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11/20. Total colonic aganglionosis.

    A rare complication after ileorectostomy for total aganglionosis of the colon is demonstrated. Eight years after the operation fistulae between rectum and sacrum appeared. Other cases from the literature are mentioned.
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12/20. Arteriovenous shunts in free vascularized tissue transfer for extremity reconstruction.

    Local vessels are occasionally unsatisfactory donor choices for vascularized tissue transfer in extremity reconstruction. Construction of a temporary arteriovenous loop facilitates not only tension-free anastomoses outside the zone of injury but also affords vascular distention at physiological pressures, an opportunity to verify vein graft patency before tissue transfer, and presumably a decrease in the ischemia time of the vein graft itself. We reviewed the cases of 25 consecutive patients who underwent upper and lower extremity reconstruction facilitated by temporary arteriovenous shunts. In single-stage procedures, greater or lesser saphenous veins were used; the venous end was left in situ in its bed in 17 patients and the entire vein harvested freely in 8. The most common destination was the leg (11), followed by the thigh (7), foot (2), sacrum (2), knee (1), arm (1), and forearm (1). There were three (12%) failures. We conclude that construction of temporary arteriovenous shunts using vein grafts is a productive adjunctive technique in vascularized tissue transfer where additional pedicle length is needed.
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13/20. External fixation as a test for instability after spinal fusion L 4-S 1. A case report.

    A case presented with severe backache after fusion of the L 4-S 1 levels; the patient became immediately painfree after external transpedicular fixation between L 4 and the sacrum. The device was kept in place for 10 weeks. After an additional 4 weeks the patient was able to return to his work after several years of sick-leave. The case indicates instability as a cause of backache. Painful nonunion of a fusion can be present in spite of signs of healing on radiographs and CT-scan. External transpedicular fixation may be a good tool in assessing instability of the lower lumbar spine.
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14/20. The management of burst fractures of the fifth lumbar vertebra.

    Burst fractures of the fifth lumbar vertebra are extremely rare. Three cases of this fracture are reported and the treatment discussed. Two patients were treated conservatively with bed rest and lumbar bracing; the third underwent posterior decompression and instrumentation. All patients showed a loss of lordosis between L4 and the sacrum, this being greatest in the surgically treated patient. It is suggested that current instrumentation cannot adequately maintain this unusual fracture in good alignment and a conservative approach is advocated.
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15/20. Transsacral approach to the rectum.

    While the proximal or upper third of the rectum is readily accessible through the lower abdomen, lesions of the distal rectum are difficult to reach both from abdomen and the perineum. The transsacral approach (Kraske) gives excellent exposure of the mid and lower rectum. The experience using this approach in sixteen cases for various indications which include local excision of benign tumours, segmental excision, repair of recto-vesical fistula, perineal excision of rectum and abdominal excision of rectal carcinoma and low colo-rectal anastomosis with preservation of ano rectal sphincters is reported. In some cases where wider exposure of the rectum is required, this was easily achieved by excising the last three pieces of sacrum and/or extending below by dividing the external sphincter. While incontinence is not a long term problem, attention to technical details and creation of a temporary colostomy are necessary for all cases of excision and end-to-end anastomosis to prevent leakage and septic complications. Temporary colostomy is not required for excision of part of the circumference of the rectum as in the treatment of most benign lesions.
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16/20. Bilateral sacroiliac dislocation with intrapelvic intrusion of the lumbosacral spine. A case report.

    A patient sustained bilateral sacroiliac dislocation in which the proximal part of the sacrum was displaced 10 cm anteriorly and 6 cm inferiorly into the pelvis. Stabilisation was initially obtained with an external fixator. Operation was carried out later: reduction was achieved by overhead skeletal traction using sublaminar wires; two screws were inserted through each sacroiliac joint and the two fragments of the sacrum were wired in place.
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17/20. Concomitant noncontiguous thoracolumbar and sacral fractures.

