The posterior antiglide plate for fixation of fractures of the lateral malleolus

Anatomical reduction and internal fixation of displaced lateral malleolar fractures are the cornerstone of the operative treatment of ankle fractures. The classical method of fixation is the application of one-third tubular plates laterally to the distal fibula, a technique, however, that has several disadvantages. In exceptional cases and under special circumstances we prefer a dorsal approach with the use of an antiglide plate. Indications, technique and experiences are discussed.

External fixation for diaphyseal femoral fractures: a benefit to the young child?

External fixation for the treatment of diaphyseal femoral fractures in children seems an attractive alternative, which explains why its application gets more and more advocates. Between 1984 and 1989 15 children aged from 4 to 10 years were treated for a diaphyseal femoral fracture with an external fixation using a small Hofmann system. Fracture healing was without complications. Four children were able to walk on crutches non-weight-bearing after a short period. Six cases had complications, such as pin tract infection, inexplicable pain, or secondary displacement. One patient sustained a supracondylar fracture through one of the distal pin tracts. Hospital stay was longer than expected. In conclusion external fixation for femoral fractures in children is simple and elegant, but has considerable complications, while presumed advantages are not always obtained. In selected cases it is an attractive alternative, but the indications must be restricted.

Aorto-caval fistula after lumbo-sacral disk surgery

A patient with an aorta-caval fistula after intervertebral disk surgery is presented. Deterioration of the condition of the patient, mainly due to a progressive congestive heart failure, was caused by a large aorto-caval fistula; emergency repair of the lesion led to complete recovery. Because of delay in diagnosis, this insidious complication generally causes serious cardiopulmonary disturbances with a high morbidity and a significant mortality. The surgical treatment consists of the reconstruction of the greater veins and arteries involved.

[Surgical treatment of toxic megacolon]

From 1978 to 1989, 11 patients suffering from toxic megacolon were treated. In eight patients it was based on ulcerative colitis, while Crohns' disease, infectious colitis and pseudomembranous colitis were seen once each. Patients were initially treated with intravenous fluids and corticosteroids. They were closely followed both clinically and radiologically. The plain abdominal X-ray was of great help. Conservative regimen was successful in 3 patients, the remaining had to be operated on in due course. Three patients proved to have a perforation of the bowel at the time of operation. The initial operations performed were one proctocolectomy, four times a subtotal colectomy, twice a partial colectomy and in one instance a diverting colostomy. Two patients had to undergo an additional colon resection. Postoperative complications consisted mainly of intra-abdominal abscesses. Two of the operated patients died. Follow-up is between 2 and 9 years. None of the patients had a recurrence of the toxic megacolon. Four patients had a recurrence of their underlying disease, which however could be resolved in most cases by medical means. In one patient total colectomy is being considered.

The femoro-femoral cross-over bypass

From 1984 to 1990 64 patients (56 men and 8 women) with a mean age of 67.1 years (36-88 yrs.) were treated with a femoro-femoral cross-over bypass (45 primary and 19 secondary procedures). All patients had an occlusion of one iliac artery. In 26 patients there were factors that made a central reconstruction unattractive. These disorders were congestive heart failure, COPD, CVA, an age over 80 years, etc. In 19 patients an occlusion of one leg of a former aortobifemoral bypass determined the choice for cross-over bypass. Three patients died (5 per cent), two patients of the so-called redo-group (septicaemia, one patient and arteriojejunal fistula one patient), the third patient died after a primary femoro-femoral bypass (myocardial infarction). The overall patency rate after three years was 78 per cent. Especially primary cross-over bypasses showed a good outcome with a primary patency of 80 per cent and a secondary patency of 85 per cent after three years. Considering that 23 of the 45 (51 per cent) primary procedures were for treatment of critical ischaemia (stage III and IV of Fontaine), a favourable limb-salvage of 21 out of 23 (91 per cent) was obtained. The cross-over bypass can be recommended as first choice therapy for patients with a unilateral iliac artery occlusion.

External fixation of Smith's fracture. 16 patients followed for 2 years

External fixation of 16 Smith's fractures was evaluated after 22 (6-42) months. In 15 patients, the radiographic results were satisfactory. There was a definite correlation between the radiographic and clinical end results. However, 6 patients had residual signs of an upper limb dystrophy. Although external fixation of Smith's fractures results in good function, this method should be used with caution because it cannot prevent reflex dystrophy; indeed, it may even initiate it.

The AO-plate for external fixation in 12 cases

The AO-plate was used for external fixation in 12 patients. The main indications were severe open fractures of the forearm and infected pseudarthroses at several locations. In 10 cases, the fixation provided enough stability to allow bone healing. The technique is simple, is convenient for the patient, and is always available without additional special equipment.

