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[How often do surgical residents operate in a category A non-university post-graduate teaching hospital?]

INTRODUCTION

After introduction of the new postgraduate training program for general surgery the completion of the operation list still represents the most important step. Based on our number of operations we examined whether residents would carry out the requested interventions at our non-university teaching hospital (category A).

METHOD

For eight tracer operations we retrospectively counted the number of cases of the non private patients from 1998-2002 and took account of the postgraduate education status of the operator. In this period the team consisted of 51 residents (71 education years), of whom 18 candidates for general surgery who carried out the interventions (35 education years, inclusive rotation in ICU, emergency room and special surgical disciplines).

RESULTS

Regarding all tracer operations, the amount of interventions per year and candidate which are necessary to accomplish the goal for the first four years of education are reached: appendectomy 8.9, laparoscopic cholecystectomy 7.3, open inguinal hernia repair 9.4, varicose veins operation 12.1, open colon sigmoideum resection 3.2, hip and malleolar fracture 6.9, hemithyreoidectomy 5.

CONCLUSION

Completion of the operation list as the major training goal was reached at our institution. Following our structured education program the demands regarding postgraduate education will be met also in future. Further studies however, must examine the impact of the new resident's work contracts dictating a reduction of the weekly working hours.

[Distal radius fractures--retrospective quality control after conservative and operative therapy]

BACKGROUND

The distal radius fracture is the most frequent fracture in the adult patient. The wide spectrum of different types of fracture and the coexisting factors make the choice for the optimal treatment difficult. As an interne quality control we retrospectively evaluated all patients with distal radius fractures treated in 1995 at our institution.

METHODS

The study included 69 adult patients with 71 distal radius fractures. After on average 26 months 58 patients with 59 fractures were clinically and radiologically evaluated. The patients were asked to give supplementary information about their follow-up treatment as well as any remaining physical difficulties and limitations in the daily life. All x-rays of the broken radius were carefully analysed and compared with the opposite side. The final results were evaluated according to the "Demerit Point System".

RESULTS

Patients were treated with five different therapeutical methods. 76.3% of the patients showed a very good/good final result. In 56.7% of the cases secondary fracture dislocation occurred; the dislocation-rate of fractures treated with percutaneous k-wires was 93.3%! A clear correlation between secondary displacement and final results was found.

CONCLUSION

A main factor for an optimal outcome is the anatomic restoration of length and axis of the distal radius as well as of joint congruency, also moderate angular deformities are well tolerated. Our collective showed an unexpected high rate of secondary displacement, especially in the k-wire group. The reasons for this unsatisfactory event are manifold: too optimistic indication, insufficient follow-up examination in the first four to six weeks, inconsequent change to a more stable fixation method in case of a secondary dislocation. The results of this retrospective evaluation had a major impact on our concept of treatment. The dorso-radial double-plate technique combined with bone graft will be more used in the future especially in younger patients. The new standardised concept is the base of a present prospective study.

[Secondary hyperparathyroidism: pathophysiology and therapy--follow-up analysis of patients of the Chur dialysis department]

Between 1982 and 1998 12 chronic dialysis patients treated at the dialysis unit of Kantonsspital Chur were operated for secondary hyperparathyroidism (HPT). In 10 patients total parathyroidectomy with autotransplantation of parathyroid tissue was performed. Two patients had subtotal parathyroidectomy. Patient data were retrospectively analyzed in regard to indication, operation techniques, pharmacological therapy and possible recurrence or persistence of HPT. Four patients had normal PTH levels upon follow up. The parathyroid function was judged "equivocal" in three patients, the average PTH being to high (1), normal (1) and too low (1). One patient showed moderate hyperparathyroidism. Two patients developed recurrence of HPT one of which was sufficiently severe to necessitate reoperation at the autotransplantation site. In the first two operated patients the data are missing. Compared with other studies the rate of recurrence is higher in our series. Intraoperative ultrasound and improving diagnosis of the frozen sections could possibly favorably influence outcome.

[Migration of Kirschner wires after surgical stabilization of injuries in the area of the shoulder--4 case reports]

Internal fixation is recommended for displaced and unstable fractures of the lateral clavicle and fractures involving the proximal humerus. Kirschner wires, although recommended in the orthopedic literature bear the risk of wire breakage and migration. 4 cases with serious and potentially hazardous complications are presented. All reported complications occurred years after the operative treatment without clinical symptoms. Regular postoperative follow-ups and early hardware removal after fracture healing is recommended.

