Bilateral anterior ischemic optic neuropathy following influenza vaccination.

Optic neuritis is an occasional complication of vaccination. Visual loss can be unilateral or bilateral, and most patients recover substantially without treatment. The presumptive mechanism is an immune-mediated demyelinating injury of the optic nerve. We report two patients who had permanent visual loss following influenza vaccination. Their pattern of visual loss, segmental optic disc changes, and failure of visual recovery were atypical for demyelinating optic neuritis and reminiscent of a primary ischemic injury to the optic nerve. We speculate that an immune complex-mediated vasculopathy following vaccination can cause anterior ischemic optic neuropathy. Clinicians should be aware of this entity because of the less favorable prognosis for visual recovery in these cases.

Apport du CT-3D dans le diagnostic et le traitement des fractures des plateaux tibiaux [Value of 3D CT in diagnosis and treatment of fractures of the tibial plateau]

A precise classification and an optimal understanding of tibial plateau fractures are the basis of a conservative treatment or adequate surgery. The aim of this prospective study is to determine the contribution of 3D CT to the classification of fractures (comparison with standard X-rays) and as an aid to the surgeon in preoperative planning and surgical reconstruction. Between November 1994 and July 1996, 20 patients presenting 22 tibial plateau fractures were considered in this study. They all underwent surgical treatment. The fractures were classified according to the Müller AO classification. They were all investigated by means of standard X-rays (AP, profile, oblique) and the 3D CT. Analysis of the results has shown the superiority of 3D CT in the planning (easier and more acute), in the classification (more precise), and in the exact assessment of the lesions (quantity of fragments); thereby proving to be of undeniable value of the surgeon.

Anterior Segment Angiography in Strabismus Surgery

Background: Anterior ciliary arteries travelling along recti muscles provide anterior segment vascularization, which can be compromised by surgery involving more than 2 muscles.Patients and Methods: We studied retrospectively the files of 10 patients in whom a fluorescein angiography of the iris had been performed as a pre-operative assessment prior to a second or third oculomotor surgery.Results: The median age of the patients was 47.5 years (range 15 to 73 years). Relative iris ischemia was present in 4 patients following multiple surgeries, none of them presenting any general cardiovascular risk. The initial surgical protocol was modified according to angiographic results in these 4 patients.Conclusion: When further surgery has to be performed on previously multi-operated patients, anterior segment angiography can be useful in the planning of surgery in order to minimize the risks of anterior segment ischemia.

Systèmes de délivrance des médicaments pour le segment antérieur: bases fondamentales et applications cliniques [Drug delivery systems to target the anterior segment of the eye: fundamental bases and clinical applications].

The development of new drug delivery systems to target the anterior segment of the eye may offer many advantages: to increase the biodisponibility of the drug, to allow the penetration of drug that cannot be formulated as solutions, to obtain constant and sustained drug release, to achieve higher local concentrations without systemic effects, to target more specifically one tissue or cell type, to reduce the frequency of instillation and therefore increase the observance and comfort of the patient while reducing side effects of frequent instillation. Several approaches are developed, aiming to increase the corneal contact time by modified formulation or reservoir systems, or by increasing the tissue permeability using iontophoresis. To date, no ocular drug delivery system is ideal for all purposes. To maximize treatment efficacy, careful evaluation of the specific pathological condition, the targeted Intraocular tissue and the location of the most severe pathology must be made before selecting the method of delivery most suitable for each individual patient.

Formation of a direct arterial blood supply to the anterior pituitary gland following complete or partial interruption of the hypophyseal portal vessels

If regions of the anterior pituitary gland received systemic blood via a direct arterial blood supply these regions would escape hypothalamic regulation and thus be a sequela in endocrine disorders. Since, in the untreated rat, all of the blood supply to the anterior pituitary gland is via the hypophyseal portal vessels, we hypothesized that partial interruption of the portal vessels could provoke the establishment of a direct arterial blood supply (arteriogenesis). We utilized the injection of polystyrene microspheres (15 or 9 micron diameter) into the left ventricle of the heart to test this hypothesis. Microspheres are trapped in the first capillary plexus they reach since they are too large to traverse the capillaries. No microspheres reached the anterior pituitary gland of control rats, a finding consistent with the fact that the anterior pituitary gland receives all of its blood supply via the hypophyseal portal blood vessels. Microspheres were observed in the primary portal capillary plexus in the infundibulum (median eminence), infundibular stalk (pituitary stalk), and infundibular process (pars nervosa), the first capillary plexus which they reached. A lesion of the medial basal hypothalamus (MBH) which destroyed the long portal vessels did not result in arteriogenesis since few, if any, microspheres were observed in the anterior pituitary gland. We confirmed, using vascular casts, that these lesions resulted in the long-term destruction of the primary portal capillaries in the infundibulum and of the long portal vessels. In MBH-lesioned animals it appears that all of the blood supply of the anterior pituitary gland is via short portal vessels arising from the infundibular stem and process.(ABSTRACT TRUNCATED AT 250 WORDS)

