[Sternoclavicular dislocations: clinical and therapeutic study. A report of 9 cases]

Sterno-clavicular dislocations represent an uncommon pathology in shoulder trauma. The authors describe the anatomical and clinical forms observed between January 1999 and December 2002, and evaluate the treatment process. The retrospective study addressed 9 patients (men only) with an average age of 26.6. Based on the duration of the consulting period, one could distinguish old forms from more recent ones. Diagnosis would help to see anterior forms from posterior forms. Evaluation criteria were: pain, mobility of the shoulder, visibility of the deformation of the sterno-clavicular joint. Six types of anterior dislocations were listed, including 4 recent and 2 old ones. There were 3 recent posterior forms. The anterior recent forms, which were treated in orthopedics, showed a positive evolution. As there was no functional disability, it was wiser to refrain from any treatment of the anterior old forms. The posterior forms, two of them were operated (osteosynthesis) revealed no functional deficit after treatment. However, one of the patients had a broken implant. Scanner facilitated the diagnosis of sterno-clavicular dislocations. The anterior forms, which are more frequent and benign, are different from the posterior forms, which are emergency cases due to the proximity of the aero-digestive and cardiovascular elements. Their surgical stabilization requires techniques related to ligamentoplasty rather than using osteo-synthesis equipment which may move away or break off.

[Trichobezoard revealed by intestinal perforation. A case report]

This paper presents a case of gastric and ileal trichobézoard on a 12 years-old girl. It was revealeds by ileal perforation which was confirmed by abdominal X-ray. Trichobézoard diagnosis was not performed before surgery despite two contradictory/abdominal ultrasound scans. The trichobézoard was removed surgicaly by ileotomy and gastrotomy. The patient had an satisfactory post-operative convalescence after a follow-up of six months.

[Spiral CT in aortic dissection]

Patients with suspected dissection of the thoracic aorta require immediate diagnostic evaluation so that urgent therapeutic interventions can begin. Two women with suspected aortic dissection and one man with abdominal aortic aneurysm underwent color-flow Doppler echocardiography and CT angiography with multiplanar reconstructions. Spiral CT showed ascending aortic dissection (type A Stanford) in two cases and descending aortic dissection (type B Stanford) in one case. It also access the visualization of the intimal flap, the extent of dissection, the size of the aorta, and the presence of pericardial fluid. CT angiography is an accurate diagnostic procedure for patients with suspected aortic dissection and possesses several advantages over other modalities such as transthoracic echocardiography, transesophageal echocardiography and aortography.

[Topographic anatomy of the tibial nerve in the medial malleolus: application to the effect of nerve block anesthesia]

To better understand the anatomical variations and pathogeny of tarsal tunnel syndrome, the tibial nerve were dissected in 20 ankles of fresh black African cadavers. The tibial nerve located to 1.75 cm on average from the posterior side of the malleolus and to 2 cm from medial side of the calcaneus tendon. The nerve always ended according to dichotomic method. 90% cases of bifurcation were noted under the flexor retinaculum at 1 cm from the malléolo_calcaneus line; in 10% of dissections, we found proximal bifurcation at 5 cm from this line. The medal calcaneus branch which is a collateral branch of tibial nerve was constant, unique in 80% of cases and double in 20% of cases. The anatomical constatations allow a more precise anesthesia of tibial nerve block. We use constant anatomical marks formed by calcaneus tendon and internal malleolus tip. Olso we more understand the possibility of lesion of tibial nerve at the ankle during the synovites, or ossifications of flexor rétinaculum.

[Vascular dysplasia in vascular surgery in an African area: 28 cases at the Dakar teaching hospital]

