An unusual cause of thigh pain after total hip arthroplasty

The aim of total hip arthroplasty surgery is to relieve pain. There are many postulated causes of thigh pain following total hip arthroplasty, some of which are not easily corrected. Muscle hernia as a result of hip surgery is a cause of thigh pain that is disabling, relatively easy to diagnose, and may be preventable.

Resection of hepatocellular carcinoma with diaphragmatic invasion

Fourteen consecutive patients with hepatocellular carcinoma (HCC) and diaphragmatic invasion found during operation and confirmed histopathologically were studied. They were treated by resection of the liver tumour en bloc with part of the diaphragm. Eight of the 14 patients had a diaphragmatic hump on chest radiography. Preoperative ultrasonography, computed tomography and hepatic angiography were unable to diagnose diaphragmatic invasion in these patients. A control group of 14 closely matched patients were selected from 98 undergoing curative resection for HCC during the period of the study. No evidence of a diaphragmatic hump was found in the control patients (P < 0.001). There was no significant difference in survival, operative morbidity or mortality rates between the two groups. In patients with HCC situated in the dome of the liver, the presence of a diaphragmatic hump on chest radiography strongly suggests invasion of the diaphragm. There was no difference in outcome in patients with or without diaphragmatic invasion; the tumour should be resected if the patient is fit for operation.

Hernia after dorsal incision into lumbar region: a case report and review of pathogenesis and treatment

Because of few associated complications and rapid recovery, dorsal incision into lumbar region has experienced a resurgence in popularity for the treatment of a variety of renal and upper ureteral disorders. We report a case of pyelolithotomy via the dorsal approach in which a symptomatic lumbar incisional hernia subsequently developed, which to our knowledge is a previously unreported complication of this approach. Reconstruction of this lumbar hernia defect necessitated the application of synthetic mesh graft sandwiched by mobilized muscle flaps. The entire repair was then sutured inferiorly to the iliac crest using drill holes. Outcome was durable and successful. The pathogenesis and treatment of this complication are discussed.

Tenotomy of the tibial insertion of the semitendinosus muscle of two horses with fibrotic myopathy

Two horses with fibrotic myopathy of the semitendinosus muscle are described. The report deals with the aetiology, clinical signs and diagnosis of the condition, and discusses the different surgical techniques described in the literature. Tenotomies were performed on both horses. Excellent results were obtained in the horse in which only the semitendinosus muscle was affected, but in the horse in which the semimembranosus and gracilis muscles were also involved the results were less satisfactory.

[Hydatid cyst of the psoas]

Recurrent hydatic cyst of the psoas is an exceptional disease in France but should not be missed in patients coming from endemic areas. A case report and a review of the literature on the aetiopathology, diagnosis and therapy are presented. Abdominal pelvic CT scan should give the diagnosis. Surgical treatment is indicated, with complete exeresis to avoid early relapse.

Free vascularized medial plantar flap with functioning abductor hallucis transfer for reconstruction of thenar defects

We devised a medial plantar flap with a functioning abductor hallucis for simultaneous reconstruction of thenar skin and muscle defects. The anatomy of the flap was studied in five cadaver dissections before surgical attempts were made in patients, who in this series included three men and one woman (average age 38 years, range 26 to 50 years). All patients were followed a minimum of 3 years (average 3 years and 9 months). In all cases, voluntary abduction of the thumb by the transferred abductor hallucis was achieved and confirmed by electromyography. The functioning medial plantar flap provides not only stable skin to the thenar area with sufficient thenar bulk but also satisfactory abduction of the thumb.

[Bronchogenic cyst of the diaphragm: a case report]

A 30-year-old man was treated surgically for bronchogenic cyst originating from the diaphragm. An abnormal shadow was found on a routine chest roentgenogram. The tumor was located in the left vertebro-phrenic angle. CT scan showed a CT number of 34.2, which MRI examination revealed with low intensity on the T1 weighted image and high intensity on the T2 weighted image. A multilocular cystic tumor filled with viscid fluid, about 3 cm in size, was resected. This was diagnosed as a bronchogenic cyst, as microscopic examination showed bronchial epithelium, one layer of smooth muscle, bronchial glands, and cartilage. This is the 10th case of diaphragm-related bronchogenic cysts reported in Japan. Of these 10, 7 were located at the vertebro-phrenic angle.