    Seventeen patients were identified with concomitant thoracolumbar and sacral fractures representing 26% of sacral fractures and 7.7% of pelvic fractures. The thirteen men and four women exhibited a bimodal age distribution. There were thirteen vertical compression thoracolumbar fractures, three transverse process fractures, and one traumatic herniated nucleus pulposus. There were seven Zone I, seven Zone II, and three Zone III sacral fractures using the Denis classification. Five of the sacral fractures were missed on initial presentation. Four of the patients had neurogenic bowel or bladder symptoms. Seven of the thoracolumbar fractures and three of the sacral fractures were treated operatively. Results were generally good or excellent unless significant neurologic injury was present at initial presentation. The authors recommend aggressive computed tomographic evaluation of the sacrum in any suspicious pelvic trauma or when the neurologic lesion does not match the more proximal bony lesion. They hypothesize that decompression of both sacral and thoracolumbar lesions may be necessary if either lesion could be responsible for neurogenic bowel or bladder symptoms.
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18/20. Pelvic fractures after long lumbosacral spine fusions.

    STUDY DESIGN. A retrospective review of late pelvic ring fractures after long spine fusions to the lumbosacral spine. OBJECTIVES. To review the clinical course and predisposing features of late fractures of the pelvic ring, usually atraumatic, in patients with long fusions to the lumbosacral spine. SUMMARY OF BACKGROUND DATA. Fractures of the pelvic ring after long fusions to the lumbosacral spine is a heretofore rarely reported complication. methods. Records from the authors' institution from 1985 to 1994 were reviewed retrospectively. Two hundred sixty-eight patients with long fusions to the lumbosacrum were identified. RESULTS. Between 1985-1994, five patients suffered late atraumatic fractures of the pelvic ring after long instrumented fusions to L5 or the sacrum. All fractures were on the left side of the pelvic ring, primarily the public rami. All patients were women, and at the time of fracture, all were aged 50 years or older. Fractures occurred from 4 months to 7 years after the last surgery (mean, 28 months). All were treated with protected weightbearing until comfortable. At average 27 months' follow-up evaluation, four patients reported no pain; the fifth had become pain-free at 31 months, but 2 months later, the patient spontaneously fractured the contralateral public rami. CONCLUSION. Stress-type fractures of the pelvic ring are a potential source of late pain after long fusions to the lumbosacral spine. Orthopedic surgeons should be aware of this possibility, especially in older, potentially osteoporotic women. Early treatment with simple protected weightbearing appears satisfactory and can prevent significant morbidity.
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19/20. Iatrogenic spinopelvic cerebro-spinal fluid fistula. Case report.

    Perineurial cysts usually affect the lumbosacral spinal nerve roots, but sometimes they can erode the sacrum and reach the retroperitoneal space. In such cases misdiagnosis can lead to an improper treatment and cause serious complications. A presacral mass was diagnosed in a young woman during routine ultrasound investigation, and an exploratory laparotomy was performed. A large, fluid-containing cyst was found and marsupialized into the pelvis. After operation the patient experienced headache, vomiting and VI cranial nerve palsy whenever she stood up. By radiculography a iatrogenic spinopelvic cerebro-spinal fluid fistula was diagnosed, which required further surgery to be repaired. The presence of a giant perineurial cyst in the pelvis in unusual but must be considered in the differential diagnosis of presacral masses; the exceptionally rare case reported in this paper is exemplar of the harmful complications that an incautious procedure can determine.
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20/20. Procidentia of the rectum after the pull-through operation: an unusual complication and report of two cases.

    Procidentia or complete prolapse of the rectum following the pull-through operation is unusual, if not altogether rare. It appears to be a late complication of the procedure. A multitude of factors may be implicated in its genesis, and certainly the inadequacy of the pelvic floor is principal among them. Though the exact mechanism is not entirely clear, we favor an intussusceptive process for the reasons and observations cited. It is surmised that its late appearance is primarily due to the formation of adhesions that effectively fix the bowel to the sacrum. The process of aging and ensuing laxity of tissues subsequently detract from this protective factor. Perineal repair was used in both cases but, in the ultimate analysis, the procedure of choice should be individualized, based upon the surgeon's own judgment and experience and particular circumstances attending procidentia.
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