Successful treatment of massive hemothorax with class IV shock using aortography with transcatheter embolization of actively bleeding posterior left intercostal arteries after penetrating left chest trauma: A case for the hybrid OR.

Hemothorax is a common occurrence after blunt or penetrating injury to the chest. Posterior intercostal vessel hemorrhage as a cause of major intrathoracic bleeding is an infrequent source of massive bleeding. Selective angiography with trans-catheter embolization may provide a minimally invasive and efficient method of controlling bleeding refractory to surgical treatment. PRESENTATION OF CASE: A 19 year-old male sustained a gunshot wound to his left chest with massive hemothorax and refractory hemorrhage. He was emergently taken to the operating room for thoracotomy and was found to have uncontrollable bleeding from the chest due to left posterior intercostal artery transection. The bleeding persisted despite multiple attempts with sutures, clips and various hemostatic agents. Thoracic aortography was undertaken and revealed active bleeding from the left 7th posterior intercostal artery, which was coil-embolized. The patient's hemodynamic status significantly improved and he was transferred to the intensive care unit. DISCUSSION: Posterior intercostal bleeding is a rare cause of massive hemothorax. Bleeding from these arteries may be difficult to control due to limited exposure in that area. Transcatheter-based arterial embolization is a reliable and feasible option for arresting hemorrhage following failed attempts at hemorrhage control from thoracotomy. CONCLUSION: Massive hemothorax from intercostal arterial bleeding is a rare complication after penetrating chest injury (Aoki et al., 2003). Selective, catheter-based embolization is a useful therapeutic option for hemorrhage control and can be expeditiously employed if a hybrid operating room is available.

"Black Esophagus" and Gastric Volvulus Following Slipped Laparoscopic Adjustable Gastric Band.

To review the entity "black esophagus" and sequela of a slipped laparoscopic adjustable band. The patient's history, physical examination, imaging, and endoscopic findings were reviewed. Detailed review of pathophysiology, presentation, diagnosis, management, and natural history was conducted. "Black esophagus," also known as acute esophageal necrosis (AEN), is a rare condition resulting in black discoloration of the mid to distal esophagus with less than a hundred reported cases. It has not been previously documented in bariatric surgery or following laparoscopic adjustable gastric banding. The volvulus was reduced at surgery, and the esophageal changes resolved without sequela. "Black esophagus" is an acute, ominous-appearing condition with a spectrum ranging from superficial mucosal disease to transmural involvement with perforation. Fortunately, esophageal resection is rarely required.

Transfracture medial transposition of the radial nerve associated with plate fixation of the humerus.

PURPOSE: The aim of this study was to illustrate safety, feasibility and advantages of transfracture medial transposition of the radial nerve during the lateral approach and lateral plating of humeral fractures located in the mid and distal shaft. METHODS: This was a retrospective review and analysis of medical records and radiographs of 19 patients who underwent a transfracture medial transposition of the radial nerve. Fifteen patients were treated for fresh fracture and four for nonunion. All patients were followed up clinically and radiographically for a minimum of 12 months. RESULTS: Pre-operative radial nerve paralysis was present in four patients in the fresh fractures group; post-operative paralysis occurred in two. All patients completely recovered a few months after the index procedure. Except for two, all patients achieved bone healing. One patient from the fresh-fracture group developed nonunion, and one from the nonunion group experienced persistent nonunion; both underwent successful revision surgeries. In addition, four patients with a fresh fracture underwent revision surgery for hardware removal. All but two patients showed no restricted elbow or shoulder joint motion compared with the opposite side. CONCLUSION: Transfracture transposition of the radial nerve during open reduction and internal fixation of humeral shaft fractures is a safe, harmless and feasible procedure when applied for fractures of the middle and distal humeral shaft; it removes the nerve from the surgical field during fracture manipulation and fixation, with a gain in length of the nerve by transforming its course from spiral to straight. Following radial nerve transposition across the fracture, a repeat surgical approach to the humerus for hardware removal or treatment of nonunion transforms the procedure into a simple one; the skin incision is carried straight down to the bone without the need to identify or dissect the nerve that was previously transposed to the medial compartment of the arm.

Comparison of Early Adverse Events After Operative Treatment of Bimalleolar and Trimalleolar Fractures Versus Pilon Fractures.

