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Experiments show that the cancellum of some femoral heads and of the trochanteric region is too weak to support a nail. A simple classification of traumatic femoral neck fractures is presented. These are either vertical or, less commonly, transversely disposed. Either type may be undisplaced, impacted, or displaced. For adequate fixation of undisplaced vertical and all displaced fractures a nail plate is essential. For undisplaced transverse fractures and impacted vertical fractures two screws usually suffice. Impacted transverse fractures require no active treatment. Hammering nails into the femoral head can cause fractures of the articular cartilage, split the femoral head in two, lead to avulsion of articular cartilage under the weight-bearing area, and osteoarthrosis. Early weight-bearing on weak implants can be disastrous. For the unsolved fracture a sliding pin compressing the fragments should be used. In a series of 54 displaced fractures so treated, 50 united. Prosthetic replacement should be reserved for patients with poor-quality bone. Children are best treated with a Coventry lag screw. Non-union after internal fixation in young patients should be salvaged by an excisional osteotomy, but a prosthesis is the answer for elderly patients. Late segmental collapse is explained in terms of contact stresses.
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PMID:The science of pinning the neck of the femur. 93 26

The natural history diagnosis and immediate treatment of patients suffering from pulmonary embolism has been discussed. Anaesthetists should use their influence to bring about a high standard of prophylactic care against deep venous thrombosis and consequently of pulmonary embolism. They are likely to be involved in the resuscitation and treatment in intensive care units of those cases who suffer from major symptoms and massive emboli and some of them will rarely be involved in anaesthetising for pulmonary embolectomy aided by cardiopulmonary by-pass and, less rarely, for IVC ligation or plication and venous disobliteration. Anticoagulant drugs appear to limit the mortality of pulmonary embolism to 5%. The mortality of IVC ligation or plication varies in different reports from 2 to 50%; it should therefore be reserved for the special indications which have been discussed. There is also an incidence of recurrent pulmonary embolism after IVC ligation and plication and leg troubles from stasis in about 30% of cases. Streptokinase is usually indicated in the immediate treatment of major pulmonary emboli which cause shock and severe distress with an immediate threat to life. In hospitals having access to cardiopulmonary by-pass, pulmonary embolectomy has a small role to play in major emboli with cardiovascular collapse, if surgery can start within 2 hours and pulmonary angiography is available. Cardiopulmonary by-pass on its own may be life-saving in supporting the circulation while the clot fragments. If cardiac arrest occurs, external cardiac massage should be undertaken as it is sometimes successful and disseminates and fragments the clot in the pulmonary artery.
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PMID:Pulmonary embolism. Prophylaxis diagnosis and treatment. 97 May 90

Various interventions are available to assist in the management of patients with pulmonary embolism. Most are reserved for patients who either fail standard systemic anticoagulation therapy or are not candidates for anticoagulant therapy. The most common intervention is placement of a vena caval filter. Several different filter devices are available, most of which may be placed percutaneously. Pulmonary thrombolysis with urokinase or streptokinase may be appropriate in some patients with severe, symptomatic pulmonary embolism. Finally, pulmonary embolectomy by means of either a transvenous catheter or surgical technique may be necessary in cases of refractory cardiovascular collapse.
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PMID:Interventions in pulmonary embolism. 269 5

The localisation of a pheochromocytoma is difficult and sometimes hazardous. There are many radiological techniques of varying sensitivity and the risks of hypertensive crises or of cardiovascular collapse are not negligeable (especially during arteriography and venography). Abdominal computerised axial tomography (CAT) would appear to be of considerable value. It gives a very precise localisation without any risk. Three personal cases confirm this opinion. The first case was of a 38 year old man with an extra-adrenal pheochromocytoma localised in the pelvis of the left kidney by CAT (after negative intravenous urography); the second case was of a 54 year old man with a left adrenal pheochromocytoma confirmed on CAT (after 2 negative aortic arteriogrammes and adrenal venography); the third case was of a 39 year old woman with a para aortic pheochromocytoma, diagnosed on CAT (after negative intravenous urography). These three cases bring to 43 the total number of reports of pheochromocytoma localised by abdominal CAT. When this method is compared with intravenous urography and aortic arteriography, abdominal CAT is over three times more sensitive than intravenous urography (90% compared to 26%) and also more sensitive than arteriography (90% compared to 76%). The false negative results on CAT usually involve small tumours (diameter less than 30 mm). The new generation of CAT should reduce these errors. The great advantage of this investigation should change the order of the radiological examinations in the localisation of pheochromocytoma. It would seem logical to carry out an abdominal CAT as soon as biological confirmation of the hypersecretion of catecholamines had been obtained. The other radiological investigations (especially aortic arteriography) should be reserved for cases with negative abdominal CAT.
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PMID:[Topographic diagnosis of pheochromocytoma. Value of computerized axial tomography]. 677 30

