[Traumatic posterior dislocation of the shoulder in adults. Apropos of 25 cases]. / Les luxations traumatiques postérieures de l'épaule chez l'adulte. A propos de vingt-cinq cas.

In a series of 25 traumatic posterior dislocations of the shoulder treated from 1960 to 1985, 16 were overlooked and the time from injury to treatment ranged from 3 weeks to 14 months. 11 cases were secondary to motor vehicle accident and 14 occurred after a convulsive fit. Early closed reduction was effective in only 4 cases; in 2 cases, reduction was unstable and further screwing of an associated fracture of the tuberculum majus was performed to prevent redislocation; 3 locked dislocations necessitated open reduction and stabilization by subscapularis transposition into the defect of the humeral head. Most of the 16 chronic unreduced dislocations were treated by the same procedure. Overall, 21 cases were reviewed with a mean follow-up of 14 years. Functional outcome was more often satisfactory in acute (5/7) than in old unreduced dislocations (6/14). Mc Laughlin or Neer's procedures yielded good results in 9 out of 14 cases; they are indicated irrespective of the patient's age whenever Mc Laughlin's notch does not involve more than one third of the articular surface of the humeral head.

[Cauda equina syndrome due to early postoperative migration of an adipose tissue flap following laminectomy]. / Syndrome de la queue de cheval par migration post-opératoire précoce d'un lambeau graisseux après laminectomie.

The authors reported an early case of cauda equina syndrome after hemilaminectomy and discectomy for lumbar disc herniation. CT-scan revealed the migration of the free fat graft used for preventing peridural scar formation. Removal of the graft resulted in total patient's recovery.

Patellar metastasis from a large bowel adenocarcinoma.

Although bone tumors are often located in the knee area, primary tumors of the patella are rare (6, 8), and patellar metastases even rarer. A few cases were reported in the literature, originating from the breast, lung, kidney, uterine cervix and oesophagus. We report a case, for the first time to our knowledge, of a patellar metastasis from a large bowel carcinoma.

[High frequency jet-ventilation in esophagotracheal fistula]. / Jet-ventilation à haute fréquence au cours d'une fistule oesotrachéale.

High-frequency jet-ventilation (HFJV) is not widely used, mainly because of technical problems and difficulty to assess its efficiency. However, there is general agreement on following major indication: artificial ventilation in patients with oesotracheal fistula. In the case reported here, HFJV allowed efficient ventilatory support through an endotracheal tube with deflated cuff. Weaning was progressively obtained. Surgery and postoperative course were uneventful.

[Treatment of humeral shaft fractures with the Marchetti nail: 50 cases]. / Traitement des fractures de la diaphyse humérale par enclouage élastique de Marchetti.

PURPOSE OF THE STUDY: There is no universal agreement concerning the most appropriate method for treating humeral shaft fractures. Orthopedic treatment was long proposed due to the risks of surgical management. Screwed plate fixation raises the risk of infection, neurological injury and nonunion. Anterograde nailing can lead to subacromial conflicts. The purpose of this study was to analyze results of an elastic retrograde nailing technique using the Marchetti nail. This method would appear to offer the advantages of closed osteosynthesis without interrupting the rotator cuff. MATERIAL AND METHODS: Fifty fresh traumatic fractures of the humerus were treated with Marchetti nailing between December 1995 and June 1999. Ten patients had died at last follow-up after having achieved bone healing. Outcome was assessed at a mean 22 months post-surgery for 39 patients. The AO classification and the Hackethal classification modified by De la Caffinière were used. Outcome was assessed according to the Stewart and Hundley classification. RESULTS: Very good outcome was achieved in 13 patients (33%), good outcome in 21 (54%) and poor outcome in 5 (13%). The assembly dismounted in 1 patient who required revision for pin insertion. Two cases of nonunion and two cases with poor function were observed. Mean delay to union was 10 weeks. There were no cases of infection or iatrogenic radial nerve palsy. Secondary fracture at material ablation occurred in 2 cases. DISCUSSION AND CONCLUSION: Closed fixation is an advantage of this method (minimal risk of infection and radial injury). In addition, the rotator cuff is not perturbed. The drawbacks include the risk of secondary fracture, almost exclusively at ablation.

