Iranian Journal of Surgery
Year:2004 | Volume:12 | Issue:32|Papers Count:14

Arthritis of the knee is a common problem: 2% of United States population older than 17 years of age and 40% of Americans over 65 years age have clinically relevant arthritis of the knee. Degenerative arthritis is a progressive disease in active patients. Over loading the articular cartilage is harmful for cartilage nutrition.Maintaining the knee in a position without motion, like casting, for a long time deteriorates cartilage. The reduction of body mass and avoiding stair climbing and descending is a fundamental concept in prevention and treatment of knee arthritis.Analgesics without anti-inflammatory properties such as acetaminophen, are the initial medications used to treat degenerative arthritis of the knee.Nonsteroidal anti-inflammatory medications are the most commonly used drugs for treatment of degenerative arthritis of the knee joint. Cox I anti-inflammatory medications are less expensive and more effective, but has more, hepatic, GI and renal side effects.Cox 2 anti-inflammatory medications are more expensive, less effective and have less side effects. Cost-effective, risk-benefit matters should be considered in prescribing these medications.Nutritional supplement such as glucosamine and chondroitin sulfate have not shown any effect on cartilage regeneration in long term studies.Acute episodes of degenerative arthritis of the knee with pain and effusion can be treated by aspiration and intra articular steroid injections. However corticosteroid injections can increase the risk of damage to articular cartilage, should not repeat more than three to four times a year. Comparing intra-articular Hyaloronan injections with corticosteroids were found to be slower, more expensive and higher risk of local inflammatory response and overall no superiority.Quadriceps exercise, hamstring stretching and weight reduction has value in the treatment for arthritis of the knee joint.Knee braces like unloaded knee braces, elastic bandages provide a feeling of increased support and pain relief in patients. Shoe inserts like wedges decrease the forces on involved side and decrease the pain of patients.

Introduction & Objective: Brachial plexus palsy that does not recover within three months is operated on. If the palsy persists more than two years, and recovery dose not take place without reparative surgery, the nerves of the plexus territory will not recover, and the paralysis is considered permanent. This article is discussing what can be done with these cases.Materials and Methods: Since the nerves of the paralyzed side have completely lost their function, the nerves of the contralteral side must be used. The transfer of C7 root of the healthy side to the paralyzed region followed by transfer of a suitable muscle as a free flap has been suggested since 1994, and was performed for a while. It was found however that the severing, of the C7 root has some complications. We have performed the procedure in a few cases and have observed some complications as well.The best procedure for the treatment of the condition is the transfer of Medial Pectoral Nerve form the healthy to the paralyzed side by the use of Sural nerve which is followed by the transfer of gracilis muscle transfer to the arm, neurotized by the transferred Sural nerve, one year after the primary operation. Elbow flexion is achieved with the recovery of transferred gracilis muscle.After complete recovery of elbow flexion, the biceps tendon is transferred to the digits flexors by a tensor fascia lata. After the procedure elbow digits contraction is achieved by the contraction of the elbow.Results: This procedure has been performed for the fIrst time in Iran. This procedure been performed on 23 patients and digits flexion attained by the procedure has been satisfactory. The treated patient can carry a medium weigh bag.Conclusions: Functional Neuro-vascularization of the paralyzed limb is attained by the transfer of the healthy side pectoral nerve to the paralyzed side, followed by the transfer of gracilis muscle.

