The advantages of minimally invasive plate osteosynthesis (MIPO) by anterior approach in distal humeral shaft fractures

Introduction: Complex distal humeral shaft fractures management is debatable due to the fact that ORIF with plates is associated with a higher morbidity while intramedullary nails do not present reliable results. Purpose: to emphasize the advantages of MIPO by anterior approach in distal humeral shaft fractures. Material and methods: We have operated 19 distal humeral shaft fractures (3 type 12-A, 11 type 12-B and 5 type 12-C / AO classification) using the MIPO technique imagined by Livani and Belangero, in order to avoid the problems related to the neural vascular structures of the arm and especially to the radial nerve. 5 patients were registered with traumatic radial nerve palsy. The proximal approach of 3-5 cm was realized between the biceps (medially) and deltoid muscle (laterally). The distal approach of 3-5 cm was performed by subperiosteal dissection of the lateral supracondylar ridge of the humerus, with retraction of brachioradialis and long carpal extensor muscle, as well as the radial nerve, even though unseen. A classic or a DCP plate of 4.5 mm with 10-14 holes was molded and twisted medially to adapt to the anterior face of the humeral lateral column and diaphysis, thus avoiding occlusion of the coronoid or of the olecranon fossae. The plate was inserted from distal to proximal and fixed onto the shaft with at least 2 proximal and 2 distal screws (after reestablishing the humeral axis, length and rotation). In a single case we have performed MIPO after surgical exploration of the nerve. The patient started a rehabilitation program immediately or after a short immobilization. 6 fractures in 6 patients (with arm wrestling mechanism in 3 cases) were operated by indirect reduction and biological plating, avoiding the related problems. According to AO classification, there was 1 fracture-type 12A, 2-type 12B and 3- type 12C. Results: 18 fractures healed within a mean time of 9 weeks after surgery, while we have recorded a non-union in an obese female patient. There were no vascular or nerve complications, except 3 transient paresthesia for the radial nerve. All primary neurological lesions recovered within 6-8 weeks. Elbow functional results were considered excellent according to SECEC score. Conclusions: The authors are promoting the advantages of this technique regarding safety and feasibility as well as plate stability which allows a fast rehabilitation. Even if it is a demanding technique, MIPO seems to be the best option for distal third humeral fractures and a viable solution for distal fractures with radial nerve palsy

FACTORI PROGNOSTICI ÎN EVOLUŢIA POSTOPERATORIE PRECOCE A ATREZIEI ESOFAGIENE. EXPERIENŢA UNUI CENTRU TERŢIAR ÎNTR-UN INTERVAL DE 5 ANI

Scop. Studierea factorilor prognostici care pot infl uenţa evoluţia postoperatorie a pacienţilor cu atrezie de esofag, ţinând cont de particularităţile loco-regionale ale problemei. Metode. S-a efectuat o analiză retrospectivă a documentelor medicale pentru 28 de pacienţi diagnosticaţi cu atrezie esofagiană între 2009-2014 în centrul autorilor, utilizând ca instrument de prelucrare a datelor regresia logistică. Supravieţuirea a fost considerată variabilă dependentă, iar detaliile demografi ce, greutatea la naştere, vârsta intervenţiei chirurgicale, anomaliile asociate, evoluţia postoperatorie şi managementul complicaţiilor au fost studiate ca şi variabile independente. Rezultate. Aplicând clasifi carea prognostică propusă de Spitz, grupul I cu greutatea la naştere (G.N.) ≥ 1.500 g, fără malformaţii cardiace majore, a cuprins 21 de nou-născuţi cu o mortalitate de 33%. Pentru 3 copii încadraţi în grupul II (G.N.≤1.500 g sau malformaţii cardiace majore) şi, respectiv, 4 copii din grupul III (G.N.≤1.500 g şi malformaţii cardiace asociate), mortalitatea a fost de 100%. Greutatea medie la naştere a fost de 2.282 g ±2DS, iar vârsta gestaţională medie de 31 de săptămâni. Vârsta la internare a fost de peste 24 de ore în 15 cazuri, cu deces în 13 dintre situaţii. Malformaţiile asociate cu cea mai mare pondere au fost cele cardiace. Tratamentul chirurgical a constat în: anastomoză primară (21 de cazuri), cervico- şi gastrostomie (6 cazuri), tehnica Foker (1 caz). Complicaţia postoperatorie cea mai frecventă a fost dezunirea anastomozei (la 6 pacienţi, cu deces în 4 situaţii). Concluzii. Analiza seriei studiate indică o rată de supravieţuire scăzută pentru această patologie în centrul autorilor. În plus, faţă de factorii de prognostic citaţi în literatură (greutatea şi vârsta mică la naştere, anomaliile congenitale asociate), întârzierea diagnosticului şi, implicit, a internării într-un centru terţiar, au contribuit la creşterea mortalităţii în lotul studiat. Rafi narea abordării multidisciplinare a acestei patologii ar putea determina în viitor o supravieţuire mai mare şi o îmbunătăţire a rezultatelor managementului terapeutic

