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Sixty-four patients underwent surgery for acromioclavicular (AC) disruption, Tossy type III, at the Department of Surgery, University of Heidelberg, between January 1983 and May 1990. Surgery consisted of a suture of the AC and coracoclavicular ligaments. Fixation of the joint was achieved with three different techniques: tension band wire with two Kirschner wires, special hook-plate (Wolter), double tension band fixation using polydioxanon (PDS) cordula. The early postoperative complication rate was higher following tension band wires (42.9%) and hook plate (58.3%) than after tension band PDS cordula (16.7%). The patients were re-examined after an average of 35.3 months. An instability of the AC joint was found in 31.8% of patients with tension band wire, 50.0% of patients with Wolter plate, and 23.8% of patients with tension band PDS cordula. The comparison of these results with those after conservative treatment, as reported in the literature, emphasizes the need for limiting surgery to young adults and athletes. The long term results of AC joint fixation are better using PDS cordula than tension band wire or hook plate. PDS cordula has the additional advantages, that dislocation and fracture of metal implants do not occur, and metal removal is avoided. Therefore, tension PDS cordula is associated with a marked reduction of the overall hospitalization period. Further improvements of results of AC joint fixation can be expected using the described technique of double tension band PDS cordula.

Within a 3-year period a total of 42 humeral fractures were treated. Nineteen of these were operated on with the Seidel intramullary interlocking nail. Most of the fractures could be classified into group A (AO classification); three type B and four type C fractures occurred. Two patients had pathological fractures due to bone metastases. Mean hospital inpatient treatment was 24 days. Besides two infections seven system-specific complications occurred. A discrepancy between the diameter of the nail and the width of medullary cavity was the reason in one case for an additional fracture and in another case for nonunion because of loosening of the nail tip in the distal fragment. Three further intraoperative fractures occurred during impaction of the nail, the reasons are also device-specific and are carefully analyzed. In two cases we were forced to remove the nail because of subacromial impingement due to an overranging proximal nail end. Finally, a normal intraoperative and postoperative course with good functional results could only be observed in approximately half the cases. Thus, our initial optimism with respect to the outstanding theoretical concept was dampened, so that the interlocking humerus nail is now just applied in pathological shaft fractures.

In a one year period 15 ankle fractures (13 B-type, two fractures of the medial malleolus) and six flake fractures were operated using biodegradable pins and documented prospectively. These are made of polyglycol acid fibrils compressed by use of a melting technique. They are available in different lengths and strengths. The shear strength is decreasing about half of the initial value within four weeks. The ankle fractures were stabilized with two systems of PGS-pins and PDS or Maxon figure-of-0 tension bands. Postoperative functional treatment was applied. The ankle fractures had healed after six weeks in twelve patients, after seven weeks in two, and in one patient only after nine weeks. Osseous healing of the flake fractures took more time. After six weeks was only one, after seven weeks were two and after nine weeks three fractures healed. Full load bearing was achieved after 8.9 weeks in the malleolar fracture group and after 10.8 weeks in the flake fracture group. Total duration of treatment was 10.2 weeks, respectively 12.4 weeks. It could be shown with this study that osteosynthesis of the ankle with biodegradable pins and functional postoperative treatment is basically possible. Furthermore these pins are apted ideally for fixation of flake fractures due to their high stiffness and simple application technique.

In a comparative study based on the diagnosis of blunt abdominal trauma, the accuracy of ultrasound (US) proved inferior, with 82-91%, to that of diagnostic peritoneal lavage, with 97-100%. The sensitivity of US, i.e. the proportion of patients with blood in the abdomen who had an abnormal test result (positive sonography) was 94%. The reasons for this may be either patient-related (severe obesity, intestinal gas superposition) or examiner-related (differing previous experience). The specificity for correct elimination of abdominal lesions was 100%. When no intra-abdominal liquid was present none appeared in the US picture; however, 3-13% of cases where intra-abdominal liquid was present this was not revealed by US. If only a small amount of intra-abdominal liquid is demonstrated after blunt trauma, the adoption of a wait-and-see attitude is justified. In intensive care conditions US can be repeated several times if necessary. In this study US showed deterioration in these circumstances in 25%, and in 21% it must be expected that an operation will be necessary.

A subtrochanteric resection was performed in 12 human corpse femora. In an experimental study stabilisation was achieved with a compound double plate osteosynthesis (condylar and medial intramedullar plate). 18 femora served as control. The loading capacity after double plate compound osteosynthesis is similar to that of normal femora. Due to the relatively rigid osteosynthesis device the plastic deformation was reduced significantly after compound osteosynthesis. The clinical evaluation comprises 26 fractures of the subtrochanteric region (out of a total of 208 pathological fractures). In 5 cases we performed a double plate compound osteosynthesis. In all patients a good or very good functional result was observed. Ten patients were treated by simple compound osteosynthesis.

