Partial repair of massive rotator cuff tears: the evolution of a concept

Partial repair of massive rotator cuff tears has eliminated the need for tendon transfers to close large defects. Side-to-side repair is usually done as a first step, with the margins of the tear then repaired to bone. Side-to-side repair causes a "margin convenience" toward the greater tuberosity, enhancing the mechanics of the construct by decreasing the strain at the free margin of the rotator cuff tear. By combining tendon-to-tendon repair with the tendon-to-bone repair, the surgeon can create a functional rotator cuff in most patients with massive tears.

Full-thickness tears: arthroscopic repair

Arthroscopic repair of rotator cuff tears is an option for a surgeon with advanced arthroscopic skills and a thorough knowledge of open repair technique. Surgical indications and a detailed description of operative technique are presented. Arthroscopic rotator cuff repair offers theoretical advantages over open repair, but long-term studies are needed to demonstrate its effectiveness.

Magnetic resonance imaging for evaluation of failed repairs of the rotator cuff. Relationship to operative findings

We used magnetic resonance imaging to evaluate thirty shoulders in twenty-nine patients who had unacceptable pain and loss of function after at least one operative procedure for a lesion of the rotator cuff. A preoperative history was recorded and physical and radiographic examinations were performed before magnetic resonance imaging. All patients had a reoperation two to 156 months (average, thirty-two months) after the operation. The results of the magnetic resonance imaging and the findings at the most recent operation were then compared with regard to the integrity of the rotator cuff, the deltoid muscle, and the long head of the biceps tendon. The sensitivity and specificity of magnetic resonance imaging for the diagnosis of full-thickness tears, partial-thickness tears, and intact rotator cuffs were 84 and 91 per cent, 83 and 83 per cent, and 80 and 100 per cent, respectively. The positive and negative predictive values were 94 and 77 per cent, 56 and 95 per cent, and 100 and 96 per cent, respectively. Three shoulders had a clinically detached and retracted origin of the deltoid muscle that was identified correctly on magnetic resonance imaging, and this finding was confirmed operatively. A rupture of the long head of the biceps tendon was identified correctly in four of six shoulders. In one of the two remaining shoulders, the rupture was obscured on magnetic resonance imaging because of a so-called balloon artefact from a nearby metal suture anchor. Magnetic resonance imaging detected two unexpected lesions: a denudation of the articular cartilage in one shoulder and a ganglion cyst in the supraspinatus muscle in another.

Intramuscular haemangioma of the chest wall. A case report

Intramuscular haemangiomas of thoracic skeletal muscle are uncommon tumours. They are locally invasive and tend to recur if not completely and widely excised. This report illustrates the diagnosis and management of a 25-year-old man with an intramuscular haemangioma of the chest wall. A literature report on the aetiology and management of these tumours is also given.

[Art and anatomy of the smile]

In this article we approach the different types of a smile, according to its anatomic characteristics, and its relation with the pathology. At the same time we establish a parallelism between the classification of Rubin and the world of Art and Literature.

Restoring elbow flexion by pectoralis major transplantation in war-injured patients

In seven war victim patients, five with brachial plexus palsy, one with biceps brachii muscle loss and one with pure injury of the musculo-cutaneous nerve and atrophic muscle, we modified Carroll and Kleinman's original pectoralis major muscle technique and then adopted it for use in all seven patients to restore elbow flexion (Carroll and Kleinman, Journal of Hand Surgery, 4:501, 1979). The entire pectoralis major muscle with the rectus sheath was transplanted to the tendon of the biceps near the insertion. Motion and power were well restored in five patients, satisfactorily in one patient, and unknown in the other case because the patient was lost to follow-up.

[Muscular echinococcal cysts. A rare differential diagnosis of a soft tissue swelling]

We report about a 48 year old female patient with a tumor of the soft-tissue of the right upper leg. The diagnostic results showed an echinococcus cyst of the muscle adductor longus. It is reported that in 0.5-5% of the cases echinococcus cysts could be located in muscles. But mostly this is not the primary location.