[Fractures of acetabulum and pelvic ring--epidemiology and clinical outcome]

From 1980 to 1995 inclusive we conducted a study on pelvic ring and acetabular fractures in Kantonspital Chur (KSC). 118 patients were studied and of these 51 had pelvic ring fractures and 67 acetabular fractures. Most of the patients with pelvic ring fractures had additional severe injuries and almost two thirds of them were polytraumatised and very shocked. One third of the acetabular patients were polytraumatised and about one fifth shocked. The length of the hospital stay was also noteworthy--an average of 47 days for the pelvic ring fractures and 30 days for the acetabular fractures. These injuries mainly affected patients in the active working age group (20-60 years of age). 56 of these had acetabular fractures and 39 had pelvic ring fractures. From 51 patients (76%) treated with acetabular fractures and 45 with pelvic ring fractures (88%) (i.e. of total 96 (81%)) we have summarised our results. About two thirds of the patients were followed up at one year and the AO documentation form completed. The remainder were sent a questionnaire. The results showed that 84% of the acetabular fracture group and 83% of the pelvic ring fractures had a good or excellent final result. Radiological complications noted in the acetabular fracture group were early signs of degenerative disease (18), a slight pelvic tilt (8), heterotopic ossification (7), early evidence of femoral head necrosis (3) and 1 definite pseudoarthrosis. Additionally 7 patients had significant motor or sensory loss. By comparison, those with pelvic ring fractures showed less in the way of radiological complications. 17 patients were seen to have a slight tilt, 9 showed initial signs of arthrosis and there was 1 pseudoarthrosis. Of the 5 patients in this group with neurological damage, 3 had difficulty in achieving an erection and 2 had urological problems. One patient who had a pelvic ring fracture had to have a caesarean section for a subsequent pregnancy.

[The floating joint injury of the lower and upper extremity--epidemiology, therapy and results in 40 extremities]

GOAL

Floating Joint Injuries (FJI) are resulting from high energy traumas and are often combined with additional neuro/vascular damage. The high incidence of severe open or closed soft tissue injuries is complicating the initial management and requires a broad surgical know-how also in minimal-invasive fixation techniques. In a retrospective analysis of our cases treated between 1980 and 1995, we try to find out some important therapeutical feedback for the future.

MATERIAL AND METHODS

Of the 37 patients, 33 had a FJI of the lower (2 bilateral) and 7 patients of the upper extremity. 90% were road traffic injuries, 75% showed an open fracture situation and 25% an associated neuro-vascular injury. All fractures were stabilised within the first hours, femur, humerus and forearm in one step, the tibia in 33% in two steps (initial external fixator ...). 80% of the FJI have been reexamined after 1-2 y.

RESULTS

Local complication: Femur: 4/33 (1 infection, 2 refractures, 1 non-union). Tibia: 11/33 (5 infections, 4 delayed/non-unions, 2 malalignements). Humerus: 0/7. Forearm: 1/7 (1 malalignement). 1-2 y-results: Very good-good: Femur: 26/27 (96%). Tibia: 23/27 (85%). Humerus: 4/5. Forearm: 3/5.

DISCUSSION

FJI should be stabilised as soon as possible in a way allowing for early functional aftercare of the affected joint. Most complications are observed in the proximal tibia fracture because of the thin and therefore often severely (open or closed) injured soft tissue cover. Despite a staged procedure, there exists a high complication rate, which probably can be reduced in the future by the single-step use of the hybrid external fixateur.

[Submucous lipoma of the colon--report of 2 cases]

Gastrointestinal lipomas are benign but rare lesions, mainly located in the colon. Depending on their size they are responsible for obstructive bowel symptoms. Diagnostic tools are either the endoscopy or computer tomography. It is recommended to investigate the entire large bowel as other pathologies are often found. Any lipoma found should be removed. Two cases with symptomatic lipoma are presented. In both cases the lipoma was removed by open surgery.

New techniques in indirect reduction of long bone fractures

The most important and demanding part of operative fracture treatment concerns the reduction and correct alignment of the fracture fragments, which must be gentle to the bone and surrounding soft parts to preserve the essential blood supply to all tissues. The so called indirect reduction techniques apply the principles of nonoperative fracture care (ligamentotaxis) in combination with surgical tools and a number of techniques, where by the exposure of the most critical fracture focus can be minimized. New implant designs, low contact plates, cannulated screws, unreamed nails, pinless and hybrid external fixators, are helpful adjuncts: however, the surgical technique remains of paramount importance. The essence of careful handling of the soft and hard tissues has been stressed time and again. With the introduction of biological or minimally invasive surgery, the techniques of indirect reduction have had a renaissance. A few examples are described.