This retrospective study was conducted to analyze the anatomic and clinical data concerning vascular dysplasia in vascular surgery patients seen in an African hospital and to assess its role in treatment. Twenty-eight patients (14 women and 14 men) were treated for vascular dysplasia between 1994 and 1998. There were 8 cases of hemangioma and 20 cases of vascular malformation. Average age of patients with hemangioma was 3.23 years, with a sex ratio of 0.33. There were 4 cases of mixed hemangioma, 3 of cutaneous hemangioma, and 1 of subcutaneous hemangioma. Cervicocephalic (n=4) and limb (n=3) localizations were the most frequent. Duplex Doppler did not reveal any signs of muscle disease. Four patients underwent surgery, for an early indication in 3 and a late indication in 1. Resection suture was performed in 3 cases and resection graft in one. Mean follow-up was 85.90 days. There was one case of early suppuration. There were no cases of recurrence or late complications and the operative wounds healed well. Vascular malformations concerned 20 patients (sex ratio 1.5, average age 15.55 years) with 16 cases of venous malformation including 4 patients with Klippel Trenaunay syndrome, three with arteriovenous malformation and one with capillary angioma. CT and arteriography were obtained in all cases. Limb localizations predominated (14 patients). In-depth extension was found in 6 cases of venous malformation. Sixteen patients underwent surgery for functional indications in 7. Resection suture was performed in 11 cases. Mean follow-up was 85.90 days. There were 4 early and 2 late postoperative complications. There has been no recurrence. Anatomic and clinical polymorphism of vascular dysplasia requires multidisciplinary collaboration in which vascular surgery plays an important role in complex or complicated forms of the disease in patients attending facilities with limited resources.

[Purulent pleurisy at the surgical emergency service: retrospective study of 34 cases at Dakar Teaching Hospital]

The empyema thoracis remain a current pathology in under developed countries. The aim of this study was to evaluate the incidence of empyema thoracis in the Surgical Emergency Unit, to analyze their causes, therapeutic procedures and their results. Between 1997 and 1998, 54 patients were received in urgency for empyema thoracis; 34 of them had a complete and exploitable file. Mean age was 20 years (3 weeks and 83 years) with 64.70% of children (0 to 15 years) and the sex ratio 3.25. Fever (85.70%) and cough (73.52%) were the most frequent symptoms. Twenty nine patients (85.3%) had pleural empyema and 5 a hydropneumothoracic image. Empyemas were related to pneumonia in 11 cases, associated to tuberculosis in 5 cases and were primitive in 18 cases. Bacteriological exam of the pus performed in only 18 patients had revealed a pneumococcus in 4 cases (22.23%) and was negative in 9 cases (50%). Closed chest drainage associated with antibiotics, pleural washing and respiratory kinesitherapy was done in all the cases. The average duration of hospitalisation was 24.56 days (1 to 55 days). Five deaths (14.70%) occurred. Two cases of recurrence were noted requiring a second drainage. Three cases of pachypleuritis had required a thoracotomy for pleural decortication in average time of 6 months. The duration of follow-up was 1 year. For the other 24 patients (70.58%) the evolution was good. Urgent closed chest drainage of empyema thoracis combined with antibiotics, pleural washing and respiratory kinesitherapy allows a good evolution and reduces the risk of pachypleuritis.

[Anatomical study of the interosseous membrane of the forearm]

The authors have dissected 20 forearms of human cadavers to study anatomy and some functions of the IOM. The fibers bundles of the IOM were arranged in one plane descending obliquely and distally from the radius to insertion to the ulna. Central band of the IOM was easily found and was thick. It's a resistant ligament for longitudinal stability of the radius. Now, it's important to know anatomical alignment of the IOM because ultrasound imaging can be used for diagnosis of its rupture or elbow injuries and in a early future, surgical methods of repair or reconstruction of IOM will be developed.

[Penetrating wounds of the abdomen. Evaluation of conservative treatment in 40 cases]

Stabbed penetrating abdominal wounds are becoming more and more frequent in our emergency surgical unit due to increase of aggressions. The goal of our study is to evaluate the conservative treatment of these wounds. This concerns a study carried out between January 1997 and October 1998. Exploratory laparotomy was proposed at each time when one or more of the following criteria was noticed: choc, evisceration of intestines, digestive hemorrhagy or hematuria, outlet of digestive fluids, sign of peritoneal irritation, wounds by gunshots or wounds at the frontal regions. In the other cases, the conservative treatment with wound dressing following an antibiotic and serovaccination therapy of tetanus was the therapeutic option. Our study was carried out on 40 patients of whom were 37 males and 3 females of average age 24.9 years with extremities of 7 to 52 years. It arrived to the following results: 32 of the patients (80%) were victim of aggression and 29 cases were stabbed wounds. The wounds were in the central region (umbilicus 29.5%) and superior to the abdomen and were associated with outlet of the omentum (50%) outlet of the intestines (12.5%), peritoneal irritation (27.5%), digestive hemorrhagy (10%), hematuria (2.5%) outlet of faeces (2.5%). 17 patients (42.5%) underwent exploratory laparotomy on the basis of criteria afor mentioned and the 23 others (57.5%) underwent medical surveillance and 3 of them developed peritonitis and underwent surgery. The rate of negative laparotomy was 5% and retarded interventions was 13%. The morbidity was also 13% and mortality 2.5%. The average period of internship in hospital was 11,4 days with extremities of 1 to 101 days. The conservative treatment of penetrating stabbed abdominal wounds out of the criteria mentioned were quite satisfactory.

