[Aggravated reduction of the posterior malleolar fracture due to incarceration of the flexor digitorum longus tendon]. / Repositionshindernis des hinteren Volkmann-Dreiecks durch Interposition der Sehne des M. flexor digitorum longus.

The indications for stabilization of the posterior malleolus (Volkmann triangle) while fixing ankle fractures are controversially discussed. Detailed descriptions of possible obstacles to reduction are scarce. The following case describes the difficulty of reduction of the posterior malleolus caused by interposition of the flexor digitorum longus tendon. The fracture line of the posterior malleolus passed in an atypical manner vertically to the posterior-medial tibial margin with direct contact to the anatomical pathway of the tendon. The impaction of the tendon was already present in the computed tomography (CT) scan taken preoperatively but the tendon hindering malleolar reduction was first realized during surgery after several unsuccessful attempts at repositioning.

[Vacuum-assisted closure therapy for the treatment of skin and soft-tissue infections. Are wound specimens of use in planning secondary wound closure?]. / Vakuumtherapie bei Haut- und Weichgewebsinfektionen der Extremitäten. Nutzen des Wundabstrichs bei der Planung des sekundären Wundverschlusses?

AIM: Vacuum-assisted closure is used frequently for the treatment of skin and soft-tissue infections (SSTI) of the extremities. After debridement and repeated VAC dressing changes, the wounds are closed by secondary suture, split-thickness skin grafts or local flaps. However, no objective parameters describe the time point for secondary wound closure. Our thesis was that negative microbiological results from wound specimens can indicate the time for secondary wound closure. PATIENTS AND METHODS: 24 patients with SSTI of the extremities were treated by serial debridements and VAC therapy and analysed prospectively. Debridements were repeated until the wounds were macroscopically free from signs of infection (good granulation/no necrosis). During each revision specimens were taken for microbiological analysis. Moreover, number of revisions, bacterial cultures, type of wound closure and wound status after 3 years and 5 months on average after the last surgery were analysed. RESULTS: 6.3 revisions on average were performed until secondary wound closure was possible. In spite of the absence of macroscopic infection, bacteria were still found in tissue samples from 14 of 24 wounds. 6 wounds were free of bacteria for the first time right before wound closure, 3 wounds had become negative during the treatment. After 3.4 years on average, the wounds of all 18 patients available for examination had healed well and were free from signs of infection. CONCLUSION: Vacuum-assisted closure resulted in clean, good granulating wounds without necrosis. However, in more than half of the wounds bacteria persisted. This bacterial load had no correlation to wound healing and outcome after over 3 years. In conclusion, microbiological tissue samples are not suitable as indicator for the time point of secondary wound closure in SSTI.

[Vacuum-assisted closure therapy for the treatment of acute postoperative osteomyelitis]. / Vakuumtherapie bei akuter postoperativer Osteitis.

AIM: Vacuum-assisted closure is used frequently for the treatment of posttraumatic osteomyelitis of the extremities. After debridement and repeated VAC dressing changes, the wounds are closed by secondary suture, split-thickness skin grafts or local flaps. However, no objective parameters describe the time point for secondary wound closure. Our thesis was that negative microbiological results from bone specimens can indicate the time for secondary wound closure. Moreover, treatment course and clinical outcome after 3.4 years should be compared to those of other surgical approaches for acute postoperative osteomyelitis from the literature. PATIENTS AND METHODS: 43 patients with acute postoperative osteomyelitis of the extremities and the pelvis were treated by serial bone and soft tissue debridements and VAC therapy and analysed prospectively. Debridements were repeated until the wounds were macroscopically free from signs of infection (good granulation/no necrosis). During each revision a bone specimen was taken for microbiological analysis. Number of revisions, bacterial cultures, type of wound closure and recurrence of infection after 3 years and 5 months on average after the last surgery was analysed. RESULTS: 9.8 debridements on average were performed until eradication of infection and secondary wound closure. Despite the absence of macroscopic infection, bacteria were still found in bone samples from 15 of 43 patients. Three biopsies were free of bacteria for the first time right before wound closure, 25 samples had become negative during the treatment. Six recurrences (19.3 %) were noted after 3.4 years on average. Four patients from the group of negative bone biopsies (19 %) and two patients from the group of persisting bacteria before secondary closure (20 %) had a recurrence of infection. CONCLUSION: In about one third of the bone biopsies bacteria persisted. This bacterial load had no correlation to wound healing and rate of recurrence after over 3 years. In conclusion, microbiological bone samples are not suitable as an indicator for the time point of secondary wound closure. Compared to other treatment options in acute postoperative osteomyelitis from the literature (especially implantation of local antibiotics), no advantage of vacuum-assisted closure could be shown concerning number of debridements and rate of recurrences.