Diagnosis of acute, primary extensive pneumopathies provoking severe hypoxemia is particularly difficult, became of the non-specific radiological findings, resulting from the oedema and associated alveolar collapse, and the fact that the clinical picture and biological test results are not very characteristic of a particular etiology. Similar findings may be obtained, therefore, in bacterial pneumopathies so-called typical pulmonary affections, certain forms of acute, tuberculosis, and other types of infection of three patients admitted for acute respiratory insufficiency, two died after treatment with a betalactamine, alone or associated with an aminoside, subsequent serology providing evidence of psittacosis. Diagnosis was immediately established in the third patient, the wife of one of the other cases, and she recovered after erythromycin treatment. The lungs of the two patients that died showed suggestive bronchiolitis and peribronchiolar alveolitis, together with obliterative alveolar granulations and fibrosis, probably secondary to the psittacosis, and responsible for the fatal outcome. Psittacosis as a cause of an extensive pneumopathy of probable infectious origin may easily pass unrecognized, typical etiologies being infections due to pneumococcus, Legionella pneumophila. Mycoplasma pneumoniae, and viruses. Erythromycin, active against these microorganisms, would therefore appear to be the antibiotic therapy that should be prescribed initially, those with wider spectrums being reserved for cases with atypical radiological findings, or when precise bacteriological data is available.
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PMID:[Psittacosis as a cause of acute respiratory distress syndrome (author's transl)]. 710 4

Bilateral chylothorax is an extremely serious complication that affects the cardiorespiratory system and places the patient in serious danger of respiratory collapse. In cases of postoperative chyle fistula or chylomas, one should consider the possibility of chylothorax. Chest film and, subsequently, diagnostic thoracentesis can provide the diagnosis. Conservative treatment, such as repeated thoracentesis, low-triglyceride diet, and possibly closed thoracostomy tube drainage, should be used. The surgical approach for the ligation of the thoracic duct should be reserved for cases that do not respond to the previously mentioned conservative measures.
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PMID:Bilateral chylothorax. Rare complication of neck dissection. 724 22

Tuberculosis is a deadly disease affecting many people in the world. The prevalence of spinal tuberculosis is likely to rise as the numbers of those infected with human immunodeficiency virus rises. This presentation summarizes present knowledge of spinal tuberculosis and its management. It describes and updates material the author has previously published on this subject. The scientific basis for the clinical management of spinal tuberculosis has been well established by the British Medical Research Council group and Hong Kong surgeons. It is believed, however, that well-controlled basic and clinical studies are required if the incidence of the three unwanted complications of spinal tuberculosis is to be reduced further. Antituberculosis agents are the mainstay of management, with chemotherapy for 12 months preferred to shorter courses. The standard is a combination of isoniazid, rifampin, and pyrazinamide, with or without ethambutol. Anterior surgery consisting of radical focal debridement without fusion does not prevent vertebral collapse. The major advantage of anterior arthrodesis is the decreased tendency for progression of the deformity. Patients who present late with deformity are candidates for anterior debridement and stabilization with corrective instrumentation. Posterior stabilization with instrumentation has been found to help arrest the disease and to bring about early fusion. Posterior instrumented stabilization to prevent kyphosis in early spinal tuberculosis is indicated, however, only when anterior and posterior elements of the spine are involved, particularly in children. With early detection, institution of chemotherapy, and improved surgical techniques, patients with kyphosis rarely are seen today, particularly in urban centers that have an effective medical system. For these same reasons, patients with spinal tuberculosis who present with paraplegia and no deformity usually respond well to treatment. It is concluded that spinal tuberculosis without unsightly kyphosis and neurologic symptoms is a medical, rather than a surgical, condition. Surgery should be reserved for those patients who have advanced tuberculosis with unacceptable complications such as paraplegia and/or deformity.
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PMID:Tuberculosis of the spine. Controversies and a new challenge. 925 93

