Rectangular tapered short stem excellently preserves proximal bone mineral density preservation than tapered wedge short stem.

Fitmore stem is a rectangular, tapered, short, cementless stem. A characteristic feature of this stem is that it provides rotational stability due to the high medullary occupancy achieved by its rectangular cross-section and thick antero- posterior width. We aimed to investigate the differences in periprosthetic bone remodelling between a rectangular- tapered short stem and a short tapered-wedge stem. Eighty patients who underwent primary total hip arthroplasty using a rectangular-tapered short stem (Fitmore) or a short tapered-wedge stem (Tri-Lock BPS) were enrolled in this study. Bone mineral densities (BMDs) in the seven Gruen zones were evaluated using dual-energy X-ray absorptiometry at baseline, and at 6 and 24 months postoperatively. Peri-prosthetic BMD and clinical factors were assessed and compared. In addition, correlations between periprosthetic BMD changes and stem anteversion error were analyzed using Pearson's correlation coefficient in the two groups. A significantly better postoperative periprosthetic BMD change was found in zones 1 and 7 in the rectangular-tapered group. Additionally, no significant correlation was observed between stem anteversion error and periprosthetic BMD changes in the rectangular-tapered groups. However, in the tapered-wedge group, there were significant negative correlations between the stem anteversion error and BMD changes at 6 months and 24 months in zones 1 and 7. In the rectangular-tapered group, a significantly better postoperative periprosthetic BMD change was found particularly in the region proximal to the stem. Rectangular-tapered short stem can be more resistant to rotation due to higher medullary occupancy and may lead to better periprosthetic BMD than the tapered-wedge short stem, especially in the proximal region of the stem.

Medial femoral head border is a reliable and reproducible reference for axis determination for femoral component of unicompartmental knee arthroplasty.

PURPOSE: The femoral component should be implanted parallel to the mechanical axis in unicompartmental knee arthroplasty. It was hypothesised that a line between medial femoral condyle centres and medial border of femoral head will be parallel to the mechanical axis; this study set out to examine this hypothesis. METHODS: One hundred X-rays in fifty patients were included for this study. Long-leg standing X-rays including hip and ankle with patellae facing forwards were obtained. On these films, we measured the angle, α, between mechanical axis and the line between the femoral head centre and knee centre (medial mechanical axis), and the angle, ß, between the medial mechanical axis and a line between medial femoral condyle and femoral head centre. RESULTS: The average value of α was 0.1 ± 0.5° and the average value of ß 3.0° ± 0.3°. These data indicate that mechanical axis and medial mechanical axis are virtually parallel to each other. CONCLUSION: As medial femoral head border is easily identified fluoroscopically, it is a reliable landmark for orientating the femoral component of medial UKA.

Recurrent hepatic portal venous gas in a patient with hemodialysis- dependent chronic renal failure.

We report a case of recurrent hepatic portal venous gas (HPVG). A 51-year-old woman who had been undergoing hemodialysis for 19 years was admitted with abdominal pain. Computed tomography (CT) scans revealed the presence of HPVG, and bowel necrosis was confirmed at operation. After 1 year, the abdominal pain recurred. CT scans on the second admission also revealed HPVG; however, an exploratory laparotomy was negative. Recurring presentation of HPVG in the same patient has not been described previously.

Choledochal cyst associated with polycystic kidney disease: report of a case.

We report a very rare case of type I choledochal cyst associated with a polycystic kidney disease. A 48-year-old female had been dependent on hemodialysis for chronic renal failure due to polycystic kidney disease and was incidentally diagnosed to have a dilated common bile duct by an ultrasonography. An endoscopic retrograde cholangiopancreatography showed a spindle-shaped, dilated common bile duct (type I choledochal cyst) without visualization of the pancreatic duct. She underwent a resection of the choledochal cyst. Intraoperative cholangiography showed no reflux of contrast medium into the pancreatic duct. Amylase level of the aspirated bile from the bile duct was not elevated. In the case of choledochal cyst combined with renal fibropolycystic disease, pancreaticobiliary maljunction may not contribute to the etiology of choledochal cyst. In such cases, management of choledochal cyst is still controversial and requires further discussion.

Effects of sevoflurane anaesthesia on renal function.

