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The idea of Televisite is to equip the patients with a camera and a communication panel at the time of their discharge from the hospital. In that way patients and physicians are able to continue the treatment and the rehabilitation program. An easy to handle interface helps the patient to answer simple questions or to send voice recordings, pictures or videos via a service centre to the doctor in attendance. This concept has the great advantage that the patients has to visit the physician in the office or in the hospital only when absolute required. Routine checks can be done by telecommunication. Thus the efficiency of the system may significantly contribute to lower costs in the health care system.

Sixty-seven fractures of the tibial shaft with concomitant soft tissue injury were managed at the "Bergmannsheil" Bochum, University Clinic between May 1, 1991 and March 31, 1993. 33 fractures underwent unreamed nailing whereas 34 fractures were stabilized with external skeletal fixation. There were 20 closed fractures with soft tissue compromise (13 types GII and 7 types GIII (Oestern/Tscherne classification)) and 25 compound fractures (8 grade I, 12 grade II and 27 grade III (Gustilo-Anderson classification)). The grade III open fractures were subdivided by the Gustilo-Mendoza-Williams classification (13 types IIIA, 10 types IIIB and 4 types IIIC). Sixty-five fractures have healed (1 amputation type IIIC, 1 patient died). The mean time to union was 28 weeks in the fixator group and 23.5 weeks in the unreamed nail group (statistically not significant, p0.095). Also the infection rate (1 case in each group), the fasciotomies due to compartment syndrome, the number of bone grafts, the number of device change and mesh grafts was not statistically significant in both groups. Only the number of performed flaps for wound coverage was statistically significant higher in the fixator group (p0.05). In the unreamed nailing population, breakage of the locking bolts occurred in 4 cases. In 3 cases secondary reamed nailing was necessary (2 delayed unions, 1 avulsion of distal bolts). Two fractures underwent dynamization by removal of the distal locking bolts 6 weeks post initial static nailing. The unreamed nail is a versatile implant for tibial shaft fractures with closed and open soft tissue compromise.(ABSTRACT TRUNCATED AT 250 WORDS)

Spinal column trauma with a fracture of the breast and lumbar spine is with 2-3% relatively uncommon in the pediatric patient population (from birth-16 years). In a review of 22 patients (7-15 years old) treated between 1978-1988 the individual management of treatment is reported. The goal of our study was to describe the absolute indications for the operative treatment and the difference between conservative and operative procedure depending on the age of the patient. The follow-up study after an average of 7 years and 8 months demonstrated an improvement of the neurological status (neurological status of Frankel) of 8 patients and a spontaneous correction of kyphotic angle from 21 degrees after treatment to 3 degrees.The treatment must be individual and depends on the age of the patient.

A total of 146 patients with 150 closed metacarpal fractures were treated between 1980 and 1981, and 109 patients with 113 metacarpal fractures (75%) were followed up (follow up 7.3 years). After conservative treatment, the functional results were good to excellent in 92.7%, while 5.8% had satisfactory and 1.5% poor functional results. After operative treatment 81.5% had good or excellent functional results, 14.8% satisfactory results and 3.7%, poor functional results. The radiological result did not correspond with the functional result. Angulation of the Ist-IVth metacarpal bones by up to 20 degrees of the Vth metacarpal bone by up to 50 degrees, and even shortening by up to 8 mm had no detrimental influence on the functional results. Axial rotational deviation of the Vth metacarpal bone by up to 15 degrees was tolerated. Joint fractures with a 1 mm step could also be treated by conservatively means.

Although local muscle flaps of the lower leg are often used, the functional problems that arise after these reconstructive procedures have not yet been adequately studied. Twenty patients who had undergone a local muscle flap of the lower leg 3 years earlier were studied using a isokinetic muscle test. The isokinetic muscle strength profile during flexion of the foot was reduced by up to 21 +/- 16% after transfer of the m. gastrocnemius and by up to 31 +/- 20% after transfer of the m. soleus at a angular velocity of 120 degrees. The isokinetic muscle strength profile during pronation and supination of the foot at an angular velocity of 120 degrees was reduced by up to 89 +/- 32% after transfer of the m. soleus. Statistically, compound tibia fractures without a local flap for soft tissue therapy showed significantly better results. In view of this functional loss, the use of local muscle flaps, particularly the transfer of the m. soleus, should be restricted in younger patients, and alternative techniques (free flaps) should be used.