Introduction & Objective: Blunt injury to the chest continues to be one of the leading causes of morbidity and mortality in trauma patients and flail chest is among the worst of these injuries. The treatment varies with the severity of injury, ranging from supportive such as oxygen enrichment, chest physiotherapy and pain relief to internal fixation with surgery or invasive and non invasive positive pressure ventilation (IPPV & NIPPV).Material & Methods: In our study 56 patients with diagnosis of flail chest prospectively were managed in the ICU with supportive management such as: oxygen therapy, analgesia and chest physiotherapy with or without invasive or noninvasive mechanical ventilation depending on injury severity score (ISS), trauma to head or other vital organs, respiratory distress and level of conscious, patients were divided into three groups. GI (n=20): were treated with supportive measures (pain control, oxygen therapy with simple mask and chest physiotherapy). GII (n=17): were ventilated with continuous positive airway pressure (CPAP) 5-12 Cm H20 and GIII (n=19): were intubated and controlled ventilation. All of the groups were received, IV infusion of Fentanyl 1µg/kg/h or Marcaine 0.5% (0.1 m1/kg/h) through epidural catheter, for pain control.Their data were analyzed to determine the effectiveness of management, ICU stays, weaning time and to know complications, morbidity and mortality following both therapies.Results: 56 patients (M=37, F=19) were studied injury severity score (ISS) in the patients from GIII was significantly higher than GI and GII.(GI:14+2.1, GII:25+3.4, GIII:36+5.5) (p<0.01). depends on PaO2 and PaCO2 at admission time in ICU or recovery ,no difference were observed between three groups. The mechanical ventilation was required 9+4.6 in GII and 12+5.6 days in GIII. (p<0.01) the most common complication was pneumonia (GI:4, GII:9 and GIII:18) (p<0.01). Correlated presence of average of ICU stays and the use of mechanical ventilation. (P<0.003) (GI: 6+3.3, GII: 12+5.4, GIII: 15+7.3). Fatality rate was 9 (GII: 1, GIII: 8) the most common cause of death was severe head injury (4 patients). Mortality rate was also comparable with injury severity score.Conclusions: We observed that outcome of flail chest patients does not depend on ventilatory or nonventilarory management but on severity of pulmonary damage, injury severity score (>30) and associated injuries specially craniocerebral. So we suggest depending on injury severity score (ISS), trauma to head or other vital organs, respiratory distress and level of consciousness, the first step of treatment of these patients is supportive measures such as oxygen enrichment, chest physiotherapy and pain relief, then non-invasive positive pressure ventilation(CPAP) and finally mechanical ventilation and we don't suggest internal fixation with surgery for these patients.

Introduction & Objective: During upper mediastinal, Surgical interventions innominate vessels may be ruptured inadvertently or divided intentionally by the surgeon for a better exposure. "The question, "Whether a divided Innominate artery or vein should be reconstructed or not?" has not yet been clearly answered.Material and Methods: In a retrospective review of hospital records of all patients who underwent any kind of surgery between 1996 and 2004 in our department, 11 patients, 7 females & 4 males were found who had an upper mediastinal surgery with ligation of a great vessel.Fourteen great vessels, 6 Innominate arteries - 4 left Innominate veins - 3 right Innominate veins – one right carotid artery were ligated with no reconstruction.In 6 patients the vessels were intentionally divided & ligated for a better exposure and in 5 for control of severe bleeding due to iatrogenic trauma.Findings: One patient with Innominate artery and right Innominate vein division suffered a 48 hours period of coma due to a cerebral edema which recovered completely. Two patients developed sternal wound infections and were managed with antibiotics and wound care. No other complication occurred. In two patients, after division of the Innominate arteries occurred, the peripheral pulses were disappeared but there was no muscle weakness, or ischemic pain of the limb.Conclusions: In critical conditions and when surgical situation is not suitable for reconstruction, Innominate veins and artery could be ligated and divided for a better exposure or control of bleeding with acceptable postop risks.

Introduction & Objective: Tracheal injuries are serious and life threatening. Before arriving in emergency departments, many patients die at the site of the accident.Tracheal injuries are due to the penetrating and non penetrating injuries, iatrogenic injuries and deceleration traumas.Material and Methods: This investigation was performed prospectively on 248 patients, from 1982- 89. Twenty seven patients had tracheo-laryngeal injuries, including twelve who had war trauma, and 15 who had civilian traumas. Findings: Nine patients had laryngeal or tracheal injuries that were treated non-surgically with nasoteracheal intubations. Three patients with tracheostomy, who had been referred from line of battle to our hospital, were explored. Esophageal perforations were found and repaired. Another fifteen patients were treated with exploration, repairing of tracheo-bronchial tree and nasotracheal-intubations.One of the intubated patients was extubated because of otitis media. Another patient couldn't tolerate oroteracheal-tube and was treated with tracheostomy. All of the patients were extubated until the 17th day. Following up the patients, we didn't find any tracheal stenosis or other complications.Conclusions: Speeding up the emergency services to victims and fast, academic transportation have the most important effect on the survival of the patients. Missed traumas were found in patients who had been referred from battle field hospitals or earthquake areas to our hospital. Special attention should be paid to these patients.

