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The major problem of reconstructing the anterior cruciate ligament (ACL) with the semitendinosus tendon (STT) is the low primary stability of the STT graft fixation techniques.On 10 cadaver knees a surgical procedure for arthroscopic reconstruction of the ACL with the double looped STT was performed. The femoral attachment was achieved with an "U-formed" tendon wrapped around a bone-plug, which then was blocked in a single-staged femoral bone tunnel. The tibial fixation was attained using a bone-plug and an interference-screw. Anatomic studies were performed on the STT of the cadaver knees. Isometrical determinations were performed intraoperatively for precise anatomical placement of the tendon. We compared these measurements with the postoperative position of the STT-transplant. The tibial and the femoral attachment was tested separately for primary stability and stiffness. The mode of failure of the fixation methods was determined.The average length of the STT was 29.4 cm (SD +/- 3.6 cm, 24-33). With comparing the measured intraoperative and postoperative isometrical values we found a high correlation. The primary stability of the attaching methods in the pullout-testing amounted for the femoral attachment to 448.2 N (SD +/- 76.5 N, 322-560 N) and for the tibial attachment to 440.0 N (SD +/- 72.5 N, 316-538 N). The average stiffness of the femoral fixation was 29.23 N/mm (SD +/- 1.64 N/mm; 26.6-32.1 N/mm). The average stiffness of the tibial fixation measured 28.31 N/mm (SD +/- 1.55 N/mm, 25.1-30.4 N/mm).The presented method provides an economical and easy to perform autologous STT-fixation technique with a high level of primary stability.

The benefit of antibiotics applied intravenously to avoid postoperative infection after intramedullary nailing has not yet been proven. Local antibiotic-releasing systems might be more effective because of the high concentration available in the compartments of interest. We report on the pharmacokinetic results of ten patients with intramedullary nailing of the tibia, respectively 15 patients undergoing the same procedure at the femur, in whom we used gentamicin-impregnated biomaterials for perioperative prophylaxis. The elution of gentamicin from a collagen sponge was complete and pharmacokinetic data suggest this drug releasing system is superior to PMMA beads in respect of the studied indication.

After operating on the injured cruciate ligaments, immediate mobilization and protection of the healing ligament are indispensible. However, no approach has yet been shown to safely provide both. Therefore, in 1984 we introduced a new technique: the repaired or reconstructed cruciate ligaments are augmented with a biodegradable material - a doubled-over PDS cord, 1.5 mm in diameter. It allows for immediate and safe mobilization. Because of its appropriate elasticity it does not cause "stress shielding." Postoperatively, the patients are mobilized on a motorized frame for 2 weeks. Subsequently, we have used a limited mobilization cast (LMC). Forty-nine out of 63 patients (78%) have now been reexamined for this follow-up study, using the score from the Hospital for Special Surgery and stress X-rays in the Lachmann, position (30 degrees flexion). The results compare favorably with a prior follow-up study of patients from our hospital without PDS augmentation and without early mobilization. The knees in the present study are more stable and have a better range of motion, particularly when the LMC was used.

In part I of this paper the radiological findings in segmental defects of long bones were discussed. The histological regeneration originates from the marrow cavity. An endostal framework of bone is formed; this is more pronounced on the proximal resection place than on the distal one. The new bone formation within the defect depends on the revascularization through medullar blood vessels. The increased osteogenesis on the proximal site of resection is due to the increased formation of vessels in this area. The vascularization and the filling of segmental defects in tubular bone occurs faster, if only one metal plate and on the opposite side an autologous bone graft (cortical bone) is used in order to stabilize the bone. This method is superior to the use of a double-plate osteosynthesis. The graft unites with the underlying bone within twelve weeks by forming a trabecular network of new bone. If the autologous bone graft has become stable, it is vascularized from the bone and from the sorrounding soft tissue. Afterwards an osteolysis and at the same time an osteogenesis take place. The dead bone graft is replaced by newly formed bone within about 40 weeks. The loss of stability which occurs does not endanger the osteosynthesis.

A bilateral aplasia of the dorsal arches of the atlas with persisting tuberculum posterius has been observed by the authors. Since the patient had suffered a severe cranio-cerebral trauma, it became necessary to exclude a possible fracture by differential diagnosis. This was possible by means of CT and conventional x-ray diagnosis. According to the classification of dorsal atlas arch aplasia by von Torklus and Gehle (1975) into 6 types, the diagnosis was, in the case under report, Keller's type of aplasia of the arch of the atlas.

Ectopic ossifications occassionally occur after stable osteosyntheses. The literature and our own observations indicate that osseous bore-chips probably favour these ossifications, especially after intermedullary nailing. Experiments determined the weight of osseous bore-chips which occur in intermedullary nailing of femur and in plate osteosynthesis of radius and ulna. Conclusions drawn from these findings should be considered when performing osteosynthesis.

