing this way a model of human violent death consecutive of septic complications that occur in the evolution of some traumas.The results of the study show that the survival period of the MMs depends on the microbial agent of the inoculated strain, the dilution of the culture suspension, the presence of associated lesions, age. In decreasing order, according to the value of LD50, the most virulent strains are Erysipelothrix Rhusiopathiae, Escherichia Coli, Proteus Mirabilis, followed by Staphylococcus Aureus and Pseudomonas Aeruginosa. The lethality index increases proportionally with the virulence of the etiologic agent and the presence of the associated lesions, confirming once again the similarity with�physiopathological mechanisms that exist in human pathology.

Surgical approach of isolated fracture of the anterior wall of the frontal sinus: The upper eyelid incision

Fractures of the frontal sinus are classified according to the topography (anterior wall, posterior wall or both), the displacement, and the presence of associated lesions (wound, nasofrontal duct injury, rhinorrhea). Isolated fractures of the anterior wall require surgical management, if the displacement is over 4 mm, to restore the forehead symmetry, to maintain the sinus ventilation and to avoid long-term complications (sinusitis, mucocele, meningitis…). Coronal incision is commonly performed but less invasive techniques are more and more used. We describe a technique of reduction and fixation of isolated anterior wall fractures by upper eyelid incision, allowing a good exposure of the lower portion of the frontal sinus, with a limited scar.

Non operative conservative management of blunt trauma to the spleen in Children: A Single Tertiary Hospital Experience

Background: Splenic injury is the leading cause of major bleeding in the patients of blunt abdominal trauma. In earlier medical practice, the blunt splenic injury was managed surgically in most cases, but the increased understanding of the splenic function in the immunological process and the identification of post-splenectomy complications have led physicians to prefer the non-operative management . Material and methods: A retrospective study of the patients with blunt trauma to the spleen in the pediatric age group between the year 2015 and 2018. The study was conducted in (Nasser Institute Hospital for research and treatment). Management of the patients was done using hypovolemic resuscitation and serial follow up. Abdominal ultrasound, complete blood picture and Abdominal CT were done. Data was tabled and analyzed. Results: A total of 123 blunt splenic trauma patients were identified. Traffic-related accident and falling from height were the main mechanisms of injury. Splenic contusion and hematoma were the most frequent finding on initial computerized tomography (CT) scans, followed by shattered spleen, blush, and devascularization. Non-operative management failed in 6 patients who underwent splenectomy. (95.12%) of the patients managed successfully using hypovolemic resuscitation without need for surgical interference. Discussion: Non-operative management is considered for patients with low-grade splenic injuries, unless operated upon for other associated injuries. In fact, higher-grade injuries could also be managed non-operatively. Splenic angioembolization of bleeding vessels increased the success rate of non-operative management in hemodynamically stable patients. In our study, although we didn`t use splenic angioembolization we were able to reach high rates of success. In comparison with the operative management of blunt splenic trauma, the nonoperative management has the added benefit of preserving the splenic functions. Conclusions: Most blunt splenic trauma patients were successfully treated non-operatively, with a low failure rate. The severity of injury and presence of associated lesions should be carefully considered in developing the management plan.

Prediction Model for the Presence of Complications at Admission to Rehabilitation After Traumatic Spinal Cord Injury.

Background: Complications frequently occur in patients with spinal cord injury (SCI) during acute care or rehabilitation and have an impact on rehabilitation outcomes. Purpose: The aim of this study was to determine the occurrence and risk factors for complications in recently injured SCI patients. Methods: Two hundred fifty patients with traumatic injuries with and without complications were counted for the following dichotomous parameters: gender (male/female), associated lesions (presence/absence), surgery (yes/no), American Spinal Injury Association Impairment Scale (AIS) grade (A/other categories), lesion level (lumbar/other levels), and lesion-to-admission time (less than/longer than 1 month). The odds ratio (OR) and 95% confidence interval were computed for all the parameters that influenced the presence of complications at admission. These factors have been included in a binary logistic regression analysis (forward stepwise). Results: Complications at admission were observed in 104 patients (41.6%), especially for males, lesion-to-admission time longer than 1 month, presence of associated lesions, AIS grade A, and motor completeness, whereas lumbar lesions were associated with a reduced presence of complications at admission. In the regression analysis, 4 factors entered into the model: motor completeness, lesion-to-admission time, associated lesions, and gender. The final model explained 74% of the variance of data. Conclusions: Despite advances in the acute management of patients with SCI, the study unveiled a high percentage of patients with complications at admission to rehabilitation. The risk factors identified in the study allow determination of the population of subjects who are at higher risk of developing complications and need special management.