[Elbow fractures in elderly patients]

Are the well established methods for operative treatment of fractures about the elbow and their results also applicable to elderly people with osteoporosis? In a retrospective study 23 of 32 patients with 33 operatively stabilized fractures of the distal humerus and the proximal radius and ulna, could be reviewed and personally questioned. The fracture type, the complications and the range of motion of the elbow were analysed and classified. Over 75% of the cases presented with a good to excellent range of motion with no increase of complications. 80% of the patients were satisfied with their result after surgical treatment of the fracture. Fractures of the elbow in elderly people with osteoporosis may be sucessfuly treated by ORIF. It appears important to start early with postoperative physiotherapy. Thereby good functional results can be expected without an increase of complications.

[The trauma patient: open hospital choice?]

Victims of trauma have usually no choice regarding the physician or hospital they are admitted to. In order to deliver the best possible trauma care it is crucial that trauma victims first receive competent on site primary care before being admitted directly to a hospital that is sufficiently equipped and qualified to take care of their injuries. Recent literature suggests that individual outcomes, but also per-case costs of trauma patients clearly improve, when prehospital care, triage and admission to specially designed trauma centres are coordinated within regional trauma systems. This provides supporting evidence for the recent proposals by the Swiss Medical Association (FMH) in 1996 who formulated 12 statements regarding rescue services in Switzerland. In order to optimise rescue and trauma care there is an urgent need for restructuring existing systems nation-wide. Trauma patients may thus to some degree lose their freedom in choosing their preferred physician or hospital.

[Blunt abdominal trauma with lesion of the abdominal aorta--a case report]

A 58-year old lady, involved in a head-on motor vehicle crash suffered a severe intestinal injury associated with an intimal flap lesion of the distal abdominal aorta. Thrombotic occlusion of the aortic bifurcation with clinical evidence of lower extremity ischemia was noted. The management of blunt injury to the abdominal aorta is discussed with special regard to placing prosthetic material in a potentially infected field.

Severe skiing injuries: a retrospective analysis of 361 patients including mechanism of trauma, severity of injury, and mortality

All ski accident patients requiring an inhospital treatment at our institute from 1984 to 1992 (n = 2,053) were analyzed retrospectively. The incidence, pattern, and severity of the injuries, as well as the 30-day mortality comparing two time slots (1984 to 1988 and 1989 to 1992) were analyzed for the 361 cases classified as "serious" injuries according to the following definitions and groupings: group 1, multiple trauma (Injury Severity Score > or = 18) and patients with multiple fractures (n = 179; group 2, abdominal or thoracic single trauma (Abbreviated Injury Scale (AIS) score > or = 2, n = 58); and group 3, isolated head injuries (AIS score > or = 2, n = 124). Serious injuries were observed in 19% in the first period compared to 16% in the second period (not significant). Two hundred thirty-eight of 361 patients injured themselves by just falling, while 117 collided with some sort of obstacle like other skiers (45), trees or rocks (27), posts, pylons, barriers (20), and moving objects (25) such as piste machines, ski lifts, automobiles, and in one case a helicopter. Six skiers were caught on the ski run by an avalanche. Comparing the two time periods, trauma circumstances did not change significantly. The number of most severe head injuries (AIS score > or = 4) increased from 11.6 to 19.3% (p < 0.05). The overall mortality increased from 2 to 7% (p < 0.05). Group 2 had the best prognosis with no mortality, while group 3 was rated worst with 8%. Skiing remains a major source of serious trauma in winter resort areas.(ABSTRACT TRUNCATED AT 250 WORDS)

Ten-year follow-up after operative treatment for intra-articular fractures of the calcaneus

Our first 16 patients with intra-articular calcaneal fractures that were managed by open reduction and internal fixation were originally reviewed on average 3 years after operation. We looked at the same patients again on average more than 10 years after surgery using the same evaluation system by the same physician. Seventy-five percent of the patients showed an excellent or good functional result. In no case was there an indication for a secondary arthrodesis. In spite of the fact that radiologically most patients showed a slowly progressing posttraumatic subtalar osteoarthritis, the subjective results (pain, capacity to work, and/or sports) at 10 years were clearly better than 3 years after surgery. These results may allow the conclusion that radiologic findings are only of limited value in the assessment of long-term results after operative treatment of calcaneal fractures. From a functional point of view and on the long-term follow-up most patients with intra-articular fractures of the calcaneus seem to profit from open reduction and internal fixation.

