Sterile abscess: a surprise diagnosis?

We present the case of an otherwise healthy female hairdresser of Brazilian origin who started to have pain and swelling in her left arm. An antecubital abscess was surgically treated at another institution and there was good initial wound healing. Swelling then recurred and fistulae appeared in the scar. Our diagnostic workup revealed an isolated intramuscular tuberculous abscess, which was successfully treated by an antituberculous drug regimen.

[5-year results of dia-/supracondylar femoral fractures, managed with the dynamic condylar screw]. / 5-Jahresergebnisse nach dia-/suprakondylären Femurfrakturen, versorgt mit dynamischer Kondylenschraube (DCS).

In 118 patients with intra- and extraarticular distal femoral fractures we used open reduction and internal fixation with a dynamic condylar screw. We recorded general implant related complications in a very low percentage of patients. In evaluation of the long-term results in eighty one patients after follow-up of more than five years we found occasional pain in eighteen patients and frequent pain in two patients. 70% of the patients presented with free range of motion in knee joint. Only five patients had a clinically important malunion of greater than five degrees. We found malrotation of greater than ten degrees in four patients. 90% of patients were found to have a stable knee joint. The functional result according to Neer was excellent in more then 50 percent and satisfying in 40 percent of the patients. Only in 5 patients the result was determined as unsatisfying or as a failure. No arthrotic changes were found in the femoro-patellar and femoro-tibial joint in about 75 percent of the cases. Grade 2 changes were found in 15 percent in the femoro-patellar joint and in 18 percent in the femoro-tibial joint. Grade 3 arthrotic changes were seen even in less than 10 percent in both parts of the knee joint.

[Aggressive debridement and early soft tissue coverage of 3d degree open tibial fractures]. / Aggressives Debridement und frühzeitige Weichteildefektdeckung bei drittgradig offenen Tibiafrakturen.

93 patients with grade III open tibial fractures were treated without a treatment protocol from 1980 to 1982. This group is compared to 147 pts. managed between 1983 to 1986 according to a standardized prospectively designed protocol with aggressive debridement augmented by pulsatile Jet-lavage. Serial debridement were performed at 48-hour intervales until early soft-tissue coverage were obtained using local or free muscle-flaps. The mean follow-up was 80 months respectively 44 months. --The aggressive regimen led to a statistically significant decrease in infection (30% vs 12%), nonunion (16% vs 6%), amputation (18% vs 6%) and combined hospitalization-periods (137 vs 74 days) [all p less than 0.001]. The aggressively treated groups showed a trend toward early fracture-healing (30 vs 23 weeks) although this was not statistically significant.

Gas-gangrene following arthroscopic surgery.

An arthroscopic anterior cruciate ligament repair was followed by gas-gangrene and the development of a compartment syndrome. Treatment consisted of extensive fasciotomy, debridement, and antibiotic therapy with penicillin G, cefotiam, and metronidazole. The patient was also treated with five sessions of hyperbaric oxygen in a pressure chamber for a duration of 2 h per session. This therapeutic regimen resulted in the preservation of a functionally intact extremity despite severe complication.

Use of ofloxacin in open fractures and in the treatment of post-traumatic osteomyelitis.

In two open prospective studies, the efficacy and tolerance of ofloxacin in the prevention of infection in patients with open fractures (n = 58) and in the treatment of chronic post-traumatic osteomyelitis (n = 115) were examined. In the study with open fractures, bone and/or soft tissue infection occurred in only four cases (6.5%). During an observation period of at least 12 months, post-traumatic osteomyelitis was seen in two patients with III degree open fractures (9%), while in the groups with I degree and II degree open fractures no bone infection could be found. Therefore, the rate of post-traumatic osteomyelitis related to all patients was 3.3%. In the second study with 115 patients suffering from chronic post-traumatic osteomyelitis 141 different Gram-positive and Gram-negative pathogens were isolated. 73% were Gram-positive cocci with Staphylococcus aureus in more than 50% of the cases. An elimination rate of more than 90% was found in the Gram-positive and Gram-negative bacteria, leading to a clinical cure in 85% and a recurrence of infection in 5% of the cases. The tolerability of ofloxacin was excellent. No drug-related allergic reactions were observed. Diarrhoea and headache occurred in less than 2% of patients. With adequate surgical treatment, ofloxacin proved to be a useful antimicrobial agent in the prevention and therapy of bone infection.

[Results of surgical treatment of pelvic fractures in polytraumatized patients]. / Ergebnisse der operativen Behandlung von Beckenfrakturen bei polytraumatisierten Patienten.

High-speed accidents involving automobiles and two-wheeled vehicles with resultant entrapment and crush injuries have led to an ever-increasing incidence of pelvic fracture within the realm of multiple trauma. Between the years 1982 and 1986 ninety-eight cases of pelvic fracture were operatively stabilised by the Department of Surgery and the Outpatient Department of the Technical University, Klinikum Rechts der Isar, Munich, West Germany. This paper is a report on fifty-five of these patients who were discovered to have suffered additional multitrauma. Independent from those patients found to have sustained multitraumatisation, twenty-four cases of isolated acetabulum fracture as well as four instances of pelvic ring fracture and one fracture of the pelvic brim were also documented. Combinations of the above mentioned fractures were uncovered in twenty-six patients. With fifty-four of the fracture injuries, osteosynthesis was carried out while in one case primary alloarthroplasty was deemed necessary. Following a mean post-treatment period of twenty-six months forty-five of the patients were objectively evaluated for results of treatment according to the methodology of Merle d'Aubigne. 70% of those patients assessed were rated with a "good" result. At the time of follow-up thirty-five (78%) of the forty-five reexamined individuals reported to be once again employed. Early operative treatment along with internal stabilisation and prompt initiation of physiotherapy have proved decisive in obtaining a favourable postoperative result.

Ofloxacin treatment in the management of chronic osteitis.

In an open prospective study, the efficacy and tolerability of ofloxacin in the treatment of chronic post-traumatic osteitis was examined in 83 patients. 103 different pathogens were isolated. More than 75% were Gram-positive bacteria with Staphylococcus aureus occurring in 61% of cases. After ofloxacin treatment bacteriological elimination was more than 90% for both Gram-positive and Gram-negative species, leading to a clinical cure in 85% of patients. Reinfection occurred in 5% of patients. These values were obtained from follow-up examinations which were carried out at least 6 months after the end of therapy. The tolerability of ofloxacin was excellent and no drug-related allergic reactions or side effects were observed. In conjunction with adequate surgical treatment, ofloxacin proved to be a useful antibacterial agent in the therapy of chronic bone infection.

Effectiveness of imipenem in the treatment of chronic post-traumatic osteitis.

In 61 patients the effectiveness of imipenem in the treatment of chronic post-traumatic osteitis was examined. The diagnosis of post-traumatic osteitis was based on clinical and radiological signs of infection, as well as a positive bone culture from a surgical specimen. The average duration of treatment was 10 days with a dosage 3 X 500 mg imipenem daily. The most commonly identified pathogen was Staphylococcus aureus. In 75% of the cases an infection with Gram-positive pathogens was found. The majority of Gram-negative infections was caused by Pseudomonas aeruginosa. The rate of elimination was greater than 90% for both Gram-positive and Gram-negative bacteria. A definite cure was achieved in 80% of the reported cases, only four patients (7%) showed a recurrence of the infection. Allergic reactions or other adverse effects were not observed except for diarrhoea in four patients. The high rate of therapeutic effectiveness as well as the excellent toleration justify the use of imipenem in the treatment of chronic post-traumatic osteitis.