The effects of sevoflurane on renal function were investigated in 34 patients anaesthetized with sevoflurane. Based on preoperative serum creatinine levels, patients were classified into three groups: Group 1 (n = 25) had normal renal function (serum creatinine < 1.0 mg/dl); Group 2 (n = 5) had slight renal dysfunction (1.0 < or = serum creatinine < 1.5 mg/dl); Group 3 (n = 4) had moderate renal dysfunction (serum creatinine > or = 1.5 mg/dl]. Serum creatinine, blood urea nitrogen and urine volume were measured preoperatively, and at Days 0, 1, 2, 7 and 28 after operation. Serum creatinine and blood urea nitrogen showed no significant postoperative differences (P < 0.05) in each group, whereas urine volume showed a significant increase until Day 2, with no further changes thereafter. Our results suggest that sevoflurane anaesthesia causes no significant renal damage in patients with normal and insufficient renal function under normal-duration anaesthesia within 3-4 h.

[Electromyographic findings in muscles around the osteoarthritic knee: integrated electromyography and frequency analysis].

An evaluation of the muscular functions of the vastus medialis, vastus lateralis, rectus femoris, medial hamstring, and of the lateral hamstring was performed using electromyography in 33 knees of 26 female patients with osteoarthritis (OA group) and in 25 knees of 19 healthy female volunteers (control group). During standing on both feet, all muscles in the OA group showed higher IEMG (integrated electromyography) and higher LMR (IEMG of vastus lateralis/IEMG of vastus medialis ratio in the quadriceps; and lateral hamstring/medial hamstring ratio in the hamstrings) than the control group. These augmentary muscular activities ameliorated the varus deformity caused by the osteoarthritis. During maximum isometric voluntary contraction, the OA group showed lower extension and flexion torque of the knees and also lower IEMG than to the control group, while the IEMG of vastus lateralis was not lower. These findings indicated decreased muscular activities in the osteoarthritic knee, and that the activity of the quadriceps was maintained mainly by the vastus lateralis under such conditions. Frequency analysis of the myoelectric signal during maximum isometric voluntary contraction revealed a single peak of low frequency in the power spectrum density function of the quadriceps and double peaks of low and of high frequency in the hamstring. In the OA group, the peak height of the low frequency component was increased in the quadriceps and decreased in the hamstring. We concluded that the duration of the motor unit action potentials was affected in the osteoarthritic knee.

[A case report of patch angioplasty of the left main coronary artery for isolated left main coronary artery disease].

A 49-year-old woman was admitted to our hospital because of palpitation and right shoulder pain. Examinations showed isolated left main coronary artery disease. Surgical angioplasty of left main coronary artery was considered. The left main stem was approached anteriorly. Pericardium was chosen for patch material and the left main coronary artery was enlarged from 1.5 to 4.0 mm in diameter. Postoperative course was very stable, and postoperative angiography revealed an excellent result.

[Analysis of left ventricular function early after coronary artery bypass grating in patients with left ventricular dysfunction].

We analyzed left ventricular (LV) function early after coronary artery bypass grafting (CABG) in patients with LV dysfunction, whose LV ejection fraction (LVEF) was less than 0.4. 11 patients were divided into two groups: Group-A patients (G-A: n = 6) improved LVEF (post-op LVEF > 0.4) and Group-B patients (G-B: n + 5) did not improve LVEF (post-op LVEF < 0.4) one month after CABG. Preoperative status of coronary artery disease, cardiac function, operative procedure, and postoperative cardiac function were compared between two groups. All patient had old myocardial infarction. There were no differences in preoperative LVEF (0.30 +/- 0.06 in G-A and 0.31 +/- 0.06 in G-B), CI, and LVEDP between two groups. LVEDVI (85 +/- 19 in G-A and 159 +/- 50 ml/m2 in G-B) and LVESVI (60 +/- 14 in G-A and 113 +/- 49 ml/m2 in G-B) values were higher in G-B, respectively. Number of grafts was not different between two groups (2.3 in G-A and 2.4 in G-B). Postoperative LVEF value (0.53 +/- 0.07 in G-A and 0.34 +/- 0.04 in G-B) was lower in G-B. Thus, it might be difficult to obtain the recovery of LV function in patients with LV dilatation, early after CABG.

[A case report of type A acute aortic dissection, which arose from true aneurysm in aortic arch].