Ankle fractures requiring open reduction and internal fixation vary in severity from unimalleolar fractures to bimalleolar/trimalleolar (BT) fractures to pilon fractures. Consequently, the postoperative outcomes with these surgeries can vary. Most previous studies of these injuries had small sample sizes, studied a single risk factor or adverse event, or did not compare different injuries by severity. The purpose of the present study was to describe and compare the patient characteristics and postoperative outcomes of 2 high-energy ankle fractures: BT and pilon fractures. The relevant patients were identified from the American College of Surgeons National Surgical Quality Improvement Program database using the Current Procedural Terminology codes for BT and pilon fractures. Patient demographics, characteristics, comorbidities, and 30-day mortality and adverse events were recorded and compared between the 2 types of ankle fractures. More than 45% of patients with these fracture types were aged 40 to 65 years. Pilon fractures occurred more frequently in younger patients, were more likely to occur in men, required a longer hospital stay and operative time, were less likely to occur in patients with a body mass index of >30 kg/m2, and conferred a greater risk of wound complications (odds ratio 1.76; p = .048) compared with BT fractures. The findings from the present study help us understand the differences in patient characteristics and potential early adverse events after open reduction and internal fixation of BT fractures versus pilon fractures.

PECTUS CARINATUM: A NOVEL METHOD OF STERNAL FIXATION.

The traditional method for fixing the sternum during surgical repair of pectus carinatum is through the use of a stainless steel bar (Adkin's strut). In this article we describe a new method of sternal fixation using nonabsorbable sutures which are placed in a transverse and crossed fashion anterior to the sternum. This method provides stable sternal fixation and spares the patient a second operation to remove the steel bar. The absence of metallic implants allows clearer view of the thoracic structures in future X-rays, CT scans and MRI, and is likely to be more acceptable to patients than the implantation of a metallic strut in their chest. In addition, it is less costly.

Massive pulmonary embolism associated with Factor V Leiden, prothrombin, and methylenetetrahydrofolate reductase gene mutations in a young patient on oral contraceptive pills: a case report.

Factor V Leiden (Factor V G1691A), prothrombin gene mutation G20210A, and homozygous C677T mutation in the methylenetetrahydrofolate reductase (MTHFR) gene are known to predispose venous thromboembolism (VTE). We present herein a rare case of a young woman heterozygous for these mutations and taking oral contraceptive pills for less than 2 months, diagnosed to have massive deep venous thrombosis and bilateral pulmonary embolism. The patient was managed for 10 days in the hospital and discharged home on oral anticoagulants. This case suggests that screening for these factors in people with family history of thrombosis and in relatives of patients with these mutations is highly recommended to prevent fatal consequences. In addition, a new guideline for treatment and prophylaxis with anticoagulant for these patients and others who are at risk of developing VTE (American College of Chest Physicians [ACCP] guidelines-Chest 2008) has been published recently. Our recommendation is to promote for the internationally published algorithms through their application, where necessary, to prevent any future thrombotic morbidity or mortality incidents.

Nuchal-type fibroma of the ankle: a case report.

Nuchal-type fibroma is rare benign fibrous tumor that has the potential to recur. It is typically located in the subcutaneous tissues of the posterior aspect of the neck, although it can affect other anatomical sites. Extranuchal involvement occurs most commonly in the back, shoulder, and face, as well as other sites specified in single case reports. In this report, we describe the case of a patient presenting with a nuchal-type fibroma arising in the ankle. The lesion infiltrated the superior extensor retinaculum. Marginal resection was performed, and there was no evidence of recurrence after 12 months of follow-up. To our knowledge, this is the first report of a nuchal-type fibroma localized to the ankle.

[Value of establishing a registry of hip prostheses in Lebanon]. / Intérêts de la mise en place d'un registre de prothèses de hanche au Liban.

A registry for hip arthroplasty is an excellent method for the surveillance of complications and of short-, mid- and long-term results of a procedure which is becoming increasingly more frequent. Surveillance may lead to improvement of results, reflected by a decrease in the rates of revisions performed after primary surgery, and of health expenses. In addition, registry data can be used for epidemiological studies. This article proposes a financial projection of savings which can be obtained as a result of hip revision rate reductions.

Hip fractures in lebanese patients: determinants and prognosis.