Combinations of fractures or dislocations with vascular damage of the leg have a high incidence of amputation or severe functional deficit. With this type of lesion 22 patients were treated at "Bergmannsheil" from 1986 to 1991. Using a pre-, intra- and postoperative protocol, the amputation rate decreased to 18%. More than 80% of the patients had a good function of their leg with only minor joint restrictions.

Complications after pilon fractures either result from lesions of the narrow soft tissue layer and the very congruent ankle joint or are brought about by treatment (e.g. infection and malalignment) [2]. To elucidate the complication rate we undertook a retrospective study of 229 patients with pilon fractures treated in the Trauma Department of the Bergmannsheil Hospital, Bochum, between 1969 and 1989.

Extremitatenverletzungen mit schwerer Weichteilschadigung stellen auch heute noch eine grose Herausforderung fur die Chirurgie dar. Nicht nur der Erhalt der so geschadigten Extremitat, sondern auch die Wiedererlangung der Funktion bedingen sowohl fur den Patienten als auch fur den Chirurgen mannigfaltige Probleme.

Bonding strength of hydroxyapatite-coated (HA) 4.5 mm AO/ASIF screws and of conventional AO/ASIF screws to bone has been compared in an animal experiment. A 5-hole AO/ASIF compression plate was fixed to the tibia in ten beagle dogs. The cortex beyond the central hole of the plate was resected up to the half of the diameter of the tibial shaft and over a length of 10 mm. In the holes immediately proximal and distal to the central hole either HA-coated or conventional screws were inserted with standardized force. Two conventional screws were inserted into the two holes at the ends of the plate. These screws were removed after 2 weeks. Four animals were sacrificed after 4 and 8 weeks and one animal after 16 and 26 weeks. The removal torque of HA-coated screws was 385.50 +/- 49.1 Ncm, compared with 29.50 +/- 7.62 Ncm for the conventional screws (P0.0001; T-test). The fluorescence and morphometric data confirmed new bone formation immediately under the HA surface without any bone resorption or intervening fibrous tissue. At the bone-implant interface of conventional screws, however, extensive bone resorption was observed and a thick intervening layer of fibrous tissue. Bone resorption of 13.6% was observed in the cortical areas under the thread of the AO/ASIF screws, in contrast to 1.9% under the surface of the HA-coated screws. These histological and biochemical data support the clinical use of HA-coated screws if early loosening of the screws is otherwise expected or removal of implants is not intended.

Seven hundred and four compound fractures - 198 (28%) grade I, 259 (37%) grade II, 247 (35%) grade III (86 IIIA, 119 IIIB, 42 IIIC) were treated in 590 patients between May 1983 and May 1989 at the University of Louisville. Of these fractures, 157 (22%, group 1) received systemic antibiotic prophylaxis only, whereas 547 (78%, group 2) were treated with additional local application of aminoglycoside beads (tobramycin). Comparison of factors (fracture grades, age, sex, fracture location, follow up) revealed no significant differences between the two groups. All fractures underwent timely irrigation, debridement and skeletal stabilization. In group 1, 52 wounds were primarily closed, 53 underwent delayed primary closure and 52 were left open. In group 2 283 wounds were primarily closed, 229 were managed with the bead pouch technique and 35 were adapted loosely (delayed closure). Forty-nine (6.96%) of the 704 compound fractures became infected (acute wound infec- tion and/or chronic osteomyelitis). Group 1 showed an infection rate of 16.6% (26/157), group 2 a rate of 4.2% (23/547). The difference was statistically highly signifi- cant (P < 0.001). Comparison of the infection rates, whether on an acute or a chronic basis, showed that infection rates were lower in group 2 than in group 1 for all fracture grades. A statistically significant difference was established only for type IIIB fractures, where the wound infection rate was 39.1% (9/23) in group I and 7.3% (7/96) in group 2 (P < 0.001). The rate of chronic osteomyelitis was 26.1% (6/23) in group 1 and 6.3% (6/ 96) in group 2 (P < 0.025). Prophylactic use of antibi- otic-bearing polymethylmethacrylate beads in addition to systemic antibiotics was of benefit in preventing infec- tious complications in compound fractures, in particular in type IIIB fractures.

