Between October 2001 and February 2002, 324 healthcare workers were screened for methicillin-resistant Staphylococcus aureus (MRSA) by nose and throat swabs. A positive finding led to activation of a standardised control programme for the affected person who was immediately excluded from work. Family members of those who were MRSA-positive were offered screening free of charge. An eradication programme was carried out in the permanent carriers. MRSA was found in 17 (5.3%) healthcare workers, 11 of whom proved to be permanent carriers, and six temporarily colonised. Three children of a positive healthcare worker showed nasopharyngeal MRSA, the acquisition of which occurred within the hospital. The standardised eradication programme for carriers was successful in most cases but failed in two individuals, whereupon systemic antibiotics were used successfully. The decolonised carriers, observed for more than one year, remained MRSA negative.

Isolation precautions in hospitals do not always prevent hospital staff and their families from acquiring MRSA. The identification of affected employees is difficult because in most cases only asymptomatic colonisation occurs. Screening and eradication can be complicated and costly, and for the affected employees the occupational consequences can be far-reaching as they have no guaranteed legal protection.

The Essex-Lopresti injury is rare. It consists of fracture of the head of the radius, rupture of the interosseous membrane and disruption of the distal radioulnar joint. The injury is often missed because attention is directed towards the fracture of the head of the radius. We present a series of 12 patients with a mean age of 44.9 years (26 to 54), 11 of whom were treated surgically at a mean of 4.6 months (1 to 16) after injury and the other after 18 years. They were followed up for a mean of 29.2 months (2 to 69). Ten patients had additional injuries to the forearm or wrist, which made diagnosis more difficult. Replacement of the head of the radius was carried out in ten patients and the Sauve-Kapandji procedure in three. Patients were assessed using standard outcome scores. The mean post-operative Disabilities of the Arm, Shoulder and Hand score was 55 (37 to 83), the mean Morrey Elbow Performance score was 72.2 (39 to 92) and the mean Mayo wrist score was 61.3 (35 to 80). The mean grip strength was 68.5% (39.6% to 91.3%) of the unaffected wrist.

Most of the patients (10 of 12) were satisfied with their operation and in 11 the pain was relieved. When treating the chronic Essex-Lopresti injury, we recommend accurate realignment of the radius and ulna and replacement of the head of the radius. If this fails a Sauve-Kapandji procedure to arthrodese the distal radioulnar joint should be undertaken to stabilise the forearm while maintaining mobility.

Objective: Spine trauma occurs frequently in multiple injured patients. Pre-hospital diagnosis is difficult. Clinical management depends on associated injuries and neurologic status.

To evaluate epidemiology and influence of recent therapeutic regimens on outcome we analyzed the data of the German Trauma Registry (German Trauma Society, DGU).

Methods: Out of 8057 patients in the German Trauma Registry 772 patients (28 % women, 72 % men; mean age 37 +/− 17 yrs.; mean ISS: 29 +/− 15 (range 9–75) points) with severe spine trauma (AIS> 2) were investigated in a retrospective analysis.

Results: MVAs were the most frequent cause for severe spine trauma (49%). The age group 25–34 years was most affected (26%). About half of all severe spine injuries were not expected in the prehospital setting. Neurologic deficit was observed in 47%. 41% of the patients with severe C-spine lesion had an initial GCS < 9 points. 89% of the patients had no preexisting comorbidity. Mortality rate (90 days) amounted to 22%. Sepsis occurred in 9%. Respiratory failure was the most common organ dysfunction (18%). Median ICU stay was 8 days. Thoracic spine lesions were almost always associated with thoracic trauma (96%; other locations 37%). Lumbar spine injuries were highly related to abdominal injuries (93%).

Conclusion: Almost 10% of all documented cases in the German Trauma Registry showed severe vertebral injuries. The extend of injury was often underestimated in the preclinical setting. Due to the high incidence of thoracic injuries in thoracic spine trauma a well balanced surgical and critical care regimen is warranted especially in this group.

Introduction: Throughout known medical literature the proximal humeral fracture is mentioned with an approximately 5% contribution to all fractures. The optimal operative strategy regarding proximal humeral fractures is still being discussed controversely. This study was conducted to show implant associated problems and their clinical relevance.

Materials and methods: Of a total 198 patients with proximal humeral fractures 166 patients, 98 females and 68 males at a mean age of 74,7 years were treated operatively from 2000 to 2004 in our clinic with an angle-stabile plate osteosynthesis and underwent a clinical and radiological follow-up. Retrospectively we characterised the fractures by using the most common classification of NEER and assessed the functional results with the CONSTANT score.