[Tension band osteosynthesis of resorbable material]

Tension-band osteosynthesis is a simple and well-known procedure applied in the surgical treatment of fractures. This type of osteosynthesis does nonetheless have some disadvantages, e.g., irritation of the skin and fistulization at the point where the metal cerclage bends, that can make removal necessary mostly under full anaesthesia. Since 1987 we have replaced the metal cerclage in 36 tension-band osteosyntheses (21 fractures of the medial malleolus, 6 lateral malleolar fractures, 4 patella, 4 olecranon and 1 distal clavicular fracture) with the resorbable suture material Vicryl No 2. Our results were good: there have been no skin problems at all and there are several advantages.

Traumatic posterior luxation of the hip

The long-term outcome of treatment of posterior hip dislocations was studied in 60 patients. Thirty-two patients had concomitant fractures of the acetabular rim and seven had also femoral head fractures. Treatment consisted of immediate reduction, followed by gentle traction during one week and progressive weight-bearing over six weeks. Thirteen patients needed internal fixation of the acetabular fracture. Fourty-six patients could be followed for a median of 6.5 years. Fifteen patients, all with associated fractures, had late complications: peri-articular ossifications (5), avascular necrosis of the femoral head (1), mild osteo-arthrosis (5) and pain of unknown origin (4). No complications were noted in patients with simple posterior dislocation of the hip. Simple traumatic posterior hip dislocation has an excellent prognosis. Poor results only occur in case of associated fractures.

[The pneumoportogram, a rare finding in septicemia due to an intra-abdominal abscess]

A man aged 73 is described with radiologically revealed air in the portal vein, a peumoportogram, on the basis of intra-abdominal sepsis. Characteristic of this finding are the air shadows extending far into the periphery of the liver in contrast to an air cholangiogram. It is an ominous sign, mostly secondary to severe intra-abdominal pathology such as ischaemic bowel necrosis, peritonitis or abscesses. Treatment should be aimed at these causes. Prognosis depends on the underlying pathology.

[Organ donation in a general hospital]

There is an acute shortage of donor organs for transplantation in The Netherlands. It is presumed that many potentially available organs are lost due to insufficient alertness. A retrospective study was made of the results of the procedure for obtaining permission for post-mortem donorship. Records of patients succumbed in the Intensive Care Unit in the period 1983-1987 were checked to ascertain whether these patients had met the current selection criteria for donorship. According to these criteria, 104 of the 531 deceased patients had been suitable. Death had been due to irreversible brain damage in 71 cases, to CVA in 29, to a primary brain tumour in three and to an intoxication in one. The donation procedure was followed in 53 cases of death. In 20 cases relatives refused permission and in 12 there were insuperable practical and technical difficulties. Relatives of 19 deceased patients were not asked for permission for post-mortem donorship. Once the procedure for obtaining permission for post-mortem donorship was implemented according to protocol and on a multidisciplinary basis, the proportion of cases in which requesting permission was omitted fell from 37% to 3%. Greater alertness of those involved to the possibilities of organ donation and good organization result in a growing number of organs available for transplantation, reducing an acute shortage.

Ascites after pleuroperitoneal shunting

If conventional therapy fails in patients with intractable malignant pleural effusion, the pleuroperitoneal shunt is a valuable alternative. In a 59-year-old man with disabling malignant pleural effusion, massive ascites developed shortly after insertion of a pleuroperitoneal shunt. This shunt was replaced by a pleurovenous shunt. The ascites disappeared, and pleural effusion did not recur. The patient died 6 months later.

[The value of roentgen studies in supination injuries of ankle and foot]

In 523 consecutive patients with inversion injuries of ankle and foot, X-ray examination revealed 52 fractures. The majority of these fractures could be treated symptomatically. On the basis of clinical examination as the diagnostic tool for these ankle injuries, the need for radiological assessment was decided. All important fractures were recognized. The patient's ability to bear weight on the injured ankle, the presence of lateral malleolar tenderness and advanced age were important clinical variables. Careful physical examination can lead to a selective radiological assessment of acute ankle injuries. Superfluous X-ray procedures can be eliminated which will greatly reduce costs without detriment to patient care.

[Partial and total patellectomy as treatment of comminuted patella fracture]

When accurate reduction and stable fixation cannot be achieved in comminuted patellar fractures, degenerative changes in the patellofemoral joint can cause troublesome complaints. Our results show that partial or total patellectomy can produce a very good percentage of satisfactory results. In spite of several biomechanical studies that demonstrated the reduced efficiency of the quadriceps mechanism after partial and total excision of the patella, most patients achieved good or excellent results after a long follow-up period. All patients showed decreased isokinetic performance of the quadriceps muscle. There was no clear correlation between the clinical score and the data on isokinetic performance. Patellofemoral or femorotibial osteoarthritis and calcifications in the patellar ligament did not lead to an unsatisfactory clinical result.