[Treatment of chronic anal fissures: report of 31 cases]

A prospective study evaluating the surgical technique used in the treatment of chronic anal fissures, which is fissurectomy, partial sphincterotomy and anoplasty, was carried out in University Teaching Hospital Dakar. Thirty one patients with chronic anal fissures (20 males and 11 females) with average age 38 years and mean consultation period of 3 years, were treated with this technique. The delay of healing was between 4 to 12 weeks for a mean period of six weeks with 27 cases healed before 2 months and 4 cases after. One patient developed transitory faecal incontinence, recurrences, anal stenosis, haemorrhoidal relapses. noticed after simple lateral sphincterotomy were not found in our study as written in the medical literature. The surgical treatment of chronic anal fissures by fissurectomy, partial sphincterotomy and anoplasty is an important corner stone in this pathology. However lately healing may be a source of discomfort for the patient.

[Anatomical and surgical study of the medial calcaneus branch of the tibial nerve]

To better understand the anatomical variations of the medial calcaneus branch, the tibia nerve were dissected in 20 ankles of fresh black African cadavres. The medial calcaneus branch which is a collateral branch of tibial nerve was constant. It was unique in 80% of cases and was detaching itself from the trunck of the tibial nerve ot the entrance of the calcaneal sulcus. It was in the form of two small nerves with point of departure from the common tibial nerve trunk. These anatomic constatations confronted with those published in literature permits us to understand the etiopathogenic aspects of certain neuropathies of the ankles. To add this they impose a certain order if precaution in the operational surgnical route of the posterior section of the ankle.

[Anatomical and surgical study of the medial calcaneus branch of tibial nerve]

To better understand the anatomical variations of the medial calcaneus branch, the tibia nerve were dissected in 20 ankles of fresh black African cadavers. The medial calcaneus branch which is a collateral branch of tibial nerve was constant. It was unique in 80% of cases and was detaching itself from the trunk of the tibial nerve at the entrance of the calcaneal sulcus. It was in the form of two small nerves with point of departure from the commun tibial nerve trunk. These anatomic constatations confronted with those published in literature permits us to understand the etiopathogenic aspects of certain neuropathies of the ankle. To add this they impose a certain order if precautions in the operational surgical route of the posterior section of the ankle.

[Descriptive study of complicated hypertension. Experience of the Principal Hospital of Dakar]

We included in a six month-period 85 patients concerned about complicated high blood pressure. Hypertension represented 33% of 276 admissions for cardiovascular cases. Among the 55 men and 30 women concerned, average age was 57 years-old. Male to female ratio was 1,8. Cardiovascular risk factors were determined as follows: obesity: 18 cases (21%), cigarette smoking: 27 cases (32%), diabetes mellitus: 11 cases (13%), hypercholesterolaemia: 44 cases (52 %). Kidney was damaged in 36 patients (42%). Seventy patients (82%) with systolic dysfunction in 21 cases (30%) presented a left ventricular hypertrophy. Malignant hypertension was noted in 13 cases (15%). Eighteen patients (21%) had stroke and 9 died (10,5%). Drugs association was needed to control hypertension. As for everywhere in Africa, complicated hypertension is the main cause to admission for cardiovascular disease in our day-to-day practice. National preventive measures should help for systematic detection process and adequate management.

