External fixation of open femoral shaft fractures.

OBJECTIVE: To determine whether external fixation proves to be a sensible technique for definitive stabilization in open femoral fractures. DESIGN: Retrospective clinical study. MATERIALS AND METHODS: From 1985 to 1989, 18 patients (mean ISS 25.4) with open femoral fractures (type II 11%, type III 89%) were treated by primary and definitive external fixation. After failure of closed reduction procedures, open reduction via debrided soft tissue wounds was employed in 72%. Supplemental internal fixation of large wedge fragments was required in 66%. External fixators were removed after a mean of 166 days. Early deep infections developed in 11%. Additional cast, brace, or traction were not required. MEASUREMENTS AND MAIN RESULTS: After a mean follow-up period of 58 months, 88% of the surviving 17 patients were clinically and radiologically evaluated and 12% were interviewed by telephone. Eleven percent developed late deep infection of the femur concerned. Eighty percent have had full or slightly restricted knee motion. The mean knee flexion amounted to 130 degrees. Relevant shortening of the femur was diagnosed in 7%. Nonunions or relevant malunions were not observed in our series. CONCLUSIONS: These morphologic and functional results compare with those published for alternative stabilization techniques of femoral fractures. For special indications, external fixation is considered to be a sensible technique for primary and definitive treatment of open femoral fractures.

[Comparative study of surgically treated shoulder injuries with or without metal implants]. / Vergleichende Untersuchung operativ versorgter Schultereckgelenksverletzungen mit und ohne metallische Implantate.

In 36 patients with acromioclavicular fracture type III, IV and V following the Rockwood classification, different surgical procedures without using metal implants were compared. Augmentation of both, the coracoclavicular and acromioclavicular ligaments was done by Vicryl-threads (5 mm) in 26 cases (group I). Solitary augmentation of coracoclavicular ligaments were done in 6 cases (group II), of acromioclavicular ligaments in 4 cases (group III). Twenty-four patients underwent follow-up regarding clinical, ultrasonic and radiological results after 30 month in average. Dislocations of more than 10 mm we found once in group I and II, three times in group III. Using the Taft score, regarding clinical, ultrasonic and radiological findings, five patients had an excellent, 15 a good five patients a satisfying result and the remaining patient had a poor reconstruction of the acromioclavicular joint. Comparing these results with previous 75 patients who underwent surgical reconstruction of acromioclavicular joint, using metal implants between 1980 and 1985, the results were nearly equal. Although severe complications like migration or fracture of the implant and the necessity for another surgical intervention for explantation were not given in patients who were treated without using metal implants. Solitary augmentation of acromioclavicular ligament showed insufficient results, therefore this therapy should not be recommended anymore.

Intraarticular autogenous bone grafting in recurrent shoulder dislocations.

In a reexamination, 24 young soldiers who had been operated on using a new method of screwing an autogenous bone graft into the glenoid rim in cases of recurrent dislocation of the shoulder joint were investigated. A major functional problem is the reduced lateral rotation, even by using other procedures for operative treatment like Eden-Hybinette or Putti-Platt. This reduction of shoulder movement results in problems using the affected arm during sporting activities or military duties. There has been an excellent result without any redislocation in a follow through of 6 to 42 months and more than 90% satisfied patients, with only a very low rate of reduction of lateral rotations about 10 degrees using this procedure. The X-rays of all the patients, reinvestigated, showed a complete healing of the bone grafts into the glenoid rim and correct position of AO-screws.

Experience in a military trauma surgery department with external skeletal fixation of femur fractures.

Our experience with external skeletal fixation of complex open and closed femoral fractures in 50 conventional trauma victims is presented. Different external fixator systems were primarily used in 26 patients and secondarily in 24 patients. The authors feel that early definitive femoral fracture care in civilian and military trauma victims employing unilateral external monofixation, which avoids casts, and allows improved wound management and early mobilization of the multitrauma patient, has decreased the complication rate commonly associated with internal fixation of open femoral fractures.

Gunshot and blast injuries to the extremities. Management of soft tissue wounds by a modified technique of delayed wound closure.

Thirty-three soft tissue wounds to the extremities from high-energy missiles were treated in 26 patients by using a modified technique of delayed wound closure. The modifications included planned re-examination and, if indicated, re-debridement of the wound every 48 hours after the initial treatment, and temporary wound coverage with synthetic skin substitutes. With this approach we observed only one wound infection postoperatively. This finding demonstrates that these modifications may be helpful in the management of this type of injury, that is otherwise associated with a high complication rate, including wound infection.

[Complications due to migration of a Kirschner wire from the clavicle (author's transl)]. / Komplikationen durch Drahtwanderungen nach Kirschnerdraht-Spickungen an der Klavikula.