The prognosis of knee ligament injury is mainly dependent on early diagnosis. In a prospective trial comprising 108 patients with fresh injury of the knee ligaments, the prognostic value of clinical non-invasive examination were assessed in awake and anesthetized patients. As a result the merely clinical examination without anesthesia gave only in 48% a diagnosis reliably enough for operation indication. Examination under anesthesia detected more than 83% of injuries with need for operation and 90% of ruptures of the anterior cruciate ligament. Lachman-test proved to be very reliable (more than 90%) and lateral pivot-shift-phenomenon almost provable (more than 86%) for ligament rupture. Arthroscopy in our hands is playing only a minor role at the event of fresh injury of the knee ligaments. In only 10% it was the decisive tool for operation. In our opinion the indication for narcosis examination should be put widely due to its high sensitivity. Since in approximately 90% on additional arthroscopy can be resigned, the entire ischemia time during pneumatic blood circulation blockage (110 to 120 min) is available for operative reconstruction of the knee joint.

After administration of antacids, gastric stress lesions due to hemorrhagic shock appear in the pig stomach quicker and more markedly than in animals which have been similarly treated with an indifferent substance or not at all. However, once treated, the administration of antacids seems to favor the healing of mucosal lesions after the end of the stress. At the same time it was observed that after administration of antacids in hemorrhagic shock, the serum gastrin level rises and does not remain constant, as in the control group. An attempt is made to explain the favorable effect of antacids on the genesis of hemorrhagic stress lesions in the pig's stomach through this observation.

The pattern of operation injuries of the arterial vessels which may occur during hip surgery is illustrated by this summary of our own cases. Injuries of the femoral vessels seem to be preventable if the Hohmann-retractor is carefully placed on the anterior margin of the acetabular rim under digital control. Furthermore drilling damage of the iliac vessel appears to be avoidable. However, the replacement manoeuvre of the artificial acetabulum can be associated with massive bleeding despite greatest care. Under these circumstances immediate surgical intervention through an inguinal retroperitoneal approach is mandatory.

Within 3 years 12 injuries of the anterior fibulo-tibial ligament without fracture of the fibula were recorded prospectively. In relation to the total number of the ankle joint fractures during the same period the incidence is 3.3%. The rupture of the ligament arose in all cases from a forced eversion combined with supination or pronation of the foot. Clinical characteristics are the circumscribed painful palpation of the area of the ligament together with eversion pain of the foot. Arthrography is the most sensitive diagnostic procedure, which, however, may be avoided if the clinical situation is absolutely clear. Differential diagnosis consists mainly in the rupture of the fibulo-talar ligament including a tear of the anterior capsule of the ankle joint. Treatment should always be surgical - suture of the ligament, reinforcement of the syndesmosis by means of a positioning screw. Aftercare is functional without external fixation.

In a retrospective study the course of 69 patients of the Surgery Department of the University of Heidelberg (66 men, 3 women, mean age 60 years) with carotid artery stenosis with contralateral carotid occlusion has been reported. 10% of the patients with carotid artery stenosis had a contralateral occlusion. Corresponding to the side of occlusion most patients had a preoperative neurological stage IV (55%, 19% stage II, 26% stage I) and corresponding to the side of stenosis most patients had a stage I (57%, 28% stage II, 4% stage III, 12% stage IV). In addition to the stenosis the occlusion had been operated on in 7 patients, in 5 of them the revascularisation was not possible. In 88% the arteriotomy could be closed using a venous patch and in 97% a intraluminal shunt was used. All operations were done under general anesthesia. The early lethality rate was 10%, in one patient a postoperative neurological deficit occurred. The late mortality rate was 21%, in 5% a new neurological deficit could be found (n = 57, mean follow-up: 3.0 years). In relation to the preoperative neurological stage corresponding to the side of stenosis the highest mortality rate was found in patients with stage IV. In a separate analysis of two periods (1962-1978 and 1979-1981) it can be demonstrated that the high early mortality rate is nearly entirely found in the first period with a low operative frequency. In the second period 1979-1981, 33 carotid endarterectomies in patients with contralateral occlusion were operated with a mortality rate of 3%.(ABSTRACT TRUNCATED AT 250 WORDS)

Between 1976 and 1980 161 patients were admitted to our department with condylar fractures of the tibia. 60% of the patients were treated conservatively, 40% underwent surgery. The patients follow-up was analysed three to seven years after therapy and an examination of a representative group of patients was performed 1983. A direct comparison of therapeutic results between the conservative and operative treatment groups is not possible, since fractures with a particularly poor prognoses including depression and impression fractures of the articular surface were more frequent in the operative treatment group. It is noteworthy, however, that the patients' activity at work and in their leisure time was increased in the operative group. Additionally in this group the remaining complaints were less and the final results more favourable according to the patients' self-judgment. Unchanged irregularities of the joint surface following initial therapy were found in 40.5% of conservatively treated patients and in 6.9% of operated patients respectively. At the time of reassessment, however, differences of radiological findings could not be seen between the two treatment groups. Whereas in the conservative treatment group a difference in length of the two legs of 2 cm or more were observed in 16% of cases, not a single case was found in the operative treatment group. There was a correlation of the functional and the result of the radiological examination, although considerable exceptions from this correlation were also seen. Therefore it is not possible from the individual X-ray findings to predict the functional results of the patient.