Die Heilungsprognose des Weichteilgeschadigten Unterschenkelbruches wird vom Ausmas der lokalen Gewebezerstorung bestimmt. Je schwerer der Weichteilschaden, desto „biologischer“ mus die Osteosynthese erfolgen. Zur Verfugung stehen der unaufgebohrte Marknagel und die einfache Fixateur-externe-Montage. Die Fixa-teur-externe-Osteosynthese ist weiterhin bei der „Ziehharmonika-Technik“ (primare Verkurzung nach Debridement und sekundare Verlangerung) indiziert. Der unaufgebohrte Marknagel ist eine Alternative mit erhohtem Patientenkomfort, aber auch mit hoheren Materialkosten.

With a total mortality of about 20%, septic multiple organ failure (MOF) is the main cause of death in polytraumatized patients. Secondary organ failure usually begins 4–8 days after primary successful treatment. A septic focus can hardly ever be identified [5–7, 20]. The gut as a shock organ and a trigger of septic macrophage reaction has become the center of research interest. In traumatic shock the alpha-adrenergic potency in the gastointestinal tract leads to a reduction in the mesenterial blood flow to 15%–20% of normal [15]. Dysfunction of the intestinal mucosal barrier with a translocation of gram-negative bacteria can be shown in analogous shock situations in animal experiments [2, 3, 8, 10, 13, 19–21].

Interlocking nailing technique offers a wide variety of indications which are associated with an increased risk of complications. A consecutive series of 208 cases were analyzed and possible complications, how to avoid them and recommendations for treatment are given. The complications were divided into common complications--like infection, pseudarthrosis, malrotation, compartment-syndrome, disorders of the arterial and venous system, neurological deficts and fat embolism--as well as into specific complications--like malreduction of the fracture, malpositioning of the guide wire, splitting fragments and problems with nail insertion and with the locking bolts. There was a 8.7% common complication rate. Specific complications occurred intraoperatively in 3.5% and postoperatively in 11% of call cases. This seems to be a high rate which is decreasing by progressive experience of the surgeon. In many cases of shaft fractures interlocking nailing technique is the method of choice.

Die Fortschritte der rekonstruktiven Orthopadie haben in den letzten 30 Jahren ausgedehnte Resektionen am Skelettsystem bei der Behandlung neoplastischer Erkrankungen ermoglicht. Der Wiederaufbau lasttragender Knochenanteile kann aber haufig nicht mehr durch autologes Gewebe erreicht werden, so das zunehmend Fremdmaterialien verwendet werden mussen.

Bacterial adhesion and its ability to elaborate a protective exopolysaccharide biofilm is a critical factor in pathogenesis of chronic osteomyelitis. Repetitive radical debridement to viable and well perfused cortical bone — controlled by scintigram and antibiogram — together with vancomycin- and tobramycin-impregnated cancellous grafts induce a permanent revascularization of the defect (biointegration).

In a retrospective analysis 93 external fixations with different rigidity after open tibial shaft fractures have been reviewed and compared concerning complications and healing time. Fracture consolidation was attained in fixation with unilateral frame after 14 weeks, with bilateral v-shaped fixator after 19 weeks and with triangular configuration in about 28 weeks. Subsequent internal fixation or extension to v-shaped fixation was necessary in about 33% after initial unilateral half-pin frame, whereas 90% of the two rigid systems could be left in situ until fracture consolidation was achieved. Cancellous bone grafts were performed in 58% after triangular, in 40% after v-shaped, and 28% after unilateral fixation. Pin infections were observed in 36% after triangular, 25% after bilateral v-shaped, and in 15% after unilateral fixation.