Tendon transfer combined with calcaneal osteotomy for treatment of posterior tibial tendon insufficiency: a radiological investigation

We present the radiographic results after flexor digitorum longus tendon transfer combined with a medial displacement calcaneal osteotomy for the treatment of posterior tibial tendon insufficiency. Eighteen patients with posterior tibial tendon insufficiency were reviewed from 12 to 26 months after surgery. The 15 women and 3 men had a mean age of 54 years (range, 38-72 years). The talar-first metatarsal and talonavicular coverage angles were measured before and after surgery on the anteroposterior weightbearing radiographs. The mean preoperative talar-first metatarsal and talonavicular coverage angles were 21 degrees (range, 3-45 degrees) and 34 degrees (range, 0-55 degrees), respectively. The mean postoperative values for these angles were 8.5 degrees (range, 0-35 degrees) and 21 degrees (range, -30-45 degrees), respectively. The mean talar-first metatarsal angle decreased from 21 degrees to 8.5 degrees, a mean improvement of 12.5 degrees, and the mean talonavicular coverage angle decreased from 34 degrees to 21 degrees, a mean improvement of 13 degrees. On the lateral weightbearing radiographs, the talar-first metatarsal angle and the distance from the medial cuneiform to the floor were measured before and after surgery. The mean preoperative values were -22 degrees (range, -10 to -40 degrees) and 9 mm (range, 1-19 mm), respectively. The mean postoperative values were -9 degrees (range, +5 to -25 degrees) and 16 mm (range, 10-28 mm), respectively. The mean talar-first metatarsal angle decreased from -22 to -9 degrees (a mean improvement of 13 degrees), and the distance from the medial cuneiform to the floor increased from 9 to 16 mm (a mean improvement of 7 mm). We conclude that the use of a combined medial displacement osteotomy of the calcaneus with a tendon transfer for treatment of posterior tibial tendon insufficiency may offset the inherent weakness of the flexor digitorum longus transfer by reducing the antagonistic deforming force of heel valgus.

Clinical outcome and quality of life following enterocystoplasty for idiopathic detrusor instability and neurogenic bladder dysfunction

OBJECTIVE

To study the long-term outcome of patients undergoing enterocystoplasty.

PATIENTS AND METHODS

The study comprised 48 patients (17 men and 31 women; mean age 46 years) who underwent enterocystoplasty for idiopathic detrusor instability (DI, 35 patients) or neurogenic bladder dysfunction (13 patients). Symptoms were scored from 0 to 14 and the overall outcome and generic quality of life were assessed using a Visick grading system (groups A to E) and the Nottingham Health Profile (NHP). These assessments were carried out before, 3 months after operation and at the final follow-up (38 +/- 18 months, range 13-78). Urodynamic studies were performed before and after operation.

RESULTS

No patient died after operation and there was minimal early morbidity. Late complications (> 30 days) included incisional hernia (3), anastomotic perforation (1), calculus formation (1) and urethral stricture (1). Clean intermittent self-catheterization (CISC) was performed by 36 (75%) patients. Early symptomatic outcome was good in 40 (83%) patients, moderate in seven (15%) and unsatisfactory in one (2%) patient. The mean symptom scores before and 3 months after surgery were 10 (range 2-14) and 3 (range 2-14), respectively (P < 0.001). There was a significant increase in total bladder capacity (307 +/- 140 to 588 +/- 217 mL; P < 0.001) and bladder compliance (37 +/- 50 to 169 +/- 162 mL/cm H2O; P < 0.001). DI persisted in 15 (31%) patients. NHP scores revealed significant improvements in all domains. Final assessment showed a less satisfactory situation, with recurrent urinary tract infection (UTI) in 17 (37%) patients, a need for long-term antibiotic therapy in seven (15%) and a change in bowel habit in 15 (33%) (13 DI, two with neurogenic bladder dysfunction). CISC was performed by 39 (85%) patients. The long-term outcome was good or moderate in 12 patients (92%) with neurogenic bladder dysfunction and good or moderate in only 19 patients (58%) with DI.

CONCLUSION

Clam enterocystoplasty remains an effective management option in some patients with DI, but most patients with neurogenic bladder dysfunction do well. The procedure is, however, associated with long-term complications such as disturbance of bowel habit and recurrent UTIs, which impair the outcome in the long-term in patients with DI despite general improvements in irritative bladder symptoms.