Clinical and Radiological Presentations and Management of Blunt Splenic Trauma: A Single Tertiary Hospital Experience.

BackgroundSplenic injury is the leading cause of major bleeding after blunt abdominal trauma. We examined the clinical and radiological presentations, management, and outcome of blunt splenic injuries (BSI) in our institution.Material/MethodsA retrospective study of BSI patients between 2011 and 2014 was conducted. We analyzed and compared management and outcome of different splenic injury grades in trauma patients.ResultsA total of 191 BSI patients were identified with a mean (SD) age of 26.9 years (13.1); 164 (85.9%) were males. Traffic-related accident was the main mechanism of injury. Splenic contusion and hematoma (77.2%) was the most frequent finding on initial computerized tomography (CT) scans, followed by shattered spleen (11.1%), blush (11.1%), and devascularization (0.6%). Repeated CT scan revealed 3 patients with pseudoaneurysm who underwent angioembolization. Nearly a quarter of patients were managed surgically. Non-operative management failed in 1 patient who underwent splenectomy. Patients with grade V injury presented with higher mean ISS and abdominal AIS, required frequent blood transfusion, and were more likely to be FAST-positive (p=0.001). The majority of low-grade (I–III) splenic injuries were treated conservatively, while patients with high-grade (IV and V) BSI frequently required splenectomy (p=0.001). Adults were more likely to have grade I, II, and V BSI, blood transfusion, and prolonged ICU stay as compared to pediatric BSI patients. The overall mortality rate was 7.9%, which is mainly association with traumatic brain injury and hemorrhagic shock; half of the deaths occurred within the first day after injury.ConclusionsMost BSI patients had grade I–III injuries that were successfully treated non-operatively, with a low failure rate. The severity of injury and presence of associated lesions should be carefully considered in developing the management plan. Thorough clinical assessment and CT scan evaluation are crucial for appropriate management of BSI.

Mason type II and III radial head fracture in patients older than 65: is there still a place for radial head resection?

To evaluate the clinical outcomes of radial head excision for multifragmentary radial head fracture in patients over 65 years old. We retrospectively examined 30 patients over 65 years of age treated with radial head excision for comminuted radial head fractures. Patients were evaluated through clinical examinations, administrative questionnaires (DASH--Disabilities of the Arm, Shoulder and Hand; MEPS--Mayo Elbow Performance Score, VAS--Visual Analog Scale) and plain films. The mean follow-up was 40 months (range 24-72 months); 27 out of 30 patients claimed to be satisfied. The mean DASH score was 13 (range 3-45.8) and mean MEPS was 79 (range 65-97). The radiographic evaluation showed 21 cases of elbow arthritis; only two of them complained about pain. Heterotopic ossification was evident in six cases with functional impairment in only one patient. Six patients with increased ulnar variance had clinical distal radio-ulnar joint instability. Radial head excision has been considered a safe surgical procedure with satisfactory clinical outcomes. Development in biomechanical studies and prosthetic replacement of the radial head question the validity of radial head excision. In current literature, there are neither long-term follow-up studies on radial head prosthesis outcomes nor studies which consider elderly patient samples. Radial head resection remains a good option when a radial head fracture occurs in elderly patients, taking into account the influence of poor bone quality and comorbidities on the outcome. Radial head excision is not indicated in the presence of associated lesions, because of the risk of residual elbow instability; complications associated with advanced age must be considered and a strict follow-up granted.

Early percutaneous fixation of spinal thoracolumbar fractures in polytrauma patients

