[Update on gunshot wounds to extremities]

Due to recent rampage and terror attacks in Europe, gunshot wounds have become a focus of attention even though they are still rare in Europe. Approximately 50% of gunshot wounds affect the extremities and to understand the sequelae, a basic knowledge of wound ballistics is indispensable. The energy transmitted from the bullet to the tissue is responsible for the severity of the injury and is dependent on the type of weapon and ammunition. A differentiation is made between low-energy injuries caused, e.g. by pistols and high-energy injuries mostly caused by rifles. The higher energy transfer to the tissue in high-energy injuries, results in a temporary wound cavity in addition to the permanent wound channel with extensive soft tissue damage. High-energy gunshot fractures are also more extensive compared to those of low energy injuries. Debridement seems to be necessary for almost all gunshot wounds. Fractures should be temporarily stabilized with an external fixator due to contamination.

[Experimental principles of the V.A.C.-therapy -- pressure values in superficial soft tissue and the applied foam]

OBJECT OF THE STUDY

Measurement of the pressure during V.A.C.(R)-therapy in superficial parts of the affected soft tissue as well as at the soft tissue/foam-interface, measurement of pressure values along bigger distances in the foam and the comparison of pressure transfer between polyurethane and polyvinyl-alcohol foams.

MATERIAL AND METHODS

A multi-channel electronic transducer-tipped catheter system based on the piezo-resistant principle was used. Measurement was performed on a plain table surface, at a bovine muscle as well as in human tibial anterior muscle of a patient after fasciotomy. Applied pressure values by V.A.C.(R)-therapy-units were 50 to 200 mm Hg (continuous suction modus).

RESULTS

100 % pressure transition through vacuum-therapy-foams to wound surface, almost 100 % pressure transition even along 60 cm in very large polyurethane-foams using only one trac-pad connector. Pressure values > 125 mm Hg using polyvinyl-alcohol-foams showed a reduction of up to 25 % in distances > 15 cm from trac-pad-connector. On the surface of the affected soft tissue there are negative and positive pressure values (25 % quartile: - 25 mm Hg; 75 % quartile: + 15 mm Hg).

DISCUSSION

Pore walls of the foam can produce positive pressure conditions resulting in soft tissue compression and consecutively hypoperfusion or ischemia. V.A.C.(R)-therapy seems to produce an heterogeneity of pressure distribution at the wound ground leading to pressure gradients and facilitating drainage of interstitial fluid. This mechanism could explain the anti-edema effects of V.A.C.(R)-therapy resulting indirectly in an increased nutritive perfusion.

[The influence of a controlled active motion splint on proprioception after anterior cruciate ligament plasty. A prospective randomized study]

BACKGROUND

A ruptured anterior cruciate ligament (ACL) leads to both mechanical and functional instability. Functional instability is caused by proprioceptive deficit. The aim of this study was to determine whether the proprioceptive deficit can be reduced by using a controlled active motion (CAM) splint postoperatively.

PATIENTS AND METHODS

A total of 50 patients with ACL rupture were randomized into two groups. After ACL plasty the PT group received postoperative physiotherapy, while the CAM group were managed with a CAM splint and physiotherapy. Proprioceptive ability was measured with a passive angle-reproduction test.

RESULTS

On the day of discharge 80% of the patients in the CAM group and 25% in the PT group had a reduced proprioceptive deficit. Overall the main measured value in the CAM group improved by 83.7%, but deteriorated by 39.3% in the PT group. There was no significant difference between the CAM group and a healthy control group.

CONCLUSION

Using a CAM splint in addition to physiotherapy after ACL plasty in comparison to physiotherapy alone decreases the proprioceptive deficit significantly. We recommend the use of a CAM splint in the postoperative management following ACL plasty.

[Results 13 years after ACL plasty using a carbon prosthesis]

AIM

The retrospective results of carbon prostheses for ACL plasty from 1985 to 1989 are reported. The aim of this study was to determine the number and kind of necessary revisions and the rate of arthrosis and instability of the operated joints.

METHOD

101 patients out of 136 patients with ACL plasty using a carbon prosthesis could be reviewed clinically in this retrospective study. All patients answered a questionnaire. Additionally, the tibial translation was examined with the KT1000 at maximum power. Conventional X-rays were taken of the knee joints. The results were evaluated using different scores.

RESULTS

70 % of the patients had pathological findings in the clinically tested tibial translation and had a positive Lachmann sign. 66 patients had a tibial translation of 2 mm or above when tested with the KT1000 at maximum power. Radiological studies had shown a gonarthrosis of grades III and IV in 93 patients. An average of 77 points was found using the Lysholm score.

CONCLUSION

The results 13.5 years after ACL plasty using a carbon prosthesis are unsatisfactory concerning joint stability and development of secondary arthrosis. There is a discrepancy between the results of the clinical tests and the subjective complaints of the patients.

Ein neues retrogrades Femurmarknagelsystem mit durchleuchtungsfreier proximaler Verriegelung

INTRODUCTION

Conventional retrograde nailing of the femur causes two important disadvantages: the proximal locking of the nail is difficult because of the anatomic conditions and a chondral defect was left into the knee.

MATERIAL AND METHODS

After the retrograde implantation the new nail was lead through the greater trochanter. An additional proximal aiming device for proximal interlocking can be fixed. The entrance portal will be sealed by an osteochondral cylinder. 50 cases of femur fractures were selected for the prospective study. We recorded all intraoperative complications and technical difficulties. The cases were followed up for 52 weeks, both clinical and radiology examinations were performed.

RESULTS

The mean follow up was 15.5+/-5 months. All fractures were healed. Knee movement was 125+/-14 degrees. The Leung Score was 84+/-12.6 points; HSS Score was 90+/-9 points. In two cases wound infections were developed. Mal-union was observed in three cases, in two cases nail brake down.

CONCLUSIONS

The new retrograde interlocking nail could be used to manage femur fractures successfully. Two aiming devices enable a easy interlocking. Replacement of the osteochondral cylinder into the entry portal reduces cartilage damage.