Calcific myonecrosis following compartment syndrome: report of two cases, review of the literature, and recommendations for treatment

Calcific myonecrosis of lower extremity muscles has been identified as an uncommon late sequela of posttraumatic compartment syndromes or ischemic myonecrosis. Previous reports have detailed a small number of cases with similar clinical and radiographic features. Two cases of calcific myonecrosis diagnosed more than 30 years following trauma to an extremity are presented. Treatment consisted of serial debridement of all infected and necrotic tissue followed by wound closure using a rectus abdominis muscle microvascular transplant in one patient and delayed primary closure in the other. Both patients have resumed active lifestyles with no recurrence of drainage or infection. Aggressive debridement and definitive soft tissue coverage are the mainstay of effective treatment for this entity.

Presentation of endometriosis to general surgeons: a 10-year experience

The presentation and management of 24 patients with endometriosis (median age 34 (range 21-68)years) presenting to general surgeons over a period of 10 years (1985-1994) was reviewed. Patients presented with an abdominal wall swelling related to a previous Pfannenstiel incision (seven patients), umbilical swelling (four), inguinal canal swelling (two), incidentally following appendicectomy (five), terminal ileal obstruction (two), rectal bleeding (two) and urinary symptoms (two). Endometriosis was not suspected in most patients but was confirmed by surgical excision or resection with minimal morbidity. No recurrence occurred during a median follow-up of 53 (range 9-113) months. Endometriosis is a disease rarely seen by general surgeons and is often diagnosed incidentally or on histological examination. Cyclical symptoms associated with menstruation are present in 50 per cent of patients and should suggest the diagnosis in those presenting with scar-related and/or subcutaneous swellings. Simple excision or resection of the presenting lesion provides adequate treatment but, since pelvic endometriosis may be present, referral to a gynaecologist is recommended in every case.

Tibialis posterior tendon dysfunction and peroneal tendon subluxation

The authors overview tibialis posterior dysfunction (TPD) with emphasis on a criteria-oriented surgical protocol for management of the various clinical and pathologic stages of TPD. Subluxation of the peroneal tendons is also detailed with respect to diagnosis and treatment.

Extensor tendon ruptures in rheumatoid arthritis

The best treatment for extensor tendon rupture is prevention, either by medical management or surgical tenosynovectomy before tendon ruptures occur. Once a rupture has occurred, tendon transfer or free tendon grafting can provide acceptable restoration of extensor function. Communication with the rheumatologist is necessary to provide timely treatment for chronic dorsal tenosynovitis (and impending tendon rupture) or for single finger extension loss before the disease progresses to multiple finger extension loss. Consideration always must be given to associated joint involvement when planning surgical treatment.

Juvenile xanthogranuloma of the pelvic origin: a case report

A case of juvenile xanthogranuloma (JXG) originating from the pelvic cavity is reported. The patient, a 4-month-old girl, was referred to our department for the examination and treatment of her left abdominal mass. As radiological studies strongly suggested the possibility of a malignant tumor of muscular origin, tumor extirpation was performed. The tumor was buried in the left psoas muscle. Histological examination showed the tumor consisted of polygonal cells containing small vacuoles with scattered Touton giant cells, and the diagnosis of JXG was made. To our knowledge, this is the first case of a pelvic JXG.

[Endometriosis of the abdominal wall. A report of a case secondary to cesarean section]

The Authors report a case of endometriosis of the surgical scar following caesarean section. The patient, arrived at surgical observation for a doubtful foreign body granuloma, underwent a diagnostic biopsy of the lesion. Histological examination confirmed the endometriosis nature of the lesion. Before surgical removal, adjuvant therapy based on GnRH analog was performed with the aim to reduce the volume of the lesion. After removal a cycle of therapy with GnRH analog was performed in oder to exclude possible residual pathologic microscopic lesions.

Salvage of extensor tendon function with tenolysis and joint release

Extensor tendon adhesions following laceration, fracture, or crush injuries will prevent normal joint function. Tenolysis often will not address the resulting stiffness. A systematic release of the extensors, joint capsule, collateral ligaments, and occasionally the flexor tendons is needed to restore function.