Acute respiratory failure is still one the main problems in surgical intensive care. Unknown pathophysiological mechanisms permit only symptomatic therapy. Today ventilatory strategies by using PEEP und IRV are established to improve gas exchange and FRC by recruiting collapsed alveoli, decreasing intrapulmonary shunting and returning V/Q matching to normal. Furthermore different studies have shown the effects of supine and lateral decubitus posture in patients with acute respiratory failure. There are only rare reports on using the prone position, which doesn't require two-lung ventilation in difference to lateral position. We have studied 16 patients with acute respiratory failure by using continuous changing between prone and supine position under mechanical ventilation. All were male, aged 41.3 years in the middle and showed an average "Injury Severity Score" of 30 (13-50). 15 were trauma patients with blunt chest trauma in 11 cases. We have used prone position on threatening or manifest ARDS. In all patients we observed an increment of PaO2 during prone position on to 48 mmHg so that FiO2 could be reduced on an average of 0.2 within the first 48 h since changing patient's position. Posture changing depends on blood gas analysis, specifically on decreasing PaO2 after previous increment. Patients remained in prone and supine position at a mean of 6.3 (4.5-20) h and posture changing was proceeded over a period of 15.4 (7-32) days. No problems recording to blood pressure or mechanical ventilation appeared during prone position. 11 of 16 patients survived (68.8%), 5 died of cardiac (2) and multi organic failure (3) in connection with sepsis.(ABSTRACT TRUNCATED AT 250 WORDS)

A consecutive series of 558 patients with abdominal trauma were treated at "Bergmannsheil" Trauma Center in Bochum between 1974 and 1989. The most common patient group was traffic casualties with an age of up to 30 years a total of 218 (31.1%) patients underwent surgery, in which can the diagnosis was made only by surgeons. Isolated injuries were predominantly in the spleen (33%), liver (29%), mesenterium (16.1%), bowel (14.2%), and bladder and urethra (10.1%). Eighty-three of the patients who were operated on had multiple intra-abdominal injuries; 208 (37.3%) patients were included with polytrauma. Despite the increasing number of patients with multiple injuries mortality decreased from 27.1% between 1974 and 1979 to 19.7% between 1980 and 1989. This emphasizes the progress that has been made in diagnostic methods, surgical intensive care and the improved education of trauma surgeons.

Arthroscopy of the wrist and elbow is a helpful diagnostic procedure in patients with chronic disability not demonstrated by clinical and radiological examinations. At the wrist, especially triangular fibrocartilage, chondral or ligamentous defects can often not be demonstrated by other tests. Arthroscopy of the wrist allows examination of more than a dozen separate articular surfaces and the function of eight discrete joints. The geometry of the elbow joint limits intra-articular inspection and the use of instruments. The risk of neurovascular injuries is great and depends on exact puncture sites and portals. Its efficiacy is not yet proven.

In 1988, we treated 47 patients with acute or chronic osteitis by means of a new industrial collagenous sponge containing gentamicin (Sulmycin Implant) as an adjuvant measure. The local surgical management was standard: total excision of all avascular or infected soft tissue and bone, stabilization of pseudarthrosis, the improvement of local circulation and the condition of the soft tissue by means of local or free flaps before autologous bone grafting and antibiotics administered according to the test results. In cases of instability AO external fixation was used. One or two Sulmycin Implants (10 x 10 cm) containing 130 or 260 mg gentamicin were placed in the remaining small cavities or in the transplanted autologous spongy bone. Gentamicin was measured in the wound exsudate for 3-5 days; during this time we found bactericidal concentration in these exsudates. The wounds healed in 44 patients, but we had a persistent fistula in 3 patients (6.3%). We see collagen-gentamicin sponges as being very useful in the treatment of osteitis. It seems to reduce delayed bone transplantation in infected areas.

