Abstract Background A diaphragmatic hernia is defined as a defect in part of the diaphragm through which abdominal contents can protrude into the thorax. It may be congenital or acquired. In this case report, we aim to demonstrate a congenital diaphragmatic hernia in an adult marfanoid patient which required emergency treatment Case presentation A 43 year old woman was admitted with classical appendicitis requiring surgery. She incidentally had Marfan's clinical features with a positive family history for the syndrome. At operation she had grossly abnormal abdominal anatomy. Radiological investigations demonstrated a large right congenital diaphragmatic hernia with an intrathoracic hernial sac containing a perforated gangrenous appendix. The hernial sac was opened surgically and the appendix excised. The patient made a full recovery. Conclusion Diaphragmatic hernias are usually congenital in nature often requiring early corrective surgery for future survival. We have demonstrated the presence of an unusually large diaphragmatic defect, almost a hemidiaphragmatic defect, of unknown direct etiology, but of some possible association with Marfan's syndrome in an adult patient presenting with an acute perforated gangrenous appendix requiring emergency life-saving surgery.
Study Design A prospective cohort study was carried out looking at the functional outcome and post procedure translational segmental instability after multi-level lumbar decompression using a hinge osteotomy technique. Objective The hinge osteotomy technique involves unilateral subperiosteal muscle dissection with osteotomy of the base of the spinous processes, thereby preserving the integrity of the posterior elements. The objective of this study was to show the results of this technique clinically and radiologically. Methods Between February 2005 and February 2007, 120 patients (51 male and 69 female) diagnosed with degenerative and/or congenital lumbar stenosis with a mean age of 64 years, underwent central and bilateral canal decompression using the hinge osteotomy technique. A mean of 2 segments (range 2 to 4) was decompressed. All patients were followed for a minimum of 3 years. Five outcome measures were used—visual analog scale for leg pain, Likert scale for functional status, symptom specific well-being score, general well-being score, and oswestry disability index score. The outcomes measures were recorded preoperatively, and at 6 months and 3 years postoperatively. Successful surgical outcome was defined as an improvement in at least 4 of 5 outcome measures. Results One hundred and eight patients (90%) had a successful surgical outcome. There was a statistically significant improvement in all outcome criteria (P<0.001), when measured at the 6-month postoperative mark as compared with preoperatively, with further marginal significant improvement (P<0.05) at 3 years post surgery. There was no evidence of progressive lumbar segmental instability at 3 years postoperatively. Conclusions Decompression of multi-level lumbar spine stenosis using the unilateral approach with the hinge osteotomy technique is a safe approach for multi-level stenosis, with good outcome and no evidence of significant segmental translational spinal instability.
Four infants with spina bifida, who had not undergone surgical closure of a lumbar myelomeningocele, were assessed and investigated for hypothyroidism. From birth, all were treated once daily with an iodine-containing ointment (Betadine) as a local antiseptic applied to the spina defect. All infants showed excess urinary iodine concentration. Two infants, without clinical evidence of hypothyroidism or goitre, showed low serum free thyroxine and high thyroid stimulating hormone concentrations at a mean age of four weeks and were started on thyroxine replacement treatment. Betadine ointment and thyroxine were stopped simultaneously at a mean age of nine months, following which all infants remained euthyroid. Thyroid function tests should be monitored routinely if iodine is applied as a topical antiseptic to infants.
