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Surgical reconstruction of the interosseous membrane may restore longitudinal forearm stability in Essex-Lopresti lesions. This study aimed to compare the longitudinal stability of the intact forearm with a single-bundle and a double-bundle reconstruction of the central band of the interosseous membrane using digital image correlation with a three-dimensional camera system. Single and cyclic axial loading of eight fresh-frozen forearm specimens was carried out in the intact state, after creation of an Essex-Lopresti lesion, after a single-bundle and after a double-bundle reconstruction of the central band using a TightRope® (Arthrex GmbH, Munich, Germany) construct. Instability significantly increased after creation of an Essex-Lopresti lesion. The stability of intact specimens was similar to both reconstruction techniques. The results of this study suggest that TightRope® reconstruction of the central band restores longitudinal forearm stability. However, the single-bundle technique may be less reliable than double-bundle reconstruction. Level of evidence: Basic Science Study

Fractures of the distal end of the radius are common injuries and are the commonest bony injury around the wrist. Management of these fractures has remained controversial as far as modality of treatment is concerned. There are aggressive concepts with open reduction and internal fixation with plates and minimally invasive pinning after closed reduction. The latter treatment concept is evaluated using own data and results from the literature. Percutaneous pinning is used as treatment alternativ in ASIF A2 and A3 fractures. In C3 type fracture they can play an important part as supplementary adjunct in combination with external fixation or plates. Furthermore percutaneous pinning techniques can be used in distal radius fractures in children with dislocation. Elderly patients with type C fractures do gain superior results in functional outcome using this technique than with reduction and casting alone. Percutaneous pinning is very cost-effective in comparison to plating. When using correct indications this technique can provide excellent functional results.

Peridurale Anasthesieverfahren werden zur Vermeidung operativer, postoperativer oder chronischer Schmerzen insbesondere in der Extremitatenchirurgie, Gynakologie und Urologie eingesetzt. Komplikationen sind selten, konnen allerdings schwere lokale und systemische Folgen haben. Es werden 3 Falle vorgestellt, bei denen es nach der Verwendung von Periduralkathetern zu einer Spondylitis oder einer Spondylodiszitis kam. In 2 Fallen fuhrte eine verspatete Diagnosestellung zu einer verzogerten Therapie. Eine gezielte antibiotische und in 2 Fallen chirurgische Therapie fuhrte bei allen Patienten zur vollstandigen Ausheilung. Chirurgisch wird nach radikalem Debridement eine ventrale und fakultativ dorsale Stabilisierung der Wirbelsaule durchgefuhrt. Das Auftreten einer Spondylodiszitis nach der Verwendung von Periduralkathetern ist in den meisten Fallen eine Spatkomplikation. Die lange Latenz zwischen Katheteranlage und Ausbildung entsprechender Keimabsiedlungen in der Wirbelsaule kann zu einer erheblichen Diagnose- und Therapieverzogerung fuhren. Insbesondere bei unspezifischen, teilweise verspatet auftretenden Wirbelsaulenbeschwerden und reizlosem Hautbefund uber der Punktionsstelle sollte diese Spatkomplikation in Erwagung gezogen werden.

Bei zunehmendem Nackenschmerz nach frontalem Auffahrunfall zeigten die konventionellen Rontgenaufnahmen bei einer 29-jahrigen Verletzten in Position auf die Spitze des Dens axis ein traumatisch gelostes Os odontoideum. Ein neurologischer Defekt bestand nicht. In den Funktionsaufnahmen wurde eine atlantoaxiale Subluxation mit Ausweichen des Os odontoideum dargestellt. Die Computertomographie (CT) bestatigte eine Sklerosierung der korrespondierenden Knochenflachen, die Kernspintomographie (MRT) wies eine posttraumatische Signalanhebung vor der Basis des Dens axis und dem Os odontoideum nach.

