Unsuccessful Conservative Treatment Research Articles

Everolimus in Immunosuppressive Treatment After Kidney Transplantation in a Patient With Tuberous Sclerosis: Case Report

BackgroundTuberous sclerosis complex (TSC) is an inherited disorder caused by mutations of TSC1 or TSC2 genes, resulting in constitutive activation of the mammalian target of rapamycin (mTOR) and impairment of the cell cycle. As a consequence, hamartomatous tumors of multiple organs may develop, but generally skin, brain, kidneys, and lungs are involved. mTOR inhibitors (mTOR-I, rapamycin/everolimus) may correct underlying defects in TSC. Previous data prove benefits and safety of mTOR-I on a wide spectrum of disease manifestations and effectiveness of rapamycin in TSC patients after kidney transplantation (KT). MethodsWe report the first case of a patient with TSC receiving everolimus initiated in immunosuppressive treatment at the time of KT. In April 2012, the 34-year-old female TSC patient, after bilateral nephrectomy due to polycystic kidneys and skin lesions related to TSC, was transplanted with a renal graft from a deceased donor (PRA, 0%; MM A/B/DR,1/2/0). Initial immunosuppressive treatment consisted of basiliximab, methylprednisolone, tacrolimus, and everolimus. ResultsThe early postoperative period was complicated by delayed graft function. Creatinine level at discharge was 1.39 mg/dL, with stable graft function in subsequent months. Nine months after KT, inflammatory infiltration of the nephrectomy site (performed in 2011) with persistent effusion was observed. After 2 months of unsuccessful conservative treatment, the patient was converted from everolimus to mycophenolate mofetil with healing of local state. During 11 months of everolimus treatment, no improvement of skin presentation of TSC was noticed. ConclusionsmTOR-I appear to be a treatment of choice in transplanted patients with TSC, although some complications precluding continuous mTOR-I therapy allowing its potential benefits, may appear.

Glenohumerale Arthrolyse der Omarthroseschulter bei anatomischer Schulterprothesenimplantation

Pain reduction and improvement of range of motion. Primary and secondary osteoarthritis, unsuccessful conservative treatment, limited range of motion with capsular contraction. General contraindications for anatomical total shoulder arthroplasty. Instability arthritis without capsular contraction. Deltopectoral approach. Detachment and release of the subscapularis tendon at the lesser tuberosity, incision of the anterior and inferior humeral sided capsule and osteophyte removal, humeral head resection and stem preparation. Glenoid exposure, capsular an labral resection. Glenoid surface preparation and prosthetic component implantation. Anatomical placement of the the humeral head without overstuffing. Implantation of the final humeral stem. Transosseous refixation of the subscapularis tendon. Wound closure. Abduction brace for 4weeks. Assisted motion starting the first postoperative day during the first 6weeks: anteversion/ retroversion 90-0-0°, abduction/ adduction 90-0-20°, internal/external rotation 90-0-individual limitation. Subsequent development of full range of motion. In 2009 and 2010 anatomical total shoulder arthroplasty with glenohumeral arthrolysis was performed in 53cases. At an average follow up of 32months the Constant score and range of motion improved significantly. The complication rate was 9%.

Synovial Chondromatosis in Temporomandibular Joint

Synovial chondromatosis (SC) in temporomandibular joint is a rare benign disorder characterized by cartilaginous metaplasia of the mesenchymal remnants of the synovial tissue. The etiology of the disease is unclear but may be associated with trauma, overuse, local infection, and embryologic disturbance. SC does not spontaneously resolve and respond to nonsurgical treatment. SC should be differentially diagnosed with other temporomandibular joint disorders such as arthralgia or osteoarthritis because surgery should be done for managing it. However, primary diagnosis of SC is not easy because of nonspecific symptoms and signs. For the patients with unsuccessful conservative treatment response, especially accompanied by crepitus, preauricular swelling or posterior open bite, computed tomography/cone-beam computed tomography or magnetic resonance imaging should to be performed to exclude SC. We discussed the importance of the early diagnosis and surgical treatment of SC from this case.

