Treatment of massive rotator-cuff tears with a polyester ligament (Dacron) augmentation: clinical outcome.

We describe the clinical outcome of a technique of surgical augmentation of chronic massive tears of the rotator cuff using a polyester ligament (Dacron) in 21 symptomatic patients (14 men, seven women) with a mean age of 66.5 years (55.0 to 85.0). All patients had MRI and arthroscopic evidence of chronic massive tears. The clinical outcome was assessed using the Constant and Murley and patient satisfaction scores at a mean follow-up of 36 months (30 to 46). The polyester ligament (500 mm × 10 mm) was passed into the joint via the portal of Neviaser, medial to the tear through healthy cuff. The two ends of the ligament holding the cuff were passed through tunnels made in the proximal humerus at the footprint of the insertion of the cuff. The ligament was tied with a triple knot over the humeral cortex. All the patients remained free from pain (p < 0.001) with improvement in function (p < 0.001) and range of movement (p < 0.001). The mean pre-operative and post-operative Constant scores were 46.7 (39.0 to 61.0) and 85.4 (52.0 to 96.0), respectively (p < 0.001). The mean patient satisfaction score was 90%. There were two failures, one due to a ruptured ligament after one year and the other due to deep-seated infection. The MR scan at the final follow-up confirmed intact and thickened bands in 15 of 17 patients. This technique of augmentation gives consistent relief from pain with improved shoulder movement in patients with symptomatic massive tears of the rotator cuff.

Graft dilatation following abdominal aortic aneurysm resection and grafting.

BACKGROUND: It has been suggested that graft dilatation following repair of abdominal aortic aneurysm (AAA) is associated with complications such as anastomotic aneurysm and graft rupture. The purpose of the present study was to document the degree of dilatation observed in grafts after aneurysm repair and to correlate this with any graft-related complications. METHODS: Between January 1987 and December 1992, 219 patients had elective repair of their AAA at St George Hospital. A follow-up ultrasound scan was available for 154 of these patients. The following factors were examined: age, sex, size of aneurysm, type and size of graft, time of follow-up scan, size of graft at follow-up and any graft-related complications. RESULTS: The mean graft dilatation observed in knitted grafts (42.6%; 95% CI: 39.1-46.1%) was significantly greater than that observed for woven grafts (25.5%; 95% CI: 19.0-32.1%; P < 0.0001). There were no graft-related complications. CONCLUSIONS: Graft dilatation is a predictable phenomenon following AAA repair. It is more pronounced in knitted than in woven grafts, but does not necessarily lead to graft-related complications or failure.

Administration of ATP-MgCl2 after trauma-hemorrhage and resuscitation restores the depressed cardiac performance.

Although adenosine triphosphate (ATP)-MgCl2 has been shown to improve cardiac performance under normal and postischemic conditions, it is not known whether this agent has any salutary effects on cardiac performance following trauma-hemorrhage and crystalloid resuscitation. To determine this, rats underwent laparotomy (i.e., trauma induction) and were bled to and maintained at a mean arterial pressure of 40 mm Hg until 40% of the maximum shed blood volume was returned in the form of Ringer's lactate. The animals were then resuscitated with four times the volume of shed blood using Ringer's lactate over 60 min and received either ATP-MgCl2 (50 mumole/kg body wt) in 1 ml volume or an equivalent volume of normal saline intravenously over 95 min. Maximum dP/dt during contraction as well as relaxation (+/-dP/dtmax) and ventricular peak systolic pressure (VPSP) were determined 15 min prior to the end of resuscitation and every 30 min thereafter for 4 hr after the completion of resuscitation. The results indicate that both -dP/dtmax and +dP/dtmax decreased significantly beginning at 0 and 2 hr after the completion of resuscitation, respectively, and remained depressed throughout the duration of the study in saline-treated animals. In addition, VPSP was significantly depressed at 2-4 hr after resuscitation. Treatment with ATP-MgCl2, however, restored these parameters. Moreover, the depressed heart rate was also restored following ATP-MgCl2 administration. Since ATP-MgCl2 restores various left ventricular performance parameters, this agent appears to be a promising adjunct for improving cardiac function after trauma and hemorrhage, even in the absence of blood resuscitation.