A new ambulatory system for comparative evaluation of the three-dimensional knee kinematics, applied to anterior cruciate ligament injuries

The aim of this study was to develop an ambulatory system for the three-dimensional (3D) knee kinematics evaluation, which can be used outside a laboratory during long-term monitoring. In order to show the efficacy of this ambulatory system, knee function was analysed using this system, after an anterior cruciate ligament (ACL) lesion, and after reconstructive surgery. The proposed system was composed of two 3D gyroscopes, fixed on the shank and on the thigh, and a portable data logger for signal recording. The measured parameters were the 3D mean range of motion (ROM) and the healthy knee was used as control. The precision of this system was first assessed using an ultrasound reference system. The repeatability was also estimated. A clinical study was then performed on five unilateral ACL-deficient men (range: 19-36 years) prior to, and a year after the surgery. The patients were evaluated with the IKDC score and the kinematics measurements were carried out on a 30 m walking trial. The precision in comparison with the reference system was 4.4 degrees , 2.7 degrees and 4.2 degrees for flexion-extension, internal-external rotation, and abduction-adduction, respectively. The repeatability of the results for the three directions was 0.8 degrees , 0.7 degrees and 1.8 degrees . The averaged ROM of the five patients' healthy knee were 70.1 degrees (standard deviation (SD) 5.8 degrees), 24.0 degrees (SD 3.0 degrees) and 12.0 degrees (SD 6.3 degrees for flexion-extension, internal-external rotation and abduction-adduction before surgery, and 76.5 degrees (SD 4.1 degrees), 21.7 degrees (SD 4.9 degrees) and 10.2 degrees (SD 4.6 degrees) 1 year following the reconstruction. The results for the pathologic knee were 64.5 degrees (SD 6.9 degrees), 20.6 degrees (SD 4.0 degrees) and 19.7 degrees (8.2 degrees) during the first evaluation, and 72.3 degrees (SD 2.4 degrees), 25.8 degrees (SD 6.4 degrees) and 12.4 degrees (SD 2.3 degrees) during the second one. The performance of the system enabled us to detect knee function modifications in the sagittal and transverse plane. Prior to the reconstruction, the ROM of the injured knee was lower in flexion-extension and internal-external rotation in comparison with the controlateral knee. One year after the surgery, four patients were classified normal (A) and one almost normal (B), according to the IKDC score, and changes in the kinematics of the five patients remained: lower flexion-extension ROM and higher internal-external rotation ROM in comparison with the controlateral knee. The 3D kinematics was changed after an ACL lesion and remained altered one year after the surgery

Les fractures du pilon tibial. Etude rétrospective à long terme de 51 fractures traitées par réduction sanglante et ostéosynthèse [Fractures of the tibial pilon. Long-term retrospective study of 51 fractures treated with open reduction and osteosynthesis].

PURPOSE OF THE STUDY: Fracture of the tibial pilon is a rare injury and its treatment remains difficult. The aim of this study was to report the complications and long term results of internal fixation using a technique which respects soft tissues and in which little material was used. MATERIAL: From 1985 to 1990, 48 patients with 51 fractures of the tibial pilon were treated by open reduction and internal fixation. All patients were submitted to a clinical and radiological review. METHODS: Both the Rüedi/Allgöwer and the AO-classification were used and determined by standard X-rays. Surgical procedure was performed with a 2 or 3 1/3 tube AO-plates and the peroneus was always fixed if fractured. Intraoperative reconstruction was analyzed. Subjective and objective scoring were used according to Olerud and Molander and the ankle arthritis was scored according to the classification determined by the SOFCOT in 1992. RESULTS: A minimal follow-up of 1 year for all cases was obtained, based on our own files. Thirty-eight patients (40 fractures) were evaluated after an average period of 88 months (56 to 124 months). Five patients developed cutaneous infection, three developed deep infection and four developed superficial skin necrosis. One aseptic non-union necessitated reoperation after 14 months. Two ankles had joint fusion after 19 and 25 months respectively due to severe arthritis. In six cases infectious and non-infectious complications led to surgical revision. According to the Olerud and Molander score, 15 per cent of the results were excellent, 45 per cent were good, 30 per cent were fair and 10 per cent poor. DISCUSSION: Literature shows a wide range of results following this surgical procedure. This is due to the difference in the type of trauma, classification system used, material used for the internal fixation and method of evaluation. The classification system of Rüedi and Allgöwer is the most commonly used but has a rather subjective tendency, especially between type II and type III. Treatment is difficult, especially for comminutive fractures associated with soft tissue damage. In this case, open reduction and internal fixation could increase iatrogenic lesions. For this reason surgical procedure can be delayed for several days, little material is used and soft tissue manipulation is reduced to minimum. In other study reports, the use of external fixation with or without minimal internal fixation have produced less complications without improving long term results. CONCLUSION: Analysis and comparison of study reports are difficult because of the absence of consensus in classification system and evaluation methods. The AO-classification, apparently the most objective, will probably be more and more used in the future. Treatment must be adapted to the bony lesion and soft tissue damage. Open reduction and internal fixation must be reserved for a specific group of lesion.