Efficacy and safety of urethral de-obstruction in boys with overactive bladder complaints

ObjectiveTo gain insight into the efficacy and safety of urethral de-obstruction in boys with overactive bladder (OAB) complaints refractory to conservative treatment. Materials and methodsAll boys, older than 5 years, referred in 2009 for OAB complaints were included, n = 180. Nine had abdominal or penile pain as predominant complaint. 82% were tertiary referrals after unsuccessful conservative treatment with antimuscarinic medication and/or urotherapy for OAB. In 121, urethral obstruction was urodynamically proven or seriously suspected, and they underwent urethrocystoscopy with relief of obstruction, when present. Average duration of unsuccessful conservative pre-treatment in this group of patients was 1.2 years. Postoperative results, in terms of relief of complaints, were analyzed. Safety was assessed by analyzing those patients who had a secondary transurethral procedure in the same year, or in the 3 years after primary treatment. ResultsOf 106 boys with OAB, urge incontinence or therapy-resistant bedwetting, after de-obstruction 33 became free of complaints and 39 showed significant improvement, totaling 72 (68%); dry after additional urotherapy 11 (10%); no change 21 (20%). Nine boys had de-obstruction because of penile or abdominal pain, with 5 completely cured after the procedure. Follow-up treatment was cognitive training in 39, temporary anticholinergic treatment in 26 and CIC in 2 cases. Recurrence of obstruction was seen in 10% during the 3-year follow-up period. ConclusionAfter failure of conservative therapy, one should actively look for any urethral obstruction as underlying cause of OAB. For such patients, urethral de-obstruction is highly effective, with only a few minor late complications resulting in recurrence of obstruction.

Pancreatic fistula: A proposed percutaneous procedure

To propose a percutaneous treatment for otherwise intractable pancreatic fistula (PF). From 2005 to 2011, 12 patients (9 men and 3 women, mean age 59 years, median 63 years, range 33-78 years) underwent radiological treatment for high-output PF associated with peripancreatic fluid collection. The percutaneous procedures were performed after at least 4 wk of unsuccessful conservative treatments. We chose either a one or two step procedure, depending on the size and characteristics of the fistula and the fluid collection (with an arbitrary cut-off of 2 cm). Initially, 2 to 6 pigtail drainages of variable size from 8.3 (8.3-Pig Duan Cook, Bloomington, Indiana, United States) to 14 Fr (Flexima, Boston Scientific, Natick, United States) were positioned inside the collection using a transgastric approach. In a second procedure, after 7-10 d, two or more endoprostheses (cystogastrostomic 8 Fr double-pigtail, Cook, Bloomington, Indiana, United States in 10 patients; covered Niti-S stent, TaeWoong Medical Co, Seoul, South Korea in 2 patients) were placed between the collection and the gastric lumen. In all cases the metal or plastic prostheses were removed within one year after positioning. Four out of 12 high-output fistulas fistulas were external while 8/12 were internal. The origin of the fistulous tract was visualised by computer tomography (CT) imaging studies: in 11 patients it was at the body, and in 1 patient at the tail of the pancreas. Single or multiple drainages were positioned under CT guidance. The catheters were left in place for a varying period (0 to 40 d - median 10 and 25(th)-75(th) percentile 0-14). In one case external transgastric drainages were left in place for a prolonged time (40 d) due to the presence of vancomycin-resistant bacteria (Staphylococcus) and fluconazole-resistant fungi (Candida) in the drained fluid. In this latter case systemic and local antibiotic therapy was administered. In both single and two-step techniques, when infection was present, we carried out additional washing with antibiotics to improve the likelihood of the procedure's success. In all cases the endoprostheses were left in situ for a few weeks and endoscopically removed after remission of collections, as ascertained by CT scan. Procedural success rate was 100% as the resolution of external PF was achieved in all cases. There were no peri-procedural complications in any of the patients. The minimum follow-up was 18 mo. In two cases the procedure was repeated after 1 year, due to the onset of new fluid collections and the development of pseudocysts. Indeed, this type of endoprosthesis is routinely employed for the treatment of pseudocysts. Endoscopy was adopted both for control of the positioning of the endoprosthesis in the stomach, and for its removal after resolution of the fistula and fluid collection. The resolution of the external fistula was assessed clinically and CT scan was employed to demonstrate the resolution of peripancreatic collections for both the internal and external fistulae. The percutaneous placement of cistogastrostomic endoprostheses can be used for the treatment of PF that cannot be treated with other procedures.