Because of the anatomical and functional peculiarities of the astragallus surgical and conservative treatment of central fractures are often unsatisfactory. A follow-up study of 40 patients with 42 central talus fractures were performed over an average of 9 years after the initial trauma. The number of poor results was extremely high; only primary surgical or conservative treatment showed good or fair results. Best results were obtained by primary surgical treatment whereas fractures operated at later stages showed worse results. Therefore fresh central astragallus fractures should be operated upon, fractures older than 1 day should be treated conservatively. If a satisfactory reduction cannot be obtained, the fracture should be operated upon in order to prevent arthrosis in the upper ankle joint.

Early operated knee band lesions (n = 61) had better end results than in those later treated (note 2.3 versus 2.6). In knee luxations (n = 8) we had an average result of 3.1. In combined knee band lesions (n = 39) the persistent instability of the anterior cruciate ligament was the main problem. In such lesions we had better results with primary substitution of the anterior ligament by a gracilis tendon graft than with suture of the torn band.

In a comparative experimental study stability of different extra- and intramedullar methods of osteosynthesis for stable and unstable pertrochanteric fractures has been examined under dynamical stress. For the treatment of stable pertrochanteric fractures in old patients the intramedullar methods of osteosynthesis (nailing by Ender of Küntscher) were shown to be biomechanically superior. Extramedullar osteosyntheses (130 degrees and 95 degrees angled plate) also guaranteed very high stability; under permanent stress however angled plates showed metal fatigue. In case of unstable pertrochanteric fractures the osteosyntheses with additional application of bone cement produced sufficient stability under permanent stress. The importance of reconstructing a stable medial support for the biomechanics of osteosynthetic materials was emphasized. According to our results especially the combination of 95 degrees angle-plates with bone cement permits immediate mobilisation of old patients in case of unstable pertrochanteric fractures.

Ninety-one patients with 108 fractures of the metacarpal and/or finger bones were treated by surgery between January 1974 and June 1982. 70 patients (76.9%) with 81 surgically treated fractures could be checked up after 3 3/4 years on an average. 24.3% out of these patients suffered from associated soft tissue leasions, 25.7% suffered from multiple fractures. 41 out of the 81 surgical interventions were performed for fractures of the metacarpus and 40 for fractures of the finger bones. The results were classified according to an evaluation scheme established for this purpose and containing the following parameters: mobility, trophism and sensitivity, gripping functions, force, and X-ray findings. Subjective troubles were evaluated, too. The great value of osteosynthesis in the surgical treatment of the hand is confirmed by the overall results with 92% of very good or good results and 7% of satisfactory results in metacarpal fractures and 60% of very good or good results, 36% of satisfactory results and 3% of poor results in fractures of the finger bones, the more as patients treated by surgery represent a negative selection among all patients treated for fractures of the bones of the hand. The results were classified and evaluated according to fracture site, severity of associated injuries, and method of osteosynthesis applied.

In unstable pertrochanteric fractures of the femur a high bending strain and much load lies on the medial part of the bone. The connecting osteosynthesis takes off this load and immediately guarantees a high stability. Clinical experiences with 44 cases of connecting osteosynthesis - among them 35 per-and subtrochanteric fractures of the femur-show, that in 11 cases complications due to the fractures occurred (breaking of the implant, pseudarthrosis etc.) These complications are probably due to a delayed healing caused by bone cement penetrating into the area of the fracture. It is recommended to use an autologous cancellous bone graft. Indications for the compound osteosynthesis are only unstable pertrochanteric fractures in old patients in poor general condition and a short life-expectancy, and fractures in patients with diffuse metastases.

The authors investigated in 25 patients with luxations of the patella if an increased incidence of defective torsions of the leg skeleton could be demonstrated. The torsion conditions of the lower extremity can be easily shown by computed tomography. This was confirmed when 32 femur preparation and 95 sound extremities were examined. The comparison of measuring results does not show any difference between patients and control group regarding the torsion of tibia and femur and the position of the tuberosity of the tibia. Patients with luxations of the patella show an increased external rotation of the tibia with respect to the femur due to a lack of medial muscular and ligamentary guide.

