[Gas gangrene after aseptic orthopedic surgery]. / Gangrène gazeuse après chirurgie orthopédique aseptique.

Gas gangrene following scheduled orthopedic surgery is not uncommon. In order to assess its frequency and prognosis, identify possible predisposing factors and suggest preventive measures, we reviewed the records of 22 patients (14 males and 8 females, mean age 40 +/- 20 years) admitted between 1969 and 1987 who developed gas gangrene in the wake of orthopedic surgery. In all cases the lower limbs were the site of operation: the knee in 9, the hip in 4, the femur in 4 and the leg in 5 cases. Surgical procedures included on-site foreign material in 19 cases, pneumatic tourniquet in 6 and prolonged vascular stretch in 9. Infection was diagnosed within 1.4 +/- 1.1 days of surgery; local signs, especially crepitants and pain, were prominent for the diagnosis. Pathologic findings consisted of myonecrosis in 18 patients and cellulitis in 4. Local bacteriological studies, carried out in 19 patients, yielded organisms in 14, including 12 with Clostridia perfringens. Four patients (one despite surgical treatment) died within 24 hours of admission. The remainder were treated with a combination of surgery, antimicrobial therapy (18) and hyperbaric oxygen (17). Subsequently, 13 patients had severe functional disability, while 5 recovered without sequelae. In view of the poor prognosis of gas gangrene, several preventive measures are suggested during aseptic surgery of the lower limbs. Careful skin preparation, cleaning of the anal region and short-term prophylactic antibiotic therapy with cefamandole or amoxycillin-clavulanic acid, are among them.

Concurrent oral surgery and orthopaedic treatment in the multiply injured patient: is there an increased incidence of orthopaedic sepsis?

Fifty-five patients requiring oral surgery and orthopaedic care were studied prospectively and compared to a control group. Six patients received no antibiotics and one developed an orthopaedic operative site infection due to a mouth organism. Seventeen patients had concurrent surgery and perioperative antibiotic usage and no infections occurred. Twenty-six patients required multiple operations and courses of antibiotic treatment and five developed infections. Enterobacter infections were common and emerge because they are resistant to first-generation cephalosporins. Treatment by a perioperative first-generation cephalosporin is recommended, followed by throat cultures and treatment by antibiotics specific for cultured organisms for patients requiring subsequent operations.

The Maquet procedure--anterior displacement of the tibial tubercle. Indications, contraindications, and precautions.

Maquet recommended 2-2.5 cm of anterior tibial tubercle elevation for patients with symptomatic osteoarthrosis of the patellofemoral joint. Fifty-three patients with osteoarthrosis were divided into three groups. The first 12 patients were treated by the classical Maquet procedure; 11 were totally relieved of patellofemoral pain, but there was one failure and five complications. In the second group of 32 patients, the patella was realigned within its groove to alter tracking of the patella to the proximal femoral condyles when necessary. Fish-mouthing technique and insertion of a drain after surgery were done. After a two-year follow-up examination, there were two failures and five complications. A third group of nine patients was treated with Ferguson's modification of Maquet's operation using a 1.25-cm tibial tubercle elevation through a transverse incision; two of the nine had complications, subsequently treated successfully by converting Ferguson's operation into the Maquet operation, as modified for Group II. The modified Maquet procedure can be an effective and reliable treatment of patellofemoral arthrosis with a relatively low incidence of complications.

Shoulder-muscle strength and range of motion following surgical repair of full-thickness rotator-cuff tears.

Postoperative measurements of the range of motion and muscle strength of the shoulder and ratings of pain and the ability to perform daily activities were made in fifty-eight patients (sixty-three shoulders) who had a repair of a full-thickness rotator-cuff tear. Postoperatively, the patients had an average of 126 degrees of active flexion of the shoulder and an average of 130 degrees of active abduction. Passive motion averaged 21 degrees more than active motion. The strength of the abductor muscles of the shoulder averaged approximately 86 per cent of normal. Most patients reported marked relief of pain and rated themselves as having mild or no deficits in their ability to perform daily activities. The length of the cuff tear significantly affected the functional results. Short tears (less than 2.5 centimeters) were associated with greater strength and range of motion than were long tears. Fifteen of the nineteen patients who were unable to work preoperatively because of the shoulder returned to work after surgery, but not necessarily to the same type of work that they had done before the onset of the problem with the shoulder.

[Iatrogenic injuries of the venous femoroiliac axis]. / Traumatismes iatrogènes de l'axe veineux fémoro-iliaque.

The occurrence of iatrogenous vascular accidents is underestimated. The authors describe 14 venous lesions to the femoro-iliac axis out of 60 iatrogenous vascular traumatisms. They consider the different aetiologies, underlining the disadvantages of femoral catheterisms and the main surgicalfactors contributing to venous traumatism. They emphasize the need for preventive measures in each discipline, and also the need for rapid diagnosis, thorough treatment, and careful post-operative after-care, bearing in mind secondary thrombo-embolic complications.

[Peroperative vascular accidents during orthopedic surgery. Apropos of 55 cases]. / Accidents vasculaires per-opératoires de la chirurgie orthopédique. A propos de 55 cas.

The functional or vital prognosis may be affected by the rare vascular accidents resulting from orthopedic operations. During a 10 year period (1970-1980), 55 vascular lesions were observed in 40 patients, and were either arterial (40 cases) or venous (15 cases) in type. Vascular injuries in 9 cases were due to spinal operations (cervical, lumbosacral or herniated disc arthrodesis), in 7 cases to shoulder operations (recurrent dislocation, excision of first rib), in 9 cases to hip surgery (prosthesis, plate and screws, fractured acetabulum), and in 15 cases to operations on the lower limbs (osteosynthesis of femur or tibia, meniscus operations, etc.). Emergency operation was necessary in 18 cases because of a hemorrhagic or ischemic syndrome, all other cases except three requiring secondary surgery for false aneurysms, arteriovenous fistulae, or residual ischemia. Four patients (10%) died, three following hip surgery, and 8 developed complications. The frequency, mechanism, diagnostic and therapy of these lesions are discussed.