[Integration and resorption of calcium phosphate ceramics in defect filling of fractures of the tibial head. Radiologic long-term results]

Calciumphosphate ceramics are considered as a substitute for cancellous bone grafts. 16 patients with traumatic impressions of the tibial plateau were treated according to the AO-principles and subchondral bone defects were filled with hydroxyapatite (10x) or tricalciumphosphate (6x). Clinical and radiological follow-up after 3 to 10 1/2 years was uneventful with primary bone healing and excellent results in all cases. No adverse reactions of the completely integrated ceramics have been observed. Hydroxyapatite, even after 10 years, showed no proof of biodegradation, whereas tricalciumphosphate showed slow dissolution and replacement by new host bone formations in the later follow-up after 2 to 6 years.

[High grade liver rupture--is nonsurgical therapy feasible?]

Although well accepted in pediatric patients, the nonoperative management of severe blunt hepatic trauma in adults remains controversial. On the basis of 3 cases with major liver injury, the rationale and prerequisites for a successful nonoperative treatment are discussed.

Osteosynthesis of 245 tibial shaft fractures: early and late complications

A consecutive series of 245 fresh fractures of the tibial shaft, including 60 open fractures underwent operation in a 5 year period (1980-1984). Two hundred and forty-two (98.8 per cent) of these fractures were followed-up for an average of 79 months (6.5 years). Early and late complications as well as complications after implant removal were taken into account for closed and open fractures. In the 185 closed fractures, infection was observed in 1.7 per cent and delayed union in 6.8 per cent. More than 94 per cent of the closed fractures had an excellent or good late result. In open fractures (60 cases) infection was seen in 6.8 per cent, and plate fatigue with delayed union was seen in 10.3 per cent. However an excellent or good functional result was obtained in 93 per cent of the open fractures. After implant removal refractures occurred in 1.3 per cent and other minor complications in 0.9 per cent.

[The primary cruciate ligament suture--is the method outdated? Results in follow-up of 58 patients]

In the present study 58 out of 105 patients, who had been operated on for anterior cruciate ligament rupture from 1980-1992 by the same experienced surgeon, were followed up clinically and by X-ray examination. Most of them were sports accidents, above all skiing and soccer. In 11 patients an isolated rupture of the anterior cruciate ligament was found, the remaining 47 had sustained additional injuries (mainly the medial collateral ligament and the medial meniscus). In 52 cases the operation was performed with primary repair of the anterior cruciate ligament. For chronic instability 4 patients (7%) had to be treated with secondary anterior cruciate ligament reconstruction. In the follow-up study 60% of all patients achieved a Lysholm-score of 95-100 points, 19% of 84-94 points. The remaining 21% achieved less than 84 points. In the side to side comparison the Lachman Test was equal or showed a slightly diminished stability of the operated knee in 91% of 54 patients without secondary reconstruction. The anterior stability with 90 degrees flexed knee in neutral position was within a similar scope, the anterior medial stability was a little worse. In 48% of all patients we found radiological signs of osteoarthritis (stage II and III according to the classification of Jäger and Wirth).

[Blessings of technology? The severely injured skier--a result of technical equipment on the ski slope]

In a retrospective manner we studied the injury pattern of 2053 patients following a skiing accident that required hospital admission in the year 1984-1992. Of these 361 or 18% were categorised as severely injured according to the AIS/ISS scoring system. 31% of these 361 skiers were injured by colliding at considerable speed with either a moving object (other skier, snow cat, ski-lift, etc) or fixed obstacles (trees, rocks, pilons, etc) along the ski slopes. As the most extensive injuries seem to result from collisions with the latter, fixed obstacles, it should be requested that more protective measures are being taken to prevent such severe accidents.

Tibial fractures treated with the AO unreamed tibial nail

During the last 2 years 20 fractures of the tibial shaft have been treated with the new, 'unreamed' solid AO tibial nail (UTN). There were 13 open fractures, while four of the seven closed fractures had severe soft tissue injuries. There were nine fractures classified as 'complex' or type C according to the AO classification. All UTNs were introduced without reaming but with proximal and distal interlocking. In all, 12 fractures (five of them open) were stabilized primarily by 'unreamed' nailing, whereas the first eight (open) fractures of the series were fixed initially by an external fixator and then nailed after about 14 days. In our series no intraoperative complications occurred, and no major soft tissue problems or infections were observed. The functional results were generally good; however, fracture healing appeared to be delayed in six cases. One patient had a further operation because of non-union. Intramedullary nailing, without reaming, seems to be a reliable and safe treatment for closed and open fractures with severe soft tissue injuries as an alternative to external fixation. The use of a thin, solid nail combined with interlocking allows the stabilization even of complex fractures. Contrary to initial assumptions, the UTN can be used as a definitive implant with no need for further stabilization in the majority of cases.

