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A prospective evaluation of 98 patients who had undergone a total hip or knee arthroplasty was conducted to assess the effect of postoperative suction drainage. Sixty-six patients undergoing elective total hip arthroplasty and 32 patients undergoing total knee replacement were randomly allocated to undergo either suction drainage or no drainage of the wound. Statistical analysis of the results showed no difference in wound healing, severity of wound haematoma, postoperative blood transfusion requirement, range of motion and duration of the hospitalization between the two groups. We conclude that the use of closed suction drainage provides no apparent advantage after uncomplicated total hip or knee arthroplasty.

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Tophaceous gout is commonly encountered and is amenable to effective medical management. A rare case of tophaceous gout in a tripartite medial sesamoid bone of the great toe is presented. Clinical presentation, differential diagnosis, and treatment of hallucal sesamoid pain are discussed.

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We report a case of post-traumatic osteolysis of the distal clavicle of a 25-year-old man. The diagnosis was missed for several months, and the patient continued to have pain in his right shoulder. The pain continued in spite of intensive physiotherapy. When he was seen for the first time in our clinic 6 months after the accident, the radiographs showed an osteolysis of the distal clavicle.

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We report four cases with very unusual manifestations of tophaceous gout. All patients were male, aged between 29 and 67 years. Only one patient had an acute gouty arthritis in his medical history, whereas the other three had never developed clinical symptoms from their hyperuricemia. Two patients had gout tophi in the patella, while the others showed gout tophi in the space of bipartite bones, one in a bipartite patella and one in a tripartite sesamoid bone of the first toe. To our knowledge, gout tophi in the space of bi- or tripartite bones has never been described before.

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Fractures of the ankle in adults are very common. Like every intraarticular fracture, they require perfect reduction and stable fixation to guarantee a good result. In most cases this can only be achieved by open treatment. The classification of ankle fractures according to Weber depends upon whether the fibular fracture is below (type A) at (type B) or above (type C) the syndesmosis. This classification also defines the importance of the tibio-fibular ligaments. From 1978 to 1992 more than 1000 ankle fractures were treated in our clinic by open reduction and fixation: 72 were type C ankle fractures, and the rest, either type A or type B fractures. When we reviewed our type C fractures we found 9 patients with so-called atypical type C fractures; these have an atypical fracture pattern insofar as a fracture of the medial malleolus is combined with tibiofibular ligament lesion and there is no fibula fracture. Definition, diagnosis, treatment and results are presented in this publication.

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Between 1980 and 1989, 210 patients with 212 femoral shaft fractures were treated at our hospital, 191 patients with 193 fractures (91%) had a follow-up control. Of these 193 fractures only 16 required totally 26 (13.5%) reosteosynthesis, with AO-Switzerland performing 625 (14.5%) reosteosynthesis in the same period of time, with the methods of primary fracture care only varying inconsiderably. The different reasons for reinterventions were planned reosteosynthesis, malposition, delayed union and pseudoarthrosis, loose and broken implants and infection. In comparison with AO-Switzerland the main difference was that we had no case with malposition (AO-Switz. 20%) leading to reosteosynthesis. The early infection rate at our hospital was 0.9% (AO-Switz. 2.6%) in comparison to a late infection rate of 2.1% (AO 2.2%). The screw-plate osteosynthesis and reamed femur-nail have both proved to be safe methods for primary fracture care, whereas combined osteosynthesis (e.g. two plates/reamed femur-nail and a plate) has a high rate of reosteosynthesis and therefore should be avoided.

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The dislocated fracture of the femoral neck (Garden type 3 and 4) in the young patient is preferably treated by open reduction and internal fixation. In the period 1980-1989 we fixed 49 fractures with a dynamic hip screw, a 130 degrees-angled plate, screws alone, or by a valgisation osteotomy fixed with a 120 degrees-plate (Pauwels osteotomy). 30 fractures were reviewed after 66 months in average. We observed radiological signs of femoral neck necrosis in 9 patients, thereof 7 with symptoms, and radiological signs of osteoarthritis in 3 patients, two with symptoms. The possible factors causing these late complications are discussed. We advocate the immediate open reduction to evacuate the intracapsular hematoma into a slight valgus over-correction for stability. For the fixation we use 3 screws in good bone quality, the dynamic hip screw and the angled plate in osteoporotic bone often combined with an accessory screw for rotational stability. The functional long-term result was good or excellent in 70%. By avoiding technical errors this rate can be improved.