The goal of this prospective study was the compilation of data concerning the complications as well as the medium-term functional outcomes obtained when using the technique of elastic stable intramedullary nailing (ESIN) for cases of diaphyseal forearm fractures in children. 51 children, average age of 8 years, were treated with elastic titanium nails for displaced forearm fractures between January 1997 and December 2001. The average period of follow-up was 38 months. The average duration of fluoroscopy was 2.2 minutes. Four cases required open manipulation for reduction. The average duration of in-hospital stay for cases without polytraumic injuries was 2 days. 8 cases resulted in painful soft-tissue irritation at the insertion point of the nail. All of the fractures healed in a timely manner. There were no cases of infection of poor wound healing. Removal of implants was performed at an average of 5.4 months post-insertion. No clinical limitations regarding angulation or rotational malposition greater than 10° were observed. Limitations of pronation and/or supination between 10 and 30° were measured in three cases, and an elbow extension deficit of 10° was measured in one case. The results here show that intramedullary stabilization with elastic titanium nails is a biologic, secure and suitable mode of therapy for the treatment of diaphyseal forearm fractures of children.

Can distal radius fractures be held in place with palmar locking compression plates (LCPs) and heal completely without an additional bone transplant? From 1 March 2001 to 1 September 2002, 40 patients with distal radius fractures (CCF: 2× A2, 13× A3, 2× C1, 22× C2 and 1× C3 fractures) were treated with locking compression small fragment titanium plates. In 37 cases, the plates were inserted in a palmar direction without an additional corticocancellous bone graft. All patients received a follow-up check-up after an average of 12.1 months. On this occasion, the range of motion, grip strength and radiological result were measured and rated according to the Gartland and DASH score. All fractures healed completely. In one case, a re-osteosynthesis was carried out after the plate had bent because full load was placed on it prematurely. An average of 5.1 points was achieved in the Gartland and 12.6 points in the DASH score. An extremely good result was achieved in 19 cases, a good result in 15 and a satisfactory result in 6. At the follow-up examination, the average range of motion was 52°-0°-50° for stretching and bending in the wrist, 20°-0°-27° for radial and ulnar deviation and 82°-0°-78° for pronation and supination. On the radiographs, the average radiocarpal angle in the anteroposterior projection was 22° with a palmar tilt of an average of 5°. Radius fractures with metaphyseal, one-sided comminuted zones can be treated with locking compression plates with good results using a palmar approach without a cancellous bone graft.

In sportsmen, one of the most frequently observed injuries is a midclavicular fracture. As the absence from their discipline until the time of fracture healing comprises the risk of significant financial loss, the fracture of the clavicle is of prominent importance to top-performance and professional sportsmen. This study presents the results of a minimally invasive operative treatment of midclavicular fractures in patients working as top-performance or professional sportsmen. Within five years the intramedullary osteosynthesis was applied to 80 patients with 84 fractures of the clavicle. Out of these patients, 12 were top-performance or professional sportsmen. These 12 patients - 2 women and 10 men - were aged 24.8 ± 10 years. Preoperatively, the sportsmen presented an abduction of the shoulder joint averaging out at 36.3 ± 8°, postoperatively, averaging out at 154.2 ± 17°. On a visual-analog scale (0 to 100 points), the subjective pain, preoperatively, revealed 71.7 ± 18 points. This was found to be significantly higher than the subjective pain on the third day after surgery: 19.2 ± 6 points. After the operation the sportsmen d their training, on average, after 5.9 ± 1 days. Attendance at contests was, on average, continued after 16.8 ± 5 days. All of the sportsmen's fractures healed. Twelve months after implant removal, the sportsmen's average Constant-Score revealed 98.3 ± 2 points. The elastic stable intramedullary osteosynthesis of midclavicular fractures offers sportsmen the chance of quickly resuming training and competition. This treatment should be offered to the patients as an alternative to conservative treatment. Training stops and financial losses of the person concerned and of the sponsors can be minimised.