[Follow-up care of surgically-treated fractures and evaluation of healing process in the roentgen picture]

The aim of surgical therapy of a fracture is the restoration of the original integrity of the limb. X-rays are the only means by which the surgeon can observe fracture healing over time. This includes direct bone healing without major radiological changes and indirect bone healing which shows callus formation. The two requirements needed for rapid bone remodelling and early mobilization after operation are an exact repositioning of the fracture fragments, if possible, and the maintenance of soft tissue and joints. Postoperative findings, complications and aftertreatment are discussed. X-ray series are presented, and the differences in fracture healing are shown.

[Initial results with the unreamed AO tibial nail]

It is generally accepted that intramedullary nailing in combination with reaming should be avoided in treating open fractures. However, the use of an unreamed, solid nail combined with interlocking also allows stabilization of open and complex fractures. 20 tibia fractures (65% open, 45% complex fractures) have been treated by the AO unreamed tibial nail (UTN), 12 (5 of them open fractures) by direct nailing and 8 after initial stabilization by an external fixator. In our series no intraoperative complications, no soft-tissue healing problems and no infections occurred. Thus, treatment of both open and comminuted fractures by UTN appears to be safe and generally needs no secondary stabilization.

[Initial experiences with the unreamed AO tibial nail]

It is generally accepted that intramedullary nailing in combination with reaming should be avoided in treating open fractures. However the use of an unreamed, solid nail combined with interlocking allows stabilization also of open and complex fractures. 20 tibia fractures (65% open, 45% complex fractures) have been treated by the AO unreamed tibial nail (UTN), 12 (5 of them open fractures) by direct nailing and 8 after initial stabilization by an external fixator. In our series no intraoperative complications, no soft-tissue healing problems and no infections occurred. Thus, treatment of both, open and comminuted fractures by UTN appears to be rather safe and generally needs no secondary stabilization.

[The dynamic hip screw (DHS) in femoral neck fractures]

Out of 224 patients with femoral neck fractures, 40 patients have been treated by ORIF with the dynamic hip screw, whereas 27 have been fixed by large cancellous bone screws and 148 femoral heads were replaced by a prosthesis. The ORIF with dynamic hip screw has been performed as an emergency intervention within 6.2 hours after accident. Good general condition without contraindication against an emergency operation as well as a biological age below 65 years and no pre-existing coxarthrosis are mandatory for the indication for open rigid internal fixation. Personal follow-up of 37 patients with x-ray documentation after at least 18 months (mean 35.4 months) showed complete rehabilitation in 31 patients and 4 femoral head necrosis (10.8%). We conclude that these good results are due to the short interval between accident and operation as well as to the evacuation of the intraarticular hematoma together with stable internal fixation and functional rehabilitation. Due to our good results we prefer long cancellous bone screws for the operative fixation of femoral neck fractures in younger patients, whereas in the older group the dynamic hip screw is preferred.

[Vascular injuries--management in a non-university central hospital]

In a retrospective study the surgically treated vascular injuries (n = 35) of the last 10 years were evaluated. One third of the patients had multiple trauma and in 57% of the cases vascular injury was accompanied by a fracture. All patients (n = 28) except those who underwent delayed amputation (amputation rate 14%) have been followed personally for an average of 5.1 years. 90% of these patients showed an excellent or acceptable longtime result in regard to vascularity, nobody complained of claudication. Diagnosis of a vascular injury was mostly confirmed by direct surgical exploration, only one third of the lesions were diagnosed by arteriogram. A positive signal in Doppler examination does not exclude vascular injury and therefore cannot replace arteriography or exact clinical evaluation.

