The most common mandibular fractures involve the condyloid process. It is necessary to diagnose and treat the cases of mandibular condylar fracture carefully, because the temporomandibular joint is complicated anatomically and functionally.
A clinical study was made in 72 patients with mandibular condylar fracture referred to the Department of Oral and Maxillofacial Surgery, Gunma University Hospital from April 1991 to March 1995.
The results were as follows:
1. Mandibular condylar fracture occurred in 42.6% of the mandibular fractures. The male-to-female ratio was 2 to 1. The largest age group of patients was from 10 to 19 years (31.9%).
2. The most frequent cause of the injury was falls (50.0%). Of all the patients 84.7% visited our department within 2 weeks after injury.
3. Fifty-nine cases (81.9%) were unilateral fractures and 13 (18.1%) were bilateral. Of the total, thirty-six cases (50.0%) were combined with other fractures of the mandible and/or maxillofacial fractures.
4. As for the fracture level and position of fragment, fractures with deviation were most frequently observed in the subcondylar region (20.5%).
5. Of the 67 cases treated at our department, 62 (92.5%) were treated with a conservative therapy for mandibular condylar fracture, primarily by maxillomandibular fixation followed by functional rehabilitation. The remaining 5 (7.5%) cases were treated surgically.
6. Fifty-nine patients were recalled after more than 6 months. As for the treatment outcome in 54 nonsurgical cases, 46 cases (85.2%) showed excellent prognosis, 6 (11.1%) had disorder I and 2 (3.7%) had disorder II. In 5 surgical cases, 3 cases showed excellent prognosis and 2 had disorder II. Most of the patients treated nonsurgically had relatively good results.

A case of mycotic aneurysm in the gastroduodenal artery associated with infectious endocarditis (IE) penetrating into the residual stomach is reported. A 50-year-old woman was transferred to our hospital because of sudden onset of hematemesis and bloody stool. She had had partial gastrectomy due to duodenal ulcer 6 years previously and aortic prosthetic valve replacement due to infectious endocarditis eight months previously. Emergency laparotomy was performed. Aneurysm of the gastroduodenal artery penetraing into the lumen of the residual stomach was found. The aneurysm had not been detected in the CT scan 8 months earlier. It was surmised that it was related to IE and had developed over the last 8 months. Aneurysmectomy was performed. The postoperative course was uneventful and she was discharged on the 22nd postoperative day. Mycotic aneurysm associated with IE developing into the gastroduodenal artery and penetrating into the stomach is rare. It is possible that a mycotic aneurysm could develop in any artery of a patient with IE. We should thus carefully examine patients with IE in order to detect mycotic aneurysms using angiography and the contrast-enhanced CT scan.

Dacron grafts have made great progress and the material has become almost perfect recently. However, we encountered a rare case of a late-graft complication. A 34-year-old man was operated on for coarctation of the aorta in July 1982. Left subclavian artery-descending aortic bypass was performed using a Cooley double velour knitted graft. Eighteen years later, the patient was admitted to our hospital with an abnormal shadow in his chest X-ray. Angiography and computed tomography demonstrated a non-anastomotic aneurysm of the graft. Under cardiopulmonary bypass and deep hypothermic circulatory arrest, reoperation with a woven Dacron graft was successfully performed. This case suggests that it is important to follow up patients with implanted Dacron arterial prostheses because of the potential for rupture.

Gelatin-resorcin-formalin (GRF) glue has been widely used in repair of dissected aortic wall tissue, and the use of GRF glue has been reported to significantly reduce mortality from this surgical emergency. On the other hand, various late complications possibly due to GRF glue have also been reported. We performed reoperations after total arch replacement for acute type A aortic dissection using GRF glue in 2 cases. In case 1, total arch replacement was performed 3 years ago. Pseudoaneurysms of the aortic root and brachiocephalic artery and redissection of the descending aorta were revealed by subsequent computed tomography (CT). Partial graft replacement for these 3 sites were performed with open distal anastomosis and right common carotid artery perfusion. In case 2, total arch replacement was performed 5 years previously. Redissection of the aortic root was revealed by CT, and ultrasound cardiography revealed severe aortic regurgitation and severe mitral valve insufficiency. A modified Bentall procedure and mitral valve replacement were performed. In these 2 cases, the sites of redissection and pseudoaneurysm were identified as the sites of use of GRF glue at the first operation. We suspected that the use of GRF glue is associated with a certain amount of risk of redissection and pseudoaneurysm. Such patients should be carefully followed for years after surgery. It is necessary to use appropriate surgical and glue application techniques to obtain the desired effect of the glue.

