[Ambulatory thromboembolism prevention in traumatology using self-injection of heparin]. / Ambulante Thromboembolieprophylaxe in der Traumatologie durch Selbstinjektion von Heparin.

In a retrospective and prospective study, 303 patients with fractures of the ankle joint treated surgically with postoperative immobilization in a plaster cast were analysed. After the introduction of thromboembolism prophylaxis with heparin for all outpatients immobilized by plaster casts the incidence of thromboembolic complications decreased significantly, from 4.5% to zero. The prophylaxis was well accepted, about 90% of the subcutaneous injections being administered by the patients themselves or family members. No serious complications were seen. Therefore, this effective prophylaxis of thromboembolism should be practised in all outpatients with a plaster cast on the lower limb and an elevated risk of thromboembolism. A simple check-up to identify patients at risk is suggested.

[Decreasing risk by individualized timing of surgery of para-articular femoral fractures of the hip in the elderly]. / Risikominderung durch differenzierte Wahl des Operationszeitpunktes bei der hüftgelenknahen Femurfraktur des alten Menschen.

While there is no doubt about the importance of early operation of fractures of the proximal femur in the very old the exact timing of the operation is still in discussion. Routine emergency operation is opposed to a carefully planned individual timing of surgery. The advantages of a medical and anesthesiological pretreatment could be clearly demonstrated in an own series of 107 patients older than 85 treated for fracture of the proximal femur in the last three years. Hospital mortality was lowered from 18.9 to 9.1%. At the same time the rate of severe complications and the length of hospital stay were reduced significantly.

[Rib span-plasty in sequestered osteomyelitis of the femoral diaphysis]. / Rippenspanplastik bei sequestrierender Osteomyelitis der Femurdiaphyse.

A case is reported of a 6-year-old boy with acute pyogenic osteomyelitis. A delay in making the diagnosis or inadequate early treatment led to chronic osteomyelitis. A delay in making a diagnosis is the most important factor in the prognosis of acute osteomyelitis. Sophisticated techniques are only indicated to detect and confirm the nature of the lesion, but they should not delay identification of the causative organisms. In our case, the diagnosis was delayed, and there was complete sequestration of the femur shaft as a result of insufficient early treatment. After diagnosis, the initial step was surgical debridement. After complete necrotomy, continuous irrigation with suction drainage was begun. To fill the defect and accelerate bone reconstruction, we performed an autogenous graft taking the 8th rib and splitting it into nine fragments. After identification of Pseudomonas aeruginosa as the causative organism, parenteral antibiotic therapy was begun and maintained. Nine weeks after admission, the boy was able to leave the hospital. Ten weeks later he was examined in the outpatient clinic and was walking and running quite normally. To date, there has been no recurrence of the infection.

[Surgical management of fresh injuries of the outer ligament of the upper ankle joint in local anesthesia]. / Die operative Versorgung frischer Aussenband-verletzungen des oberen Sprunggelenkes in Lokalanästhesie.

Fresh, isolated external ligament ruptures in adults have been surgically treated almost without exception under local anaesthesia for more than a year now at the Department of Surgery of the Rhenish-Westphalian Technical University (RWTH) at Aachen. No complications due to anaesthesia developed in these 119 patients; all of them expressed great satisfaction at this mode of surgical approach. What is more: this method is less costly and requires less personnel than surgery under peridural anaesthesia or intratracheal (intubation) anaesthesia. Hence, in the authors' opinion, isolated fresh ruptures of the outer ligaments of the ankle joint should be operated on more often under local anaesthesia than is actually being done at present.

["Sesamoiditis" of the metatarsophalangeal joint]. / Die "Sesamoiditis" des Grosszehengrundgelenks.

Reference is made to three of the authors' own cases and to relevant literature in an account of clinical manifestation, diagnosis, and therapy of osteochondrosis and osteomyelitis of the first metatarsal sesamoid bone. Eighty per cent of the incidence are related to the age groups between 13 and 22 years. The disease is probably based on aseptic ischaemic necrosis.