IntroductionCare of polytrauma patients is complex and requires that a particular treatment sequence be followed during what is typically a short period of time. Early, temporary stabilization of injuries (damage control orthopedics [DCO]) is a validated strategy for the care of polytrauma patients. Application of this concept to spinal fractures has also led to good outcomes for patients. The recent development of percutaneous thoracolumbar fixation could improve the initial care of these vulnerable patients even more. The purpose of this study was to evaluate preliminary results in a series of polytrauma patients presenting with thoracolumbar fractures without neurological deficits who were treated according to DCO principles using early percutaneous fixation. Materials and methodsAll severe polytrauma patients admitted with a thoracic and/or lumbar spine fracture without neurological deficit were included in this prospective study. The care was standardized according to the degree of urgency of the initial injuries, with percutaneous spinal fixation being performed as early as feasible. The outcomes were evaluated using clinical parameters (duration of stay in intensive care unit, surgical data, blood loss) and radiographic parameters measured during a systematic postoperative CT scan (traumatic deformity, placement of pedicle screws, fusion rate). If needed, an anterior intervertebral graft was performed during a secondary procedure. ResultsIn all, 10 patients (average age of 40years) were included, corresponding to 18 vertebral fractures. During the initial assessment, at least one peripheral bone fracture was found in 90% of cases and at least one organ was injured in all patients (thoracic in 80% of cases, cerebral in 50%, facial area in 40% and abdominal-pelvis in 30%). The average time elapsed between admission and spine surgery was 4days (80% of cases before day 7). There were no cases of deep infection in any of the patients. An additional anterior procedure was needed in three patients within 1month of the initial surgery. DiscussionThe strategy for treating thoracolumbar fractures in polytrauma patients is still not widely accepted. The presence of associated lesions could make it difficult to perform conventional spine surgery early on. Development of percutaneous techniques that reduce perioperative morbidity seems to be an alternative approach well-suited to DCO, as long as there are no neurological deficits. However, a secondary evaluation of the anterior spine is essential to determining if an anterior graft remains needed. Level of evidenceLevel IV.

Secondary repair of flexor tendon injuries

Tendon adhesions or even secondary ruptures causing severe hand functional impairment still represent a frequent complication after repair of flexor tendon injuries. Secondary treatment of these problems includes tenolysis, one or two stages flexor tendons reconstruction by grafts or even the use of tendon prosthesis. The mechanism and severity of injury, the status of the surrounding tissues and injured finger, the presence of associated lesions, the age of the patient, post-operative management, patient motivation and the surgeon's skill, may all have implications in the final outcome of the tendon reconstruction. A correct evaluation of the problem by means of classifications such as the one described by Boyes, may help the surgeon in choosing the appropriate technique.

M-Node Echocardiographic Assessment of D-Transposjtjon of the Great Arteries and Associated Defects

INTRODUCTION: M-mode echocardiography has proven to be a reliable means for the diagnosis of d-transposition of the great arteries (8, 5). The M-mode echo diagnostic criteria are the demonstration of: (1) an anterior aorta, identified by delayed opening of its semilunar valve compared to the pulmonary valve, and (2) the aorta being situated rightward and anteriorly vis-a—vis the posterior pulmonary artery. MATERIAL AND METHODS: Forty—one patients with d-transvositjon of the great arteries were studied prior to, and 73 following Mustard operation and correction of associated lesions. Seventeen patients had sequential pre- and postoperative echocardio— graphic and cardiac catheterization studies. The echocardiograrns were obtained within 24 hours of cardiac catheterization. Hemodynamic data were obtained at cardiac catheterization using fluid—filled catheters and Statham gauge pressure transducer prior to the angio-graphic studies. Right ventricular angio— graphic volumes and ejection• fractions were obtained in 18 patients using Simpson’s method (7). Superior vena caval, right ventricular and left ventricular selective cineangiograms were also obtained. RESULTS: Preoperative Studies Forty-one patients with d-transposition of the great arteries were studied prior to the Mustard operation and correction of associated lesions. The echocardiographic and hemodynamic data of these patients are presented in Table 1. The age ranged between 1 day and 13 years (mean 3.2±4.2 years). Preoperatively, the PEP/RVET ratio was > 0.50 in only one patient; postoperative1y,.the ratio was 0.50 in 4 patients and in 2 of these hemodynamically significant tricuspid regurgita‘ don and angiographically estimated reduced ejection fraction (0 . 50) was noted. DISCUSSION: This study confirms that M-mocle echocard iography is a reliable means for diagnosing d-transposed great arteries. The transducer angulation (from the standard 4th intercostal parasternal space) required to detect the transp osed aorta is rightward and anterior (toward the right shoulder) from the posterior vessel, as opposed to an anterior and leftward angulation required to detect the anterior vessel (pulmonary Artery) in normally related great vessel.In summary, M-mode echocardiography prov ides not only a reliable means of diagnosing d-transposition of the great arteries, but is also useful for assessing the presence of associated lesions. Changing hemodynamic parameters in patients with transposition of the great arteries can be followed before and after the Mustard operation by longitudinal echocardiographic ass essment -

Aortopulmonary window in infants

One of the rarest congenital heart diseases that results from a defect between the main pulmonary artery and the proximal aorta is named aortopulmonary window (APW). Such abnormality could be isolated, but in fifty percent of patients may be associated with other cardiac abnormalities, including arch abnormalities, specifically coarctation of the aorta, interrupted aortic arch, tetralogy of fallot, and atrial septal defect (ASD). Surgical closure or catheter-delivered devices is recommended in all patients with APW and should be performed after diagnosis as soon as possible to prevent irreversible pulmonary vascular disease. In the current era, early mortality following repair of simple APW is low and depends on the presence of associated lesions, especially interrupted aortic arch. We report an 8-month-old boy with APW who was referred to our center by respiratory symptoms and heart murmurs.