Value of endovascular stent placement for symptomatic spontaneous isolated superior mesenteric artery dissection

ObjectiveTo evaluate the feasibility and efficacy of endovascular stent placement for the treatment of symptomatic spontaneous isolated superior mesenteric artery dissection. Materials and methodsThis retrospective study was undertaken in 12 consecutive patients who suffered from symptomatic spontaneous isolated superior mesenteric artery dissection. Seven patients with severe clinical symptoms underwent endovascular stent placement as a primary treatment and the other 5 patients received conservative treatment. The technical results, complications and clinical outcomes were analyzed. Follow-up was performed with computed tomographic angiography. ResultsPrimary endovascular stent placement was successfully performed in 7 patients with severe clinical symptoms. Successful conservative treatment was achieved in 3 patients. Endovascular stent placement was additionally performed in 2 patients with unsuccessful conservative treatment. A stent was misplaced in the false lumen in one of those two patients due to a severely stenotic true lumen. The fasting time and length of stay were significantly shorter in patients with successful endovascular therapy (median: 3 days and 5.5 days) than in those conducted conservatively (median: 9 days and 14 days) (p<0.05). During the follow-up period (median, 21 months; range, 10–36 months), 1 patient with endovascular stent placement had recurrent abdominal pain because of the wall adherent thrombus in the proximal segment of the superior mesenteric artery during the first follow-up month. No thrombosis or stenosis was found in the lumina of the stents. ConclusionEndovascular stent placement is a safe and feasible therapeutic approach for symptomatic spontaneous isolated superior mesenteric artery dissection with immediate success and satisfactory outcomes.

Endoscope-Assisted Excision of a Juxtafacet Cyst in an Adolescent Athlete: A Case Report

Juxtafacet cysts (JFCs) are a cause of back and radicular pain that can be treated conservatively and operatively. Such strategies include lumbosacral brace, epidural injection, open surgery, and minimally invasive surgery; although surgical treatment is usually reserved for unsuccessful conservative treatment. The role of minimally invasive surgery in athletic youth with JFCs has yet to be determined. The patient is a 16-year-old basketball player with a JFC. We performed endoscope-assisted cystectomy. Endoscope-assisted JFC excision immediately and completely resolved the patient's lower back and leg pain with no recurrence of symptoms 4 years after surgery. We suggest that JFCs of the lumbar spine be a part of the differential diagnosis in young patients with back and radicular pain. Furthermore, we recommend that endoscope-assisted surgery be employed in the treatment of JFCs in young athletes.

Pathomorphologic Findings of Wrist Arthroscopy in Children and Adolescents With Chronic Wrist Pain

The purposes of this diagnostic study were to show pathomorphologic findings of children and adolescents with persistent wrist pain and to compare these arthroscopic findings with preoperative magnetic resonance imaging (MRI). A total of 41 arthroscopies in 39 patients were retrospectively reviewed. The patients underwent diagnostic wrist arthroscopy because of persistent wrist pain after at least 3 months of unsuccessful conservative treatment. Of the patients, 22 (56.4%) reported an injury before the onset of pain. The mean age at arthroscopy was 15.3 years (range, 9.8 to 19.4 years), and the mean duration between the onset of symptoms and arthroscopic exploration was 19.9 months (range, 3.0 to 121.0 months). Among all affected wrists, 33 (80.5%) showed a triangular fibrocartilage complex (TFCC) tear on arthroscopy, with 75.6% also showing other pathomorphologic findings. Retrospectively, the condition of the TFCC was correctly identified by MRI in only 17 wrists (41.5%). In contrast, 23 wrists were incorrectly classified as having "no tear" whereas arthroscopy later indeed showed a TFCC tear. Concerning the TFCC, MRI and arthroscopy showed a significant difference of outcome (P < .01), indicating low agreement (κ = 0.09) for the outcome of the 2 methods. A larger proportion of TFCC tears was found for patients with injuries (91.3%) as compared with the other patients (66.7%), although this was not significant on statistical analysis (P = .11). No significant difference in the time to surgery was found between patients with TFCC tears and those without TFCC tears classified by MRI (P = .76) and by arthroscopy (P = .99). Wrist arthroscopy in children and adolescents with chronic wrist pain shows TFCC lesions in a high percentage. However, most of these lesions have not been correctly identified by MRI before arthroscopy. Thus diagnostic wrist arthroscopy may be recommended to rule out underlying pathologies and initiate further therapeutic steps. Level III, diagnostic study of nonconsecutive patients.