Purpose The movements at each thumb joint are flexion and extension (called radial abduction in the CMCJ) and additional movements of anteposition, retroposition and opposition at the CMCJ, due to the saddle shape of the articulation. Our study was designed to provide a means of thumb movement measurement and provide a range for each. Methods A prospective cohort study was performed looking at 100 consecutive individuals without thumb pathology to determine thumb joint range of movements and evaluate the reliability of such measurements. Results The mean age was 26 (range of 18–37) with 62 female individuals. The mean range of movement of the IPJ was flexion of 88 ° (80–90 °) and extension of 12° (0–45°). That of the MCPJ was flexion of 60° (43–70°) and extension of 8.1° (0–15°). That of the CMCJ was anteposition of 61.2° (50–71°), retroposition of 31.1 mm (25–38 mm), radial abduction of 62.9° (53–71°), opposition Kapandji grade 9 (grades 9–10) and adduction of 10.2 ± 4°(5–20°). CMC adduction was difficult to measure with a poor intra- and inter-observer correlation (inter-reliability correlation coefficient of 0.02 and intra-reliability coefficient of 0.04). For the remaining measurements, the mean inter-reliability correlation coefficient was 0.82 ( p<0.01) while the mean intra-reliability correlation coefficient was 0.93 ( p<0.01). There was negative correlation identified between IPJ extension and MCPJ extension (−0.50) and between CMCJ radial abduction and MCPJ extension (−0.60). Conclusions Having established the normal ranges of movements for the thumb joints and shown that our measurement methods are reliable and reproducible, we have identified that a reduction in certain thumb joint movements appears to be compensated for by an increased movement range in the other joints.
Introduction: Blount’s disease is an idiopathic, non-physiological form of genu varum. Deformity usually occurs in the proximal tibia with progressive varus, but also with valgus in the distal femur. Treatment in the infantile stage includes observation or bracing, and surgery for acute marked proximal tibial varus. Recurrence is common with conventional surgery after the age of four. Method: A new surgical technique is proposed as definitive treatment of this condition which includes an arthrogram to visualise the knee joint, acute elevation of the varus aligned medial tibia plateau with second plane correction of posterior slope deformity, lengthening and derotation of the tibia by application of a Taylor spatial frame, application of an 8 plate on the distal femur to correct valgus deformity and finally proximal tibial and fibular epiphysiodesis to prevent recurrence. Results: Five patients with Blount’s disease had this definitive corrective procedure performed at a mean age of 9.8. Radiographs and CT scans taken pre-operatively demonstrated marked medial plateau varus deformity and increased posterior slope. Surgery was performed by the senior author. Follow-up X-rays demonstrated satisfactory alignment, length and rotation of the lower limb. Conclusions: This new surgical technique allows correction of all deformities of Blount’s disease at one operation and maintains alignment, length and rotation clinically and radiologically at follow-up.
A 24 year old man presented to the emergency department with clinical signs of cardiac tamponade requiring emergency surgery. The cause was a sternal wire from a pectus excavatum repair two years previously that had fractured and migrated through the pericardium causing an epicardial injury and a haemopericardium.
and preference is dependant onpersonal experience and/or local hospital guide-lines. However, complications arising from eitherthe original injury or its treatment are less wellreported.Joint stiffness is almost universal postinjury.Damage to the rotator cuff muscles occurs inapproximately15—32%ofcases,
We measured and compared critical parameters on antero-posterior radiographs from 28 patients who had undergone hybrid hip replacement (CPS/EPF), with 28 patients who had undergone cemented hip resurfacing (Cormet). All operations were performed by a single surgeon or under his supervision. We measured the femoral offset, acetabular offset, cup height and leg length on pre and post operative radiographs. The mean difference in femoral offset post-operatively was 3.52 mm (95% CI: -1.10 to 8.14 mm) in the hybrid group and -1.30mm (95%CI: -2.88 to 0.29 mm) in the resurfacing group. Using the independent sample t test (two-tailed), the difference between these means was significant, test statistic t 2.025, p<0.05. This suggests that resurfacing restored the femoral offset more accurately than hybrid hip replacement. The mean difference in leg length post-operatively was 11.91 mm (95% CI: 8.21 to 15.62 mm) in the hybrid group and 4.87 mm (95% CI: 3.32 to 6.42 mm) in the resurfacing group. Using the independent sample t test (two-tailed), the difference between the means was significant, test statistic t 3.597, p<0.001. This suggests that resurfacing produced less change in leg length post-operatively than hybrid hip replacement. We found no statistically significant difference in ideal pre and post operative centre of rotation in the two groups. Proximal femoral anatomy was restored during hip resurfacing by resecting bone of a thickness determined by corresponding preoperative templating and implant thickness rather than relying on placement of the cutting ring at the head-neck junction. No femoral neck fractures occurred in the resurfacing group.
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