Chronic exertional compartment syndrome of the forearm in an elite rower.

We report a case of chronic exertional compartment syndrome (CECS) affecting the volar forearm compartment of an elite rower. CECS of the forearm is a less well recognised entity than lower limb CECS. We describe a typical history and detail a potential treatment.

The first 20 years of heart transplantation in Ireland.

BACKGROUND: The first Irish heart transplant was performed on the 10th of September 1985. Over the next 20 years, 229 transplants were performed in 228 recipients. AIMS: To evaluate the success of the first generation of cardiac transplantation in Ireland. METHODS: Analysis of clinical outcomes and survival statistics for patients undergoing heart transplantation in Ireland and comparison with international standards. RESULTS: There has been a steady improvement in transplant outcome over this time and survival figures for recipients between 2000 and 2004 show a hospital, 1-year and 5-year survival rate of 85.7%, 84.1% and 76.8% respectively. Thirty-eight of the 99 heart transplants performed between 1985 and 1994 are still alive more than 10 years later and the longest survivor is now 19 years post transplantation. CONCLUSIONS: The results compare favourably with international figures. Heart transplantation offers excellent longterm survival and quality of life but remains challenged by a shortage of suitable donor organs.

Hip arthroplasty, changing trends in a national tertiary referral centre.

BACKGROUND: Despite changes in techniques and management, little has been published comparing hip replacement surgery over a three-decade time span. AIMS: To document change in the practice of hip arthroplasty in a large elective orthopaedic centre. METHODS: A retrospective analysis of 100 patients in 1979 and in 1999 comparing demographics, surgical approaches, blood loss, transfusion requirements, morbidity and length of stay. RESULTS: In 1999, males predominated, spinal anaesthesia had largely superceded general anaesthesia, the anterolateral approach had replaced the trans-trochanteric approach, osteoarthritis remained the main aetiology and the Charnley prosthesis remained the implant of choice. Average blood loss was higher in 1999 compared to 1979 (1,378 vs 1,225 ml) but all patients in 1979 were transfused with an average of 2.8 units while in 1999 one-third of patients were transfused with an average of 1.6 units (p<0.0001). Length of stay had fallen from 30.5 days in 1979 to 16.2 days in 1999 (p<0.0001). Thromboembolic complications fell from 13% to 2% (p=0.0083). CONCLUSION: The incidence of deep venous thrombosis (DVT), pulmonary embolus (PE) and length of hospital stay has fallen. Blood loss had changed little but fewer patients receive blood transfusion.

Long-term clinical outcome following coronary artery bypass grafting for isolated stenosis of the left anterior descending coronary artery.

AIMS: To detail the clinical and angiographic profile, and long-term outcome in consecutive patients with isolated stenosis of the left anterior descending coronary artery undergoing bypass surgery. METHODS: A retrospective study of all patients (n = 301) (January 1984-December 1990) and undergoing coronary artery bypass grafting for isolated left anterior descending disease, in the Irish Republic, was performed. Survival was compared with that of an exact age- and gender-matched cohort. RESULTS: Mean age was 53 (+/- 9.3) years. There were 238 (79%) males. In 241 (80%) patients an internal thoracic arterial bypass graft was used. Operative mortality was 1.3%. Of the 280 (93%) patients alive (16 cardiac deaths) at 7.1 (+/- 1.9) years, 105 (35%) had angina, 26 (9%) suffered an interval myocardial infarction, and repeat revascularization was required on 29 (10%). Female gender (P = 0.002), pre-operative myocardial infarction (P = 0.02), significant diagonal disease (P = 0.04) and postoperative myocardial infarction (P = 0.0001) were independently associated with survival. Females were more likely to develop congestive cardiac failure (P = 0.01) or postoperative angina (P = 0.03) than their male counterparts. CONCLUSIONS: Survivorship (97%) and event-free survival (96%) at 5 years following coronary artery bypass grafting for isolated left anterior descending coronary artery disease is excellent and equivalent to an age-matched and gender-matched cohort.

Surgical relief of tracheobronchial obstruction in infants and children.