Marjolin’s ulcer on a burn graft site after 86 years

Sir, Marjolin's ulcer has generally been accepted to refer to as a long-term malignant complication of the scars resulting from burns [1]. It has been estimated that about 2 % of the burn scar undergo malignant transformation, with an overrepresentation in males [1]. The precise pathogenesis of burn scar carcinomas is not known; however, it is clearly distinct from that of more usual skin cancers. A 90-year-old man, with past medical history of prostate hyperplasia and high blood pressure presented to plastic surgery practice for an easily bleeding chronic ulceration between the skin graft and local flap involving the right flank, since autumn 2008. He originally suffered from a full thickness flame burns, % total body surface area (TBSA) 10 %, at the age of 4 and was treated operatively. The ulceration was managed conservatively by general practitioners with dressings and topical antibacterial and anti-fungoidal treatments. After unsuccessful conservative treatment, he was referred to plastic surgical consultation for further management. A tumour with fungating appearance with ulceration covering the whole tumour surface in between the skin graft and intact skin fold was noted (Fig. 1). At this time, no histology was evaluated. The tumour's appearance and history was unmistakable malignant and operative treatment was planned. The right axilla was preoperatively scanned with ultrasound and revealed no enlarged masses. Sentinel node biopsy was omitted. Wide excision at the level of fascia was carried out with 5cm margins. The specimen measured 12×8×2.5 cm. There was a fold of loose, intact skin that could be released and used as a local random pattern flap to cover the defect. In the first postoperative day, the distal part of the flap was bluish and venous congestion was suspected. Soon the purple colour disappeared and flap vascularity was excellent. The wound was found completely healed when the patient came to outpatient clinic visit on day 21 (Fig. 2) Histological description of the specimen was welldifferentiated squamous cell carcinoma (SCC). The diameter was histologically 35 mm and depth of invasion 10 mm, no perivascular or perineural invasion was detected. The malignant transformation of burn scars is a long-term complication of burns. Kowal-Vern and Criswell summarized 146 articles on burn scar cancer between 1923 and 2004 indicating a mean scar age of 31 years [1]. We were interested in the long latency period after and sought to find articles with latency>50 years, Table 1 [2–8]. Thus, to best of our knowledge, our case represents the longest latency between the initial thermal injury and malignant transformation in burn scar. Two population-based cohort studies from Scandinavia determined skin cancer in people with scarring as a result of burn injuries [9, 10]. There were no differences in the rates of skin cancer (in general, on any site) compared with the general population. The Danish study provided Standardized incidence ratios for SCC 0.9 (95 % confidence interval (CI)00.6–1.5), for basal cell carcinoma (BCC) 0.7 (95 % CI00.6–0.9) and for malignant melanoma (MM) 0.7 (95 % CI00.4–1.1) [9]. The respective figures for the Swedish study were 0.88 (95 % CI0 0.70–1.09) for SCC and 0.88 (95 % CI00.68–1.12) for MM [10]. The Danish group analysed further skin cancers restricted to the anatomic site of the burn injury, the standardized incidence ratio (SIR) for SCC increased to 1.2 (95 % CI00.4–2.7) [9]. Marjolin's ulcers usually occur in old burn site that was not grafted and left to heal secondarily. Only 5 % of the T. A. Partanen (*) Department of Surgery, South Karelia Central Hospital, Valto Kakelan katu 1, 53100 Lappeenranta, Finland e-mail: partanenta@gmail.com

Surgical management of acute upper gastrointestinal bleeding:still a major challenge.

