Rehabilitation after amputation following lower limb fracture.

Twenty-two patients were interviewed after lower limb amputation above the ankle joint following fractures. Their median age at the time of the injury was 44 years (range, 14-77 years), and median amputation delay was 2 months (range, 0-213 months). Of the 15 patients who were working before the injury, ten returned to gainful employment after amputation. Amputation delay did not affect the ability to return to work. Twenty patients could walk outdoors; two patients aged 69 and 71 years could not, but regularly went outdoors using a wheelchair or a three-wheeled moped. Eleven patients were more or less dependent on help from others. The study indicates that most patients have an acceptable functional result, but with increasing age the chance of a return to employment decreases, and the need for help with everyday demands increases.

Gentamicin-collagen sponge for local applications. 10 cases of chronic osteomyelitis followed for 1 year.

A bovine collagen sponge containing gentamicin was applied locally in 10 patients with chronic osteomyelitis who were then followed for 1 year postoperatively. No adverse effects or recurrence of infections was observed. The release of gentamicin from the sponge was more complete and rapid than has been reported with polymethyl methacrylate (PMMA) beads. Compared with previous reports on PMMA beads, a much higher gentamicin concentration in the wound exudate can be expected after implantation of the collagen sponge, which is easy to apply and does not require a second operation for removal.

Selection of amputation level in ischemia. Skin blood flow and perfusion pressure equally predictive.

In 33 patients who had major amputation for ischemia of the lower extremity, skin blood flow and perfusion pressure were compared in terms of prediction of amputation level. Skin blood pressure was measured photoelectrically. Only the blood flow was known to the surgeon. The primary amputation was performed below the level of the knee in 15 patients, through-knee in 14, and above the knee in only 4 patients. Primary healing was achieved in 27 patients, 5 patients had delayed healing at the same level, and 1 patient was reamputated. The same amputation level was predicted in 24 patients (primary healing/secondary healing/failure = 20/3/1) and a different one in 9 patients. In 4 patients the perfusion pressure suggested a more proximal amputation (2/2/0) and in 5 patients a more distal amputation (all primary healing). There was no difference between the two methods in predicting wound healing.

Hematogenous osteomyelitis in children.

In a 10-year period, 31 children, including 9 infants, were treated for hematogenous osteomyelitis. Fifteen children were treated closed and 16 open. Thirteen of 14 positive cultures were Staphylococcus aureus. Three recurrences could possibly have been prevented by a more aggressive primary approach. At follow-up after 5 (1-12) years, 3 neonates had developed severe growth disturbances despite optimal initial treatment. Acceptable results were obtained with antibiotic therapy for 6 weeks or more. We recommend ampicillin and a penicillinase-resistant penicillin, unless bacterial resistance patterns indicate a different antibiotic. We operate if pus has formed and if a child with severe symptoms does not improve during adequate antibiotic treatment and immobilization.

Muscle transposition for treatment of osteomyelitis of the tibia.

A series of 24 consecutive patients with osteomyelitis of the tibia and soft tissue defects were treated according to the principle of radical excision of the infected bone together with transposition of muscle flaps and primary skin cover as a one-stage procedure. External fixation was used for stabilization of bone. The mean duration of osteomyelitis before radical operation was 72 weeks and the previous stay in hospital averaged 15 weeks. Twenty-one patients had previously undergone 3.7 operations because of the infection. Staphylococcus aureus was cultured in 50% of the patients, while no bacteria could be identified in six patients. Appropriate antibiotics were given for an average of eight weeks. In four patients a secondary bone transplant and in three patients another skin transplant was necessary. One patient refusing further reconstructive surgery insisted on an above-knee amputation because of persisting infection. After an average observation time of 2 1/2 years no infection or instability of the tibia could be demonstrated, but one patient showed two small skin defects. These results indicate that radical excision of infected bone in combination with muscle transposition and primary skin cover is effective in the treatment of posttraumatic osteomyelitis of the tibia.

Treatment of chronic osteomyelitis; a prospective study of 55 cases treated with radical surgery and primary wound closure.

