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We report 43 consecutive surgically treated patients with pyogenic (37 patients) and tuberculous (6 patients) osteomyelitis of the thoracic and lumbar spine encountered within an 8-year period, including 1 with late recurrence after 15 months. There were 24 men and 18 women, ranging in age from 21 to 83 years. Twenty-six patients were in poor general condition because of associated illnesses, especially diabetes mellitus. Disease occurred at the thoracic level in 19 patients and on the lumbar spine in 24. After diagnosis, five patients were merely treated by posterior decompression; three of them, however, required further surgery for recurrent infection, spinal instability, and secondary neurological impairment. They are included in the 40 patients who underwent combined posterior débridement and internal fixation with transpedicular screw-rod systems. Autologous interbody bone grafting was performed simultaneously in 18 patients and in a second stage operation in 21 patients. One of them (tuberculous) experienced early recurrence and required anterior fusion. In two patients, methylmethacrylate packing was used for spine reconstruction; one of them had a late recurrence. Of the 26 patients with preoperative marked or severe neurological deficit (Frankel Grades A, 2 patients; B, 1 patient; C, 17 patients; and D, 6 patients), 23 (88%) had significant improvement of one grade (15 patients) or more (8 patients). There were no permanent complications. However, intensive care treatment was necessary in 20 of the 26 patients in reduced general condition (mean age, 72 yr). Two patients required further surgery because of postoperative epidural hematoma and pedicle screw malpositioning. In conclusion, most patients with thoracic and lumbar osteomyelitis can be successfully treated by combined débridement and internal fixation using only a posterior approach. Autogenous interbody bone grafting can be simultaneously performed and allows early mobilization of the patient.

We treated 49 patients at an average age of 80 years (75 to 90) with distal mostly intraarticular humeral fractures by open reduction. There were 8 class A, 13 class B and 28 class C fractures on Muller's classification. The patients were reviewed at a postoperative average of 18 months. The patients' assessment of the result was very good in 31%, good in 49%, fair in 15% and poor in 5 %. The flexion-extension range was very good in 41%, good in 44% and fair in 15%. The incidence of implant failure, pseudarthrosis of the olecranon osteotomy and ulnar nerve lesion was no higher in these elderly patients than in younger patients. Old age is not a contraindication to open reduction and internal fixation; it is important to restore full function.

A total of 111 patients referred with a diagnosis of suspected "appendicitis" were entered into a prospective study. The surgeon and radiologist in charge of ultrasonography made separate diagnoses, and their findings were then combined and discussed as indications for surgery. Clinically, a history of pain migration proved to be reliable (p < 0.0001) as a diagnostic indicator, in contrast to nausea and initial irregularity of bowels. The duration of symptoms was significantly shorter in patients with proved appendicitis than among patients with negative findings (median 24 hours compared with 41 hours, p < 0.04). Among patients with perforated appendicitis, the symptomatic history was prolonged (not significantly) by 3 hours. Peritoneal signs such as pain on percussion, rebound tenderness, guarding, and a leukocytosis of more than 13,000/mm3 were indicative of appendicitis (p = 0.0001 for each sign). Lively bowel sounds excluded the possibility of appendicitis (p = 0.001). Scanty bowel sounds, rectal tenderness, axillorectal temperature difference, and a left shift in leukocytes were of no diagnostic significance. The doctor's "clinical experience" is significant at the level of p < 0.03. On ultrasonography, the following signs were indicative of appendicitis: periappendicular infiltration (p = 0.0003), a visible "cockade," and an appendix larger than 12 mm in diameter (p = 0.04). For 75% of the patients the surgeon was sure of his own clinical diagnosis and did not allow himself to be influenced by the sonographic findings. In 12% of doubtful cases ultrasonographic results decisively favored operation, and in 4.5% (n = 5) it prevented an unnecessary laparotomy in the presence of positive clinical symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

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