The complications due to migration of a Kirschner wire from the clavicle are described. The major complication of a vascular and pulmonary kind were found in five cases. Migration of the wire into major vessels (aorta, subclavian artery) were seen twice and in three cases, the wire entered the lung. Removal of the wire from the aorta had a fatal result. Before removing displaced fixation wires, accurate localisation is necessary, if necessary using angiography in order to plan the subsequent operation. To avoid migration of the wire, one end should be bent to form a walking-stick shape, and the arm should be immobilised.

[Xero-radiographic examination of the capsule and ligaments of the knee joint. II. Demonstration of injuries to the cruciate and lateral ligaments and menisci (author's transl)]. / Xeroradiographische Untersuchungen am Kapsel- und Bandapparat des Kniegelenks. II. Mitteilung: Darstellung von Verletzungen an den Kreuz- und Seitenbändern sowie den Menisken im Xerotomogramm

The value of xero-radiography for demonstrating injuries to the capsule and ligaments of the knee has been investigated. A tomographic method was used in conjunction with arthrography of the knee. The results have shown that, in vitro, injuries of the cruciate and lateral ligaments and of the capsule are well shown by xero-tomography and that it is possible to evaluate their extent. Simultaneous demonstration of injuries to the menisci is less certain. In order to show these accurately, special methods would have to be employed. Despite the higher radiation dose which must be expected, and the greater complexity of this technique, we consider that a clinical investigation of the method is indicated.

[Xeroradiographic studies on the capsule and ligaments of the knee joint. 1. Anatomy of the cruciate and lateral ligaments in the xerotomogram]. / Xeroradiographische Untersuchungen am Kapselund Bandapparat des Kniegelenkes

The suitability of xeroradiography for contrast arthrography was investigated by in vitro studies. Special attention was devoted to the cruciate and lateral ligaments on xero-ty lateral tomography. The anterior and posterior ligments can be evaluated and defined satisfactorily in the antero-posterior view. The lateral ligaments can be seen on xero-tomography without difficulty. The use of xero-tomography promises to improve the radiological diagnosis of injuries of the capsule and ligaments of the knee joint.

[The simultaneous management of rupture of the urethra and the symphysis (author's transl)]. / Die simultane Versorgung der Harnröhrenruptur und Symphysensprengung

The combined injury-rupture of the urethra and the symphysis--is no respecter of the surgical disciplines, urology and accident surgery. Therefore, a combined operating team from both specialties should simultaneously undertake primary care. First comes the restoration of urethral continuity. The retropubic approach favors the gaping pubic symphysis. A stationary osteosynthesis of the symphysis with an AO-tension band plate follows. In that way the urethra and its suspension apparatus are brought into the right position. Immobilization damage is avoided through exercise stability which allows early maximum stress of the patient. A persisting instability of the anterior pelvic girdle through shearing force is a risk in reconstructive urethral surgery. Simultaneous primary care is contraindicated in cases of irreversible shock and life-threatening injury where the need for surgery is urgent.

[Angina abdominalis: Clinical findings and therapy (author's transl)]. / Klinik und Therapie der Angina abdominalis

Angiographic and clinical findings of angina abdominalis are demonstrated by the clinical course of four patients. Two of them suffered from athero-sclerotic stenosis and the remaining two from compression of the coeliac trunc respectively the upper mesenteric artery by fibrotic strings. One patient was treated by an interposition of a saphenous vein graft another one by tissue decompression. Two patients were not operated upon, because one of them had sufficient collateral circulation on angiography, and the other denied an operation, he died one year after diagnosis because of an occlusion of the coeliac trunc and the upper mesenteric artery with following gangrene of the small and large intestine. Danger of complete intestinal necrosis following arterial vessel occlusion as well as reconstructive operative procedures on arterial occlusion should be considered.

[Clinical aspects and surgical treatment of thrombosis of the inferior vena cava (author's transl)]. / Klinik und chirurgische Therapie der unteren Vena-cava-Thrombose

The infrequent thrombosis of the inferior vena cava usually arises as a transmission of a thrombosis from a leg or pelvic vein. The indication for treatment must be made early and quickly, because only complete removal of the thrombus is sufficient. The operation we recommend is transperitoneal or retroperitoneal exposure of the inferior vena cava and pelvic veins, By this method the detachment of thrombi during the operation with consequent pulmonary emboli can be prevented. On the other hand, it is possible to remove, under direct vision, thrombi extending into the renal veins. The 3 cases presented show this and therefore both the surgical treatment and the technique used for the treatment of thrombosis of the inferior vena cava can be recommended without restriction.