A prospective and consecutive series of 55 patients were treated for chronic osteomyelitis occurring mainly in the lower extremity and after fractures treated with internal fixation. The mean duration of osteomyelitis was 27 months. Sixty-five per cent had previously undergone operations and had been hospitalized for an average of 131 days. Staphylococcus aureus was cultured in 72 per cent of the cases as the solitary agent. In 6 cases no bacteria were found. The remaining cases had more than one species. The treatment consisted of radical operation, removal of all internal fixation, sequestrectomy, partial decortication and primary wound closure with suction drainage. External fixation was used for bone stabilization. In 13 cases plastic procedures were carried out. Antibiotics appropriate for the sensitivity patterns were given for a maximum of 3 months. Primary wound healing was obtained in 98 per cent of the cases. In practically all cases the sedimentation rate normalized within 4 weeks after the operation. The results in the available literature indicate that radical operation is effective in the treatment of osteomyelitis and this treatment seems economical as regards hospitalization time and quantity of antibiotics required.

Clinical and social status following injury to the lateral ligaments of the ankle. Follow-up of 144 patients treated conservatively.

Out of 174 patients treated conservatively for injuries to the lateral ligaments of the ankle 144 were seen at follow-up after 3.1--6.1 years (mean 4.2 years), and clinical as well as social sequelae were recorded. The diagnostic criterion was a difference in talar tilt of 6 or more degrees between the injured and uninjured foot on inversion stress radiographs. Occupational and athletic injuries, almost equally represented, made up a total of 64 per cent. Residual symptoms were present in 21 per cent, mainly in the form of functional instability, but only four patients (3 per cent) reported daily complaints. One patient had developed reflex dystrophy, and this was the only patient who had been referred for further orthopaedic treatment. There was a close correlation between pain on movement in the ankle joint and residual symptoms which were, incidentally, unrelated to the degree of primary talar tilt. All the patients seen at follow-up had normal range of movement in the talocrural and subtalar joints. Two patients with residual symptoms had stopped working, while in the others the working ability was unaffected. The period off work had been twice as long for patients having heavy and fairly heavy work as for those doing light work. All football players with residual symptoms had had to give up playing, but only a few had daily complaints. This indicates that some symptom-free patients have in fact latent symptoms, elicited only by fairly severe strain.

Radiological and muscular status following injury to the lateral ligaments of the ankle. Follow-up of 144 patients treated conservatively.

An average of 4.2 years after conservative treatment of injury to the lateral ligaments of the ankle 144 patients attended a follow-up examination which included radiography and measurement of the strength of plantar flexion. Prior to treatment all of the patients had a difference in talar tilt of 6 or more degrees between the injured and uninjured side. At follow-up there was instability in 28 patients, or 19.4 per cent, but no correlation between instability and residual symptoms. Nine patients had an anterior "drawer sign" exceeding 2 mm, but this was also without relation to residual symptoms. Radiological evidence of osteoarthrosis was found in five patients, but four of them had a stable ankle joint and only one had residual symptoms. The mean age of the patients with osteoarthrosis was twice that for the entire material. Two patients had osteochondritis of the talus. The strength of plantar flexion was measured in 124 patients. There was significantly less strength in the injured than in the uninjured leg, but there was no statistically significant correlation between residual symptoms and reduced strength or between radiological instability and reduced strength. According to the results of the present study and a previous one (Hansen et al. 1979) and to the results reported in the literature, we find no reason to alter our present principles regarding the diagnosis and conservative treatment of injury to the lateral ligaments of the ankle.

Asymmetry of plantar flexion strength in the foot.

A study of plantar flexion strength and calf circumference in 30 conscripts is submitted. It showed an asymmetry of strength amounting to 6--11 per cent (95 per cent confidence limits). The right leg was significantly stronger than the left, but there was no difference in strength between the dominant and non-dominant leg. There was little correlation between circumference and strength.

Quadriceps function following indirect nailing of femoral shaft fractures.

A series of 24 adult patients with isolated, unilateral fractures of the femoral shaft treated by indirect Street-Hansen nailing is submitted. Follow-up included clinical and radiological assessment as well as measurement of quadriceps power. Isometric strength as well as dynamic endurance were significantly decreased at the 5 per cent level as compared with the unaffected leg. There was a poor correlation between thigh circumference and strength. The decrease in strength and endurance after indirect nailing was less than that found in previous investigations of femoral fractures treated by direct nailing.