[A case of muscle metastasis of renal cell carcinoma treated by local resection and tensor fascia lata myocutaneous flaps]

A 44-year-old male with a little finger tip-sized tumor palpable on the left epigastric wall and a left renal tumor detected on computerized tomography (CT) was referred to this hospital in June 1991. Nephrectomy was performed in July 1991 under the diagnosis of a left renal tumor. Histologically, the tumor was a renal cell carcinoma, grade 2, clear and granular cell type. The tumor in the left abdominal wall was not extracted. As a tumor also developed in the scapular tunica muscularis, tumors in the left musculus rectus abdominis and the scapular tunica muscularis were extracted to the extent possible in July of 1992. Histologically, these tumors were metastatic clear cell carcinomas. The tumor in the left musculus rectus abdominis recurred and another was palpable in the left lateral femur. In August of 1993, the tumors in the left musculus vastus lateralis and the left musculus abdominis were extracted together with the tunica muscularis, and the defective region on the abdominal wall was closed with a left musculus tensor fascia lata flap. No evidence of recurrence has been observed to date.

Bilateral multiple muscle hernias of the leg repaired with Marlex mesh

We report a case of multiple muscle hernias of the legs, resulting from regular, intense, physical exertion. The multiple fascial defects were closed with Marlex mesh. On review after 5 years, there were no recurrences of the hernias.

Myxoid liposarcoma. Experience with chemotherapy

BACKGROUND

Myxoid liposarcoma (ML) is the most common type of liposarcoma. It has been classified as an intermediate grade tumor with a definite metastatic potential but a relatively indolent natural history. Little is known about its sensitivity to chemotherapy.

METHOD

The authors reviewed their experience with chemotherapy in ML from 1986 to 1992. The patient population was identified through a search of the database maintained by the Department of Melanoma-Sarcoma Medical Oncology of the M.D. Anderson Cancer Center.

RESULTS

Forty-four patients each with a histologically confirmed diagnosis of ML were identified. Twenty-one were treated with chemotherapy. The median age was 45 years (31-69 years); there were 14 men and 7 women. The ML in 19 patients was in the lower extremity, one in the head and neck, and one pelvic. The median size of the primary tumor was 15 cm (range, 7-48 cm) in maximum dimension. Of the 18 patients who received doxorubicin- and dacarbazine-based chemotherapy as a frontline regimen [median of 3 (2-9) cycles] and were evaluable for response, 8 (1 completed response, 7 partial responses) achieved an objective response (44%, 95% confidence interval 21-67%). Two of the remaining three patients who were also treated with a similar regimen were not evaluable for response (one received chemotherapy postoperatively, and the other received concomitant radiation and doxorubicin), and the third patient received ifosfamide as frontline chemotherapy because of a significant cardiac history. Seven patients received chemotherapy in the neoadjuvant setting, 13 for recurrent or metastatic disease, and 1 postoperatively after complete tumor resection. At the last follow-up, 10 patients were alive with no evidence of disease, 3 were alive with disease, and 8 had died. The median follow-up was 51 months (range, 6-199 months) from diagnosis.

CONCLUSION

The authors conclude that doxorubicin- and dacarbazine-based chemotherapy is effective in the treatment of ML.

[Results of surgical treatment of diastasis of the rectus abdominis muscles]

The work gives a comparative analysis of the treatment of 249 patients with diastasis of the rectus abdominis muscles according to the degree of restoration of the working capacity, the existence of gastrointestinal discomfort, recurrence of the disease, and the dynamics of changes of the morphological and functional values of these muscles. The clinical and functional-morphological results were best after plastics of the anterior abdominal wall by the method suggested by the authors. With the use of this method the results were good in 40 (71.4%) and satisfactory in 16 (28.6%) of patients. Recurrences were not encountered.

Streptococcal myonecrosis: survival by aggressive surgical management

Eight consecutive cases of skeletal muscle infections due to streptococcal species are presented. The clinical presentation of the condition and recommendations for treatment by early recognition and aggressive, early surgical intervention together with high doses of penicillin are discussed. Advancing age was associated with poor survival rates.

[The therapeutic posture in desmoid tumor]

BACKGROUND

The desmoid tumor is a histologically benign neoplasm originating in muscular-aponeurotic structures and possesses a high tendency of local recurrence. The aggressive nature of the tumor obliges radical surgery to be performed principally in extra-abdominal tumors.