OBJECTIVE: Congenital tracheobronchial obstruction (TBO) presents a complex problem both in terms of diverse aetiology, presence of associated anomalies and the operative strategy to be adopted. We report a single centre experience in managing this difficult problem. METHODS: Twenty-four infants and children with TBO referred to our unit over a 12-year period are reviewed. Aetiology of TBO included vascular rings (n = 9), anomalous innominate artery (n = 6), congenital tracheal stenosis (n = 5), segmental bronchial stenosis (n = 2) and pulmonary artery compression of the main bronchi (n = 2). Seven patients had concurrent cardiac anomalies. Stridor was the commonest presenting symptom (67%). Mean delay from onset of symptoms to referral was 19 months. One patient died preoperatively due to acute airway obstruction. Mean age at operation was 33.1 +/- 42 months (range 4 days-156 months) and 11 children were under 1 year at the time of surgery. In cases of TBO secondary to vascular rings, division of the ring resulted in relief of symptoms in seven cases, with two requiring further surgery for resultant tracheomalacia. Four of the five patients having tracheal resection were operated on with the use of cardiopulmonary bypass; three of these patients had concurrent correction of cardiac lesions, with two survivors. Tracheobronchial anastomoses were carried out using continuous polydioxanone (PDS). Patients with anomalous innominate arteries required aortopexy in five and innominate artery suspension in one, while those with pulmonary artery compression of the main bronchi had correction of their intracardiac defects (n = 2). RESULTS: Hospital mortality was 8.7% and there has been one late death due to Eisenmenger syndrome secondary to pulmonary regurgitation, atrial septal defect (ASD) and patent ductus arteriosus (PDA). On follow-up (mean 40 +/- 31 months), 19 patients are alive and symptom free. There have been no anastomotic strictures following tracheobronchial resection. The single most important predictor of mortality was the presence of associated cardiac anomalies. CONCLUSIONS: TBO can be managed effectively by a single operation in both infants and children without a detrimental effect on tracheal growth. We advocate consideration of concurrent repair of the tracheal and cardiac lesions. Cardiopulmonary bypass (CPB) allows this concurrent correction of cardiac lesions and also facilitates tracheal resection.

Orthopaedic complications following cardiac transplantation.

Cardiac transplantation has become the treatment of choice for end stage heart disease. In 1990 2,000 transplants were performed worldwide. Orthopaedic Surgeons will be asked with increasing frequency to evaluate and treat bone and soft tissue problems with these patients. Orthopaedic service at the Mater Hospital has been involved in the follow-up treatment of orthopaedic complications in 46 transplant patients over a six year period. Thirty eight were male and eight were female. The ages were between 12 years and 65 years (mean 44.3). Nine (20%) of these patients developed thirteen orthopaedic complications: A vascular Necrosis of the hip (AVN) (4), Soft tissue infections (3), Osteoporosis (2), Stress Fractures (2), Osteomyelitis (1) and Ostomalacia (1). The mode of presentation, investigation and management of orthopaedic problems particular to these patients is described. Most patients who develop bony complications have had increased doses of steroids for episodes of rejection. This study highlights the special features of this patient population that require modification of the treatment approach such as the need to avoid the drug Erythromycin and the increased risk of AVN of the hip in patients who require high dose steroids.

Ten years' experience of an aggressive reparative approach to congenital mitral valve anomalies.

OBJECTIVE: Mitral valve repair is now well established in adults. Congenital anomalies of the mitral valve, however, represent a more complex and diverse population with a high prevalence of associated cardiac anomalies. Less is known about the results of valve sparing surgery in this group of patients. We reviewed our experience to determine these results. METHODS: Twenty three children with mitral valve anomalies and concordant atrioventricular and ventriculoarterial connections but excluding partial and total atrioventricular canal defect (AVC) or isolated cleft were operated on between January 1 1983 and January 1994. Mean age at operation was 3.2 years (range 2 months-10.7 years) with 10 patients less than 1 year. Eighteen patients (78%) were in New York Heart Association Functional class (NYHA) 111/1V. Aetiology of mitral valve disease was congenital in 21 (91.3) and ischaemic of congenital origin in 2 (8.7%). mitral regurgitation was dominant in 13 (57%), mitral stenosis in 10 (43%)-5 parachute valves. Associated defects occurred in 15 patients (65.2%). All mitral incompetence patients (13) had some form of annuloplasty-modified de Vega 5, Wooler Kay 5, Paneth 2 and Puig Messana 1. RESULTS: Hospital mortality was 13% (3 patients). Mean follow up time was 51.3 months with a cumulative follow up of 102.6 patient years There were 2 late deaths. Repeat operations were required in 3 patients-2 reparative and 1 mitral valve replacement. One patient awaits reoperation and the remaining 17 have no, minimal or mild mitral stenosis or incompetence on echocardiography. Seventeen (94%) of the surviving patients are in NYHA 1/11. One and 7 year actuarial survival rates are 82.2% +/- 7.9% and 77.4% +/- 8.7% while actuarial freedom from reoperation was 95.5% +/- 4.3% at 1 year and 84.1% +/- 7.6% at 7 years. There has been no incidence of thromboembolism. CONCLUSIONS: Reparative techniques can be successfully applied to congenital mitral valve disease, especially in children less than 1 year of age, and can be accomplished with a low hospital mortality and acceptable long term survival rates.

Unilateral Fontan operation for tricuspid atresia.