Five years' follow-up of severely injured ICU patients

We conducted a 5-year follow-up study of a group of 461 consecutive trauma patients treated in our Intensive Care Unit from 1980 to 1983. The entry criteria (initial survival and severe injury: ISS greater than or equal to 18) were fulfilled by 233 patients with a mean ISS of 29.3 and mean age of 35.6 years. Data on prehospital care, type and timing of surgery, and hospital and ICU stay were recorded during hospital discharge. The protocol strictly asked for a personal interview and a physical examination. Mailed questionnaires or phone interviews were not allowed. The areas of medical sequelae, aftercare, missed injuries, occupation, insurance, social integration, economics, legal aspects, and traffic involvement were covered. We were able to gather final information from 223 (95.6%) of the 233 cases. Forty-three patients (18.4%) died in the hospital, 13 patients (5.6%) died later, and 167 (76.5%) were eventually seen. Only 10 patients (4.4%) were lost to follow-up. Outcome was judged using the Glasgow Outcome Scale (GOS), which was compared with a GOS value given prospectively at the time of hospital discharge. Eighty-nine percent of the survivors were healthy or slightly disabled (GOS 5 and 4), 9% were severely disabled, and only 2% were in a persistent vegetative state. Outcome after 5 years was better than tentatively prognosed at the time of hospital discharge. Ninety-one patients with severe head injuries (AIS 4-5) were additionally tested using the Mini Mental State instrument. This test revealed normal mental functions in 77% and dementia, mostly of a minor degree, in 23% of the head-injured patients. Almost all the early deaths and two thirds of the late deaths were related to severe head injury. Seventy-nine percent of the survivors were working after 5 years. During the post-trauma period, patients experienced reduced social well-being and also changed professional and recreational activities. There appears to be extensive room for improvement in the posthospital recovery phase. We conclude that survivors of critical trauma have a very good chance, after 5 years, of regaining a high quality of life. All efforts at improving trauma survival and quality of trauma care are therefore worthwhile and deserve high priority.

[Pleural empyema--rational diagnosis and therapy]

A pyothorax is a relatively rare occurrence in a general hospital and is posing a number of problems. Among these the long mean duration of hospitalisation is of note lasting 47 days for 24 patients at our clinic. The course and the mortality rate are influenced by early detection and judicious use of interdisciplinary treatment. Small effusions accompanying pneumonia are frequent and likely to disappear after treatment of the underlying disease. In these instances a precipitate punction may lead to secondary infection. In case of a sterile punctate the pH value and consideration of glucose and LDH values determine further measures. Computed tomography is of great value since it yields decisive information not available from conventional radiography. If the empyema is not segregated in compartments a closed drainage with a large caliber chest-tube ist the method of choice. Limited thoracotomy is advised when several empyema chambers develop after short duration of the illness. Persistent disease or widespread scarring necessitate decortication in most cases.

Results of operative treatment for intra-articular fractures of the calcaneus

Since 1980 our treatment of displaced intra-articular calcaneal fractures consists of open reduction with distractor, bone grafting, and internal fixation. Thereby no splints are applied and early postoperative movement is possible. For precise preoperative planning a CT scan is required. Proper timing and careful preoperative planning are essential to prevent soft-tissue complications. In a total of 16 fractures good clinical and radiologic results were achieved in 50% of the cases; results were satisfactory in 25% and poor in 25%. The patients returned to work after an average of 5 months. Only three patients (19%) received disability compensations, which compares favorably with nonoperative treatment. We believe that a majority of comminuted intra-articular fractures of the calcaneus profit from open reduction and internal fixation and that more reliable functional results are achieved than with conservative therapy.

[Interlocking intramedullary nailing of the femur: is the advantage of early mobilization gained by risking a malposition?]

We report a follow-up of 57 consecutive femoral fractures treated by internal fixation with the AO Universal Interlocking Nall. All fractures (91% follow-up) had healed within a mean of 22 months (range 9-50) after operation. Full weight-bearing was possible after an average of 9 weeks (range 2-20). The only infection occurred after a secondary open lengthening osteotomy. In 5 cases a rotational malposition or length discrepancy had to be corrected shortly after initial surgery. Rotational malposition in excess of 10 degrees occurred in 26% of cases (mostly external rotation) and length discrepancy exceeding 1 cm in 13% (mostly shortening). The frequency of malposition is explained by the absence of rotational or length control during operation. We recommend that malposition be correlated without delay by reoperation.

[Talus fracture. Injury pattern, treatment tactics and results of operation (1980-1989)]

The results of 25 operated talus fractures are presented. 7 of these were peripheral fractures with excellent results, 18 central fractures with only satisfying or even bad outcome. Although we didn't see any avascular necrosis of the talus, almost all patients had pain and slight or even severe signs of arthrosis in the ankle or subtalar joint.