[Trochanteric fractures in elderly patients: management and prognosis of 68 cases]

The authors studied restrospecively their cases of trochanteric fractures to evoluate the frequency, the mortality, the morbidity and the results according to the diferent types of osteosynthesis used. 68 cases were collected in a 45 months. Mean age was 75 with 33 men and 35 women. 28 patients were sick before the accident. Using the A.O. classification, the patients were divided in three groups: 19 type A1, 37 type A2 and 12 type A3. 28 patients were operated an emergency basis. An A.O. nail plaque was used in the 43 cases and a staca screw plaque was used in the 11 remaining cases. Early in hospital mobilisation and weigh bearing with assistant was used and continued after discharge. After 17 months of follow up and according to Merle d'AUBIGNE'S, criteria, 91. 42% of the patients showed satisfactory results--16 patients died 8 of them had another desease. Anatomically, bone consolidation was gained after a mean period of 97 days and 40 % of Coxa-vara was reorganised. The frequency of trochanteric fracture inthe elderly is 69,3% in our experience. The patients operated on in emergency for whom a stacca nail plate had a better results with an earlier walking autonomy. In mean follow up there was no different in the two groups.

[Evaluation of surgical treatment of anal fistula]

Second reason for consultations in proctology in our department after hemorroïds-linked illnesses, fistulas in ano constitute a chronic disease which causes therapeutic difficulties linked mainly to the futur functionning of the sphincter, especially in its most complex types. In our group of 43 patients in whom surgical exploration with stylet was the key of the diagnosis, the anorectoscopy and even less chirurgical examination were not often contributive, the fear of post-operative incontinence forced us to prefer ligation-section with rubber every time that the sphincter was involved. With our results, the majority of patients (41/43) healed in normal periods with a sufficient functionning of the anus. This result confirmed our attitude towards the sphincter: that is to save if possible.

[Duodenal ulcer: truncal vagotomy with celioscopy. Report of 53 cases]

The recent introduction of laparoscopic surgery in the therapeutic arsenal of duodenal ulcer enabled us to carry out these interventions by abdominal route in order to appreciate the early results. It concerned a prospective study from March 1999 to August 2000 of 53 cases of which were 47 men and 6 women, aged from 16-75 years average age 52 years. Twenty six patients had pyloro-duodenal stenosis, the rest, chronic duodenal ulcer. Vagotomy was carried out on a patient on dorsal decubitus under general anesthesia with oro-tracheal intubation operator within the legs of the patient and the monitor at the right hand side. The process required four trocars depending on the morphology of the patient. A pneumoperitoneum of 3-5 litres permitted to attain the oesophagial hiatus by collapsing the pars-flaccida of the minor epiploon, the reperation of the right diaphragmatic pillar and the discovery of the posterior vagus nerve which was coagulated and sectioned. The traction of the body of the stomach towards the ombilious exposed the anterior portion of the stomach, thanks to the coagulator, the anterior branches of the vagus nerve are sectioned. Drainage by minilaparotomy terminates the intervention if only stenosis existed. Mortality was nul. The time of intervention was 35 to 135 minutes with an average of 71 minutes. The hospital stay was between 3 and 12 days with an average of 5 days. Three conversions to laparotomy (difficultdissection, liver cirrhosis, breakdown of materials), pleural wound consisted the morbidity. Two cases of re-operation due to evacuaton poorly appreciated in pre-operation period were observed. The results according to Visick criterias were: 1 : 51; II : 0; III : 0; IV: 2 patients for a follow up of 3-17 months. Vagotomy under coelioscopy is an intervention which permits to obtain results comparable to those of conventional surgery.

Connections between the trigeminal mesencephalic nucleus and the superior colliculus in the rat

Retrograde tracing methods are employed here to demonstrate that neurons in the trigeminal mesencephalic nucleus (5me) project to the superior colliculus (SC) in the rat. These neurons, mainly of small size, are situated bilaterally in the caudal part of the nucleus. Anterograde tracing studies demonstrated the existence of SC projections to neurons in 5me. The SC fibers contact 'en passant' small as well as large cell bodies of 5me neurons. These pathways suggested a role of the 5me neurons in oculomotor control and associated oro-facial functions.