Acute upper gastrointestinal bleeding (UGIB) that cannot be managed with conservative interventional techniques is a life-threatening condition. This study assesses patient outcome and the role of different risk factors. We retrospectively analyzed data from 91 patients (58 men, 33 women) admitted between 2000 and 2009 and who underwent surgery for UGIB requiring transfusion. Mean patient age was 67.4 years. Overall mortality was 34.1%. Causes of bleeding were duodenal ulcer in 57 patients (62.6%) and gastric ulcer in 25 (27.5%). A median number of 21 blood units (range 6-120) were transfused. Surgical treatment consisted of non-resective surgery (52.7%), Billroth II (31.9%), Billroth I (4.4%) or gastric wedge resection (4.4%). The use of anticoagulants (p=0.040), a need for postoperative ventilation (p=0.007) and an intensive care unit (ICU) length of stay >7 days (p=0.004) were identified as significant risk factors for mortality. Transfusions of more than 10 units of blood (p=0.013), the need for further surgery (p=0.021), a prolonged ICU length of stay (p=0.000) and recurrent bleeding (p=0.029) we identified as significant risk factors for postoperative complications (such as pneumonia, sepsis, re-bleeding and anastomotic leakage). Over the past decade, mortality has not decreased in patients requiring surgery for acute UGIB despite diagnostic and therapeutic advances, explained by the fact that these cases represent a negative selection of patients after unsuccessful conservative treatment as well as by the rising age of the population and associated increases in comorbidity. Resective surgery, a need for postoperative ventilation and a prolonged ICU length of stay should be added to the list of significant risk factors for mortality.

Dual-portal Endoscopic Gastrocnemius Recession for the Treatment of Severe Posttraumatic Equinus Deformity: A Case Series and a Review of Technical Modifications

Several authors have recently reported the benefits of endoscopic gastrocnemius recession (EGR) for the treatment of nontraumatic equinus contracture. However, little is known about its potential for correcting severe posttraumatic equinus contracture. This study aimed to evaluate the effectiveness of dual-portal EGR in patients with severe, intractable equinus following severe trauma to the leg and foot. The recent technique of EGR with supplemental modified procedures was reviewed to improve its capability for correcting deformities and to provide information to avoid complications. The subjects were 4 patients with intractable, progressive, severe posttraumatic soft-tissue equinus contractures after at least 3 months of unsuccessful conservative treatment. The exclusion criteria were spastic contracture, including osseous equinus. One patient with gastrocnemius equinus underwent EGR alone as a straightforward correction. Three patients with gastrocnemius-soleus equinus underwent EGR to correct the gastrocnemius component followed by a modified percutaneous tendo-Achilles lengthening (TAL) procedure to correct any residual deformities. All data of the preoperative period and each successive postoperative period (1, 3, and 6-12 months) were prospectively collected and included the degree of ankle dorsiflexion, American Orthopaedic Foot and Ankle Society (AOFAS) clinical rating scale score, the Visual Analogue Scale-Foot and Ankle (VAS-FA) score, and any related complications. Intraoperatively, the degree of ankle-dorsiflexion was recorded immediately following each procedure. The mean increase in intraoperative dorsiflexion was 35° ± 9.1° (range: 25°-45°) in all 4 patients and 21.7° ± 10.4° (range, 10°-30°) in the 3 patients undergoing EGR and modified TAL, respectively. There were significant differences in the improvements (p<0.05) in the preoperative period and each successive postoperative period in the increased values of ankle dorsiflexion, AOFAS scores, and VAS-FA scores. There were no significant iatrogenic complications. Intractable, severe posttraumatic equinus is not commonly encountered by orthopaedic surgeons. Despite the rarity of this condition, which is responsible for the limited number of patients in this series, our results indicates that dual-portal EGR, with or without modified TAL, is a promising treatment, with satisfactory effectiveness and lower risks of complications, for correcting this problematic deformity.

Efficacy of bipolar release in neglected congenital muscular torticollis patients

Surgical correction of the congenital muscular torticollis (CMT) is recommended for patients with unsuccessful conservative treatment. The aim of this study is to evaluate the efficacy of surgical release of congenital muscular torticollis in neglected cases. We retrospectively evaluated the data of our patients in terms of age, sex, clinical presentation, localization of the lesion, diagnostic tests, and additional abnormalities. The age at operation ranged from 6 to 23 years. Complete muscular release as determined by pre-operative and postoperative range of motion measurements was achieved in all of the patients by bipolar release. In this study, neck motion and head tilt showed marked improvement with surgical treatment in cases with CMT who were admitted to the hospital lately. Congenital muscular torticollis patients can benefit from surgical intervention above the age of 5. Bipolar release is an adequate and complication-free method.

