Arthroscopic synovectomy in the treatment of patients with juvenile rheumatoid arthritis.

Since January 1982, operative arthroscopy in the knee joint has been performed by us to 22 patients with juvenile rheumatoid arthritis, by whom synovectomy was considered to be indicated. The age of the patients varied from 5 to 16 years. In general anaesthesia, in the connection of arthroscopy, the abrasion of the hypertrophic synovial membrane was made by Stryker's chondrotome. The surgical debris was evacuated by suction. The mobilisation of the knee joint was started 2 days after the operation, and most of the patients walked on the fifth postoperative day. The arthroscopic synovectomy is considered to be a safe operation and, in our opinion, a good alternative method for synovectomy. Rehabilitation time is decisively shorter and, if necessary, operative arthroscopy can easily be repeated, without disturbing scars.

Early surgical exploration and epineural repair in birth brachial palsy.

The management of birth brachial palsy (Erb-Duchenne, Klumpke) has been traditionally conservative, and that is why the condition leaves some patients with impaired upper limb function for life. Development of anaesthesiology and microsurgical techniques have made safe early surgical repair of selected palsies possible. A 12 years' experience of early exploration of 11 patients aged from 2 weeks to 7 months is evaluated. The technique of direct epineural repair of ruptured roots has been successful in the early treatment of birth palsy. In the follow-up of 1 to 13 years after operation 7/11 patients regained good to excellent hand function.

Intraperitoneal hepatic bile duct fistula following blunt abdominal contusion.

Injuries to intrahepatic biliary ducts rarely cause severe clinical manifestations in context with blunt abdominal trauma. A case with mild symptoms and signs, but slowly developing bile peritonitis due to posttraumatic intraperitoneal hepatic bile duct fistula is described here. A young girl sustained a blunt contusion on the right lower thoracoabdominal region by the handle bar of a bike. A week after the accident ultrasonography revealed fluid under the liver. The patient showed no signs of peritonitis but had occasional shoulder pain. At laparotomy 200 ml of biliary fluid was drained from the subphrenic space, and excoriation was observed on the upper surface of the liver. A second operation was necessary due to continuous bile leakage via the drain in the subphrenic space and a bile-fistula was demonstrated by contrast x-ray examination. A local resection of the liver was performed and the intrahepatic bile duct fistula closed by a ligature. The postoperative course was then uneventful and the patient was symptomfree on examination six months after the accident.

Saccular cyst of the larynx in infants.

A saccular or congenital cyst of the larynx is a mucus-filled dilatation of the laryngeal saccule and can distort the aryepiglottic fold, the false cord or the laryngeal ventricle. The most common symptom of the laryngeal cyst is respiratory distress with inspiratory stridor and the diagnosis can usually be made by laryngoscopy. Treatment includes incision and drainage together with extirpation of the cranial wall of the cyst through a laryngoscope. Sometimes tracheostomy is also needed. Usually there are no complications afterwards and the development of these infants is perfectly normal. Our 3 cases and clinical features of this very unusual disorder are presented.

Intrapleural endodermal sinus tumor arising from the diaphragm.

We report a primary endodermal sinus tumor (EST) of the right hemidiaphragm, presenting as a right-sided hemothorax in an 18-month-old female. Four operations were performed, the last three being indicated solely by an elevated level of serum alpha-fetoprotein (AFP). Cyclic chemotherapy with varying drug combinations together with irradiation therapy were not effective in controlling the disease. To our knowledge, this is the first instance of a primary EST arising from the diaphragm.

Selenium and other elements in human maternal and umbilical serum, as determined simultaneously by proton-induced X-ray emission.

Using PIXE (proton-induced X-ray emission), we simultaneously determined the concentrations of Se, Ca, Fe, Cu, Zn, Br, and Pb in blood serum from 56 pregnant women, 25 healthy controls, and 31 others with twin pregnancy or some complicating condition (diabetes, hypertension, epilepsy, hepatosis gravidarum, pre-eclampsia, small baby), and in cord-blood serum from 21 newborns. Pellets, pressed from the serum samples after addition of yttrium as an internal standard, mixing, and evaporating at 30 degrees C with or without reduced pressure (less than 1 kPa), were bombarded by 2.2 MeV protons from a Van de Graaff accelerator in the air and the induced X-rays collected by a Ge(Li) detector. Relative to mean Se values for early six- to 12-week pregnancy (0.045 ppm), those for 35-42 week pregnancy (0.028 ppm) were low (p less than 0.001). Umbilical cord blood serum showed even lower values (0.016 ppm, p less than 0.001)--findings in harmony with the incidence pattern of Keshan cardiomyopathy. Pb crossed the placenta; values for cord serum were not significantly different from those in pregnancy serum. Cu, Zn, Fe, and Ca showed the significant expected patterns in the different groups. Compared with the late-pregnancy controls, Fe was high in mothers of small-birth-weight babies (1.70 ppm, p less than 0.02). Br was high in pre-eclampsia (3.59 ppm, p less than 0.05) and mothers with twins (3.61 ppm, p less than 0.05).

Operative reduction and fixation of a difficult supracondylar extension fracture of the humerus.