[Scaphoid-trapezium-trapezoid dislocation. 5 cases]. / La luxation scapho-trapézo-trapézoïdienne. A propos de cinq cas.

The authors report 5 cases of scaphoid-trapezium-trapezoid dislocation (STT) which occurred in crush injuries of the hand. A good functional result was achieved by closed reduction and pinning whenever there was no associated soft tissue damage. However, lateral mid carpal osteoarthritis may develop and produce reduction of the abduction of the thumb as well as slight stiffness of the wrist.

Mass spectrometric measurements of oxygen uptake during epidural analgesia combined with general anesthesia.

Oxygen uptake was measured using a mass spectrometer system in 12 patients scheduled for abdominal surgery who intraoperatively were mechanically ventilated with 50% nitrous oxide and given continuous intravenous infusions of methohexital (3.5 mg.kg-1.h-1) plus repeated epidural injections of lidocaine. At the end of the surgical procedure, meperidine (0.7 mg/kg) was epidurally injected in six patients (group A). The other six patients (group B) received no epidural injections during the first 2 h after surgery. Intraoperatively, oxygen uptake decreased in both groups by an average of 28%. Within the first two postoperative hours, clear-cut differences among the two groups arose. Patients in group A had smoother increases in oxygen uptake and core temperatures, greater cardiovascular stability as reflected by the rate-pressure product, and no visible shivering. We suggest that epidural meperidine given immediately at the end of a surgical procedure might be beneficial, especially, perhaps, in patients with impaired cardiac function.

Oxygen uptake after major abdominal surgery: effect of clonidine.

To examine the effect of an alpha-2 agonist, clonidine, on oxygen uptake and on the incidence of postoperative shivering, 28 patients presenting for major abdominal surgery were randomly assigned in a double-blind manner to one of two groups. Intraoperatively, 14 patients received 5 micrograms.kg-1 clonidine infused over 3 h (clonidine group), and 14 patients received placebo (placebo group). Oxygen uptake was measured continuously over the first 3 postoperative hours with a mass spectrometer system. Circulatory variables, esophageal temperature, and skin temperature were measured over the first 6 postoperative hours. Heart rate, mean arterial pressure, rate pressure product, and norepinephrine concentration were decreased in the clonidine group (P less than 2 x 10(-4)). There were no differences among groups in the incidence of shivering and in the rate of increase of esophageal temperature. By contrast, oxygen uptake was lower in the clonidine group (P = 4 x 10(-4)). This contrasting pattern may be secondary to a reduction in the intensity of mean muscular tremor in the clonidine group.

Clonidine for major vascular surgery in hypertensive patients: a double-blind, controlled, randomized study.

The utility of clonidine for hypertensive patients presenting for major vascular procedures remains debatable. Twenty-one hypertensive patients presenting for aortic surgery were given clonidine (n = 11) or placebo (n = 10) in a double-blind, randomized manner. Clonidine was administered 6 micrograms/kg per os 120 min before induction of anesthesia and 3 micrograms/kg intravenously (i.v.) over 60 min from aortic declamping to skin closure. Anesthesia was induced with alfentanil 20 micrograms/kg, midazolam, and atracurium and maintained with nitrous oxide 70%, an alfentanil infusion (0.25 microgram.kg-1. min-1), and isoflurane. Anesthetic requirements, circulatory variables, interventions, and isoproterenol dose-response curves (pre- and postoperatively) were determined. Plasma concentrations of clonidine, alfentanil, and vasoactive hormones were measured. When the clonidine group was compared with the placebo group, (a) isoflurane, alfentanil, and midazolam requirements were reduced by 38%, 42%, and 41%, respectively (P = 0.04, 0.03, 0.0002, respectively); (b) supplemental circulatory and anesthetic adjustments were reduced by 51% (P = 0.0006); (c) interventions with vasopressors were not significantly increased (placebo: two; clonidine: five); (d) systolic and mean arterial pressures and heart rate were reduced; (e) increases in norepinephrine, epinephrine, and plasma renin activity were suppressed, whereas vasopressin surge was attenuated; and (f) chronotropic response to isoproterenol was unaffected. Clonidine was effective in reducing anesthetic requirements and in improving circulatory stability in hypertensive patients presenting for major vascular procedures.