Spinal cord injury and its association with blunt head trauma

BackgroundSevere and moderate head injury can cause misdiagnosis of a spinal cord injury, leading to devastating long-term consequences. The objective of this study is to identify risk factors involving spine trauma and moderate-to-severe brain injury.MethodsA prospective study involving 1617 patients admitted in the emergency unit was carried out. Of these patients, 180 with moderate or severe head injury were enrolled. All patients were submitted to three-view spine series X-ray and thin cut axial CT scans for spine trauma investigations.Results112 male patients and 78 female patients, whose ages ranged from 11 to 76 years (mean age, 34 years). The most common causes of brain trauma were pedestrians struck by motor vehicles (31.1%), car crashes (27.7%), and falls (25%). Systemic lesions were present in 80 (44.4%) patients and the most common were fractures, and lung and spleen injuries. 52.8% had severe and 47.2% moderate head trauma. Fourteen patients (7.8%) suffered spinal cord injury (12 in cervical spine, one in lumbar, and one thoracic spine). In elderly patients, the presence of associated lesions and Glasgow Coma Scale (GCS) < 9 were statistically significant as risk factors (P < 0.05) for spine injury.ConclusionSpinal cord injury related to moderate and severe brain trauma usually affects the cervical spine. The incidence of spinal lesions and GCS < 9 points were related to greater incidence of spinal cord injury.

The Fontan Operation: The Pursuit of Associated Lesions and Cumulative Trauma

Our programmatic approach to the Fontan operation has evolved to include using an extracardiac conduit with aggressive presumptive treatment of associated lesions either in the catheterization laboratory or the operating room. Fenestration is used selectively based on hemodynamics, anatomy, and presence of associated lesions. We reviewed our experience to determine the effectiveness and outcome of this strategy and to assess the cumulative trauma to the patients. The records of 137 consecutive patients who underwent Fontan at Miami Children’s Hospital from 1995 to 2008 were reviewed. At mean follow up of 5.76 years, freedom from death or transplantation is 94.2% (129/137). Median age at operation was 4.6 years. Longer length of stay correlated with older operative age (P = 0.0056). Pacemakers were implanted in 11.7% (16/137). Additional (not pre-Glenn or pre-Fontan) interventional catheterizations were performed in 51.8% (71/137). Additional operations were done in 10.2% (14/137). No patient has required replacement or revision of the extracardiac conduit. Our current approach to the Fontan operation provides acceptable midterm results. The pursuit of residual lesions results in a significant number of additional interventional catheterizations and operative procedures but might have an important influence on long-term survival after the Fontan procedure.

Atlantoaxial rotational dislocation and associated multiple-level fractures to the spine

We present a case of a young woman with multilevel spinal injuries. The injury includes a rotational atlantoaxial dislocation associated with concomitant injury at C5 and at the sacrum. Rotational dislocation at C1–C2 level is not frequently encountered in young adults, and the presence of associated lesions to the spine makes this condition a challenging one. The medical record of a patient who sustained three spinal injuries at different levels of the spine was evaluated. The prevalence of this type of injury, the diagnosis, the clinical behavior, and the applied treatment are evaluated. The patient was treated non-operatively, and a satisfactory clinical outcome was recorded at the last follow-up visit.

Aortopulmonary Window

Aortopulmonary window is a rare defect caused by failure of fusion of the two opposing conotruncal ridges that are responsible for separating the truncus arteriosus into the aorta and pulmonary artery. Aortopulmonary window may occur as an isolated lesion or it can be associated with other cardiac abnormalities in one third to one half of cases. The most common associated lesions are arch abnormalities, specifically interrupted aortic arch and coarctation of the aorta. Antenatal diagnosis is rare. In the current era, early mortality following repair of simple aortopulmonary window approaches zero and depends on the presence of associated lesions, especially interrupted aortic arch. Long-term outcome should be excellent. Early morbidity includes pulmonary artery stenosis and residual aortopulmonary septal defects. Long-term follow-up is indicated to look for recurrent lesions such as the development of branch pulmonary artery stenosis and arch obstruction.