Synchronous, bilateral mastectomy.

Sixty-four patients (mean age, 51 years) had mastectomies which were synchronous and bilateral. Sixty-one premastectomy biopsies (bilateral, 34 and unilateral, 27) demonstrated the following: invasive carcinoma, 17; noninvasive carcinoma, 24; combination of above, 10; and benign disease, 10. Twenty-two patients had bilateral mastectomy because of bilateral positive biopsy. Twenty-nine patients with unilateral carcinoma on biopsy had bilateral mastectomy. Thirteen patients had bilateral mastectomy despite benign disease only on biopsy (10) or no biopsy (3). Ten unexpected carcinomas (34%) were found in the contralateral breast in the 29 patients with carcinoma diagnosed on unilateral biopsy. The biopsy pathology of these 10 specimens was invasive ductal carcinoma in 1 and multifocal, noninvasive carcinoma (ductal, 3 and lobular, 6) in 9. An unexpected carcinoma may be found in the contralateral breast in a significant number of patients who are selected for bilateral mastectomy, particularly if the selection is on the basis of a noninvasive, lobular histology. Bilateral mastectomy may be appropriate for such patients, particularly when complicated by a strong family history and breasts which are difficult to assess by physical or mammographic examination.

The natural history of asymptomatic carotid artery disease.

PURPOSE: The purpose of this article is to determine the natural history of carotid artery disease among asymptomatic patients with cervical bruits or other risk factors for stroke and to study the value of duplex ultrasonography in predicting future neurologic events. METHODS: Two hundred forty-two asymptomatic, unoperated patients, referred for evaluation of asymptomatic carotid artery disease, were followed prospectively with duplex ultrasonography. RESULTS: Fifteen ischemic strokes (6.2%) and 20 transient ischemic attacks (TIA) (8.3%) occurred in 34 patients during a mean follow-up of 27.4 months. Annual stroke, TIA, and combined event rates were 2.7%, 3.6%, and 6.2%, respectively. Although patients with 80% to 99% lesions had a 20.6% annual event rate, most events occurred contralateral to these lesions; the vessel-specific annual event rate for 80% to 99% disease was 5.1%. Only one of 15 strokes occurred ipsilateral to an 80% to 99% stenosis. Echolucent plaques were associated with TIA and stroke (5.7% annual vessel event rate vs 2.4% for echogenic plaques, p = 0.03). Disease progression was highly correlated with TIA and stroke (p < 0.0001), but it usually occurred in association with rather than before ischemic events, thus proving more useful in explaining pathogenesis than in predicting future events. There was no association between aspirin use and TIA, but patients taking aspirin had a threefold higher annual stroke rate (1.6% vs 4.8%, p = 0.027). CONCLUSIONS: This study, while confirming significant risk for asymptomatic patients with critical stenosis or echolucent plaque, demonstrates the importance of contralateral disease and the absence of orderly progression from minimal disease through high-grade stenosis to symptomatic cerebral ischemia. TIA and stroke commonly occur in association with abrupt, unpredictable, quantum changes in carotid artery disease.

The MR contribution after CT demonstration of supratentorial mass effect without additional localising features.