[Emergence and course of the ilioinguinal nerve of the groin]

The aim of our study was to find a way of preserving the ilioinguinal nerve during surgical procedures for the repair of inguinal hernias. 40 inguinal regions were dissected, 37 ilio-inguinal nerves studied. The emergence of the nerve was at 4.21 cm of the anterior superior iliac spine, at 0.78 cm of the inguinal ligament on average. Its course was parallel to the inguinal ligament, always lay under the aponevrosis of the external oblique abdominal muscle, it passed through the superficial abdominal ring in 67.56% before proceeding on anterior side of spermatic cord. This result allowed us to examine the possibility of the nerve course variation's, of anastomosis with iliohypogastric nerve and particularly the best way to identify it when surgical procedures are performed in the lower portion of the abdomen.

[Fibrodysplasia ossificans progressiva or Munchmeyer disease apropos of 2 cases]

Fibrodysplasia ossificans progressiva or myositis ossificans progessiva or still Munchmeyer disease is a genetic ailment with dominant autosomic transmission. It includes a high rate of change and doesn't appear any race. The authors gave an account of two remarks about it on a causal and late discovery upon two young black Africans. The first observation is a nine year-old-boy, without any similar family previous history and who has been hospitalized in maxillo-facial milieu for a mandible osteitis staphiloccocus. It showed some muscular ossifications of paravertebral, cervical, dorsal and lumbar nature--from a spontaneous appearance and evolving progressively since the age of three months. The radiographic results displayed some specific bones disorders which enable to retain the diagnosis above. The second observation is the case of a twenty four-year-old-woman who has previously benefitted from a surgical exploration a non-inflammatory muscular tumefication at the right arm which occurred at the age of twenty one. Three years later, she took surgery for the restriction of the oral gap and a right hand side lumbar paravertebral tumefaction which was thus restricting the mobility of the rachis. The radiological results have found some specific bone disorder++ at the hands and the feet which enable to link the paravertebral ossifications to their fibrodysplasic origin. Munchmeyer disease remains a affection of easy radio-clinical diagnosis. The essential point is to precociously think of it before the specific osseous anomalies occurring at the level of the feet and the hands. The functional or even vital prognosis remains closely linked to both the important and the topography of conjunctivo-muscular ossifications.

[Adnexal masses in the Surgical Clinic of the University Hospital Center of Dakar, 74 cases]

The aim of this study was to assesss epidemiological, clinical and the therapeutic aspects of annexial masses. We have performed a retrospective study from 15/09/1994 up to 31/12/1997 including 74 patients. The prevalence rate was 18.40% of the overall gynecologic surgery in our department. Mean age was 36 years old. The range 30-41 years represented 40.5% of our cases. The mean gestity was 4 and the average parity 4. The most common clinical features were pelvic pains (75.57%) and hypogastric masses (50%). The duration of the disease ranged from 1 to 10 years. The general status was good in 94.59% of cases, bad with ascites in 5.41%. The annexial masses were cystic in 87.83%. The ovarian cysts were located at the both sides in 45.94, and bilateral in 8.10%. The annexial masses were solid in 9.45%. An abscess was found in 6.75%. We have performed an annexectomy in 66.1% and a cystectomy in 16.21%. The post operative complications were wound suppuration in 13.51%. The mortality rate was 1.35%. At the long-term follow up we have noticed an eventration in 1.35% and a recurrence with need of reintervention in 16.21%. The pathologic exam found a benign tumor in 95.16% and a carcinoma in 4.84%. The annexial masses are very common in our practice. They involve young multipare women. The main clinical outcome is pelvic pains. Annexectomy is the principal treatment.

[Recent traumatic peroneal tendon dislocation: a case report]

Peroneal tendons dislocation describes a permanent or intermittent displacement of these tendons out of the retro malleolar sucket to its lateral side. It was described in fist in 1803 by Monteggia. It remains a rare affectation, dominantly of traumatic causes, mostly by passed in emergency situation. Also in its rarity, it remains remarkable for its diagnostic interest but also for its management which remains only surgical. This case concerned an adult of 24 years old, victim of closed trauma of the right ankle, the ankle was forced in varus and supine position. Ths initial diagnosis was a benign sprain which was later rectified 14 days after for a diagnosis of peroneal tendons dislocation. During the operation, a rupture of the retinaculum like type II of Eckert and Davis was noticed. A simple suture technique using Exner method give a good result 14 months later. The authors insist after this case indifferential diagnosis with sprain and recommended a surgical repair in recent lesions.