In seven patients (mean age 22 years) with injuries of the pelvic ring, the rupture of the symphysis was treated by polydioxanone ligaments. Complete rupture of the ileosacral joint was treated twice by additional external fixation, twice a compression screw osteosynthesis was applied. Incomplete iliosacral rupture in another three cases was not operated. Patients were treated functionally without signs of loosening or instability. After a control examination after 5 months all patients were free of symptoms in the area of the symphysis. Infection of the operation area did not accur. In our opinion the advantages of this method are simple operative technique, reduced risk of infection and no need for removal of metallic implants. Our excellent initial experience with synthetic PDS ligaments in operative treatment of symphysis ruptur seem to justify its application for other injuries like iliosacral or acromioclavicular rupture.

An atraumatic, pneumatic occlusive colostomy appliance has been described which in animal experiments was well tolerated and was effective in preventing leakage. It is hoped that this may improve the unsatisfactory aspects of management in patients using conventional colostomy appliances.

In polytraumatized patients, pulmonary contusion complicated by pneumonia is associated with a high risk of fatality. The effects of both contusion and bacterial infection on pulmonary function can be estimated early by measuring the parameters PAPd-PCWP, pulmonary shunt volume and maximal PaO2 following FiO2 = 1.0 for 20 min.

In 24 femora an unstable intertrochanteric osteotomy was performed. In twelve an endernail osteosynthesis and in the other twelve a 145 degree-plate osteosynthesis was performed. Eight femora were tested as control. The loading capacity was 500 N higher in the endernail group. In four cases after 145 degrees-plate osteosynthesis but only in one case after endernailing the osteosynthesis becomes unstable under an alternating load of 2000 N. In femora with pronounced osteoporosis the maximal loading capacity is higher in the endernail osteosynthesis group. The loading capacity increase with the CCD-angle. The deformation after alternating load of 500 N is significantly lower in the 145 degree-plate osteosynthesis group. At higher alternating load the deformation of the 145 degree-plate osteosynthesis exceeds that of the endernail osteosynthesis.

Within seven years 506 patients with blunt abdominal trauma were included into a prospective trial. The aim of the study was checking of the validity of clinical parameters, routinely performed laboratory examinations and of the initial circulatory situation in relation to an abdominal organ lesion. Three groups were separated out of the total collective: Group 1: Patients without abdominal lesion (N = 274). Group 2: Patients with abdominal lesion, verified by operation, sonography or CAT scan (N = 232). Group 3: Patients with rupture of the spleen (N = 107) (subgroup of 2). Among the clinical parameters: spontaneous abdominal pain, contusions marks, abdominal tenderness, shoulder pain, and abdominal palpation, the latter does have a high validity (92%). However, in group 1, more than half of the cases also had palpation pain. Shoulder pain has a high sensitivity. Of the laboratory parameters: hemoglobin, hematocrit and leucocytes, only the leucocyte count provided a certain importance: 83% of group 2 had values above 10,000. The circulatory parameters blood pressure and pulse as initial spot picture are of minor validity. Continuous registration of these values at clinical observation has much higher relevance indicating trends towards improvement or deterioration.

Between 1984-1987 6 multiple trauma patients with pelvic fractures and bleeding from pelvic vessels were treated by transcatheter embolization. Although diagnosis and therapy were early in two cases, there was an overall time delay of median 17 hours (1-38 h) until localisation of bleeding lesions. In this period multiple transfusions (median: 33.7 units of packed erythrocytes, 14.5 units of fresh frozen plasma) could not control hemorrhage. After successful transcatheter embolization circulation stabilized immediately and durably. 4 patients died, 2 of them from septic-toxic multi-organ-failure.

54 human corpse femora were tested. In 18 unstable pertrochanteric osteotomies were performed, in other 18 femora valgisation osteotomies were performed. 18 femora served as control. In the unstable pertrochanteric osteotomy-group 135 degrees-DHS-osteosynthesis was performed. In the valgisation-osteotomy-group a 150 degrees-DHS-osteosynthesis was performed. Half of the femora were tested under physiological load, the other femora were tested with the load acting from cranial-lateral (50 degrees difference to the physiological load direction). Under physiological condition the load capacity was 5769 N in the 135 degrees-DHS-group and 7261 N in the 150 degrees-DHS-group, and so 8 to 10 times higher as the body weight. In the groups with the false loading direction the mean stability of the osteosynthesis was 2937 N in the 135 degrees-DHS-osteosynthesis-group and 3942 N in the 150 degrees-DHS-osteosynthesis-group. The load capacity of the control femora was 7451 N. The deformation under physiological load was similar in both groups. Under unphysiological load the deformation was 2-3 times higher in the 135 degrees-DHS-group because of the higher bending compared with the 150 degrees-DHS and because of the medical cortical defect. The results demonstrate the effectivity of the sliding osteosynthesis technique of the DHS. After DHS-osteosynthesis of unstable pertrochanteric fractures with limited medial defect in all cases full weight bearing after operation is possible. Valgisation osteotomy is not necessary in this type of fracture.