Colectomia eletiva laparoscópica esquerda para a doença diverticular: estudo monocêntrico sobre 205 pacientes consecutivos

RACIONAL: O aumento da prevalência de doença diverticular tornou o seu manuseio mais adequado uma questão de debate constante. Especialmente para os casos de diverticulite, progresso considerável tem sido feito em termos de diagnóstico e tratamento. A ressecção cirúrgica do cólon envolvido é a única maneira de erradicar definitivamente essa condição e, portanto, a colectomia laparoscópica eletiva surgiu como uma opção segura e interessante entre as várias formas de tratamento. OBJETIVO: Analisar os resultados das colectomias laparoscópicas esquerdas para a doença diverticular realizadas durante um período de 17 anos em uma única instituição. MÉTODOS: Entre abril de 1990 e maio de 2007, um total de 205 colectomias consecutivas esquerdas laparoscópicas foram revistas retrospectivamente. Os dados obtidos incluíram o pré-operatório, indicações para a operação, os dados cirúrgicos, complicações e seguimento. Análises estatísticas univariada e multivariada foram realizadas em um esforço para identificar os fatores de risco e efeitos adversos na série. RESULTADOS: As indicações foram diverticulite aguda (80%) não-complicada, diverticulite aguda ou crônica complicada (18,05%) e sangramento na doença diverticular (1,95%). A taxa de conversão foi de 5,85% (12 casos). A mediana do tempo operatório foi de 180 minutos (100-420), com internação hospitalar de 7 (5-44) dias. O comprimento médio do espécime ressecado foi 29,12 centímetros. A maioria dos casos (88,3%) teve curso pós-operatório normal, mas complicações ocorreram em 24 (11,7%) pacientes. Em ordem de frequência foram: íleo paralítico (n = 6), coleções pélvica (n = 4), obstruções intestinais (n = 4) e fístulas (n = 2), entre outros. Re-operação foi necessária em oito casos e houve um óbito (0,48%). O seguimento mediano foi de 26,5 (1-156) meses, com resultado satisfatório em 179 (87,32%) dos pacientes. Em 18 (8,78%) casos, os sintomas persistentes de distúrbios funcionais do cólon foram anotados. Houve sete (3,41%), estenoses da anastomose e em dois precisou de re-operação. A taxa de recidiva foi de 1,95% (4 casos). Idade e complicações intra-operatórias foram identificadas como fatores de risco para a conversão. A presença de lesões associadas foi significativamente correlacionada com a persistência de sintomas funcionais do cólon durante o seguimento. CONCLUSÕES: A colectomia laparoscópica esquerda é segura e eficaz em comparação com todas as outras modalidades de tratamento da doença diverticular. Diagnóstico preciso e cuidado nas indicações são essenciais para atingir bons resultados.

Comminuted Radial Head Fractures Treated with Pyrocarbon Prosthetic Replacement

We had evaluated our experience in the treatment of displaced and comminuted radial head fractures with pyrocarbon radial head prosthesis. From May 2003 to July 2008, radial head prostheses were performed in 47 patients. There were 29 female and 18 male with mean age 51 (34-70years). The follow-up was a mean of 48 (12-60months). Fractures of the radial head have been classified by Hotchkiss. The indications for a radial head replacement were type III fractures in 27 cases, type IV fractures in ten cases, comminuted radial fracture associated with disruption of the medial collateral ligament in three cases, Monteggia variant in five cases, and Essex-Lopresti in two cases. Functional outcomes were assessed by visual analog scales (VAS) of pain, joint motion and stability, and using the Mayo Elbow Performance Index. The mean VAS score for elbow pain was 1 (0.5-2.1). Patients showed an average arc of motion from 6° to 140°, with 75° of pronation and 67° of supination. By using the Mayo Elbow Performance Index, 42 patients had good/excellent results, with three fair and two poor outcomes. Complications were two implant dislocations, one elbow stiffness, one dissociation of the implant, one stem rupture, and two posterior interosseous nerve palsy that recovered from 5 to 8weeks. We had not seen persistent instability, infection, synostosis, severe degenerative changes, or impingement. The treatment of comminuted radial head fracture with pyrocarbon implant usually gives an optimal result depending on the severity of the initial injury and the presence of associated lesions. The size of the prosthesis is often overestimated, causing restriction in motion due to impingement, overstuffing, or dislocations.