Necrosis of the Ungual Process of Great Toe as Cause for Long-standing Disabling Pain: A Case Report

We report a case of necrosis of the ungual process of the great toe, which caused longstanding disabling pain in a 34-year-old woman. After a 3-year history of unsuccessful conservative treatment, surgical excision led to complete and persistent relief of the symptoms. Although rare, idiopathic osteonecrosis, even small in size, should be taken into consideration in patients who complain of pain of the foot and lacking conclusive etiologic evidence.

Posterior Spinal Fusion for Scoliosis in Ehlers-Danlos Syndrome, Kyphoscoliosis Type

The Ehlers-Danlos syndromes comprise a clinically and genetically heterogeneous group of heritable connective tissue disorders characterized by articular hypermobility, skin extensibility, and tissue fragility. Surgical treatment of scoliosis associated with Ehlers-Danlos syndrome poses a challenge to spine surgeons because of the high risk of major complications. There is a paucity of evidence in the literature on surgical treatment for scoliosis in the Ehlers-Danlos syndrome patient.This article describes 3 adolescent patients diagnosed with Ehlers-Danlos syndrome, kyphoscoliosis type, which was treated by posterior spinal fusion only. After unsuccessful conservative treatment for at least 1 year, the patients underwent posterior spinal surgery for the correction of spinal deformity. A satisfactory correction in the spinal curve was achieved, with no obvious loss of correction during follow-up. No intra- or postoperative major complications were observed.Our experience supports that a satisfactory correction of scoliosis can be achieved by posterior spinal fusion only in patients with Ehlers-Danlos syndrome, kyphoscoliosis type.

Management of Patients with Ulcerative Colitis after Proctocolectomy:Pouchitis is a Real Danger

Pouchitis develops in about 50% of the patients with ulcerative colitis (UC) undergoing colectomy. Aim: The aim of this study was to evaluate the frequency of pouchitis, to determine risk factors and to assess the efficacy of infliximab in refractory pouchitis. Patients and Methods: 76% of the 46 UC patients requiring colectomy underwent ileal pouch-anal anastomosis (IPAA) procedure. Demographic, clinical and therapeutic parameters were compared between patients who did and did not develop pouchitis and between those with pouchitis responding or being refractory to the conservative therapy. Results: 40% of the patients developed pouchitis. Six patients received infliximab therapy. Extraintestinal manifestation and non smoking was characteristic for refractory pouchitis. Discussion: Pouchitis developed in 40% of our patients undergoing IPAA. The development of pouchitis seems to be predisposed by frequent preoperative hospitalization. The earlier onset of pouchitis seems to be a prognostic factor for the unsuccessful conservative treatment and the need for biological therapy.

Endoscopic transaxillary approach for congenital muscular torticollis

Background Surgical correction of the congenital muscular torticollis (CMT) is recommended for patients with unsuccessful conservative treatment. Open operative techniques all leave noticeable scars. We proposed a modified endoscopic 1-trocar transaxillary and neck microincision approach for the treatment of CMT. Methods Endoscopic release of the sternocleidomastoid (SCM) muscle was performed in 45 infants and children aged 6 months to 15 years. One 5-mm incision was made in the anterior axillary fold, and a subcutaneous tunnel over the clavicular and sternal heads of the SCM muscle was made. A subcutaneous space was established by CO 2 inflation at a pressure of 8 mm Hg and then endoscopically using a 5-mm endoscope. Two additional 1.5- to 2-mm supraclavicular mini-incisions were made beside the SCM muscle for the introduction of miniforceps and electrocautery, respectively. The sternal and clavicular attachments were dissected and divided by electrocautery. Clinical evaluation was performed using the Lee scoring system. Results The operation was successfully completed endoscopically in all 45 children. The mean operative time was 40 minutes. No injuries of major blood vessels or nerves were encountered. A small bleed was noted in 1 child owing to reoperation. Follow-up for 6 months to 3 years in 42 patients showed complete muscular release and satisfactory cosmetic appearance with no recurrence. The results were classified as excellent in 88.1% (37/42), good in 9.5% (4/42), fair in 2.4% (1/42), and poor in 0 using the Lee scoring system. The neck scars were not visible 1 month after the procedure. Conclusions The subcutaneous endoscopic transaxillary and micro–neck incision approach for the treatment of CMT is a safe, practical procedure that provides good functional and cosmetic outcomes without vascular or neural injury.