Bending burdening of stable and unstable per- and subtrochanteral fractures after osteosynthesis with Y-nails (Küntscher), Ender-nails, 130 degrees and 95 degrees angled plates of the AO were tested in a comparative experimental study. The unstable fractures were also tested after treatment with osteosynthesis and additional application of bone cement in the artificial defect. The essential results were as follows: in the group of stable pertrochanteral fractures the Ender-nails bear in the mean 147 kp, the 130 degrees angle plate 200 kp. In the fracture-group with lacking medial support a highly burdening osteosynthesis could only be achieved by filling up the defects with bone cement. The 95 degrees-angled plate-osteosynthesis combined with bone cement bearing more than 300 kp was superior to the other procedures in the unstable per- and subtrochanteral fractures. In our investigation the stabilizing forces of muscles and fascia have not been taken into consideration.

33 CT-investigations of 23 patients with malignancies of the shoulder girdle were analyzed. In 80% of the surgically treated bone tumours of 17 patients the presence and extend of soft tissue infiltration and of osseous destruction could be delineated. The size of the 6 soft tissue tumours was better demonstrated by CT than by any other radiologic procedure. As CT is the most reliable noninvasive method to visualize the extend of a tumour of the shoulder girdle it is a valuable aid in treatment planning. Diagnostic pitfalls and results of follow-up studies are discussed.

The influence of cyclophosphamide (Ctx) upon the healing of fractures in the femur of the rabbit is reported. During treatment with Ctx the x-ray shows a reduced callus-formation; the fluorescence-microscopy reveals a decreased apposition of bone. Fracture-load, fracture-energy and mineral content of the intact bone are not influenced by Ctx. Four weeks after an operation fracture-load and fracture-energy are reduced almost by one half and the mineral content is decreased significantly.

Primary operative care with debridement and the soft tissue protective osteosynthesis is the method of choice in the management of open fractures. A follow-up study of 307 so treated fractures was performed over an average of 3 years after the initial trauma. The overall rate of osteomyelitis was 8.5% in below knee compound fractures and 4.9% in all other areas. During the past two years while using the external fixation device in 2nd and 3rd degree compound fractures in the lower leg the osteomyelitis rate was reduced to 5.5%. In the 2nd and 3rd degree compound crural fractures due to the delayed bone healing with the external fixation method alone we recommend the so called "combination osteosynthesis" in which a screw or a AO-2-hole-plate is employed additionally. Furthermore it seems essential to perform an autologous cancellous bone graft in these fractures to reduce the long healing time.

For chest X-ray in the ward and for intraoperative cholangiography the registered doses were low. A limitation of the exposures or the operations was not necessary. For osteosynthesis operations the doses for the patient and the staff could be kept low by preparing the operation adequately, by using modern image-intensifer units with grid and automatic regulation in fluoroscopy, and with discipline in using fluoroscopy. During one week a surgeon could do eight osteosynthesis operations without reaching legally imposed dose limit. The control area could be restricted to a space around the patient with a radius of two meters.

The authors wanted to study the effect of non-physiologic muscular forces on growing rat bones. 35 animals were submitted to a total extirpation of the femur, 40 animals served as control group. They were killed immediately, six, twelve, or 24 weeks later, respectively. The results determined by macroscopic X-ray and fluorescence microscope examination are identical. As opposed to the control tibiae, the tibiae exposed to a greater load showed an increased bone density, increased ventral and lateral annexes, above all within the proximal third, and a torsion apparent in the cross-section. The less loaded tibiae showed a smaller bone density, increased medial and lateral annexes, above all within the proximal third, and a torsion apparent in the cross-section. The results are explained by the varying action of pressure and muscular forces and compared to those achieved by other authors.

Industrial accidents resulting from technical defects have decreased in the last eights because of improved safety precautions. In contrast, accidents resulting from "human error" are increasing steadily. Toxicological urine analysis for drugs--directed mainly at soporifics, sedatives, tranquilizers, and pain-relievers--on 84 patients involved in industrial accidents yielded the following results. 1. Drugs were identified in 44 patients (= 52%). 2. In 13.4 patients, more than one drug was identified (= 16%). 3. Only five of the 44 patients admitted on being questioned that they had taken drugs (= 10%). On the other hand, in a control group of 47 persons who and not suffered any accident, drugs were detected in 19 cases (= 40%). The results show that the physician will have to take into account that healthy and efficient persons, too, are very often likely to practise drug abuse. It must be considered probable that this helps to promote accidents. Medical prescription, especially of neuroleptics and psychotropics, as well as of sedatives, should be practiced more.

The article reports on 11 patients with metastases in the femoral shaft. In 5 patients, a pathological fracture had occurred, whereas in 6 patients the femur, which was liable to fracture, was prophylactically stabilised by means of the femoral shaft nail. Eight of these patients were able to walk after the operation, whereas 4 patients died after an average period of 19 weeks following surgery of their primary diseases. The method employed in these cases was of a palliative nature, resulting in considerable relief from pain, improved ability to walk, and hence in an improvement of the quality of life of these patients.