Although several studies of various treatment modalities have been reported during the past decade, osteonecrosis of the femoral head remains a difficult therapeutic problem. Total hip replacement which is reserved for patients showing collapse of the femoral head, usually shows poorer results in patients with osteonecrosis compared with those with osteoarthritis. Uncemented total hip arthroplasty was performed on 29 patients with avascular necrosis of the femoral head and 29 patients with degenerative osteoarthritis. After a mean followup of 7.6 years and 7.1 years for the two groups of patients, only one failure was observed in one patient with osteonecrosis. Clinical evaluation after cementless total hip arthroplasty in both groups of patients revealed improvement in all parameters. Postoperatively, pain improved from 1.4 to 5.1, walking ability from 3.4 to 5.3, and range of motion from 4.5 to 5.5 in patients with osteonecrosis, and pain improved from 1.2 to 5.3, walking ability from 3.2 to 5.4, and range of motion from 3.1 to 4.7 in patients with osteoarthritis. Thigh pain was observed postoperatively in only two and three patients treated for osteonecrosis and osteoarthritis, respectively. The present results using cementless arthroplasty seem to be somewhat better than those reported for cemented arthroplasty in patients suffering from osteonecrosis. The clinical and radiographic findings after noncemented arthroplasty in patients with osteonecrosis of the femoral head and in patients with degenerative arthritis of the hip were similar in the two groups.
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PMID:Total hip arthroplasty for avascular necrosis and degenerative osteoarthritis of the hip. 926 56

Idiopathic osteonecrosis of the medial femoral condyle is a well recognized cause of spontaneous, sudden onset of severe pain, usually at the anteromedial aspect of the knee joint. At the Department of Orthopaedic Surgery of the University of Ioannina, 105 knees in 101 patients were evaluated and treated for idiopathic osteonecrosis of the medial femoral condyle. The disease was found to follow a four-stage course, which consisted of a progression from no radiographic findings (Stage I), to a slight flattening of the medial condyle (Stage II), followed by the appearance of a radiolucent lesion (Stage III), and finally, articular cartilage collapse (Stage IV). Although Stages I and II potentially were reversible, Stages III and IV were associated with irreversible destruction of the subchondral bone and articular cartilage. Although bone scan is a nonspecific diagnostic modality, it was helpful in establishing diagnosis in the early stages of the disease. Conservative treatment was found appropriate for the first two stages, whereas surgical management was effective for patients with Stages III and IV. Specifically, osteotomy was useful for patients younger than 60 years of age with limited necrotic lesions, whereas unicompartmental arthroplasty was effective in older patients with more extensive lesions. Total knee arthroplasty can be reserved for cases where the disease has expanded to the lateral compartment.
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PMID:Idiopathic osteonecrosis of the medial femoral condyle. Classification and treatment. 926 59

Paroxysmal supraventricular tachycardia caused by atrioventricular re-entry is the most frequent arrhythmia in children of all age groups. It represents the most frequent clinical situation where antiarrhythmic drug therapy has to be considered in a child. Acute termination of an episode of tachycardia in all paediatric age groups is nowadays best achieved with an intravenous bolus injection of adenosine. Since the introduction of adenosine into clinical practice, the need to proceed to electrocardioversion has been limited to the infant (or in rare cases an older child) with severe cardiovascular collapse. In the haemodynamically stable infant or child, several other antiarrhythmic agents such as flecainide or propafenone can be used with relative safety and with a high probability of immediate success. The same is true for verapamil, although intravenous administration should be avoided in the first year of life. In newborns and in infants with first presentation of an episode of tachycardia, drug prophylaxis of recurrences is usually recommended for the whole of the first year of life. Prophylactic treatment may consist of oral digoxin as first choice, with a beta-blocker as an alternative. In an infant with Wolff-Parkinson-White syndrome it may be wise to avoid digoxin and to start treatment with a beta-blocker. Antiarrhythmic class Ic drugs such as propafenone or flecainide, and the class III agent sotalol, are widely used as the next steps of therapy when digoxin and beta-blockers fail to prevent recurrences. These agents are about equivalent with regard to their efficacy and risk profile. Amiodarone is considered to be an agent that should be reserved for use in situations when the tachycardia is refractory to the previously named agents. Older children may commence treatment with a beta-blocker and the subsequent steps of treatment are the same as those for infants. Curative catheter ablation of accessory pathways has been shown to be as efficient and well tolerated in the paediatric age group as it is in adults. This treatment option is nowadays quite often offered to older children. However, in infants and smaller children, ablation is used as a last resort. Rare forms of paediatric supraventricular tachycardia (other than atrioventricular re-entry through the atrioventricular node or accessory pathways) are occasionally difficult to treat and present special problems. For each of these arrhythmias, a specially tailored individual therapeutic approach is needed.
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PMID:Safety issues in the treatment of paediatric supraventricular tachycardias. 958 46


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