Hip fractures are the most costly of osteoporotic fractures, but little is known about their epidemiology in the Middle East. Hip fracture patients and controls with osteoarthritis admitted to our institution from 1992 to 2002 were studied. Information on gender, age, type of fracture, comorbid conditions, and medications use was obtained. The mean age for hip fracture patients (n = 274) was 72.1(8.5) yr, and for controls (n = 112), it was 71.1(4.4) yr, two-thirds of fractures occurred in women. Fractures were 59% intertrochanteric, 34% femoral neck, and 7% subtrochanteric, with no gender differences. Hip fracture patients were more likely to have had a prior fracture and to suffer from neurological, gastrointestinal, or renal comorbidities, as compared to controls. Less than 10% of hip fracture patients received any therapy for osteoporosis, either on admission or discharge. In a subset of patients with follow-up, the mortality rate was 47% in subjects with hip fracture, and most deaths occurred within the first year postoperatively. Gender but not fracture type affected mortality. Lebanese patients with hip fractures are younger, more likely to sustain intertrochanteric fractures, and experience higher mortality than Western counterparts. Few subjects received osteoporosis therapy. This study carries important public health implications on the management of hip fracture in subjects from Lebanon and, possibly, the Middle East.

Correlation between withdrawal symptoms and medication pump residual volume in patients with implantable SynchroMed pumps.

OBJECTIVE: To investigate whether patients with implantable SynchroMed pumps (Medtronic, Inc., Minneapolis, MN) develop symptoms of drug withdrawal at residual medication volumes that exceed 2 ml (the alarm residual volume recommended by the manufacturer). METHODS: The data sheets of 88 patients with implantable SynchroMed pumps were retrospectively reviewed. The following parameters were analyzed: development of symptoms of drug withdrawal; drugs used in the pump; disease state; drug residual volume in the pump; intake of orally administered medications; time of development of withdrawal symptoms; drug flow volume through the pump; daily intrathecally administered drug dose; and drug concentration in the pump. RESULTS: Of 88 patients, 21 (24%) consistently developed symptoms of drug withdrawal 1 to 7 days before the drug residual volume reached a mean of 2.7 ml (range, 2.1-3.8 ml; median, 2.6 ml). Symptoms first developed 1 to 18 months after surgery. In all patients, symptoms of drug withdrawal subsided after pump refill and did not recur after the alarm volume was increased to 4 ml. Symptom development did not correlate with intake of orally administered medication, drug flow volume through the pump, intrathecally administered drug dose, drug concentration in the pump, drugs used in the pump, or disease state. CONCLUSION: Some patients develop symptoms of drug withdrawal at residual volumes that exceed 2 ml. We could not identify factors that predict this occurrence. Withdrawal symptoms did not recur when the alarm volume was increased to 4 ml.

Outcomes of cubital tunnel surgery among patients with absent sensory nerve conduction.

OBJECTIVE: To report the outcomes of cubital tunnel surgery for patients with absent ulnar sensory nerve conduction. METHODS: The charts of 34 patients who exhibited clinical symptoms of ulnar nerve entrapment at the elbow and who had electromyography-confirmed prolonged motor nerve conduction across the cubital tunnel in association with absent sensory nerve conduction were reviewed. The mean age was 63 years, and the mean symptom duration was 17 months. Four patients had bilateral symptoms. Surgery was performed for 38 limbs, i.e., neurolysis for 21 limbs and subcutaneous transposition for 17 limbs. Fifteen limbs demonstrated associated ulnar nerve-related motor weakness. The mean postoperative follow-up period was 4 years (range, 3 mo to 11 yr). RESULTS: Sensory symptoms (i.e., pain, paresthesia, and two-point discrimination) improved in 20 limbs (53%), and muscle strength improved in 2 limbs (13%). Improvements in sensory symptoms were not related to patient age, symptom duration, cause, severity of prolonged motor nerve conduction, select psychological factors, associated medical diseases, associated cervical pathological conditions, or type of surgery. Improvements in sensory symptoms were significantly decreased among patients who had experienced cervical disease for more than 1 year and patients with bilateral symptoms. CONCLUSION: Patients with cubital tunnel syndrome who have absent sensory nerve conduction seem to experience less improvement of sensory symptoms after surgery, compared with all patients with cubital tunnel syndrome described in the literature. Bilateral symptoms and delayed surgery secondary to associated cervical spine disease seem to be significant negative factors for postoperative improvement of sensory symptoms. Sensory symptoms improved similarly among patients who underwent neurolysis or subcutaneous transposition