Vascular injuries in orthopaedic surgery.

(1) Vascular injuries in orthopaedic surgery are of great importance for the postoperative function of the extremity. (2) Hip replacement operation and orthopaedic operations on the knee seem to be predestined to such complications because of the close proximity of bone and vessels. (3) Early diagnosis and operative correction as soon as possible may prevent severe damage of the extremity.

Treatment of severe spondylolisthesis. A combined approach for reduction and stabilization.

A technique for combined posterior and anterior reduction of spondylolisthesis is presented. Preliminary results suggest that this is a valid technique for obtaining satisfactory reduction of the deformity and stabilization in severe cases of spondylolisthesis (greater than 50%). The indications for this approach and possible complications are described in detail.

[Chronic osteomyelitis: open excision and grafting after saucerization (author's transl)]. / Ostéomyélite chronique: excision et greffe de spongieux à l'air libre après mises à plat extensives.

From January 1960 to January 1974, 180 cases of chronic osteomyelitis were treated by the same surgeon in the infection unit of Notre-Dame Hospital in Montreal. Of these cases, 71.4% were treated by saucerization, followed by secondary closure or by skin grafting. In ten cases (5.4%) the limb was amputated. However, in 39 cases two similar techniques of open excision and grafting were used. The infection was mostly traumatic in origin and a staphylococcus was cultured in 75% of cases. The organism was sensitive to cloxacillin and dicloxacillin in the majority of cases. Since 50% of these 39 cases were referred for amputation, the results were much betts. Two late recurrences were recently seen and treated, one 17 years and one 4 years after the initial treatment.

[Postoperative complications of wound healing in orthopaedic surgery (author's transl)]. / Zur Beeinflussung der Wundheilungsstörungen in der operativen Orthopädie.

From 1. 1. 1971--30. 6. 1977 (6.5 years) 4,169 aseptic orthopaedic operations were performed in the Orthopädische Universitätsklinik Düsseldorf. 42 complications of wound healing have been observed (1%)9 Without an ultrasteril operationbox it is also possible to reduce the complications of wound healing in orthopaedic surgery. It is important to know the principles of asepsis and antisepsis, the method of our preoperative preparation of patients is described; the indication of prophylaxis of chemotherapeutic agents should be severe.

[Avoidable surgical errors in hallux valgus surgery according to Brandes (author's transl)]. / Vermeidbare Fehler bei der Hallux-valgus-Operation nach Brandes.

In postoperative follow-ups in a large number of patients who underwent Hallus valgus surgery according to Brandes, residual pain was found due to insufficient resection of the proximal phalanx. It is pointed out that the results of this frequent and beneficial Hallux valgus surgery can be improved by using a more subtile surgical technique. Figs. 1-5 show that errors continue to be made. If these errors can be avoided in the future this report will have fulfilled its purpose.

[Arthrolysis in the treatment of post-traumatic extensor rigidity of the knee (author's transl)]. / Die Arthrolyse in der Behandlung posttraumatischer Kniestrecksteifen.

Extensor rigidity of the knee may be due to a wide variety of causes and is certainly quite often a sequela of an injury. Rigidity is caused by damage to tissue distant or proximal to the knee joint, in the joint itself, or simultaneously at several locations. In many cases considerable improvement can be achieved by arthrolysis. However, this requires detailed knowledge of the involved and expected pathologic changes. Besides detailed clinical and x-ray examination via arthrography it is particularly important to select and prepare the patients properly. Knee arthrolysis can never be based on only one surgical procedure. The authors differentiate between covered and open loosening of the stiffened joint besides intraarticular and extraarticular arthrolysis, and a combined intraarticular and extraarticular procedure. Postoperative followup treatment is at least just as important as the surgical procedure itself. Complications can be largely avoided via subtile technique and sufficient experience. The authors report on 16 followup examinations effected during the past four subsequent to arthrolyses of the knee. On the average there was an improvement in flexibility and stretch-ability by 70 degrees, or a relative flexibility increase by 80%. No serious complications were seen. Arthrolysis of the knee is recommended as a well-tried and highly successful surgical procedure.

[Longitudinal growth of the tibia using the model of a congenital pseudarthrosis of the tibia (author's transl)]. / Längenwachstum der Tibia anlässlich eines Modellexperimentes der kongenitalen Unterschenkelpseudarthrose

Authors could not confirm a growth disturbance--suggested by other workers--at the distal end of the tibia in a modell experiment of congenital pseudarthrosis of the leg.

Acute neurological complications in the treatment of scoliosis. A report of the Scoliosis Research Society.

A survey conducted by the Scoliosis Research Society found eighty-seven patients with acute neurological complications resulting from the treatment of scoliosis. The incidence of these complications was determined to be 0.72 per cent. Seventy-four major complications involving the spinal cord were reported, half of them complete paraplegia and half partial paraplegia. Thirty-six per cent recovered completely, 32 per cent had partial recovery, and 32 per cent had no return of function. Thirteen minor complications involving cranial and peripheral nerves were reported. Major complications occurred in forty-two cases of posterior spine fusion with Harrington instrumentation and in twenty cases of posterior spine fusion without instrumentation. Six patients became paraplegic following skeletal traction alone.