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Background: Ankle fractures are extremely common in the elderly, with an incidence of up to 39 fractures per 100,000 persons per year. We found a discrepancy between intraoperative findings and preoperative X-ray findings. It was suggested that many relevant lesions of the ankle joint in the elderly cannot be detected with plain X-rays. Methods: Complete data sets and preoperative X-rays of 84 patients aged above 60 years with ankle fractures were analysed retrospectively. There were 59 women and 25 men, with a mean age of 69.9 years. Operation reports and preoperative X-rays were analysed with respect to four relevant lesions: multifragmentary fracture pattern of the lateral malleolus, involvement of the medial malleolus, posterior malleolar fractures and bony avulsion of anterior syndesmosis. Sensitivity, specificity, positive predictive value, negative predictive value, accuracy and prevalence were calculated. Results: The prevalence of specific ankle lesions in the analyzed cohort was 24 % for the multifragmentary fracture pattern of the lateral malleolus, 38 % for fractures of the medial malleolus, 25 % for posterior malleolar fractures and 22.6 % for bony avulsions of the anterior syndesmosis. Multifragmentary fracture patterns of the lateral malleolus (sensitivity 0 %) and bony avulsions of the anterior syndesmosis (sensitivity 5 %) could not be detected in plain X-rays of the ankle joint at all. Fractures of the medial malleolus and involvement of the dorsal tibial facet were detected with a sensitivity of 96.8 % and 76.2 %, respectively, and specificity of 100 % in both cases. Conclusions: This study confirms that complex fracture patterns, such as multifragmentary involvement of the lateral malleolus, additional fracture of the medial malleolus, involvement of the dorsal tibial facet or bony avulsion of the anterior syndesmosis are common in ankle fractures of the elderly. Therefore, CT scans should be routinely considered for primary diagnosis, in addition to plain X-rays., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: In the constantly evolving, increasingly important field of foot surgery, the question arises as to whether the incision types currently in use are adequate. Whether Langer's lines should be considered during the operative approach to the foot is examined here. The goal of the current study was to investigate the pattern of skin cleavage lines of cadaveric feet and to establish the optimal incision type for surgical approaches to the foot., Materials and Methods: Twelve feet from older deceased subjects were examined. The samples were fixed. The cleavage lines of the individual skin regions were outlined and evaluated. To emphasize the significance of the investigative findings, the cleavage lines and the current, relevant operative approaches were compared., Results: Standard current approaches often ignore skin cleavage lines, understandably resulting in cosmetically unsatisfactory scars. A chart with ideal incision types for individual operations was created., Conclusion: The ideal incision should run parallel to skin cleavage lines. If this is not completely possible due to operative requirements, then at least a large part of the incision should follow these lines.

Aim: The aim of the study is to correlate the CT-morphological changes of fractured calcaneus and the classifications of Zwipp and Sanders with the clinical outcome., Method: In a retrospective clinical study, the preoperative CT scans of 75 calcaneal fractures were analysed. The morphometry of the fractures was determined by measuring height, length diameter and calcaneo-cuboidal angle in comparison to the intact contralateral side. At a mean of 38 months after trauma 44 patients were clinically followed-up. The data of CT image morphometry were correlated with the severity of fracture classified by Zwipp or Sanders as well as with the functional outcome., Results: There was a good correlation between the fracture classifications and the morphometric data. Both fracture classifying systems have a predictive impact for functional outcome. The more exacting and accurate Zwipp classification considers the most important cofactors like involvement of the calcaneo-cuboidal joint, soft tissue damage, additional fractures etc. The Sanders classification is easier to use during clinical routine., Conclusion: The Zwipp classification includes more relevant cofactors (fracture of the calcaneo-cuboidal-joint, soft tissue swelling, etc.) and presents a higher correlation to the choice of therapy. Both classification systems present a prognostic impact concerning the clinical outcome.

Until December 2001 84 midclavicular fractures in 80 patients were treated with intramedullary nailing. Postoperatively there was a significant decrease of pain and a significant increase of mobility compared to the situation preoperatively. 6 months after hardware removal the mean Constant-Score was 97.4 points. There was one none union. In one patient there was a loss of reduction with shortening of 1.5 cm. In 5 patients a shortening of the proximal end of the nail had to be performed, due to painful skin irritation. Intramedullary nailing of midclavicular fractures is a safe and minimally invasive operation technique. It should be offered to the patient as an alternative to conservative treatment.

Candida species have emerged as important pathogens in human infection. Although a variety of deep-seated candidal infections have been reported, Candida spondylitis has rarely been described. One patient with candida tropicalis spondylitis L I and L II in combination with candida coxitis is presented, and the 31 adult cases with vertebral involvement previously reported are reviewed. Candida spondylitis is noted as a simultaneous occurrence or late manifestation of hematogenously disseminated candidiasis. Spondylitis may not be prevented by a course of Amphotericin B adequate to control the acute episode of disseminated candidiasis, particularly in immune suppressed patients. Spondylitis does not present as a postoperative wound infection. The insidious progression of infection, the nonspecificity of laboratory data, and the failure to recognise Candida as a potential pathogen may lead to diagnostic delay. Diagnosis can be made by either open biopsy or CT controlled needle aspiration. Successful therapeutic regimes have employed combinations of antifungal therapy (Amphotericin B or fluconazole) with radical surgical debridement. Ventral and facultatively dorsal instrumentation is required to stabilize the spine. It is anticipated that the spondylitis will become a more commonly recognised manifestation of hematogenously disseminated candidiasis. A increasing significance of candida species as etiologic agents of infection immune compromised humans has been recognised in the recent years. In those patients whom an antecedent Candida septicaemia was documented, a striking delay of 3.3 months was found between the septicaemia and the onset of symptoms as well as the time of diagnosis.