PROGNOSTIC FACTORS IN THE EARLY POSTOPERATIVE OUTCOME OF ESOPHAGEAL ATRESIA. THE EXPERIENCE OF A TERTIARY CENTER OVER A 5 YEARS PERIOD

Purpose. The aim of this study was to determine the infl uence of prognostic factors on the postoperative outcome of esophageal atresia patients, taking into consideration loco-regional particular features. Methods. A retrospective analysis of the medical records of 28 patients diagnosed with esophageal atresia was conducted, using a logistic regression model. Patients had been admitted in our hospital between 2009-2014. The survival rate was recorded separately from the independent factors, such as demographic features, weight at birth, the timing of surgical treatment, co-morbidities, postoperative prognosis and management of complications. Results. According to the Spitz prognostic classifi cation, there were 21 patients in group I (birth weight over 1500 g with no major anomaly), 3 patients in group II (birth weight less than 1500 g or major cardiac anomaly) and 4 patients in group III (birth weight less than 1500 g plus major cardiac anomaly). The mortality rate was 33% in group I, 100% in group II and 100% in group III. The mean birth weight was 2282 g ±2SD, and the mean gestational age was 31 weeks. The age at initial presentation was over 24 hours in 15 patients, with fatal outcome in 13 of them. The cardiac malformations presented as the associated anomalies with the highest risk. Surgical treatment was as follows: primary anastomosis in 21 cases, cervicostomy and gastrostomy in 6 cases, and Foker technique in 1 case. Conclusions. The analysis of this series indicated a low survival rate for this pathology in our center. Besides the prognostic factors cited in literature (low birth weight and age at birth, associated cardiac malformations), we include, as risk factors for the increased mortality, the delayed diagnosis and presentation at our tertiary center. The further refi nement of a multidisciplinary approach towards this pathology would contribute to a higher survival rate and an improved result of the therapeutic management

EVENTRAŢIA DIAFRAGMULUI – FACTOR DE RISC PENTRU INFECŢIILE RESPIRATORII. PREZENTARE DE CAZ

Eventraţia diafragmului este o anomalie congenitală sau dobândită, cu o incidenţă de 1 la 10.000 de copii. Presupune ascensiunea anormală a domului diafragmatic, datorată înlocuirii fi brelor musculare cu un ţesut fi broelastic în exces. Simptomatologia este variată, putând fi absentă sau sub forma unor acuze respiratorii ce pot merge până la detresă respiratorie. Infecţiile respiratorii recurente sunt cele mai frecvente manifestări. Autorii prezintă cazul unui pacient în vârstă de 3 ani de sex masculin, spitalizat în repetate rânduri pentru infecţii respiratorii, „dextrocardie“ aparentă, datorate unei eventraţii diafragmatice stângi, pentru care s-a realizat cu succes plicatura diafragmului

EVENTRATION OF THE DIAPHRAGM, A RISK FACTOR FOR RECURRENT RESPIRATORY TRACT INFECTION – A CASE REPORT

Eventration of the diaphragm, congenital or acquired, represents a rare condition (1 to 10,000 live births), in which the dome of the diaphragm is abnormally elevated, due to an excessive amount of fi bro-elastic diaphragmatic tissue. The child may be asymptomatic or present with respiratory symptoms as aggressive as life threatening respiratory distress. Recurrent pulmonary infections are the commonest presenting complaints. We present the case of a 3 years old boy with recurrent chest infections and apparent “dextrocardia”, both caused by a left eventration of the diaphragm, successfully treated by plication