A 12-year-old child with tricuspid atresia and acquired hypoplasia of the left pulmonary artery was successfully treated with unilateral Fontan operation. Angiography at age 2 months had shown a normal left pulmonary artery, and a modified Potts shunt was performed. An emergency central shunt was required a year later. Reinvestigation 5 years after the initial operation revealed severe hypoplasia of the left pulmonary artery.

Metastatic malignant schwannoma in the heart.

A rare case of metastatic malignant schwannoma is described. The secondary tumor in the right lung grew along the pulmonary vein and filled almost the whole of left atrium. Operation was later performed, and a large tumor extension from the left atrium was removed.

Atrial myxoma: national incidence, diagnosis and surgical management.

Despite being the most common benign intracardiac tumour with an excellent prognosis after surgical excision the incidence of atrial myxoma (except at autopsy) is unknown. We reviewed all patients admitted to the National Cardiac Surgery Unit (n = 26) with an atrial myxoma over a fifteen year period (1977-1991) to compile national incidence data and assess pre-operative diagnosis, management, surgical technique, and outcome. Preoperative symptoms were: congestive cardiac failure (12 patients), embolism (8 patients), constitutional (3 patients), asymptomatic (2 patients) and tachyarrhythmia (1 patient). The diagnosis was confirmed by 2D echocardiography alone in thirteen patients and by a combination of echocardiography and angiography in thirteen patients. At operation the site of the tumour was left atrial in 24 patients and bi-atrial in two patients. All cases were confirmed by histology. All patients made a good post-operative recovery, although one patient survived a pulmonary embolus and one patient developed a deep venous thrombosis. There has been one late death (five months after surgery) from a cerebrovascular accident. Serial echocardiography has revealed one recurrence to date (8 years after surgery). The surgical incidence of these tumours in the Republic of Ireland over the study period was 0.5 atrial myxomas/million population/year. Although rare atrial myxomas are the most important cardiac tumours to diagnose as the results from surgery are excellent.

Systemic lupus erythematosus a rare cause of mitral stenosis.

An unusual case of mitral stenosis in a patient with Systemic Lupus Erythematosus (SLE) is presented. A middle aged lady, known to be suffering from SLE, was initially suspected to have left atrial myxoma. Only during surgery was the true rare pathology discovered: the valve was excised and replaced with a mechanical prosthesis.

Avascular necrosis of the femoral head post heart-transplantation and steroid dosage.

Avascular necrosis (avn) post heart-transplantation has been considered to be due to the high doses of steroids used to immunosuppress these patients in attempting to prevent transplant rejection. This study shows that avascular necrosis occurs even when low dose steroids regimes are used and demonstrates no significant correlation between steroid dosage and the development of avn. Patients with symptomatic avn benefit from early diagnosis and management of their condition in that the need for total joint arthroplasty can be prevented in many cases.

Coronary artery bypass grafting for coronary thrombosis complicating polycythaemia rubra vera. Case report.

Coronary thrombosis complicating polycythaemia rubra vera in a 42-year-old woman was treated with coronary artery bypass grafting. Nonatherosclerotic causes of coronary obstruction, though rare, should be considered, especially in younger patients.

Lipomatous hypertrophy of the interatrial septum: an unusual intraoperative finding.

Lipomatous hypertrophy of the interatrial septum was an incidental finding in a man of 45 undergoing coronary artery bypass grafting for unstable angina. He was not overweight and did not have any rhythm disturbances. The diagnosis was made on frozen section.

Cardiac surgery in Down syndrome.

Between January 1976 and December 1987 42 children with Down syndrome and congenital heart disease underwent cardiac surgery. Four children had two operations. Age at the time of surgery ranged from 11 days to 14 years. The commonest operative procedure was repair of a patent ductus arteriosus. Four patients died post-operatively, two following repair of a complete atrio-ventricular canal defect (CAVD), one following correction of tetralogy of Fallot in association with a CAVD, and a fourth following closure of ventricular septal defect and atrial septal defect. The mortality for those who had open heart surgery was 13.3% and for the series as a whole the mortality was 6.6% over a period of follow-up ranging from two months to four years. A relatively conservative approach has been adopted with regard to surgery, based on the shorter natural expectation of life in Down syndrome, the complexity of many of the cardiac lesions involved and the recognition of the frequency of early intellectual deterioration in Down patients.

Contractions to 5-hydroxytryptamine in human coronary artery and human saphenous vein.

Isometric contractions were obtained to 5-hydroxytryptamine receptor agonists in human saphenous vein and human coronary artery. Based on the interaction with the 5-HT2 receptor antagonist ketanserin, both 5-HT1 and 5-HT2 receptors are involved in contractions of human saphenous vein, but the predominant subtype involved in contractions of human coronary artery is the 5-HT1 receptor.