METHODS

Twelve patients were treated from 1983 to 1993. The treatments performed prior to and after histologic diagnosis, the time of evolution when radical treatment was carried out upon diagnosis and the evolution after treatment were evaluated.

RESULTS

Of the patients with desmoid tumor 8 were males with a mean age of 29.9 +/- 12.5 years. In eleven cases the presentation was as a tumor and was of pain in only one case. All the patients were surgically treated with a total of 27 interventions being carried out. Three patients also received pharmacologic treatment with tamoxifen, in 2 cases associated to sulindac. In two radiotherapy was used but not as a first line treatment. Following a mean follow up of 38 +/- 17 months no mortality has been registered but 5 patients are not disease free.

CONCLUSIONS

The therapeutic attitude to the desmoid tumor should be radical surgery in both the primary tumor and the recurrences with medical treatment being performed in specific situations.

[Reconstruction possibilities following resection of malignant musculoskeletal tumors]

Great advances have been achieved in the treatment of musculoskeletal tumors, and as a result limb-conserving resection is now possible in most cases. These advances are based on adjuvant therapy, development of histological criteria, new surgical techniques, and improved imaging methods. The use of computed tomography and magnetic resonance imaging has allowed more accurate preoperative staging. At the same time, an improvement in prognosis has also been achieved. After resection of the tumor, the following methods of reconstruction are available: reconstruction with no implant, endoprosthetic replacement, autogenous grafting, and allograft replacement. Postoperative monitoring is performed with plain-film radiography.

[Use of Diprivan in muscular diseases and malignant hyperthermia]

An unknown myopathy can be revealed by the administration of an anaesthetic agent. The symptoms are those of malignant hyperpyrexia (MH). The MH phenotype can be detected by means of contracture tests in vitro. All anaesthetics, excepting the triggering agents, can be given. The safety of propofol as an induction and maintenance agent in this category of patients has been demonstrated. When the presence of a myopathy is known before an anaesthetic, the administration of succinylcholine associated or not with a halogenated inhalational agent carries a risk of severe complication. Among the anaesthetic agents having little effect on the skeletal muscle, propofol seems interesting, also because of its pharmacokinetic properties. Myopathy is difficult to diagnose, either because the patient undergoes surgery before being symptomatic or because he is only a carrier of MH. In case of an abnormal reaction following the administration of recognized triggering agents or the occurrence of MH, the procedure should be discontinued. In case of absolute necessity, the procedure may be continued but with non-triggering agents only.

Swallowing disorders in muscular diseases: functional assessment and indications of cricopharyngeal myotomy

Thirty-four patients with an identified muscular disease were referred to our department for assessment and treatment of swallowing difficulties. Their ages ranged from 16 to 91 years (mean 59). The diagnoses were oculopharyngeal dystrophy in 17 patients, Steinert myotonic dystrophy in 6, mitochondrial myopathies in 4, polymyositis in 3, and other types in 4 patients. The main consequences of the dysphagia were weight loss (12 patients), pulmonary infections (15 patients), modified food consistency (18 patients) and non-oral feeding (3 patients). Several techniques were used to assess the different stages of deglutition: physical examination during swallowing, videofluoroscopy, pharyngoesophageal manometry, videofibroscopy of the pharynx during swallowing. Major pathological features found in the pharynx were decreased pharynx peristaltis and impaired UES relaxation. Cricopharyngeal myotomy was performed in 11 myopathic patients (median follow-up 24.9 months), while it was unnecessary, refused or contraindicated in the other patients. The procedure was successful in 8 patients whose dysphagia was dramatically improved, and failed in 3 patients. Pharyngeal perstaltis was severely impaired only in the 3 failures and was partly preserved in the improved cases. We conclude that pharyngeal function is the major prognostic factor. Cricopharyngeal myotomy is an effective treatment in those cases where cricopharyngeal dysfunction is a predominant problem or where pharyngeal peristaltis is partly impaired, since the procedure removes one obstacle. It is contraindicated when pharynx propulsion is severely impaired.

[Endometriosis of the abdominal wall: a clinical case report and a review of the literature]

The authors report one case of abdominal wall endometriosis secondary to cesarean section. They emphasize the rarity of this localization and discuss about the incidence of extrapelvic endometriosis stressing the importance of this pathology in the differential diagnosis with other disease.