Blasenfunktionsstörung in Folge einer großen präsakralen Retentionsmukozele

Large pelvic masses can displace the urinary bladder and cause bladder dysfunction with various symptoms. We report the case of a 42-year-old man who described a feeling of reduced urinary stream and bladder filling and residual urine since his youth. After various unsuccessful conservative treatments, the patient was evaluated by our neuro-urologic department. The diagnostic workup revealed a large cystic mass that displaced the urinary bladder. Histopathological examination showed a retention mucocele (the patient had been surgically treated for connatal anal atresia). The lesion was surgically excised.

A comperative clinical study of mucotomy and KTP laser treatment of the inferior turbinate in allergic and non-allergic subjects

Mucotomy is one of the most frequently applied surgical techniques for the management of inferior turbinate hyperplasia. Mucotomy guarantees patent airway, however, it might lead to the emergence of sicca syndrome. In contrast, KTP (potassium titanyl phosphate) laser treatment spares the medial part of the inferior turbinate mucosa, contributing to maintenance of physiological nasal function. A retrospective comparative clinical study was performed to reveal the advantages and side-effects of both surgical methods in medium- and long-term in allergic rhinitis and non-allergic patients. Furthermore, we wished to determine the exact indications of the up-to-date laser treatment. Ninety-one of the 117 patients who underwent bilateral turbinate surgery during an 8-year period (2000-2007) responded to our questionnaire focusing on subjective postoperative changes. Patients were separated into 6 groups, based on the type of operation they underwent, the length of the follow-up and whether they suffered from allergies. The major complaint, nasal obstruction, improved in all 6 groups, which reached significance (p ? 0.05) in 4 groups. The most pronounced improvement was observed in the group of non-allergic patients with medium-term follow-up who underwent mucotomy. Nevertheless, a serious side- effect: crusting also increased significantly (p ? 0.05) in the latter group, while it was absent in allergic patients with medium-term follow-up, who underwent mucotomy. These results lead us to propose the following protocol for the treatment of inferior turbinate hyperplasia: 1) after unsuccessful conservative treatment, laser treatment is suggested for non-allergic patients; 2) following unsuccessful conservative and even repeated laser treatment in the allergic group, mucotomy or turbinoplasty should be attempted.

Surgical treatment of patellar tendinopathy in athletes. A retrospective multicentric study

The purpose of this study was to evaluate the results of surgery, in particular arthroscopic procedures in the treatment of patellar tendinopathies that are refractory to conservative treatment in athletes.A retrospective multicenter study was performed in four centers. Patients were athletes who did not respond to carefully followed conservative treatment and who underwent surgery. Sixty-four patients were included, 10 who underwent arthroscopy. Patients were questioned and followed-up for an average of 22 months (6-116 months).At the final follow-up, 87% of the patients had an improved Blazina score and 63% were again practicing their sport at the same level. None of the preoperative factors influenced the final result and one surgical technique was not more effective than another (patellar tip resection versus arthroscopic approach).The results of this study are comparable to those in the literature which show a success rate of more than 80% whatever the surgical technique. This study limits a certain number of biases because the patient group is homogenous (athletes, unsuccessful conservative treatment) with similar functional scores, and well-defined protocols for postoperative rehabilitation. However, the study of this entity is difficult because of the limited number of subjects and its different anatomopathological forms.Surgical treatment is indicated in motivated athletes if carefully followed conservative treatment is unsuccessful after more than six months, making it impossible to practice a sport (Blazina grade 3). Arthroscopic techniques seem to be as effective as open surgery with an equivalent delay for beginning sports activities.

Patellar tendinosis. “Traditional” treatment and new frontiers

Patellar tendinosis is usually seen in young athletes, particularly those who forced extension of the knee. Overuse is considered to induce the condition. For the diagnosis, clinical examination should be combined with ultrasonography or ecocolordoppler. Operative treatment seems to give good results in most cases after an unsuccessful conservative treatment.