The aim of this study was the evaluation of patient-oriented outcome scores for shoulder function and residual complaints after diaphyseal clavicular fractures with respect to shortening deformities.The analysis was based on data of 172 adult patients (mean age 39 ± 14 years) with healed clavicular fractures treated operatively (n = 104) or conservatively (n = 67). The control population consisted of 35 healthy adults without shoulder problems and 25 patients with nonunion after conservative treatment. The subjective estimation of the level of pain was collated on a visual analog scale (VAS 1-100 points), together with the relative Constant and Murley score, the Cologne clavicle score, the disabilities of the arm, shoulder and hand (DASH) score and a bilateral comparison of the length difference of the clavicles.Patients with a clavicular length difference of 2 cm had significantly (p 0.001) more pain, a greater loss of mobility and significantly lower values in the scoring system of Constant and Murley, the DASH and Cologne clavicle scores compared to patients with clavicular length differences 0.5 cm and healthy controls (p 0.001).The results of this study showed that shortening deformities after clavicular fractures in adults have a large impact on the functional result and patient-oriented outcome scores. The aim of the therapy of diaphyseal clavicular fractures should therefore concentrate on reconstruction of the anatomical length of the clavicle.

Recent publications have renewed the debate regarding the number of foot compartments. There is also no consensus regarding allocation of individual muscles and communication between compartments. The current study examines the anatomic topography of the foot compartments anew using 32 injections of epoxy-resin and subsequent sheet plastination in 12 cadaveric foot specimens. Six compartments were identified: dorsal, medial, lateral, superficial central, deep forefoot, and deep hindfoot compartments. Communication was evident between the deep hindfoot compartment and the superficial central and deep central forefoot compartments. In the hindfoot, the neurovascular bundles were located in separate tissue sheaths between the central hindfoot compartment and the medial compartment. In the forefoot, the medial and lateral bundles entered the deep central forefoot compartment. The deep central hindfoot compartment housed the quadratus plantae muscle, and after calcaneus fracture could develop an isolated compartment syndrome.

To compile an evaluation system (score) for post-treatment outcomes of midclavicular fractures, 172 patients were studied on average 15 months post-injury. As a control group 45 healthy volunteers were examined. The most relevant elements were filtered out for use in a new classification system, the Clavicle Score (CS).The CS is based on a system of three partnered objective/subjective items as well as radiographic assessment of fracture healing. For the partnered items, subjective responses with the most significant correlation to the specific objective parameters were selected. Total score cutoff values (very good, good, moderate, poor) were established to keep interpretation simple. To validate the system, linear regression analysis was performed comparing the CS to two established assessment systems (Constant Score and the DASH Score). ERGEBNISSE: The correlation coefficients R=0.756 (Constant) and R=0.687 indicated that the conclusions were comparable and therefore valid. The reliability coefficient Cronbach's alpha was calculated at 0.8241, indicating high reliability.The CS is a simple, valid and reliable instrument to assess outcomes post-midclavicular fracture.

Background: Radiographic examinations of the skeleton are the most commonly performed radiologic procedures, even outnumbering examinations of the chest. The imaging systems used in skeletal radiography must meet high standards in terms of contrast and spatial resolution to effectively visualize the high contrast between bone and soft tissue as well as fine bone structures. Purpose: To determine the performance of amorphous silicon flat-panel detector radiography compared to mammography film in detecting rheumatologic bone defects at different exposure doses. Material and Methods: The study enrolled 44 patients with known or presumed skeletal changes of the hand associated with inflammatory rheumatic diseases. Following a clinically indicated radiographic examination of the peripheral extremities using mammography film, a survey radiograph of one hand was taken in the posteroanterior (PA) view by digital radiography, at the same exposure dose and at a dose reduced to one quarter of the mammography film doses. Four independent radiologists scored the resultant images using the Sharp/van der Heijde and Ratingen scoring methods. The study received University of Cologne Ethics Committee and German Federal Radiation Protection Agency approval. Results: Compared to mammography film, digital flat-panel detector radiography produced a significantly better image quality at identical uptake doses. A greater number of erosions were detected with the digital flat-panel detector than with mammography film at the same and at reduced doses. Conclusion: Although the spatial resolution of the digital flat-panel system used in this study was poorer than mammography film, this was compensated for by its wider dynamic range and improved contrast resolution, even at the reduced dose.