Results: The 166 evaluated patients with 8 cases of a type I fracture, 13 patients with type II fracture, 34 patients with type III fracture, 47 cases with type IV fracture, 42 patients with type V fracture and 22 cases with type VI were all operatively treated with an angle-stabile plate osteosynthesis. 142 patients underwent early assisted physical therapy. Of all assessed patients the average CONSTANT score was 79,7 points. Among the 8 patients with type I fracture the average CONSTANT score was 84,4 points, among the 13 patients with type II fracture it reached an average 87,4 points. The average score of the 34 patients with type III fracture was 78,8 points. The more complex fractures, according to NEER’s classification, reached average scores of 71,2 points among the 47 cases with type IV fractures, 69,8 points (42 patients, type V) and 61,6 points (22 patients, type VI). The presence of avascular necrosis of the humeral head in 18 cases resulted in a significantly worse functional outcome and therefore a lower average score of 48,1 points. For 36 patients the follow-up revealed intraarticular dislocation of the proximal locking screws which required operative revision in 15 cases.

Conclusion: Even in the complex proximal humeral fracture one can achieve good clinical results for the patients by using an angle-stabile plate osteosynthesis and therefore establishing a secure and rigid situation for an optimized consecutive physical therapy, especially in the elderly. To prevent from intraarticular screw placement the proximal locking screws should be chosen shorter, if possible, then initially measured.

Introduction: Infection following arthroplasty is a rare but significant and threatening complication. The incidence is about 2%. Treatment of an infected joint replacement may be demanding, time consuming and expensive. The aim was to evaluate the average cost of an infected arthroplastic in our own department under the given reimbursement system in Germany.

Material and Methods: During 3 month 20 consecutive cases of infected joint refered to our institution were monitored for treatment costs and final reimbursement by the health insurances.

Results: In 65% of the included cases the amount of reimbursement by the health insurance organisations did not cover the costs of the treatment in our department. The amount of financial loss in total was 48.142 € with more than 9.000 € in some cases.

Conclusions: For the treating institution there is a risk of substantial financial losses due to inadequate reimbursement. Calculated on the basis of ~ 150.000 implanted joint protheses / a, an infection rate of 2% and treatment costs of ~50.000 € / infected case the economic burden is an estimated 150 million € / a in Germany. This amount should justifie a sound evaluation of costs related to infection in arthroplasty, which should be the effort of the health insurance organisations. Additionally specific research in the field of infection prevention must be sponsored. The system of reimbursement should be adeaquately adopted and corrected.

Introduction: Since the establishment of osteosynthesis as the treatment of choice for bone fractures, the issues relating to complications and their prophylaxis have become a major topic of scientific discussion and research in the field of traumatology. Infection of the bone and soft tissue represents one major complication that arises after the implantation of osteosynthetic material at the fracture site. The treatment of these infections is often time-consuming and involves repeated, extensive surgical interventions. The aim of this study was to acquire information about the effect of an antibacterial and biodegradable poly-L-lactide (PLLA) coated titanium plate osteosynthesis on local infection resistance.

Material and Methods: We compared infection rates in white New Zealand rabbits after titanium plate osteosynthesis of the tibia with or without antibacterial coating after local percutaneous bacterial inoculations at different concentrations (2x10⁵–2xlO⁸):

group I (n=12):uncoated titanium plate,

group II (n=12): PLLA coated titanium plate,

group III (n=12): titanium plate coated with PLLA + 3% Rifampicin and 7% Fusidic acid, group IV (n= 12): titanium plate coated with PLLA + 2% Octenidin und 8% Irgasan.

The plate, the contaminated soft tissues and the underlying bone were removed under sterile conditions after 28 days and quantitatively evaluated for bacterial growth. A stepwise experimental design with an “up-and-down” dosage technique was used to adjust the bacterial challenge in the area of the ID50 (50% infection dose). Statistical evaluation of the differences between the infection rates of both groups was performed using the two-sided Fisher exact test (p< 0.05).

Results: The overall infection rate was 50%. For group I and II the infection rate was both 83% (10 of 12 animals). In group III and IV with antibacterial coating the infection rate was both 17% (2 of 12 animals). The ID50 in the antibacterial coated groups III and IV was recorded as lxl10⁸ CFU, whereas the ID50 values in the groups I and II without antibacterial coating were a hundred times lower at lxl10⁶ CFU, respectively. The difference between the groups with and without antibacterial coating was statistically significant (p=0.033).