Introduction & objective: Spaghetti wrist is an extensive volar wrist laceration in which at least 10 structures, including tendons, at least one major nerve and usually one major vessel are divided. These injuries are usually accompanied with severe permanent complications. The aim of this study was to evaluate the spaghetti wrist injury in IRAN and find the ways of decrease the complications and obtain better results.Materials & Methods: Medical records of all patients with spaghetti wrist lacerations whom operated on by the authors between March 1999 and March 2003 in the Department of Plastic and Reconstructive Surgery of 15th Khordad Hospital were reviewed retrospectively.Results: This study reviews 124 patients with" spaghetti wrist" lacerations. All injuries were sharp lacerations. A total of 115 men and 9 women with average age of 24.5 years (range 8 to 62 years) sustained spaghetti wrist injures. The most commonly injured hand was right hand (74.9 percent). The most frequently injured tendons were third and fourth FDS (98.3 percent). The ulnar nerve was more commonly injured than the median nerve. The ulnar artery was more commonly injured than the radial artery.In the subset of 30 patients available for follow-up examination, range of motion was excellent in 14 patients and good in 8 patients. Intrinsic muscle recovery was good in 9 patients and fair to poor in 21 patients. Sensory return was disappointing: 17 patients recovered only protective sensation and 13 patients demonstrated return of two-point discrimination that ranged from 7 to 13mm in 10 patients and from 2 to 6mm in 3 patients.Conclusions: Generally recovery of function in "spaghetti wrist" after repair is not satisfactory. In order to better results we should first pay precise attention to repair of injured structures, second early movement, appropriate physiotherapy and patient's co-operation are required.

Introduction & Objective: From the beginning of the development of medical science the problem of infertility and sterility had been an issue with great concern. Particularly in our community, in a way that infertility might influence the consequence of the successful marriage, so in order to investigate the cause of infertility lately the laparoscopy procedure is the most important step toward the correct diagnosis.Material and Methods: In this paper 300 infeirtile cases were underwent laparoscopy procedure during the years 1370 to 1380. The age distribution was 56.3% between 21-30 years of age, which account for majority of the patients, the less numbers were 40 to over 40.Results: Our analysis revealed the main cause of infertility among the 300 patients overall was tubal factors in 19% and adhesions in 12.6%. In patients with secondary infertility the leading cause was tubal 33.8%. However among the primary cases was PCOD (polycytic ovarian disease) 22.2%. Conclusions: From the outcome of our investigations the main cause of infertility are tubal factors and adhesions. The laparoscopy procedure is most reliable way of proper diagnosis, in the mean time this procedure proved To be safe with few minor complications.

Introduction & Objective: Since 1969, Committee on Young Surgeons (CYS) have started to improve the educational condition and some other purposes for young surgeon in USA. For some years educational committee and scientific director of IRAOS has raised up the feeling of needs for a young surgeons committee and for selecting active members, a pilot study of attitude and tendency of young surgeon (<45yr) was conducted in Tehran, Iran.Material and Methods: A simple randomized cross - sectional descriptive study based on data sheet, was collected, and 122 young individuals (81 surgeons, 41 residents) in Teheran has filled our data sheets.Results: 49% of residents were in 31-35 range of age and 46% of surgeons were in 36-40 range of age. 91% of residents and 66% of surgeons had male sex. 54% of residents and 88% of surgeons had awareness from annual congress. 27% of residents and 47% of surgeons said that the advertising was enough for congress. 37% of residents and 63% of surgeons had incitation for being in congress. 30% of residents and 64% of surgeons said that they participate in these congresses. 25% of residents and 27% of surgeons have sent an article to IRAGS.Conclusions: Committee on young surgeons in IRAGS will start and these guidelines and results will help to conduct it.