To localize optimal donor regions for osteochondral graft transplantation, the chondral thickness and the radii of curvature of femoral condyles and the talar trochlea were determined. Optosil impressions of the articular surfaces of ten formalin fixed distal femora and talar domes were prepared. Therefrom, 5-mm thick frontal sections were made in order to measure the radii of curvature. Femoral condyles and talar trochleas were sliced sagittally into 2-mm thick sections. Chondral thickness was measured on x-rays. Talar cartilage thickness measured 0.7 to 2.0 mm. Cartilage thickness of the femoral condyles was 0.7 mm to 3.1 mm. The smallest radial values of the talar surface were proximal and distal. Flattening of the medial and lateral talar margins and of the central articular surface was evident. For the femur, the curvature was greater in the edge areas than in the central region. For talar defects, the grafts should be taken from the condylar edges, where the chondral thickness is decreased.

Insertion of titanium nails for type A and B clavicular fractures can fail intraoperatively due to the small diameter or irregular nature of the medullary canal. At present, such failures lead to open reduction and fixation (ORIF) with plates. In type C fractures (comminuted fractures), a telescoping effect is observed so that ORIF is the only suitable alternative besides nonoperative therapy. A suitable minimally invasive solution for type C fractures and as a salvage procedure for failed intramedullary nailing of type A and B fractures is presented here for the first time with a percutaneous application of an LC plate to the clavicle.

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.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.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.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.

The goal of the current investigation was to make a comparative analysis of regenerative tissue after autologous de novo cartilage transplantation on the femoral condyles of sheep after a chondral defect. One chondral defect measuring 4 mm in diameter was placed in the center of one medial femoral condyle of each of 48 Suffolk sheep. Twelve defects were left to heal spontaneously, 16 defects were covered with periosteal flaps, and 20 defects were filled with autologous de novo cartilage graft. Macroscopic and microscopic assessments were performed at 26 and at 52 weeks. Regeneration was significantly better (p0.05) in the transplant group than in the control groups at both 26 weeks and 52 weeks. The differences were most evident in the grade of defect filling, cartilage stability, cell distribution, and matrix assessments. Transplantation of immature, autologous de novo cartilage leads to qualitatively better regeneration both macro- and microscopically than does periosteal flap placement alone. The transplanted, immature cartilage tissue undergoes maturation in vivo. The regenerated tissue has hyaline-like features.

This prospective clinical trial was performed to assess healing, clinical outcome and complications after intramedullary nailing of midshaft clavicular nonunions. Over 2.5 years, 14 patients were included. Exclusion criteria were pathological fractures, bony defects, previous operative therapy, atrophic and infection pseudarthrosis and the patient's age:18 years or70 years. Results were evaluated after 3, 6, 12 and 18 months. Beginning 3 months after the operation, pain (VAS), subjective satisfaction, Constant score and DASH score were significantly better than preoperatively during the follow-up period (p0.001). There were no infections, no implant displacements or refractures.Intramedullary fixation of midshaft clavicular nonunions with an elastic titanium nail is a safe, minimally invasive surgical technique, producing excellent functional and cosmetic results without additional bone grafting.

Peridural anaesthesia is used to avoid operative, postoperative and chronic pain, especially in surgery, gynecology and urology. Complications have rarely been described but can entail serious local and systemic sequelae. Three cases with spondylitis and spondylodiscitis after peridural anaesthesia are presented. The failure to recognize the peridural catheter as the cause of vertebral pain led to therapeutic delay in two cases. The result of antimicrobial therapy and in two cases radical surgical treatment was complete recovery. The occurrence of spondylodiscitis after the use of peridural catheters is often a late manifestation of disseminated pathogens. The insidious progression of infection and non-specificity of clinical symptoms may lead to diagnostic delay. Awareness of the possibility of even delayed complications after the use of peridural anaesthesia is important.