Management of Pharyngeal Fistulas After Anterior Cervical Spine Surgery: A Treatment Algorithm for Severe Complications.

STUDY DESIGN:: Retrospective database- query to identify all anterior spinal approaches. OBJECTIVES:: To assess all patients with pharyngo-cutaneous fistulas after anterior cervical spine surgery. SUMMARY OF BACKGROUND DATA:: Patients treated in University of Heidelberg Spine Medical Center, Spinal Cord Injury Unit and Department of Otolaryngology (Germany), between 2005 and 2011 with the diagnosis of pharyngo-cutaneous fistulas. METHODS:: We conducted a retrospective study on 5 patients between 2005 and 2011 with PCF after ACSS, their therapy management and outcome according to radiologic data and patient charts. RESULTS:: Upon presentation 4 patients were paraplegic. 2 had PCF arising from one piriform sinus, two patients from the posterior pharyngeal wall and piriform sinus combined and one patient only from the posterior pharyngeal wall. 2 had previous unsuccessful surgical repair elsewhere and 1 had prior radiation therapy. In 3 patients speech and swallowing could be completely restored, 2 patients died. Both were paraplegic. The patients needed an average of 2-3 procedures for complete functional recovery consisting of primary closure with various vascularised regional flaps and refining laser procedures supplemented with negative pressure wound therapy where needed. CONCLUSION:: Based on our experience we are able to provide a treatment algorithm that indicates that chronic as opposed to acute fistulas require a primary surgical closure combined with a vascularised flap that should be accompanied by the immediate application of a negative pressure wound therapy. We also conclude that particularly in paraplegic patients suffering this complication the risk for a fatal outcome is substantial.

Lésions du ligament croisé antérieur de l'enfant [Anterior cruciate ligament injuries in children].

An increasing number of anterior cruciate ligament injuries are now seen in children and girls seem to be equally affected. Such neglected or untreated lesions could be the cause of early degenerative changes. Recently, many authors support the trend toward early surgical management in skeletally immature patients with complex meniscal tear or recurrent knee instability after proper rehabilitation. Improvement in pediatric knowledge and surgical techniques tend to support a tendency for more surgical treatment in children. The type of management is choosing according to history and physical examination. Magnetic resonance imaging is a useful tool not only for diagnosis but also for surgical treatment planning. We usually recommend anterior cruciate ligament reconstruction in children with knee instability or with further damages to the joint.

Anterior inferior cerebellar artery aneurysms mimicking vestibular schwannomas.

BACKGROUND AND PURPOSE: Unruptured anterior inferior cerebellar artery (AICA) aneurysms are rare but potentially lethal cerebellopontine angle (CPA) lesions that may be misdiagnosed as vestibular schwannomas when they present with vestibulo-cochlear symptoms. METHODS: We report two cases of unruptured but symptomatic AICA aneurysms initially referred to us as atypical vestibular schwannomas requiring surgery. Two discriminant MR features are described. RESULTS: One patient refused treatment. The other was successfully treated by coil occlusion. CONCLUSIONS: Caution is advised before suspecting a CPA mass to be a purely extra-canalicular schwannoma, given its extreme rarity. Deafness and cerebellar ischemia may be prevented if AICA aneurysms are correctly identified preoperatively. In the absence of specific arterial imaging, two MR features may distinguish them from vestibular schwannomas: (1) the absence of internal auditory canal enlargement and (2) the "blurry dot sign," representing blood flow artefacts on pre- and postcontrast studies.