We evaluated the results of the operative treatment of a difficult supracondylar fracture of the elbow. A series of 45 consecutive children, the majority presenting initially with a complete dislocation of the humerus, was reexamined. Thirty-two of the patients had undergone an early operation applying the anterior cubital approach and 13 patients had been treated by traction. The lengths of the follow-up periods were 3.1 +/- 1.5 and 8.8 +/- 2.6 years, respectively. Normal range of extension-flexion and rotation movements was preserved almost invariably by either modality of therapy, whereas the carrying angle of the elbow was reduced significantly more often in the group treated by traction. None of the patients presented with permanent nerve dysfunction, keloid formation, or myositis ossificans. The two preventable early complications, slipping of the osteosynthesis and entrapment of the ulnar nerve, were related to the fixation of the fracture. There were no early or late infectious complications. When the anterior approach was used, operative reduction and fixation of a difficult supracondylar fracture of the humerus proved to be both safe and timesaving. Anatomical results of operation were superior to those attained by traction therapy in our series.

Foreign body in the airways of children.

During the years 1969-1981 57 children with inhaled foreign bodies in the tracheobronchial tree were treated at Turku University Hospital. Of the patients 91% had a history of foreign body inhalation and 25% had a radiopaque foreign body which was seen in the X-ray of the chest. In 9% of 57 patients a foreign body was found unexpectedly at bronchoscopy. The foreign body was removed by bronchoscopy from all the patients but one, who required a segmentectomy due to a fragment of a spike in the lung parenchyma. The patients presented no major complications, and they were all discharged from the hospital in good condition.

Desaminocysteine-D-arginine vasopressin test inthe evaluation and postoperative followup of obstructed kidneys in infancy and childhood.

Maximal renal concentrating capacity was determined with the aid of intranasal desaminocysteine-D-arginine vasopressin, a derivative of natural vasopressin, in 9 infants and 2 children with congenital or acquired pelvioureteral or vesicoureteral stenosis. Urinary tract infection was present in some but not all cases. Immediately postoperatively all 13 renal units displayed rather subnormal maximal renal concentration capacity (355 plus or minus 81 mosm. per kg. or mean plus or minus 1 standard deviation), which was corrected to some extent at the time of removal of the ureteral splint 5 to 10 days later (455 plus or minus 129 mosm. per kg.). Between 5 and 15 months postoperatively all but 1 renal unit displayed further significant increment in maximal renal concentration capacity. This single unit, operated on initially for vesicoureteral reflux secondary to neurogenic bladder, was found to be stenotic at the level of the ureterovesical junction. Routine determination of maximal renal concentration capacity at the time of operation could enable one to judge the kidney drainage postoperatively.

Anastomotic leakage in oesophageal atresia. Diagnostic and therapeutic considerations.

Oesophageal anastomotic leakage complicates 5-38% of operations performed for congenital atresia, and continues with prematurity and concomitant anomalies to be a cause of a fatal outcome. After a short review of the diagnostic and therapeutic possibilities of this complication the authors present their own series of 37 consecutive oesophageal atresia and/or oesophagotracheal fistula. Seven of these had anastomotic leakage within 2 to 8 days after operation. Three of them had been primarily operated on through a retropleural approach. The remaining four had had a transpleural approach and were all treated with an immediate rethoracotomy and resuture of the disruption with good primary results. A few cases reported earlier and the authors' present experience support the view that rethoracotomy and resuture of the disruption in transpleurally operated patients provides a method which allows early debridement of the pleural cavity and pulmonary reexpansion, accelerates secondary anastomotic healing and shortens the period needed for pleural drainage and intravenous nutrition.

Loperamide as a symptomatic treatment in pediatric surgery: a double-blind cross-over study.

The effects of oral loperamide, in doses of 2-6 mg per day, on the stool consistency, daily number of bowel movements and general inconvenience was investigated in seven children and juveniles suffering from incontinence and abnormal bowel habits due to congenital abnormalities. The study was conducted as a double-blind, cross-over analysis. According to the data collected loperamide essentially improves the quality of life of these patients.

Malignant histiocytosis. Histiocytic medullary reticulosis.

Three cases of malignant histiocytosis occurring in children aged 2 months, 10 months and 14 years, are described. In all children the diagnosis was based on anaemia, granulocytopenia or thrombocytopenia, splenomegaly and marked erythrophagocytosis by bone marrow and lymph node atypical histiocytes. Two children aged 10 months and 14 years, underwent splenectomy after which combined chemotherapy with cyclophosphamide, vincristine and prednisone (COP) was started. In the older child a complete remission was achieved. The younger child died soon after the onset of the treatment. The youngest child was treated with bleomycin, adriamycin, cyclophosphamide, vincristine and prednisone (BACOP). He died of pneumonia and sepsis two months after the start of the treatment.

Preventive treatment of congenital pseudarthrosis of tibia.

If an osteotomy is carried out in a child with congenital angulation of the tibia with segmental sclerosis, a pseudarthrosis develops in many cases. This should be prevented by a bone-graft operation along the concave side of the tibia. The results described illustrate this contention.