Increasing neck pain in a 29 year old woman after a frontal car collision gave reason for a conventional x-ray that presented a traumatically displaced os odontoideum positioned at the top of the dens axis. No neurological defect was seen. Dynamic flexion/extension film showed a movement to an atlantoaxial dislocation with a shift of the os odontoideum. The sclerotic structure of the corresponding bony surfaces was confirmed by computed tomography, whereas magnetic resonance imaging demonstrated a posttraumatic signal change in front of the base of dens axis and os odontoideum. Fusion was achieved by computed navigation with C1/C2 transfacetal screws as described by Magerl and interspinal fusion with a bicortical autologous iliac crest graft and a posterior tension band as described by Brooks. An exact positioning of screws past the asymmetric course of both arteria vertebrales was possible by navigation. The patient was free of pain 5 months after the fusion.

The aim of this prospective study was to evaluate the intra- and postoperative problems as well as the complications of elastic stable intramedullary nailing (ESIN) of femur fractures in children.47 consecutive children, mean age 6 years, were reviewed clinically and radiologically until hardware removal and after this annually. Mean time of follow up was 37 months.Intraoperatively one cortex perforation and one displacement of a third fragment occurred. Two correction operations were necessary: In one case due to an implant displacement and in another case due to an unacceptable loss of reduction. There were no infections, non union, implant breakage, refracture or disturbance of growth.ESIN is a safe procedure in femoral shaft fractures of children. Most of the problems and complications can be avoided by a careful consideration of the indication and a correct operation technique.

The aim of this prospective clinical controlled trial was to investigate the early and midterm results of shaft fractures in children treated with elastic stable intramedullary nailing (ESIN). From January 1997 to December 2001, elastic stable intramedullary nailing was carried out on 112 children with 118 diaphyseal fractures. The mean age was 7.7 years. There were 51 fractures of the lower arm, 46 femoral fractures, 14 of the lower leg, and 7 of the humerus. A total of 92 children have been followed up for more than 12 months. The mean time of follow-up was 38 months.The mean time of fluoroscopy was 2.2 min. Open reduction was necessary in 3.4 %. In children with injuries of the lower extremity, full weight bearing was achieved after a mean period of 9.3 days. In 1.8% of the children, reoperation was necessary within the first 10 days after the operation. In 3.6 % there was painful skin irritation due to the protruding end of a nail. No infection or delayed union was observed. Implant removal was done after a mean time of 5.6 months. There was no rotational or angular deformity of more than 5 degrees in children with isolated fractures of the lower extremity. Mean lengthening of the injured leg was 2.4 mm. In three children who had fractures of the upper extremity, a deficit in range of motion of the adjacent joints was detected. The current results show that intramedullary fixation of displaced diaphyseal fractures in children with a flexible titanium nail is a safe, minimally invasive surgical technique producing excellent functional and cosmetic results.

Reduction of the depressed joint surface in tibial plateau fractures often leaves large cancellous bone defects. These metaphyseal voids are typically filled with autogenous bone grafts that can cause a significant donor site morbidity. The use of injectable bone cement offers the opportunity to support the reduced joint surface without bone grafting. The aim of this study was to evaluate the clinical and radiological outcome as well as the period of partial weight bearing after the use of Norian SRS in tibial plateau fractures. Twenty-one patients with a mean age of 48 years were included in this prospective trial. According to the AO/OTA Classification, there were seven fractures of type B2, ten B3, one C1, one C2, and two fractures of type C3. The period of partial weight bearing was 3.7 weeks. In 18 patients the follow-up was more than 24 months. After a mean follow-up of 30 months, the Lysholm score was 87.9 at mean. The radiological part of the Rasmussen score was excellent and good in eight cases each and fair in four cases. Soft tissue reactions due to the cement were not observed. On all radiographs taken 36 months after the operation the cement bloc was still visible. The results show that Norian SRS can be used to fill metaphyseal bone defects in tibial plateau fractures. Clinical and radiological results are comparable to those of fractures treated with autologous bone graft. The high compression strength allows early full weight bearing without the risk of secondary loss of reduction.

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.

