Single hemicerclage for lateral type B malleolar fracture--a novel, minimal and reliable osteosynthesis.

AIM OF STUDY: To investigate the short- and long-term outcome of patients with isolated lateral malleolar fracture type B treated with a single hemicerclage out of metallic wire or PDS cord. METHODS: Over an 8-year period 97 patients were treated with a single hemicerclage for lateral malleolar fracture type B and 89 were amenable to a follow-up after mean 39 months, including interview, clinical examination and X-ray controls. RESULTS: The median operation time was 35 minutes (range 15-85 min). X-ray controls within the first two postoperative days revealed an anatomical restoration of the upper ankle joint in all but one patient. The complication rate was 8%: hematoma (2 patients), wound infection (2), Sudeck's dystrophy (2) and deep vein thrombosis (1). Full weight-bearing was tolerated at median 6.0 weeks (range 2-26 weeks). No secondary displacement, delayed union or consecutive arthrosis of the upper ankle joint was observed. All but one patient had restored symmetric joint mobility. Ninety-seven percent of patients were satisfied or very satisfied with the outcome. Following bone healing, hemicerclage removal was necessary in 19% of osteosyntheses with metallic wire and in none with PDS cord. CONCLUSION: The single hemicerclage is a novel, simple and reliable osteosynthesis technique for isolated lateral type B malleolar fractures and may be considered as an alternative to the osteosynthesis procedures currently in use.

Imipenem (N-F-thienamycin) versus netilmicin plus clindamycin. A controlled and randomized comparison in intra-abdominal infections.

In a randomized study the clinical and bacteriologic effectiveness of imipenem was compared with the classical combination of netilmicin with clindamycin in patients who had surgery for an intraperitoneal infection, localized or generalized, with positive bacteriologic findings of the specimen taken at surgery. Excluded were all patients who received other antibiotics before surgery, or who died within 3 days after antibiotic therapy was started. Imipenem was given at a dose of 500 mg t.i.d., clindamycin 600 mg t.i.d., and netilmicin according to serum levels. The diagnoses ranged from postoperative peritonitis, gallbladder empyema, perforated gastroduodenal ulcer, small bowel perforation with and without obstruction, and perforated appendicitis to perforation of the colon. The bacteriologic work-up included examination of the primary specimen (aerobic and anaerobic), the urine, feces, and serologic testing for Candida albicans once or twice a week and after the course of antibiotic therapy. In addition, pH measurements of abscesses and drainage fluids were performed. Ninety-three patients entered the study. Forty-seven patients were treated with imipenem (test group), and 46 patients were treated with the combination therapy (control group). The two groups did not show significant differences in age, sex, diagnostic groups, risk factors, primary bacteriology, and duration of therapy (mean: 6.7 days). Thirty-eight patients (80.9%) treated with imipenem were cured, six patients (12.8%) were improved, and there were three (6.4%) failures. The respective numbers for the control group were 31 (67.4%), 10 (21.7%), and 5 (10.9%). The mean duration of hospitalization was 19 days for the test group and 24.5 days for the control group. There were four wound infections in the test group and 11 wound infections in the control group. Imipenem is at least as effective in the adjuvant therapy of intra-abdominal infections as the combination of netilmicin with clindamycin.

[Treatment of intra-abdominal infections with beta-lactam antibiotics. Results of some controlled prospective studies]. / Die Behandlung intraabdomineller Infektionen mit Beta-Laktam-Antibiotika. Resultate einiger kontrollierter prospektiver Studien.

