[Recreational or professional participants in Nordic skiing. Differences in injury patterns and severity of injuries]. / Breiten- und Vereinssport beim Nordischen Skisport. Unterschiede in Verletzungsmuster und Verletzungsschwere.

A total of 441 Nordic skiing injuries were observed and analysed for a period of two winter seasons. The data showed that athletes in squads (0.02/1000 days) or professional clubs (0.09/1000 days) have lower injury risks compared to those doing Nordic skiing in their leisure time (0.51/1000 days). Amongst recreational athletes, women (0.65/1000 days) sustain trauma more frequently than men (0.40/1000 days). In professional athletes, the upper limb is commonly injured, whereas there are fewer head and trunk injuries. Furthermore the injured in this group are younger and have less severe injuries. Recreational athletes more often injure their lower limb and 20 % have injuries to the head and trunk. Those injured in this group are older and have a higher percentage of overweight people, are not well trained and have more severe or complex injuries compared to professionals.

Prospective documentation and analysis of the pre- and early clinical management in severe head injury in southern Bavaria at a population based level.

Treatment of patients suffering from severe head injury is so far restricted to general procedures, whereas specific pharmacological agents of neuroprotection including hypothermia have not been found to improve the outcome in clinical trials. Albeit effective, symptomatic measures of the preclinical rescue of patients (i.e. stabilization or reestablishment of the circulatory and respiratory system) or of the early clinical care (e.g. prompt diagnosis and treatment of an intracranial space occupying mass, maintenance of a competent circulatory and respiratory system, and others) by and large constitute the current treatment based on considerable organizational and logistical efforts. These and other components of the head injury treatment are certainly worthwhile of a systematic analysis as to their efficacy or remaining deficiencies, respectively. Deficits could be associated with delays of providing preclinical rescue procedures (e.g. until intubation of the patient or administration of fluid). Delays could also be associated in the hospital with the diagnostic establishment of intracranial lesions requiring prompt neurosurgical intervention. By support of the Federal Ministry of Education and Research and under the auspices of the Forschungsverbund Neurotraumatology, University of Munich, a prospective system analysis was carried out on major aspects of the pre- and early clinical management at a population based level in patients with traumatic brain injury. Documentation of pertinent data was made from August 1998 to July 1999 covering a catchment area of Southern Bavaria (5.6 mio inhabitants). Altogether 528 cases identified to suffer from severe head injury (GCS < or = 8 or deteriorating to that level within 48 hrs) were enrolled following admission to the hospital and establishment of the diagnosis. Further, patients dying on the scene or during transport to the hospital were also documented, particularly as to the frequency of severe head injury as underlying cause of mortality. The analysis included also cases with additional peripheral trauma (polytrauma). The efficacy of the logistics and organization of the management was studied by documentation of prognosis-relevant time intervals, as for example until arrival of the rescue squad at the scene of an accident, until intubation and administration of fluid, or upon hospital admission until establishment of the CT-diagnosis and commencement of surgery or transfer to the intensive care unit, respectively. The severity of cases studied in the present analysis is evident from a mortality of far above 40% of cases admitted to the hospital, which was increased by about 20% when including prehospital mortality. The outcome data notwithstanding, the emerging results demonstrate a high efficacy of the pre- and early clinical management, as indicated by a prompt arrival of the rescue squad at the scene, a competent prehospital and early clinical management and care, indicative of a low rate of avoidable complications. It is tentatively concluded on the basis of these findings that the patient prognosis is increasingly determined by the manifestations of primary brain damage vs. the development of secondary complications.

[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.

[Programmed debridement, combined with jet lavage in extensive hand infections]. / Programmiertes Debridement, kombiniert mit Jet-Lavage bei ausgedehnten Infektionen der Hand.

108 patients with a distinct infection of the hand were treated according to a protocol with serial debridements in combination with jet-lavage. In 106 patients the infection could be controlled with good functional result (79%) and normal neurological findings (85%). Microbial count in different tissues showed a significant decrease during the serial debridements.

[Chronic osteitis--modern therapy]. / Khronicheskii ostit--sovremennaia terapiia.