Ziel.Fixierung kleinerer und groserer osteochondraler Frakturen mit biodegradablen PolyL/DL-Lactidstiften (Polypin®) und Prufung der Knochen-und Weichteilreaktionen im Langzeitverlauf.

The aim of this study was to compare the results achieved in two groups of 20 patients treated for midclavicular fracture. The first group (mean age 36 years) was treated non-operatively with a rucksack bandage, whereas the second group (mean age 37 years) underwent intramedullary fixation with a titanium pin using a minimally invasive, unreamed technique. At follow-up, which averaged 3.1+/-0.9 years in group 1 and 2.9+/-0.7 years in group 2, the result of treatment, as indicated by the Constant score, functional outcome and cosmetic outcome, was significantly better in the group undergoing operative treatment. Clavicle shortening was significantly ( P=0.027) higher in patients treated with a rucksack bandage. The absolute Constant score averaged 78+/-23 in group 1 and 97+/-4 in group 2 ( P=0.001). The Constant rating scale showed a significant difference between patients with clavicle shortening of less than 1 cm and 1 cm shortening or more. There were two non-unions in group 1 but none in group 2. Refractures were not observed in either group. According to these results, intramedullary fixation with a titanium pin seems to be more advantageous in midclavicular fractures than non-operative treatment. As the operation is well received by the patients, it should be offered to them as an alternative treatment to the rucksack bandage.

This prospective controlled clinical trial was performed to assess fracture healing and clinical outcome after intramedullary nailing of midclavicular fractures. Within 3.5 years elastic-stable intramedullary nailing was performed in 62 patients with 65 midclavicular fractures. Surgery was performed in supine position. The ventral cortex of the proximal clavicle was opened using a 2.5 mm drill. The nail was advanced laterally under fluoroscopic control. If closed reduction failed, an additional incision was made to enable direct manipulation of the fragments. There were no infections, no implant displacements or refractures. Postoperatively, the mean subjective pain was significantly lower, and the range of motion improved. We observed one nonunion. The mean Constant-score 6 months after hardware removal was 96.9 +/- 3.3 points. Intramedullary fixation of midclavicular fractures with an elastic titanium nail is a safe minimally invasive surgical technique, producing excellent functional and cosmetic results.

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.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.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.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.

Introduction: We investigated whether the additional presence of severe head trauma (SHT) in multiple injury patients leads to an increase in systemic mediator levels. Methods: Blood samples were collected from 125 trauma patients every 6 h during the first 3 days post-injury and with longer time intervals thereafter. For controls, 37 healthy blood donors were studied. The systemic levels of interleukin (IL)-6, IL-10, soluble TNF receptors (sTNFR) P55, sTNFR P75, and PMN-elastase were determined. Mediator levels were compared between patients with and without SHT while adjusting for age, sex, and injury severity score (ISS) in multivariate linear regression models. Results: The patients’ mean (°SD) age and ISS were 38°17 years and 27°13 points, respectively. At all four time points (3,12,24, and 108 h post-injury) sTNFR P55 levels were significantly increased by the additional presence of head injuries: +55%, +37%, +32%, and +24%, respectively. The levels of sTNFR P75, IL-6, IL-10, and PMN-elastase were similarly, but non-significantly increased. Conclusions: SHT leads to a systemic mediator release that is independent of injury severity itself as described by the ISS.

Two cases of severe spinal cord injuries to professional horse-racing jockeys are presented. There is only one comprehensive study conducted to ascertain the nature and incidence of injuries in the literature. The pathomechanism and surgical therapy of vertebral trauma in jockeys was analysed.