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Snowboarding has become increasingly popular in recent years. A prospective multicenter study was therefore performed during the winter 1992/93. 345 injuries were analysed and compared with 305 healthy snowboarders on the slopes. Preliminary results show predominantly injuries of the upper extremity comparative to those suffered from alpine skiing. Protection of the hand and wrist is recommended as well as an instruction for a special technique for falling as measurements for accident prevention.

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In approximately 1% of all ankle sprains a fracture of the lateral process of the talus can be found. This fracture is probably even more common than this suggests, as it is often missed. We recommend that CT examination be performed in the investigation of ankle sprains when swelling, hematoma, and pain are present, when there is no instability of the ankle ligaments, and when no conclusive findings are yielded by conventional X-ray. Various theories on the best therapy have been propounded in the literature. Our retrospective study involved six patients. In two cases the fracture was treated by surgical operation. The remaining four patients received conservative therapy. Both patients who were operated upon had dislocated fractures sustained shortly before. On follow-up they were found to be completely symptom free. One further patient, who underwent conservative treatment for a fresh undislocated fracture, was also found to be free of all symptoms at follow-up. The late radiological findings in these three patients were incontestable. The three remaining patients, whether they had undergone conservative our functional treatment, reported considerable problems at follow-up, i.e. starting pain and a decreased range of motion in the talo-calcanear joint.

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Between January 1987 and December 1988 36 patients with injuries resulting from hanggliding were admitted to the Interlaken hospital. 6 (17%) of them were women. 14 patients were between 20-30 years old. 24 patients presented injuries of the lower limb, in 10 cases the spine was affected. From the total 39 injuries 20 had to been treated by operation. The accidents occur equally while starting or landing, during the flight incidents are very rare. The majority of the patients had only little experience in hanggliding or underwent insufficient training, indicating the most important point to be dealt with in the future.

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514 patients with total hip replacement were operated in 3 years in our county hospital. The patients were divided in two groups: 1. high risk patients: these patients had an antibiotica prophylaxis with 3 doses of 2 g of cefamandole beginning at the time of the induction of the anaesthesia; 2. patients without risks: they had no antibiotica. The two groups of patients were controlled at 3 and 12 months after the operation. 159 patients had a risk for an infection and had antibiotica, 355 patients had no antibiotica. The infection rate after 1 year was 0.6% in the group of patients with antibiotica, and 1.4% in the group of patients without antibiotica. This gave no statistical significance. The only statistical difference between the 2 groups was a significantly higher rate of urinary infection in the group with antibiotica. Thus it has been shown that urinary infections after total hip replacement correctly treated with antibiotica are not a high risk for an infection in the prosthesis. We conclude that antibiotica prophylaxis for total hip replacement in patients with high risk factors (like diabetes, corticotherapy, intraarticular injection, obesity and operation on the same hip) may help to have a postoperatively low infection rate, in our case 0.6%.

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Ruptures of the lateral ligaments of the ankle joint occur very frequently in young persons and this subject is therefore one which deserves more attention. Once a fracture or avulsion of a ligamentary insertion has been excluded the nature and extent of the ligamentary lesion should be precisely assessed. The only objective criterion of rupture of a ligament is demonstrable instability of the joint. Since the anterior talo-fibular ligament is always found to be torn immediately following supination-inversion injury to the ligaments the talar drawer sign will be demonstratable both clinically and radiologically in such cases. This test causes almost no pain and can be carried out without anesthesia. The radiological visualization of ligamentary instability with the aid of a simple jig which stresses the ankle joint provides diagnostic information which is definitely superior to that obtained from an a-p roentegenogram of the stressed joint. This conclusion was reached by statistical analysis of 384 roentgenograms.

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In 400 fractures of the upper and lower leg, 7 patients had an additional lesion of the posterior cruciate ligament. This combination occurs in people, who had a high energy frontal impact in the sitting position. The ligamenteous injury is often overlooked because of multiple injuries and difficulty in examination of a knee joint on a fractured leg. In high velocity injuries of the lower extremity, knee and hip joint injuries must not be overlooked. The diagnosis of knee injury can be made by inspection and palpation of a joint effusion and by a knee joint X-ray, which shows an avulsion fracture of the dorsal tibial spine. Repair is recommended within the first 3 weeks if possible. Later, scarring in the subluxed position and osteoporosis of the fragment will make a reconstruction very difficult.

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