Neglected ruptures of the patellar tendon. A case series of four patients.

We describe a series of four patients treated for chronic ruptures of the patellar tendon (more than 6 months old). The proximally retracted patella was brought back to its anatomic position, and the tendon stumps were repaired and protected with multiple strands of strong circlage wire, in a figure-of-8 pattern, from the quadriceps tendon to the tibial tubercle. Postoperatively, immediate mobilization without the use of a brace was initiated. The patients averaged 29 months (range, 8 to 80) from the time of injury until definitive treatment and were observed for an average of 27 months (range, 11 to 40) after treatment. Before treatment, all patients had an extensor lag of at least 20 degrees. At initial follow-up, all patients had full active extension with no extensor lag, and this did not deteriorate postoperatively or after wire removal. At the last follow-up, the average flexion was 0 degrees to 112 degrees. This technique avoids the use of autograft or allograft tissue and does not require lengthening of the quadriceps tendon.

Simultaneous pyloric and colonic obstruction associated with hiatus hernia in a weightlifter: a case report.

Hiatus hernia is usually attributed to conditions that cause a chronic increase in intra-abdominal pressure such as multiple pregnancies and obesity. A 30-year-old man, a weightlifter, had a massive hiatus hernia causing both high and low gastrointestinal obstruction but no involvement of the gastroesophageal junction or fundus. The onset of the obstruction is attributed to an extreme increase in intra-abdominal pressure caused by the action of lifting weights.

Quality and customers: Type 2 change in mental health delivery within health care reform.

The traditional separation of mental health and medical programs is problematic because mental health issues are inseparable from the larger medical system. By contrast, a collaborative primary care model of mental health care, augmented and supported by secondary specialty mental health services, has the potential to optimize quality and cost goals while reinforcing health care reform principles. The flexibility of mental health treatment in this delivery structure provides opportunities to customize services according to patient and purchaser expectations.

Tube thoracostomy for occult pneumothorax: a prospective randomized study of its use.

Occult pneumothorax is defined as a pneumothorax that is detected by abdominal computed tomographic (CT) scanning, but not routine supine screening chest roentgenograms. Forty trauma patients with occult pneumothorax were prospectively randomized to management with tube thoracostomy (n = 19) or observation (n = 21) without regard to the possible need for positive pressure ventilation, to test the hypothesis that tube thoracostomy is unnecessary in this entity. Eight of the 21 patients observed had progression of their pneumothoraces on positive pressure ventilation, with three developing tension pneumothorax. None of the patients with tube thoracostomy suffered major complications as a result of the procedure. Hospital and ICU lengths of stay were not increased by tube thoracostomy. Patients with occult pneumothorax who require positive pressure ventilation should undergo tube thoracostomy.

Vena cava bypass with stented polytetrafluoroethylene bifurcated grafts. A report of 2 cases.

Severe stenosis or occlusion of either the superior or the inferior vena cava requires surgical bypass grafting in a selected group of patients. When the obstruction extends into the major tributaries, a bifurcated graft becomes necessary. We present the cases of 2 surgically treated patients, each of whom received a stented polytetrafluoroethylene bifurcated graft constructed at the time of the operation. Symptoms disappeared post-operatively in 1 patient and abated in the other. Both grafts became occluded within 1 year; however, that was sufficient time for collateral venous circulation to develop, enabling both patients to respond well to conservative therapy. We conclude that stented polytetrafluoroethylene bifurcated grafts may be suitable for selected patients as a bridge until collateral veins can form. The development of more compliant venous grafts may provide even more favorable results.

Determination of operability in candidates who undergo lung resection for bronchogenic carcinoma.

In this prospective study the authors attempted to determine the effect of lung resection for bronchogenic carcinoma on final pulmonary function in patients who had severe limitation of lung air flow preoperatively and were therefore likely to have severe, progressive pulmonary failure and in those who had acceptable pulmonary function preoperatively. Preoperative and postoperative pulmonary function tests were performed on 20 patients chosen to undergo various types of resection for bronchogenic carcinoma. Those who underwent pneumonectomy had changes in lung volume that were expected for a resection of that magnitude. Patients who underwent lesser resections had more variable postoperative lung volumes and flows. The patients whose preoperative pulmonary function was poorest had the least change postoperatively and even, in some cases, showed some improvement in function, yet they were the ones most likely to be denied surgery, because of their poor preoperative pulmonary function.

Primary pulmonary fibrous histiocytoma: report of three cases.

Since 1969, fibrous histiocytoma has been recognized as a distinct entity. It occurs in benign and malignant forms. The authors describe two cases of the malignant pulmonary variety, which is considered very rare, and one case of benign pulmonary fibrous histiocytoma. All patients were treated successfully by local excision; there was no recurrence or metastases after a postoperative follow-up of 1 month, 8 years and 7 years respectively. The diagnosis is confirmed histologically according to criteria set forth by the World Health Organization. Treatment is by early complete surgical excision. Further study is needed to determine the merits of radiotherapy and chemotherapy postoperatively.