This study was conducted to analyze extraosseous and intraosseous vascularization of the os calcaneum and to elucidate possible clinical manifestations. The arteries of 13 lower leg and foot specimens of human cadavers were injected with a polymer and subjected to maceration or were embedded in plastic. The examination revealed that 45% of the bone is vascularized via medial arteries and 45% via lateral arteries, whereas the remaining 10% is supplied by the sinus tarsi artery. From the medial side, two or three vessels branch off the posterior tibial artery, penetrate the calcaneus below the sustentaculum, and supply the medial part of the posterior joint. The lateral calcaneal artery normally is a branch from the posterior tibial artery. In two of 13 specimens, this lateral supply comes from the peroneal artery. The medial and lateral intraosseous arterial supply for the calcaneus is equal. Inside the bone there is a water-shed zone where the medial and lateral arterial supply meet in the midline. Only 10% of the blood flow is supplied by vessels in the sinus tarsi. Clinically, interruption of the lateral calcaneal artery during the conventional lateral surgical approach for a calcaneus fracture may result in ischemic bone necrosis. The lateral calcaneal artery could supply a local microvascular flap to cover soft tissue defects of the heel. A compartment syndrome after a calcaneus fracture may be caused by bleeding from the medial calcaneal arteries into the quadratus plantae compartment.

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.

The cytotoxic activity of the galactoside-specific lectin from mistletoe (mistletoe lectin-1, ML-1) towards the anaplastic glioma cell line (F98) was investigated in vitro (three dimensional spheroid model) and in vivo (Fischer 344 rats). Both model systems demonstrated the dose dependent cytotoxicity of ML-1. F98 glioma cell spheroid growth was significantly inhibited after incubation with defined ML-1 concentrations of 10 and 100 ng/mL. To investigate the in vivo efficacy Fischer 344 rats were intracerebrally implanted with F98 glioma cells and assigned to local and systemic ML-1 treatment, respectively. Histological and immunohistochemical evaluations proved a reduction of tumor volume for both treatment modalities, most pronounced and statistically significant after systemic (immunomodulating) administration of the optimal ML-1 dosage (1 ng/kg BW, subcutaneously) and after low dose (10 ng ML-1 per application (10 microL) local treatment. High dose ML-1 administration (10 ng/kg BW; systemically; 100 ng/application, locally) was less effective than low (optimal) dose treatment and apparently the systemic/immunomodulating approach gained greater benefit for glioma bearing rats.

Surgeons agree that interrupted peripheral nerves should be reconstructed ‘soon’ to enable neural regeneration. Delayed nerve repair will result in impaired outcome, but experimental data on such detriment due to delay are scarce. In a quantitative study we transected the right sciatic nerve of 80 adult female Lewis rats (LEW/SsNHsd), transflected the proximal nerve stump into a muscle pouch and let the animals wait 0 (immediate repair), 3, 6, 9 and 12 months after axotomy, until reconstruction was performed with a 5-mm long allograft from congenic age-matched donors. All hosts were studied with two different methods. First, the functional outcome of sciatic nerve reconstruction was evaluated 4–12 weeks after transplant by walking track analysis, calculating de Medinaceli's Sciatic Functional Index (SFI). Second, 12 weeks after transplantation the fibular communal nerve and the soleus branch of the tibial nerve close to its muscle entry were cut and the proximal stumps labelled with the retrograde neuronal tracers DiI or Fast-Blue. Fourteen days later the rats were perfused with formaldehyde, and the numbers of fluorescently labelled motoneurons were counted in 50 μm serial vibratome sections of the spinal cord. All measurements were done on coded material and codes broken only at the end of the study. Our results are clear-cut and deeply disappointing. The SFI was around 0 (normal value) in all rats before transection of the sciatic nerve; expectedly dropped to −85 to −125 after denervation, but stayed at −108 to −130 up to 12 weeks after transplantation. No improvement of gait at all occurred after sciatic nerve transplant performed immediately or 3, 6, 9 or 12 months after denervation. This failure of functional recovery is not due to lack of regeneration, as the numbers of labelled motoneurons prove. In normal rats we have labelled 549 ± 83 motoneurons by DiI and Fast-Blue. After immediate nerve repair we counted 533 ± 95 labelled motoneurons; after repair delayed for 12 months we still counted 474 ± 108 motoneurons that had regenerated. In all rats the labelled motoneurons were randomly interspersed with a complete lack of myotopic distribution. This misdirection of reinnervation sadly prevents recovery of motor function.