A 69-year-old woman was admitted to our hospital because of back pain. Examinations showed type A acute aortic dissection, which arose from true aneurysm in aortic arch, and emergency operation was considered. Deep hypothermic selective cerebral perfusion was carried out for brain protection. Ascending to aortic arch was replaced with 24 mm woven Dacron graft. There was no postoperative neurological complication.

[A case report of congenitally bicuspid aortic valve and ascending aortic aneurysm treated by wheat operation].

A 59-year-old man who complained of palpitation was diagnosed as having a congenitally bicuspid aortic valve, severe aortic regurgitation, and an ascending aortic aneurysm. He underwent aortic valve replacement and conduit replacement by the modified Wheat technique. Since this technique requires no coronary artery anastomosis, it causes no problems associated with reconstruction of the coronary artery. Postoperative angiogram revealed no aneurysm formation of the aortic root or paravalvular leakage. This case suggest that aneurysm of the ascending aorta with aortic regurgitation is more effectively treated by the modified Wheat technique if cephalad displacement of the coronary ostium is not extensive.

[Coronary artery bypass grafting in six patients with familial hypercholesterolemia].

UNLABELLED: From June 1989 through November 1991, six patients with familial hypercholesterolemia underwent surgical treatments. The surgical procedures were coronary artery bypass grafting (CABG) alone 4, ligation of coronary aneurysm + CABG 1, and CABG + femoro-femoral bypass 1. There were no operative or hospital deaths. Early post operative patency rate of the grafts was 100%. CASE PRESENTATION: A 44-year-old man whose anginal pain recurred 11 years after CABG. Coronary angiogram revealed stenosis and a large aneurysm in the circumflex coronary artery. Previous grafts to the left anterior descending coronary artery and diagonal branch were patent. Ligation of the aneurysm and internal mammary artery bypass grafting were performed. Postoperatively, the patient has remained asymptomatic. Our data indicate that CABG for FH patients is effective in the early postoperative period.

Coronary artery bypass grafting for left main trunk coronary artery lesion associated with essential thrombocythemia.

Effort angina due to left main trunk (LMT) lesion was diagnosed in a 58-year-old man. Platelet count was markedly increased and essential thrombocythemia was also diagnosed. Because of LMT disease, coronary artery bypass grafting (CABG) was performed prior to medication for essential thrombocythemia. There were no complications during the operation or in the early postoperative period. Melphalan was administered postoperatively resulting in the decrease of platelet count. Postoperative coronary angiography demonstrated that both grafts were patent; however, immediately after coronary angiography, the patient suffered from a sudden onset of myocardial infarction and cerebral infarction. The therapeutic problems associated with hematological disorder in such patients are discussed in this report.

[Report of a case of angiodysplasia of the sigmoid colon associated with aortic stenosis].

Partial sigmoidectomy and then after 84 days aortic valve replacement were performed as a staged operation on a patient with Heyde syndrome, consisting of aortic stenosis and angiodysplasia of the sigmoid colon. An emergent sigmoidectomy was performed because of continuous bleeding from angiodysplasia of the sigmoid colon. Postoperative arteriography showed the persistence of angiodysplasia. Endoscopic examination of the residual angiodysplasia was performed before and after valve replacement and there was no morphological change.

[The effectiveness of preservation of hepatic arterial blood flow by modified Appleby procedure with reconstruction of the hepatic artery--serial changes in postoperative liver function].

We investigated whether modified Appleby procedure with reconstruction of the hepatic artery can avoid complications due to a decrease in heptic arterial flow which has been comprehended in conventional Appleby's operation. The postoperative liver function of 17 patients undergoing modified Appleby's procedure was compared with that of 16 patients undergoing total gastrectomy and distal pancreato-splenectomy (control group). (1) Anticoagulant therapy was not required during and after operation. The common hepatic arterial flow after vascular anastomosis was 396 +/- 101 ml/min. Postoperative celiac arteriography revealed good patency of anastomosis. (2) There were no significant differences between the modified Appleby group and the control group in any of the blood levels of GOT, GPT total bilirubin and alkaline phosphatase at any point until the fourth postoperative week. In none of the patients in the modified Appleby group, the blood levels of GOT and GPT exceeded 250 IU/l. (3) In the modified Appleby group, ICG-R15 was 4 +/- 1% before operation and 6 +/- 3% at the first postoperative month. These results suggested that modified Appleby procedure enabled us to perform resection according to Appleby's operation safely, without need for preoperative or intraoperative examination about the retrograde blood flow mediated by the gastrodudenal artery.