The Matti-Russe technique yields a 95% success rate in treating scaphoid non-unions diagnosed in the first years after trauma and without osteoarthrosis of the radiocarpal joint. Between October 1981 and December 1989, 215 patients were treated by Matti-Russe procedure at the University Hospital of "Bergmannsheil" Bochum. In ten cases, this operation did not lead to osseous consolidation. The results are presented and discussed.

The specific cellular host defence in patients with chronic post-traumatic bone infection was analyzed in a prospective study. The study included 120 patients with chronic post-traumatic osteomyelitis and 60 healthy volunteers. The number of CD-5, CD-4, CD-8, natural killer cells and the CD-4/CD-8 ratio were significantly decreased. The immunodeficiency seems to be trauma-induced and reinflammation seems to be due to other immunodeficient factors. The potential key role of a defect in cytokines is discussed.

Displaced three- and four-part fractures of the humeral head detached from their blood supply are at high risk for a poor functional outcome after internal fixation. Primary prosthetic replacement can restore the pretraumatic anatomy, and early function is possible. Head replacement within 2 weeks after trauma, reapproximation of the tuberosities, and reconstruction of the rotator cuff tear establishes early stability and good functional results in up to 80%.

Die Beurteilung von Organverletzungen, z. B. Milz, Leber- und Nierenrupturen, mus nach funktionellen Gesichtspunkten erfolgen und hat die verbliebene Funktionseinschrankung zu berucksichtigen. Die Begutachtung sollte daher von den Vertretern des jeweiligen Fachgebietes (Internisten, Urologen) durchgefuhrt werden. Es ist bekannt, das es gerade bei Leber- und Milzrupturen nicht selten zu Narbenhernien kommt, die hinsichtlich der gutachterlichen Beurteilung kaum Schwierigkeiten machen. Selbstverstandlich mussen auch Bauchwandbruche nach Operationen als mittelbare Unfallfolge anerkannt werden, wenn ein ursachlicher Zusammenhang mit dem Eingriff besteht und die Operation als Folge des Unfallgeschehens erforderlich wurde. Anders ist es mit der Anerkennung von Leistenhernien als Unfall- oder Verletzungsfolge.

Posttraumatische Fehlstellungen nach korperfernen Speichenbruchen treten trotz standardisierter Therapieverfahren mit einer Haufigkeit von bis zu 20% auf (Rehn 1965). Eine primar ungenugende Reposition und Retention, versaumte oder fehlgedeutete Rontgenkontrollen sowie unterschatzte schleichende Dislokationen fuhren zu unbefriedigenden Behandlungsergebnissen. Achsenabweichungen des distalen Speichenendes fuhren zu einer Speichenverkurzung mit relativem Ellenvorschub. Dadurch entsteht uber das biomechanische Ungleichgewicht ein Beschwerdekomplex mit schmerzhaft eingeschrankter Handgelenksbeweglichkeit sowie einer durch den Ellenvorschub bedingten Behinderung der Unterarmdrehung. Die Inkongruenz im distalen Radioulnargelenk mit Diskusverletzung und Zerreisung des triangularen Bandkomplexes fuhrt im weiteren Verlauf uber ein ulnokarpales Impingement zur schmerzhaften Arthrose mit zunehmender Einschrankung der Pro- und Supination. Hierbei korrelieren Bewegungseinschrankung und Schmerzausmas nicht immer mit dem rontgenologischen Befund.

Obgleich die Sonographie in der chirurgischen Diagnostik einen festen Platz besitzt, nimmt sie beim Thoraxtrauma im Gegensatz zum stumpfen Bauchtrauma noch eine Ausenseiterposition ein. Prognostisch ist fur den Mehrfachverletzten das zusatzliche Thoraxtrauma von groser Bedeutung und fuhrt zur Erhohung der Letalitat [2]. Daraus resultiert die Forderung nach einer raschen, unkomplizierten und aussagekraftigen Diagnosetechnik mit effizienter Verlaufskontrolle.

Ziel der Untersuchung war es, die Druckbelastung und die Reisfestigkeit laserunterstutzter und ausschlieslich gelaserter mikrovascularer Anastomosen im Vergleich zur konventionellen mikxochirurgischen Nahtanastomose zu vergleichen.