Between April, 1980 and August, 1985, 240 patients were operated on for localised or generalised intraabdominal infection and in addition received anti-microbial therapy. Thirty-one patients were treated with latamoxef, 33 with ceftazidime, 20 with ceftriaxone, 47 with imipenem/cilastatin, and 109 with a combination of aminoglycosides and clindamycin (control group). The indications for surgery included: post operative peritonitis; gall bladder empyema; perforated gastroduodenal ulcer; perforation of the small intestine with or without ileus; perforated appendicitis; perforation of the colon. On average, treatment with latamoxef amounted to 12 days, with ceftazidime: 9.4 days, with ceftriaxone 8.4 days and with imipenem/cilastatin 6.7 days. The clinical success occurred in 84% of those treated with latamoxef, 79% for ceftazidime, 50% for ceftriaxone and 81% for imipenem/cilastatin. The rate of clinical success for patients treated with an aminoglycoside/clindamycin combination was 58%. The effectiveness of the beta-lactam antibiotics studied was at least equal to that of the aminoglycoside/clindamycin combination. The beta-lactam antibiotics had the advantage of a simpler clinical application, unlike treatment with aminoglycosides, where serum level monitoring is necessary. These clinical results were not as a rule improved upon following an extension of the period of treatment by one week.

Aminoglycoside monitoring: timing of peak levels is critical.

Recommendations for optimal therapeutic peak concentrations of aminoglycosides are often not differentiated with respect to duration of infusion and timing of peak sample thereafter. To document the relevance of the timing, 139 dose intervals were analyzed in 58 patients during administration of gentamicin, amikacin, and netilmicin. Serum concentrations measured immediately after 30-min infusions were compared with concentrations obtained 90 min later (2 h values). The ratio of 30 min/2 h concentrations showed considerable variability. This ratio was less than 1.5 in 15% of the dose intervals analyzed and greater than 3 in 8% of the intervals. The poor correlation between concentrations measured at 30 min and at 2 h was documented by the coefficients of variation of 0.82, 0.30, and 0.67 for gentamicin, amikacin, and netilmicin, respectively. This variability was not explained by interindividual differences, renal function, or drug half-life. However, the initial decrease in concentrations was significantly lower in patients with impaired renal function (p less than 0.001). These data suggest that timing is critical for the sampling of serum to determine peak levels in patients and the definition of optimal therapeutic concentrations.

[Moxalactam - a beta-lactam antibiotic in the monotherapy of severe infections in surgery. Clinico-bacteriological study of 35 patients]. / Moxalactam - ein beta-Lactam-Antibiotikum in Monotherapie bei schweren Infektionskrankheiten in der Chirurgie. Klinisch-bakteriologische Studie an 35 Patienten.

Moxalactam, a new beta-lactam antibiotic, was given to 35 patients at the Department of Surgery, Cantonal Hospital, St. Gall. The trial period started in April 1980 and ended in October. Moxalactam was not combined with any other antibiotic. The clinical course was observed closely and extensive bacteriological, mycological, and pharmacokinetic studies were carried out to evaluate the new antibiotic. Most of the patients had an intra-abdominal infectious disease and primary treatment was surgery. The antibiotic therapy was started at surgery. A total of 290 different bacteria could be isolated from the 35 patients. 220 isolates were aerobic and 7 0 anaerobic. The minimal inhibitory concentration was calculated for every isolate. In addition, the serum levels of moxalactam was determined in almost every patient. In 31 patients (88.6%) the therapy was successful, in 2 patients no evaluation was possible and in 2 patients the therapy was unsuccessful, including one patient with a primarily moxalactam-resistant Bacteroides fragilis responsible for sepsis. In some patients a massive increase in Candida was noted in the urine, stool, or wound drainage. Primarily moxalactam-resistant organisms, such as Streptococcus faecalis, were often found alone in the samples taken later in the course of therapy. An extraordinary change in the fecal flora could be observed during therapy, but no clinical complications resulted. No specific antifungal therapy nor any additional antibiotic against Streptococcus faecalis was necessary. Moxalactam was well tolerated and side effects were minimal. No impairment of renal function was noticed.

[Primary malignant lymphomas of the gastrointestial system]. / Primäre maligne Lymphome des Magen-Darm-Traktes.

In a retrospective analysis of 25 cases of primary non-Hodgkin's lymphoma of the gastrointestinal tract, tumors with diffuse histologic pattern predominated. Among the lymphomas of the small and large bowel there was an increased percentage of tumors of lympho-plasmocytoid type. The course of gastric lymphomas is less favourable than that of intestinal lymphomas. No correlation was found in this study, between histologic type and initial stage on the one hand, and the course of the disease on the other.