Bilateral, simultaneous quadriceps tendon rupture (QTR) represents a rare entity and delay in establishing the correct diagnosis is not uncommon. Another three cases are reported here and in all the correct diagnosis was missed initially. A review of the English and German literature retrieved 105 cases of bilateral, simultaneous QTR and in 32 patients (30.5%) the correct diagnosis was established with delay. In 28 cases--representing 25 men (89.3%) and 3 women (10.7%)--sufficient data was available for further analysis. In the majority of patients (n = 19/28; 67.9%) rupture was associated with trauma, while no trauma was reported in 9/28 cases (32.1%). No direct correlation between age and the kind of rupture form (traumatic/spontaneous) could be detected (P = 0.35). Most partients (n = 18/28; 64.3%) presented risk factors associated with QTR and obesity (n = 6/28; 21.4%) was most frequently encountered. A direct association between the rate of risk factors and the rupture form was not seen (P = 0.5). Overall diagnostic delay lasted 64.7 days on an average (traumatic ruptures 67.7 days/spontaneous ruptures 58.7 days) with this period being longer than 2 weeks in 51.9% and longer than 3 months in 33.3% of patients. Delay varied distinctly in different medical institutions as this period lasted in hospital departments 93.9 days, in ambulances 24 days and in General Practitioners 7.6 days on an average. Initially 25 incorrect diagnoses were established in 21/28 (75%) patients, while 7/28 cases (25%) were discharged initially without any diagnosis. Clinical examination revealed most often palpable suprapatellar gaps (n = 17/24) and effusions (n = 13/24), while the classic trias of painful swelling, suprapatellar gap and loss of knee extension was found in only 58.3% of reported patients (n = 14/24). The correct diagnosis of bilateral QTR was established in 60.7% (n = 17/28) by history and clinical examination alone. In 10.7% (n = 3/28) clinical suspect was supported by sonography and in 14.3% (n = 4/28) by MRT; in 14.3% (n = 4/28) the correct diagnosis represented a by chance finding during diagnostic or operative procedures of other indication. In 52 tendons detailed information about repair was provided and most often transosseous fixation (n = 30/52; 57.7%) and direct repair (n = 14/52; 26.9%) were used, while a tenoplasty was performed in only 15.4% (n = 8/52). Only 34.6% of patients (n = 9/26) with follow-up data (n = 26/28) reported a full recovery with a trend that early surgical repair (limit 2 weeks) improves the final outcome.

Early esophago-gastroscopy is the most effective investigation for the classification of caustic burns. Evaluation includes graduation of the pathological lesion. Assessment of extension of spread and of control of motility of esophagus and stomach. The aim of all therapeutic procedures is to preserve the patients' own esophagus. All endoscopies were done under general anesthesia. From September 1988 to April 1992, 102 endoscopies were carried out on 39 patients. Gastric lesions with clinical relevance were found in 10 patients (26%). First degree of corrosion was found in 21 patients (54%): they were discharged without any therapy within 48 hours. Maximal second degree was seen in 14 patients (36%), who were successfully treated with diet, antacids and H2-blockers: they were discharged after control-endoscopy after one week. Four patients (10%) suffered from third-grade lesions: a gastrostomy was performed as well as treatment with cortisone, antibiotics and H2-blockers. Bouginage was started between the 5th and 7th day after ingestion and was necessary for 8, 11 and 16 weeks in three patients and more than 2 years in one patient. Even in this last case we could preserve the esophagus, although a gastric or colon interposition was discussed.

PURPOSE OF THE STUDYRetrograde nailing represents an established fixation method for fractures of the distal femur and offers in femoral shaft fractures an alternative to the existing technique of antegrade nailing. The aim of this study was to investigate in a retrospective analysis the results of retrograde nailing in distal femoral fractures and selected cases of femoral shaft fractures. Emphasis was posed on long-term functional outcome, especially in daily activities. MATERIALRetrograde femoral nailing was used from 1999 untill 2006 in two Level 1 trauma centers for the treatment of distal femoral (AO/ASIF-type 33) and femoral shaft fractures (AO/ASIF -type 32) in 40 patients with 41 fractures. The mean age of patients was 63,7 years (min: 21 / max.: 103) and 70, 7% presented with ipsilateral local pathologies or associated entities. A pre-existing reduced activity level was found in 12 /40 patients (30%) and was equally caused by neurologic conditions and geriatric entities. METHODSIndication for retrograde nailing was left in AO/ASIF fracture-type 33 to the individual estimation of the surgeon, while it was restricted in AO /ASIF fracture-type 32 to problematic cases. For fracture fixation the Distal Femoral Nail (28/41 68,3%) of Synthes Int. ® and a spupracondylar /; retrograde modified sc -UFN (13 /41 31,7%) produced by Synthes ® Austria were used. Patients were followed till fracture healing and invited to a functional follow-up using the Lysholm / Gilquist score and the Tegner /Lysholm score. RESULTSOsseous healing occured in shaft fractures in 18,1 weeks on an average compared to 16,5 weeks in supracondylar fractures. Postoperative complications requiring re-intervention were seen in 6/41 (14,6%) fractures. 28/40 patients (70%) were evaluated with a mean follow-up period of 20,4 months using the functional score of Lysholm /Gilquist and the activity score of Tegner/ Lysholm. Both scores were balanced among shaft fractures and distal femoral fractures (Lysholm -mean: 87,7 pts shaft. vs. 80,1 pts. distal Tegner-mean: 5,2 pts. shaft vs. 3,9 pts. distal), while motion showed better results in shaft fractures (arc of motion -mean: 120°) than in distal femoral fractures (arc of motion -mean: 105). DISCUSSIONDespite a high age of patients (average 63,7 years) and a reduced activity level with many local co-morbitities, retrograde nailing resulted in the majority (95,1%) in reliable osseous healing. Thus, achievement of a painless fracture-site and a stable knee-joint provides early mobilization even in problematic cases. Impairment of functional outcome, mirrored in an over-all Lysholm /Gilquist score of 83,3 pts. and an over-all Tegner /Lysholm score of 4,4 pts. , was mainly related to preexisting restrictions of the loco-motor system. CONCLUSIONRetrograde nailing represents a reliable fixation method for extra-articular (33 -A1-3) and simple intra-articular (33 -C1-2) fractures of the supracondylar area. In femoral shaft fractures retrograde inserted nails offer a valuable alternative, especially when the ...

Open fractures still represent a major challenge for the treating surgeon and frequently demand a complex of soft tissue and bone procedures to achieve an undisturbed healing with adequate limb function. However, despite improvement in operative techniques and antibiotic therapy septic complications still occur in severe open fracture forms up to 50%. They are still deleterious for the patient as well as a major economic factor for the treating hospital. Radical (repetitive) debridement of the wound and coverage of soft tissue defects are of utmost importance in the prophylaxis of septic complications along with antibiotic therapy. If the local wound requires flap coverage, early performed procedures yield a clear decrease of infection rates even in most severe fracture forms. Osseous stabilization contributes to infection prophylaxis, especially when the implants can be inserted in a minimal invasive way and provide an adequate handling of soft tissues and the wound. Thus, most often intramedullary nails and external fixators are used today for osteosynthesis. Recently developed plates with angular stability offer a promising alternative even in open fractures, especially when there is an extension of the fracture into the meaphyseal area though indications have to be evaluated. Manifest septic complications demand an early and aggressive approach with radical eradication of the septic topic. While acute infections require most often only minor surgical procedures and offer the chance to leave implants in situ, chronic infections usually demand complex reconstructive measures of bones and soft tissues.

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