[Serial rib fractures: a differentiated treatment concept, illustrated by 59 severely injured intensive care patients]

In a group of 59 consecutive ICU trauma patients with blunt chest injury and considerable injury severity (ISS = 29) a three-staged therapeutic approach was followed, depending seriousness of chest injury, overall injury severity and age. Stage 1: i.v. analgesia and conventional respiratory therapy. Stage 2: continuous epidural analgesia (local anesthetics and opiates) and intermittent CPAP (continuous positive airway pressure) by face mask. Stage 3: Endotracheal intubation and internal pneumatic stabilization of the chest, preferably spontaneous breathing. Only 44% of the patients needed intubation, and none died. The authors recommend this three-step approach towards blunt chest injury and serial rib fractures.

[Simple, safe postoperative parenteral nutrition with a ready-to-use all-in-one solution]

A newly developed, stable and ready-to-use industrially manufactured all-in-one solution for parenteral nutrition, containing amino acids, fat, glucose, xylitol and electrolytes, was tested in a prospective trial involving 21 patients from the 2nd to the 8th postoperative day. No side effects requiring interruption of the nutritional regimen, a positive nitrogen balance and a documented metabolic steady state proved that this solution is a safe therapeutic concept with respect to the typical postoperative metabolism. The all-in-one Vacu-Mix system is easy to handle, reduces the possibility of technical error and ensures safe and constant TPN administration.

[Initial results with the new tibial interlocking nail of the Orthopedic Study Group]

The new AO universal tibia nail with interlocking possibility has several new features. The wall thickness has been increased from 1.0 to 1.2 mm. In order to give the stiffer nail smoother insertion properties and better cortical contact, the overall design has been altered with the help of computer calculation. Proximally there are 3 holes for locking purposes in the frontal plane, while distally we find two holes in the frontal and one in the sagittal plane to accommodate the locking bolts. The new nail has been applied in 17 clinical cases with overall good results. The indications were deliberately pushed to the extremes and even 5 open fractures were nailed after minimal remaining. There were 2 major perioperative complications: one proximal blow-out of the anterior cortex due to a wrong point of insertion and several other technical mistakes. The situation was salvaged with an external fixator. In an 85-year-old multiple injured lady with a 3-degree open tibia, the initial fixateur externe was replaced after 3 weeks by a 10 mm universal nail. Due to severe porosis and rather proximal extensive cortical comminution, the locking bolts and therefore the nail did not find a good hold in the tibia plateau. After uneventful healing of the soft tissues and additional splinting, the fracture, however, consolidated within 4 months. There were two superficial soft tissue infections early postoperatively, but no cases of osteitis. Healing of the fractures seems to progress without delay.(ABSTRACT TRUNCATED AT 250 WORDS)

[After-care of fractures, especially following osteosynthesis]

Depending on the choice of fixation and implant, the aftercare of fractures has to occur in different manners. Postoperatively the CPM-machines have taken the place of conventional supports, and there is a distinct tendency to even earlier mobilisation of fracture patients. Except for comminuted, intraarticular fractures, partial weight bearing with 10 to 15 kg (toe-touch) is encouraged as of the first postoperative week. Since the introduction of the locked nail for shaft fractures, we have to get used to look at X-rays with hardly reduced fragments and abundant callus formation. This contrasts to what we are used to from the conventional plate fixations. In case of stable plating, the old rules remain valid: anatomic reconstruction and direct fracture healing without visible callus.

[The dynamized external fixator. Use and problems]

We report our experience with 11 patients treated with an external fixator that was dynamized at some stage of the treatment. In 7 patients bone union occurred without any other measures, 2 patients were protected in a cast after the external fixator removal, while 2 patients developed a non union that was plated and subsequently healed. According to these experiences, dynamization of an external fixator seems to be a reliable and elegant way to treat simple open shaft fractures, the method is however not advocated for more complex or comminuted fractures.

[Plate osteosynthesis in humeral shaft fractures. Indications and results]

Non operative management of humeral shaft fractures is well recognized as the standard of care for uncomplicated injuries. Operative treatment of humeral fractures may be performed when limited indications are present as in patients with multiple trauma including ipsilateral forearm injuries, arterial injury or primary radial nerve palsy. 18 patients with humeral shaft fractures underwent open reduction and internal fixation (ORIF) using the AO plating technique at the Kantonsspital Chur from 1980 to 1986. Follow-up was available for 17 patients of whom 16 suffered from multiple injury trauma. The broad DC plate combined with lag screws was used in most cases. Two brachial artery transections were repaired at the time of primary osteosynthesis by the same surgeons with full functional recovery. Concomitant nerve injuries were repaired primarily in one case and postprimarily in 3 more cases. The overall result was excellent in 9 patients, good in 5 patients, fair in 2 patients and poor in one patient with complete brachial plexus injury. Bone healing was uneventful in all 17 patients. No infection and no delayed union or pseudarthrosis has been observed.