Conclusions: Using an antibacterial biodegradable PLLA coating on titanium plates, a significant reduction of infection rate in a canine infection model could be demonstrated. For the first time we were able to show, under standardized and reproducable conditions, that an antiseptic coating leads to the same reduction in infection rate as an antibiotic coating. Taking the problem of antibiotic-induced bacterial resistance into consideration, we thus regard the antiseptic coating, which shows the same level of effectiveness, as advantageous.

Introduction: Knee arthrodesis is a well-recognized salvage procedure in patients with septic destruction of the knee joint. If fusion can be achieved, it offers the opportunity for a stable lower limb and eradication of infection, but at the expense of knee motion. However, knee arthrodesis in this setting may be difficult to achieve because of poor bone stock, persistent infection and soft tissue compromise. In this study we present clinical and radiological results after knee fusion as well as an algorithm according to different surgical techniques (hybrid external fixator (HEF), antegrad compression nail (ACN) and modular cement less titanium rod (MCR)) and types of soft tissue damages and bone loss caused by infection

Patients and Methods: Between 10/2000 and 10/2002 in 37 patients knee arthrodesis was indicated after septic joint destruction. In 23 Pat. (67.0 y, 19.4–88,8 y) septic failure of total knee arthroplasty (TKA)caused severe bone loss and soft tissue damage. Because solid bony fusion was not to be expected weight bearing capability was restored by the use of MCR in a second stage procedure, using a PMMA Gentamycin spacer for eradication. In 14 Pat. (54.3 y, 23.l–87.7 y) remaining bone stock indicated direct fusion. In 10 of these cases HEF was used (6x primary joint infection, 3x septic failure of TKA, lx infected osteosynthesis). 2 pat. denied written consent for HEF, another 2 pat. had infected ipsilaterale midshaft femor-and/or tibia non unions. Because of these we used the ACN.

Results: In 5 pat. (21.7%) treated with MCR 1,4 revision procedures were indicated to eradicate infection before the implantation of MCR. Recurrence of infection after implantation occurred in 13% (n=3): 2 pat. were treated non surgically, lx amputation had to be done. No radiological signs for implant loosening were seen. HEF was removed after 15 weeks (12–18w) on average. 5 revision procedures were necessary in HEF cases (lx Pin-, lx ring exchange, lx sequestrectomy after pintractinfection,)- hi 2 cases the procedure was changed to MCR because of a non-union. Using the ACN we saw a 100% fusion rate, in one case the sinus tract persisted. The check up examinations were done 8,7 month (2,4–22,4mo) after arthrodesis procedure. 82,6% of pat. after MCR, 100% after HEF- and ACN-had full weight bearing capability. Eradication of infection was achieved in 86,9% (n=20) after MCR, in 70% (n=7) after HEF and in 75% (n=3) after ACN. In all 3 groups soft tissue reconstruction by flap surgery was indicated in 20%.

Conclusion: HEF is indicated when bone loss allows bony fusion. Failure occurred when bone defects were underestimated ort he fixator was removed before the 14th week. MCR can be used when eradication of infection is success and because of bone defects direct fusion is not possible. When eradication is not possible and bone stock makes the fusion reliable the ACN can be used under ongoing infection. ACN is also used when HEF is not recommended by the patient or because of mechanical reasons (floating knee).

We analysed the long-term results of arthrodesis of the shoulder after infection in 15 patients. At the time of operation, 14 cultures were positive for Staphylococcus aureus. The mean follow-up was 8.3 years (3 to 14) and 90% of the patients were satisfied with the outcome. There were complications in five patients (33%); in three there was nonunion with loosening of the implant. One patient had a sound bony union but with a persistent sinus six years after arthrodesis and another had a sinus which healed after the metal was removed. Four of these five patients (80%) were heavy smokers (> 20 cigarettes/day). Cancellous bone grafting did not affect the incidence of complications. The mean age of the patients with complications was 58.6 v 48.6 years for those without (p = 0.2808 ; not significant). Those with complications had had more previous operations (6.4 v 2.5, p < 0.05). Antibiotics, as determined by the bacteriological cultures, were administered for six weeks.

The complication rate was higher in patients with active sepsis but the younger the patient and the fewer number of previous operations (< 50 years, < four previous operations), the better was the outcome. Considering the rate of complications, we recommend early surgery in these patients.