[Ligament rupture of the lateral Chopart joint]. / Der Bänderriss im lateralen Chopartgelenk.

Rupture of the dorsal calcaneo-cuboid ligament has to be expected in about five per cent of all cases of supination trauma in the ankle joint and foot. The injury can be safely verified by standardised holden radiographs, with the other side involved for comparison. Surgical treatment does not appear to be necessary. Four-week immobilisation by cast was found to be sufficient for elimination of complaints and restoration of adequate functionality.

[Follow-up and late results following treatment of childhood femoral shaft fractures]. / Verlaufsbeobachtungen und Spätergebnisse nach Behandlung kindlicher Oberschenkelschaftbrüche.

On reexamining 82 femoral shaft fractures in children (50 conservatively and 32 operatively treated) 75% of the patients did not have any complaints. 25% showed a mild limping which in the majority was caused by a longitudinal overgrowth of more than 5 mm. This overgrowth was mostly to be found in patients with unstable osteosynthesis. Muscular atrophy was seen mainly in the operative group. Cutaneous necrosis after plaster extension was the most common complication. Only one rotational deformity was observed. In conclusion we think that the conservative treatment of the uncomplicated femoral shaft fracture in children is the proceeding of choice. Open fractures, especially in polytraumatic cases, should be treated by osteosynthesis, which has to be motion stable. The worst therapy of femoral shaft fractures is, as our results show, an unstable osteosynthesis.

[Fracture healing after plate osteosynthesis in acute post-traumatic osteitis]. / Zur Frakturheilung nach Plattenosteosynthese im Stadium der akuten posttraumatischen Osteitis.

The inoculated rabbit tibia served as experimental model to evaluate the influence of stabilization for the healing of infected fractures. We also examined the importance of stabilization for the course of posttraumatic osteitis. The most important results are: 1. The course of posttraumatic osteitis is influenced positively by stabilization. In spite of the implanted foreign material the osteitis will often be reduced to a bland stage. 2. Even in the state of manifest osteitis fracture healing primarily depends on stability. After stabilization of the infected fractures we even saw primary fracture healing in a high percentage (36,4%). 3. Any instability is a much greater danger for the infected fracture as for the non-infected one. The combination of instability, inflammatory destruction and impaired circulation resulted in a pseudarthrosis in most cases examined. Furthermore our experiments showed that the stabilization of infected fractures should be done as soon as possible, i.e. at a moment, when the inflammatory destructions have not yet proceeded too far. These results confirm the findings of other authors and especially demonstrate that for the infected fracture stabilization is the decisive therapeutic principle. To obtain this stabilization one should not hesitate to implant foreign material (e.g. metal plates) even into an infected area. In selected cases therefore the "septic plate osteosynthesis" is an enlargement of the therapeutic possibilities in the difficult situation of posttraumatic osteitis.

[Intraoperative bacterial contamination and posttraumatic wound infection (author's transl)]. / Intraoperative Keimbesiedelung und posttraumatische Wundinfektion.

In a consecutive series of 150 fractures treated surgically 16 wound infections were observed. Evaluating the intraoperative wound swabs, type and localisation of the fractures, duration of operation and tourniquet time it was tried retrospectively to find a relationship to these posttraumatic wound infections. The highest rate of infection was found in fractures of the tibia. Open fractures had a higher risk than closed ones. Furthermore, a prolonged duration of operation was related to a rising risk of infection. The intraoperative wound swabs themselves did not allow any conclusion concerning the risk of postoperative infection. Postoperative wound infections appeared nearly as frequent after negative as after positive intraoperative swab. Only the species of bacterias found intraoperatively allowed a conclusion concerning subsequent wound infection so far that after an intraoperative finding of gram-negative bacterias and - surprisingly - apathogenic sporogenic bacterias postoperative wound infections were observed more frequently than after finding other bacterias. In summary, however, the routine intraoperative wound swab does not seem to be suitable as a sreening-test for early recognation of impending postoperative wound infections.