The results of the clinical trials with ofloxacin in the treatment of osteitis are presented. The drug was used according to 3 regimens: 200 mg thrice a day, 200 mg twice a day and 400 mg once a day for 6 to 24 months. The disease diagnosis was based on the bacteriological investigation of the biopsy specimens and hemocultures. The isolates were shown to be susceptible to ofloxacin. The majority of the patients (78 per cent) was treated with ofloxacin after the preliminary surgical operations. The treatment was started with the ofloxacin intravenous administration in a dose of 400 mg followed by the drug oral use in the same dose once a day for at least 14 days. The most frequent causative agents were: Staphylococcus aureus (52 per cent of the cases) and Staph.epidermidis (13.7 per cent of the cases) which were eradicated in 91.7 and 93.9 per cent of the cases respectively when the ofloxacin MICs were 0.26 and 0.22 mg/l respectively. The number of the gram-negative isolates on the whole amounted to 72.56 per cent and that of the gram-negative isolates amounted to 27.46 per cent of all the pathogens. As for the latter Pseudomonas aeruginosa and Enterobacter spp. were the most frequent (11.14 and 5.4 per cent respectively). The eradication of the pathogens amounted to 80.6 and 94.43 per cent respectively when the drug MICs were 1.78 and 0.42 mg/l respectively. The regimen with the drug oral use in a dose of 400 mg once a day proved to be the most expedient. It provided the complete therapeutic effect, minimum cost and maximum comfort for the patients.

[Reducing the risk of infection by use of an unreamed intramedullary nail in open tibial fractures]. / Reduktion des Infektionsrisikos durch Einsatz des unaufgebohrten Marknagels bei offenen Unterschenkelfrakturen.

An intramedullary stabilisation with an unreamed tibial nail (UTN) was carried out in 75 patients suffering from first (n = 45) and second (n = 30) degree open fractures. In 23 cases (8 of which had a second degree and 15 a third degree open fracture) the treatment regime was changed from external fixation (EF) to an UTN. The results were compared with 112 patients with first degree open tibial fractures treated with a reamed tibial nail (RTN). A change from EF to RTN was carried out in 93 cases (21 patients had a first degree, 55 a second degree and 17 patients a third degree open fracture). The rate of infection seen in open fractures was reduced by using an UTN for the tibia (4.5% using RTN versus 1.3% using UTN in primary implantation; 6.5% versus 4.3% in case of changing from EF to tibial nailing). The UTN does not disturb the healing of the fracture and there is no increased risk of axis deviation.

[Possibilities for the use of the basic cephalosporin cefuroxime in bone surgery. Tissue levels, effectiveness and tolerance]. / Einsatzmöglichkeiten des Basiscephalosporins Cefuroxim in der Knochenchirurgie. Gewebespiegel, Wirksamkeit und Verträglichkeit.

In a prospective study with 725 patients we demonstrated the effectiveness and tolerability of cefuroxime as antibiotic prophylaxis in trauma surgery. The infection rates were 0.5 to 1.2% in the different treatment groups. Only in patients with third degree open fractures infection occurred in 8.3%. In addition, the serum drug levels (112 mg/l) and tissue concentrations in bone cortex (15 mg/kg), spongiosa (28 mg/kg), joint cartilage (44 mg/kg) and capsule (57 mg/kg) were measured 1 h following infusion of 1.5 g cefuroxime in 14 patients using HPLC. In a further clinical study with 68 patients suffering from chronic posttraumatic osteomyelitis of the tibia, we could show the value of the surgical treatment with unroofing of the tibia and performing muscleflaps in combination with antibiotic treatment using cefuroxime. Only 4.6% of the patients showed a persistent infection and the reinfection rate was 7.4%.

[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.

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.

[Determination of surgical status: stomach cancer]. / Chirurgische Standortbestimmung: Magenkarzinom.

In spite of a decrease in the frequency of gastric carcinoma as shown in some statistics this malignoma still is an almost daily challenge in surgery. The prognosis of the gastric cancer, in general, depends upon the time of onset of therapy and the tumor grading. At present, chemotherapy and radiation therapy cannot be regarded as alternatives to surgical therapy. An improvement in the preoperative diagnostic procedures including the use of CT has not altered the prognosis of the gastric carcinoma. The procedure of choice in the treatment of gastric cancer should be total gastrectomy. The only exception to this rule is the small antrum carcinoma of the intestinal type, in which subtotal resection seems sufficient. This should comprise a 4/5-resection of the stomach and should be carried out with the same radicality concerning lymphadenectomy in the extragastric region as in total gastrectomy. The problem of intraluminal recurrency is declining provided that sufficient safety distances are maintained. An additive Brachy-radiation type therapy with intraoperative application of 125Jodine-seeds into remaining metastatic lymph-nodes seem to be a new approach to improve the prognosis of the palliatively resected gastric carcinoma. In our experience esophago-jejunoplication for reestablishment of passage following gastrectomy serves best the demand for creating a food reservoir and in preventing intestino-esophageal reflux. It seems to be of prime importance to prepare the patient psychologically for the loss of the stomach and to endow him with dietary plans for the food intake later on.