[Fournier's gangrene]

Two patients with a necrotizing soft tissue infection of the scrotum and perineum are described. The etiology was found to be a gram negative synergistic gangrene. Patients were managed with extensive necrotectomy with a planned second look operation and supportive antibiotics (aminoglycosides, amoxicillin, metronidazole). Despite this aggressive approach one of the patients died of ongoing necrosis. The therapeutic management for necrotizing soft tissue infection comprises early surgical intervention with supportive antibiotic treatment. Nevertheless the disease is associated with a high mortality rate.

Cecal carcinoma: a different colon malignancy?

Cecal carcinoma has been associated with a poorer prognosis than other colon carcinomas because of the presumed longstanding obscure symptoms. In a combined study of three Dutch hospitals, a total of 166 patients with cecal carcinoma were evaluated after right hemicolectomy. Special emphasis was placed on clinical symptoms related to advanced tumor growth, e.g., pain, anemia, and palpable mass. These factors and clinicopathological staging were evaluated with aid of the Cox regression model. Ninety percent of the resected specimens contained a Dukes' B or C carcinoma. Only 5% were found to have widespread metastatic disease. Overall 5 year survival rate was found to be 0.57. No statistically significant relation to pain or palpable mass was found. Anemia, however, was related to a better survival, especially in patients with a Dukes' B carcinoma. Clinicopathological staging according to Dukes' is closely related to survival. It is concluded that carcinoma of the cecum behaves similarly to other colon malignancies.

Percutaneous endoscopic gastrostomy as a standard procedure in head and neck surgery

Adequate nutritional support is essential in patients with head and neck cancer, especially if extended oropharyngeal surgery is indicated. Enteral nutrition is an effective and safe alternative to parenteral nutrition, but the use of nasogastric tubes has several disadvantages in these patients. We describe our experience with percutaneous endoscopic gastrostomy as a standard procedure prior to surgical resection in patients with head and neck cancer.

[Rupture of the biceps tendon]

Ruptures of the tendon of the biceps muscle usually occur spontaneously because of degeneration and almost always in the proximal tendon of the long head. Experiences of 13 patients with a rupture of the long head are described. Ten patients were treated by operation, the results of simple transposition of the tendon are excellent as long as ruptures have not existed for more than 6 weeks. The indication to operate ruptures of the long head is relative.

[Prevention of wound infection following abdominal surgery]

In the surgical department described, prevention of wound infection after abdominal operations involving endogenous bacterial contamination consists of a single preoperative administration of antibiotics according to a simple scheme, suitable for nursing staff also (using a combination of amoxicillin, tobramycin or metronidazole) with liberal application of open wound treatment. During the period from 1 July 1985 to 1 July 1986, 519 abdominal operations were performed, classified by increasing degree of contamination according to the classification of the American National Research Council (NRC) as NRC classes II to IV. In 371 cases, the wound was closed (NRC class II: 285; NRC class III: 86). In 148 cases (40%) the wound was intentionally left open (NRC class III: 51; NRC class IV: 97). In the group with NRC class II only two wound infections were seen. Inter alia there were no infections after 141 gall bladder/biliary tract operations, none after 46 gastrectomies and only one after 54 elective colon resections. In the group with NRC class III with 86 closed wounds, no wound infections occurred. All 148 wounds left open (NRC classes III and IV) healed smoothly, without significant morbidity, prolonged hospital stay or increase of the number of out-patient follow-up visits; moreover, the cosmetic results were good. With specific antimicrobial prophylaxis in a single administration combined with liberal open-wound treatment, postoperative wound infection after laparotomy appears to be virtually controlled.

Ankle fractures treated with a stabilizing shoe

Twenty-four patients with a Lauge-Hansen Stage II supination-eversion fracture of the lateral malleolus were treated with a stabilizing shoe, which prevents supination and eversion of the foot, but allows a tibiotalar motion. In 23 patients the result was excellent, without secondary dislocation during healing. We therefore conclude that this fracture type can be treated functionally.

Repair of the proximal interphalangeal joint with a homograft

We describe the delayed reconstruction of a destroyed proximal interphalangeal joint by implantation of a partial articular homograft in a 17-year-old boy. One year after the operation the joint is painless and has a normal range of motion.

[Treatment of isolated ulnar shaft fractures using Sarmiento's method]

Twenty-three patients with an isolated fracture of the ulnar shaft were treated by functional bracing as proposed by Sarmiento. Complete functional recovery was achieved quickly in all cases. No pseudarthroses occurred. In those cases in which the ulna had healed with some angulation, no clear restriction of rotation of the forearm was observed. The patients tolerated the treatment well. It is concluded that functional bracing of isolated fractures of the ulnar shaft is an elegant method of treatment with a minimal risk of complications. It is important that associated dislocation of the head of the radius is excluded before the treatment is instituted.