The contribution of magnetic resonance (MR) imaging was retrospectively evaluated in 24 patients in whom CT demonstrated a supratentorial mass effect without significant additional localising features. Using a combination of T1-weighted inversion recovery (IR) and T2-weighted spin echo sequences, the MR images localised the lesion with greater precision than CT in 80% of cases. Areas of contrast enhancement were visible on the IR images in five of nine (56%) patients assessed after intravenous gadolinium-diethylenetriamine pentaacetic acid, where no comparable enhancement was seen on CT. Twenty of the 24 patients subsequently underwent surgery; eight had biopsies and 12 had resections. Magnetic resonance accurately predicted the site of the tumour in all these patients. Three of the remaining four cases were treated with radiotherapy on the basis of the MR findings without a tissue diagnosis being sought. Magnetic resonance produces better localization than CT and provides a sound basis for further diagnostic and therapeutic procedures.

Magnetic resonance imaging of the solitary hepatic mass: direct correlation with pathology and computed tomography.

Magnetic resonance images (MRI) of the liver were obtained using a combination of short time inversion recovery (STIR) and spin echo (SE) sequences. These were correlated with comparable tissue slices generated from resected specimens obtained at partial hepatectomy. All 10 cases appeared to have solitary masses on contrast enhanced computed tomography (CT). Histological examination revealed five primary tumours (two hepatocellular carcinomas, two haemangiomas and one cholangiocarcinoma) and five metastatic tumours. The STIR images demonstrated a high signal intensity in all areas of viable tumour involvement and reduced signal intensity in regions of confluent necrosis with superimposed haemorrhage or calcification. This sequence also demonstrated additional areas of high signal intensity adjacent to several lesions which were not visible on CT. Microscopy of these regions in the specimens demonstrated no tumour involvement or steatosis and their precise cause remains obscure. All the lesions demonstrated on the CT images were visible on MRI and no additional lesions were discovered on detailed microscopical examination of the specimens. Delineation of the extent of the cholangiocarcinoma was a problem with both techniques. MRI showed no major advantage over CT except for a higher contrast of the lesion compared with normal liver and also a better delineation of the tumour mass.

Pleural surgery in patients with cystic fibrosis. A review of anaesthetic management.

Eighteen patients with advanced cystic fibrosis complicated by pneumothorax required either pleurectomy or abrasion pleurodesis. Anaesthesia with nitrous oxide and oxygen was combined with controlled ventilation to both lungs, usually through a double lumen endobronchial tube. Spontaneous ventilation was restored at the end of operation in all but a minority of cases. Ten of 25 procedures were uncomplicated and a further five were followed by non-respiratory events. Respiratory complications developed after the remaining ten procedures which were carried out on six patients, of whom only one survived for more than 6 months. All five fatal cases suffered a recurrence of pneumothorax within 6 months whereas three patients requiring re-operation 2-6 years later survived. The principles of management are discussed and it is concluded that the operative and anaesthetic hazards of thoracic surgery in this group of high-risk cases can be avoided successfully, except when re-operation is required within 6 months.

A quantitative analysis of extraocular muscle cooperation and squint.

The mechanical properties of human extraocular muscles have recently been described. This allows one to use the force-balance equation of mechanics to solve for the complete mechanical state of all six extraocular muscles and the passive orbital tissues in any eye position. This includes each muscle's force, length, innervation, and unit action vector, which describes how its force is distributed to act horizontally, vertically, and in torsion. Most important, this calculation method allows one to predict the tropias that occur in an eye subject to any imaginable form of peripheral pathology. It also permitts, by calculation, an estimation of the correction that might be expected from any sort of muscle surgery. The tight lateral rectus syndrome is used to illustrate the application of the method in diagnosis and surgery. It also offers, for the first time, a quantitative estimate of the multitude of ways in which muscles can interact and interfere with each other when they hold the globe. Two of the results are interesting: because muscles have different lengths and sizes, their innervational participation in a movement can appear to be quite different than their mechanical participation. From an innervational standpoint, the vertical recti and obliques participate equally in vertical gaze. Muscles interfere with each other a good deal and necessitate changes of innervation to counteract these cross-couplings. This causes unexpected dependencies of innervation on eye position and leads, for example, to the fact that the superior rectus innervation in up gaze is just as large in adduction as in abduction.