Role of pharyngeal propulsion as an indicator for upper esophageal sphincter myotomy

Thirty-eight patients with swallowing disorders underwent cricopharyngeal myotomy. The causes of the disorders were muscular in 12 cases, neurologic in 12, cricopharyngeal achalasia in 7, and unknown in 7. Surgery succeeded in 21 patients, gave a partial improvement in 4, and failed in 13. The quality of residual pharyngeal propulsion on clinical, manometric, and radiologic assessment appeared to be a more important predictor of surgical outcome than upper esophageal sphincter relaxation and the major factor in establishing the indications for cricopharyngeal myotomy. Achalasias in the elderly and oculopharyngeal muscular dystrophies had the most favorable outcome.

Contact neodymium:yttrium-aluminum-garnet laser ablation of the external sphincter in spinal cord injured men with detrusor sphincter dyssynergia

OBJECTIVES

The purpose of this study was to determine the efficacy and safety of contact neodymium:yttrium-aluminum-garnet (Nd:YAG) laser external sphincterotomy as an alternative treatment of detrusor-external sphincter dyssynergia (DESD).

METHODS

Twenty-two spinal cord injured men with video-urodynamically verified DESD underwent external urinary sphincter ablation using the contact Nd:YAG laser. Three patients with bladder neck obstruction required concurrent contact laser bladder neck incision. Preoperative urodynamic parameters of voiding pressure, bladder capacity, and residual urine were compared with those obtained 1 year postoperatively.

RESULTS

Each procedure was performed with the Nd:YAG contact laser set at 40 to 50 W, with a total accumulated energy of 23,800 to 60,000 J for each patient. The mean duration of surgery was 45 +/- 21 minutes. Bladder voiding pressure decreased from 87 +/- 23 preoperatively to 47 +/- 11 cm H2O at 12 months (P < 0.01). Residual urine volume decreased significantly, from 122 +/- 77 to 33 +/- 19 mL at 12 months (P < 0.01), and bladder capacity remained unchanged at 174 +/- 84 and 230 +/- 92 mL (P = 0.57). Three patients were found to have recurrent sphincter obstruction 1 year after laser sphincterotomy. Two patients experienced complications associated with condom catheter urinary drainage and returned to the use of an indwelling catheter. One patient experienced diminished reflex erectile function postoperatively. No patient required blood transfusion. No deleterious effects on renal function or symptoms of autonomic dysreflexia were noted.

CONCLUSIONS

External urinary sphincter ablation using the contact Nd:YAG laser compares favorably with electrosurgical techniques.

Essentials of surgical treatment for intramasseteric hemangioma

Although rare, surgical treatment may become necessary for patients with intramasseteric hemangiomas. Possible bleeding, neural injury or postoperative dysfunction are factors limiting surgical approaches. We present the following surgical highpoints for tumors involving the masseter muscles. These include careful preoperative planning with computed tomography and magnetic resonance imaging, as well as a surgical approach that provides adequate exposure for optimal tumor resection and identification of vital anatomic structures. In particular, care must be taken to preserve branches of the facial nerve. In certain cases, preoperative embolization or ligation of vessels feeding tumor helps to minimize blood loss. Whenever possible, complete tumor should be adequately resected with a surrounding margin of normal muscle. Postoperative lymphedema can be minimized by preserving the mandibular periosteum and oral or parenteral use of medication with anti-inflammatory agents. At the University of Tokyo, continuous suction is preferred with a fenestrated drain or pressure dressing with a Penrose drain should be applied to prevent hematoma. Postoperative dysfunction, such as trismus, is prevented by supportive measures.

Recurrent abdominal pain from abdominal adhesions in an endurance triathlete

Abdominal adhesions have been described as developing postoperatively and as developing "spontaneously" in patients over 60 yr old. To our knowledge, abdominal adhesions have not been described as an etiology of recurrent abdominal pain in young endurance athletes, without prior history of abdominal surgery. We present a 28-yr-old endurance triathlete with recurrent abdominal pain in which multiple diagnostic imaging studies were unable to diagnose the etiology. Diagnostic laparoscopy revealed adhesions between the ascending colon and the anterior abdominal wall. Laparoscopic adhesiolysis was performed successfully and the athlete resumed his training several weeks post-laparoscopy without symptoms. One year later, the athlete remains pain free.

Bronchogenic cyst of the right hemidiaphragm

A rare case of bronchogenic cyst of the right hemidiaphragm is reported. The literature is reviewed briefly. Clinical presentation, diagnosis, and treatment of this entity are discussed further.