[Antidiabetic activity of Zizyphus mauritiana Lam (Rhamnaceae)]

In traditonnal medicine, several plants were used in diabetes treatment. Among them, the aqueous extract from the leaves of Zizyphus mauritiana Lam (Rhamnaceae) was studied. The extract was administrated per os to Wistar rats made diabetics either temporarily by oral glucose tolerance test (first case) or definetely by subcutaneous injection of alloxan (second case). It was observed a striking decrease of the hyperglycemic arrow (p < 0.05) in the first case, with 300 mg/kg administrated 90 minutes before starting the test. In the second case, the results obtained with a dose of 300 mg/kg once or twice a day were identical as those with glibenclamide at 0.2 mg/kg per day. So, the antidiabetic activity of Zizyphus mauritiana Lam was experimentally born out but it has to be standardized for common use.

[Deep onchocerciasis of the left thigh. An unusual case]

INTRODUCTION

Commonly onchocercoma has been presented as superficial and multiple nodules. When it's unique and deeply situated, its clinical diagnosis is difficult. An uncommon form of onchocercoma is reported.

CASE REPORT

A 37 years old man presented a big tumor at the inferior third of the left thigh like lipoma or liposarcoma because of microcalcifications. The tumor was removed. It was a cyst containing a liquid like an "mango juice". The histological examination was performed. Degenerated microfilariae of Onchocerca volvulus was found.

DISCUSSION

A big and deep onchocerma of the thigh is uncommon and diagnosis before operation is very difficult. Histological examination have eliminate filarial infections like Dracunculus medinensis and have given the right diagnosis. Radiological microcalcifications and absence of microfilariae at the parasilogical and ophthalmological examinations recall an "aged" onchocercoma. For this reason, we didn't realise a chemotherapy.

CONCLUSION

This tumor in Sahel areas is very difficult to diagnose before operation. The histological examination is very important in this case. We don't use chemotherapy because this onchocercoma looks old without alive microfilariae.

[Evaluation of the predictive value of fibrin degradation products in the detection of deep venous thrombosis after total knee prosthesis]

The total knee arthroplasty (TKA) favours deep venous thrombosis (DVT), more often sural thrombosis. In this case, pulmonary embolism is exceptional but sural thrombosis can give a poor functional prognostic by trophic disorders. The purpose of this work is to verify the predictive value of D-Dimer by Elisa technic in the detection of DVT after TKA. We have studied 42 TKA at the Edouard HERRIOT Hospital(Lyon) between April 2, 1992 and October 20, 1994. Patients were divided in two groups: with DVT (n = 5) and without DVT (n = 37). Prophylactic heparinotherapy was systematic. The biologic follow-up by ELISA technic(Fibrinostika FbDP, Organon Teknika) of the D-Dimer were realized at D0 (Day 0) preoperative period and D1, D4, and D6 postoperative period. An echo-Doppler exam were effected at D8 postoperative. The analysis of mean rate of the D-Dimer didn't show significative difference between the two groups at D0, D1, D4 and D6. But, we observed that the rate of D-Dimer increased after TKA significantly in both groups. We can't evaluate predictive interest of the D-Dimer after TKA but the little number of DVT authorizes to pursue this study and to moderate our conclusion.

[Early evaluation of surgical treatment for patella fractures]

From mars 1989 to mars 1992, 26 fractures of the patella were treated surgically in the "Orthopaedic and Traumatological center in Dakar". We have evaluated the functional and the anatomical results. The mean age of the patients was 45 years. The most common mechanism was direct trauma (24 cases). We have registered 12 opened fractures, 24 displaced fractures and 13 comminutive fractures. Surgical methods were modified tension band internal fixation (18 cases), tension band wiring for fixation (5 cases) and circumferential wire loop fixation (3 cases). The mean follow-up was ten months. Only eight patients have adequate post-operative kinesitherapy. So functional results was poor in 50% of cases. The anatomical reconstruction of the patella were achieved in 18 cases. We have observed a relation between: anatomical results and inadequate indications; excellent functional results and adequate kinesitherapy. So the authors recommend modified tension band internal fixation in transversal fractures and fracture with central communication. Tension band wiring for fixation is used in others comminutive fractures. Post operative kinesitherapy must be realized in a adequate center and criteria of functional evaluation be wider theses.