[Principles and practice of nutrition following trauma]

Nutrition should form part of intensive care for all polytrauma patients to prevent catabolic breakdown of body proteins. Enteral (tube) feeding is preferable whenever normal gastrointestinal function is confirmed. Parenteral nutrition is best tolerated via an adapted "all-in-one" solution. Due to the catabolic trauma reaction, a high protein content of 1.5-2 g/kg body weight/day and a calorie-nitrogen ratio of 80-100:1 is recommended. Energy supply should be partly in the form of fat and carbohydrates, mainly glucose. Xylitol as sugar substitute can be added to prevent hyperglycemia in the event of trauma-related glucose intolerance.

[Morbid obesity. Our results with the appetite-depressing stomach balloon]

Morbid obesity still remains a controversial topic with varied therapeutic approaches. In cases of unsuccessful conservative management we implant a gastric balloon or bubble. 30 balloons have been introduced in 24 patients with a mean age of 43 years (26-68 y.) and a mean body weight of 115 kg (87-160 kg). Mean overweight was 47 kg. The balloons were introduced immediately after gastroscopy performed to identify possible contraindications. Except in the initial 3 patients this procedure was carried out in the outpatient clinic. 25 silicon mammary prostheses were implanted until a special balloon (Ballobes-Balloon) became available for the last 5 cases. Implantation and follow-up has been uneventful in all cases. Our data suggest that a combination of this approach with close dietary management provides more efficient and rapid weight reduction than any diet alone.

[Morbid obesity: what is still justified in surgical therapy?]

The main surgical procedures in the treatment of obesity are described. Plastic surgery, e. g. apronectomy or breast reduction, may be discussed in patients after successful weight reduction, but not as a primary operative treatment of massive obesity. Different intestinal bypass procedures inducing malabsorption have been abandoned because of severe metabolic sequels. More physiologic conditions can be achieved with gastric partitioning creating a small upper gastric pouch in continuity with the remainder of the stomach. If strict rules of patient selection and operative technique are observed, satisfactory weight loss without significant late complications may be achieved.

[Comparative study of a new commercially produced combination solution (fat, carbohydrates, aminoacids) for complete parenteral feeding of surgery patients in intensive care]

In 10 randomly selected surgical ICU patients, a new regimen of total parenteral nutrition (TPN) using a so-called all-in-one (AIO) solution was tested prospectively. Another 10 patients receiving conventional TPN served as a control group. For a minimum of 7 days the patients were given either an AIO solution containing 40 g crystalline L-aminoacids, 38 g fat, 75 g sorbitol and 45 g xylitol in 1000 ml or a conventional TPN with glucose and aminoacids. The regimens were identical regarding caloric intake and Joule/N ratio. Amounts of infused solutions were adjusted according to patient's weight. Both regimens were well tolerated and side effects requiring interruption of the protocol did not occur. A set of 36 laboratory parameters underwent detailed statistical analysis. Efficiency of both regimens in improving nutritional status was documented. Comparing the two groups, we found only two important differences: glucose levels in the AIO group were lower than in the control group, and the bilirubin increase observed in both groups (probably a sign of cholestasis) was higher in AIO patients. Immediate postoperative or posttraumatic nutrition with an AIO solution was safe and simple to administer. Because glucose metabolism is only minimally overstrained, AIO compares favorably with conventional TPN and is a promising alternative when stress-induced glucose intolerance occurs.

[Experience with measurements of intracranial pressure in post-hypoxic and post-traumatic coma]

In 27 patients intracranial pressure monitoring (ICP) was carried out for 4-5 days (severe head injury 23, hypoxia after cardiac arrest 3, brain tumor 1). Patients were included who reached a score of 8 or less on the Glasgow Coma Scale and who did not need immediate surgery. The measurements were done with epidural screws (20 patients) and with indwelling ventricular catheters 7). The individually highest ICPs were recorded 3-4 days after incident. 14 patients recovered completely, 3 remained slightly and 3 severely disabled, and 7 patients died. ICP monitoring permitted precise and rational therapeutic management but was of little value prognostically. Poor Glasgow scores were linked to high mortality. The advantages and disadvantages of the two ICP monitoring techniques are discussed. ICP monitoring is recommended as a useful and safe tool for titrated management of deeply comatose patients.