Introduction & Objective: Breast cancer is the most common cancer and the leading cause of death in women between 40-45 years old. Although its incidence has increased in recent years, but, its mortality has been constant because of identification predisposing factors and early diagnosis. Material and Methods: In a cross sectional study, 638 women with breast cancer referring to educational hospital were studied for risk factors. Most of subjects were in 50-59 years old age group (55.9%).Conclusions: Ninety percent of subjects were married. Eighty percent of subjects were in menopausal period. Menarche age was 10-12 years old in 56.6% of women. 17.1% had history of benign breast disease. 26.5% had positive family history of breast cancer. 4% had history of primary ovarian or endometrial cancer. History of contralateral breast cancer was positive in 3% of subjects. Chest radiation history was positive in 1.4% of women were living in cities. 14% of subjects were infertile. 34% had 60-69Kg weight. Old age, living in city, early menarche, late menopause age and positive family history are the most important risk factors.Discussions: History of primary ovarian and endometrial cancer, contralateral breast cancer and also weight above 60kg are less important. Single, first delivery in old age and parity aren't important risk factors.

Introduction & Objective: The histologic status of the axillary nodes remains the single best predictor of survival in patients with breast cancer. The sentinel node is defined as the first lymph node in a regional lymphtic chain that receive lymph flow from a primary tumor. Several investigators have confirmed the hypothesis that the histologic status of the sentinel node accurately predicts the pathologic status of the entire axilla. The aim of this study was to evaluate lymphatic mapping for breast cancer.Material & Methods: In a descriptive study from 1379 to 1380.In amid and alzahra hospital in Isfahan 36 patients with clinical Tl-3 breast cancer clinically negative axilla were studied mapping procedures and sentinel node were performed using isosulfan-blue injected at the primary breast cancer site followed by axillary lymph node dissection sentinel node and axillary were evaluated pathologically (H&E) after opration.Results: In 2 of 36 cases the sentiel node (SN) biopsy was false negative. The overall sensivity of the SN technique was 85/7% with a specificity of 90/9% the overall positive and negative predictore values were 85/7% and 90/9% respectively.Conclusions: Our study indicates that intraoperative lymph mapping using isosulfanblue and sentinel lymph node dissection can accurately prediet the axillary of primary breast cancer, in patient with clinically negative axilla.

Introduction & Objective: Acute appendicitis is one of the most common causes of acute surgical abdomen. The inaccuracy of available diagnostic methods has led to an unacceptable high negative appendectomy and perforation rate. We decided to determine the population based age and sex incidence of negative appendectomy.Methods: In a clinical trial study, 666 consecutive patients with a clinical diagnosis of appendicitis were done. After determination of negative appendectomy rate in different age and sex groups, their relationship, analyzed by chi-square test.Results: 666 patients evaluated, 57% were males and 43% females. The average of age was 27.17±13.2 years. In supplemental studies, 448 cases were evaluated as suspected appendicitis. Pathology revealed 342 positive appendicitis (case=77%) and 106 negative appendectomy (control=23%). The negative appendectomy rate in males was higher than females (36% vs. 17%, p=0.000).A rate of normal appendectomy for the young (male and female 6-12 years) and reproductive female (13-50 years) groups was higher than elderly (over 60 years) and the rest (male 13-59, female 51-59 years) (68% vs. 32%, p=0.001).Conclusions: Regarding to the high incidence of negative appendectomy, in some sex and age groups, it is suggested that surgical intervention in their acute cases should scrutinized cautiously.

Introduction & Objective: While reviewing the literature on this topic and using self experiences, it will be tried to investigate the pros and cons about randomized controlled trial (RCT) as a technique for researches in the field of surgical investigations. It is not intended to review the classical methodologies as mentioned in the related textbook but only the main points about the classic milestones of researches and investigations will be reminded and the limitations in setting the surgical protocols along with those principles will be discussed.Material and Methods: Reviewing the history of research programs and methods in the fields of clinical and surgical researches, a brief recall will be made about the preventive health sciences and clinical therapies research methodology. It will be tried to confirm the necessity of performing randomized trials (RCT) specially in the field of surgery while denoting the difficulties and possible problems encountered.Results: We will come to the conclusion that even though there are limitations and draw backs in performing clinical trials and RCT in surgical investigations, but there are several key points that match between the main protocols.Conclusions: The milestone for confirming the best method for surgical management of a disease is RCT. The methodologist colleague should be aware of the surgical milestones and the surgeon fellow should know the principles and guidelines of evidence based surgery.