[Single-stage management of postoperative sternal wound infection using a pectoral musculocutaneous flap].

Two patients with postoperative sternal wound infection were successfully treated by a pectral musculocutaneous flap. A single-stage procedure of debridement and immediate closure with a pectral musculocutaneous flap can eliminate irrigation, open wound management, or reoperation for closure. Therefore, this method is very safe, simple, and effective for the management of sternal wound infections.

A new technique for the resection of gastric cancer: modified Appleby procedure with reconstruction of hepatic artery.

The Appleby operation allows resection of gastric cancer with lymph nodes around the stomach and celiac axis en bloc. Hepatic arterial blood flow after resection of the celiac axis is supplied by the superior mesenteric artery. In some patients, however, hepatic arterial flow becomes decreased after resection of the celiac axis. This abrupt reduction of hepatic arterial blood flow sometimes causes postoperative complications such as severe liver dysfunction or gallbladder necrosis. To prevent the reduction of hepatic arterial blood flow and to perform the Appleby operation more safely, we modified the Appleby operation to include reconstruction of the hepatic artery. We found that after dissection of lymph nodes around the hepatoduodenal ligament, the proper hepatic artery and gastroduodenal artery can be well mobilized and it becomes possible to anastomose the celiac axis to the common hepatic artery directly without using anticoagulants. From May, 1989 to November, 1990, 15 patients with advanced gastric cancer underwent the modified Appleby procedure at Kinan General Hospital. Postoperatively, serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were determined for evaluation of liver function. These levels were almost the same as those found after traditional total gastrectomy without resection of the celiac axis. Indocyanine green (ICG) clearance tests were performed before and 1 month after operation. There was no significant difference between the preoperative and postoperative values. Common hepatic arterial flow after celiacohepatic anastomosis was 390 ml/min on average. The modified Appleby procedure can be done quite safely.

[A case of ischemic mitral regurgitation treated by mitral annuloplasty (MAP) and coronary artery bypass grafting (CABG)].

A 79-year-old woman with a previous history of myocardial infarction, suffered acute myocardial infarction again. A coronary angiogram revealed triple vessel disease, and a left ventriculogram showed severe mitral regurgitation. The patient fell into cardiogenic shock after cardiac catheterization, and IABP was started. She underwent MAP and saphenous vein bypass grafting to the left anterior descending coronary artery and left circumflex coronary artery. Although the postoperative course was complicated by acute renal failure and respiratory dysfunction, the patient recovered from the operation and was discharged on the 137th postoperative day. Since the operative mortality of conventional valve replacement combined with CABG in ischemic mitral regurgitation has been high, we preferred MAP for this case.

[Two cases of severe ischemic mitral regurgitation treated with CABG alone].

We report here two cases in which patients fell into pulmonary edema due to ischemic mitral regurgitation (ischemic MR) after cardiac catheterization and underwent emergency coronary artery bypass grafting (CABG) using an intra-aortic balloon pumping. The patient were a 65-year-old man and a 80-year-old woman, and both had a chief complaint of angina after myocardiac infarction. In both cases, coronary angiography revealed triple vessel disease, and left ventriculography showed severe MR. However echocardiography, when they were hospitalized, did not show significant MR. Therefore we thought that they had gone into congestive heart failure because cardiac ischemia and volume load following cardiac catheterization provoked MR. In fact, postoperative left ventriculography and echocardiography showed decreased MR. We now think that it is important to keep in mind the cases of severe ischemic MR for which CABG alone is adequate treatment and to evaluate ischemic MR not only by left ventriculography but also by echocardiography.

[Operation of coronary artery aneurysm after previous coronary artery bypass grafting].

A 43-year-old male, who had undergone coronary artery bypass grafting 11 years ago, developed exertional chest pain. Selective coronary angiograms revealed severe stenosis and a large aneurysm in the obtuse marginal branch of the circumflex coronary artery. Previous grafts to the left anterior descending coronary artery and diagonal branch were patent. Ligation of the aneurysm and internal mammary artery grafting were performed through a left anterolateral thoracotomy. This approach made it easy to reach the aneurysm and to minimize bleeding during dissecting the adhesions. The patient had an uncomplicated postoperative course, and postoperative coronary angiograms revealed an obstructed aneurysm and a patient internal mammary artery graft. He has done well without recurrence of symptoms.