A semicomatose 53-year-old woman who had been injured in an automobile accident was admitted. Injury to the thoracic descending aorta was suspected because of widening of the upper mediastinum on a chest X-ray film and confirmed by chest contrast-enhanced computed tomography (CT). We postponed surgical treatment because brain CT showed traumatic intracerebral hemorrhage. She was maintained in an intensive care unit and had pharmacological treatment and medical support. Two days later, brain CT showed that the intracerebral hematoma was a stable and inactive lesion, so she underwent aortic repair 3 days after the accident. Left thoracotomy was performed and an artificial vascular prosthesis was interposed under hypothermic circulatory arrest (open proximal method). The postoperative course was uneventful and the patient was discharged 44 days after the operation. Hypothermic circulatory arrest may be a valuable adjunct for traumatic injury of the thoracic aorta at risk for impending rupture.

A 16-year-old schoolgirl had aortic valve insufficiency, detected incidentally on electrocardiogram taken for a physical checkup. She was noted to have hyperextensibility of joints, hyperelasticity of the skin and an atrophic scar over the knees on physical examination and type II Ehlers-Danlos syndrome (EDS) was diagnosed by skin biopsy after admission. A Carpentier-Edwards pericardial bioprosthesis was chosen for aortic valve replacement because she was of childbearing age and had EDS. Seven years after the replacement she became pregnant, resulting in spontaneous vaginal delivery of a healthy male infant at 39 weeks. However, a second aortic valve replacement was staged for structural failure of the bioprosthesis which was accelerated during the gestation. Aortic valve re-replacement was carried out using a 21-mm Sorin Bicarbon mechanical prosthesis 4 months after the delivery. She was discharged on the 10th postoperative day without any complications.

A 77-year-old man with diabetes mellitus and hypertension presented with acute onset of pain and swelling of the right thigh. Physical examination showed a pulsatile mass in the mid-portion of the right thigh. Computed tomography revealed the presence of a 7-cm diameter aneurysm at superficial femoral artery with gas shadow around the aneurysmal wall. A diagnosis of infected superficial femoral aneurysm was made and emergency surgery was undertaken. The total resection of the aneurysmal wall, debridement of necrotic tissues including part of sartorius and quadriceps muscles were done. Femoro-popliteal bypass through subcutaneous route using a 6-mm diameter Dacron prosthesis was used as the mean of vascular reconstruction procedure. Citrobacter koseri was cultured from the infected aneurysmal wall. The antibiotic treatment was continued for total of 2 weeks. Although additional debridement was required, the patient was amkulabony when discharged on the 37th postoperative day.

A 74-year-old woman had undergone right axillo-bifemoral bypass for infrarenal aortic stenosis due to aortitis syndrome in another hospital. She was admitted as an emergency case to our hospital with a ruptured thoracoabdominal aortic aneurysm, and an emergency operation was performed. We used arterial cannulation to the artificial vascular graft implanted for axillo-bifemoral bypass and first cooled the body temperature to below 25°C, then dissected the aorta. In the case of ruptured descending and thoracoabdominal aortic aneurysm, profound hypothermia is a valuable adjunct for unexpected blowout rupture during the preparation of the aneurysm and spinal cord and visceral protection.

Mediastinitis following graft replacement of the ascending and total arch aorta is a fatal complication of cardiac surgery. When graft infection is suspected, one choice of treatment is to remove the infected prosthesis and replace it with a new one. However such a procedure seems to be very risky. We report 2 successfully treated cases of mediastinitis following graft replacement of the ascending and total arch aorta. In one case, we treated with primary sternal closure after debridement and omental flap implant. In another case, the wound was left open and irrigation with iodine solution was undertaken for 6 days. The sternum was closed with pectoralis major muscle flap implantation. When graft infection is not suspected, primary sternal closure with implantation of tissue flaps is recommended. When graft infection is strongly suspected, we prefer secondary sternal closure after open irrigation.

A 44-year-old man underwent total arch replacement for acute type A aortic dissection. He was treated postoperatively in the intensive care unit for acute renal failure and respiratory failure. Although recovery of organ functions was seen, an unexpected fall in platelet count (PLT) occurred abruptly on postoperative day (POD) 7. The patient was treated with gabexate mesilate and platelet transfusion because disseminated intravascular coagulation (DIC) was initially suspected. Nevertheless, PLT dropped rapidly below 1.0×10⁴/μl. We suspected heparin-induced thrombocytopenia (HIT) and stopped all heparin administration including flush solution for pressure monitoring lines. The platelet factor 4-reactive HIT antibody test was performed and we began to give intravenous argatroban, 60mg/day. However, PLT did not increase at all. Multiple organ failure developed and metabolic acidosis deteriorated rapidly resulting in death on POD 15. HIT antibody was positive on POD 13 and a definitive diagnosed of HIT was made. For those patients treated with heparin continuously or repeatedly, HIT may occur and increase the mortality risk if the diagnosis is delayed.