Balloon Guided Cement Augmentation of Iliosacral Screws in the Treatment of Insufficiency Fractures of the Sacrum - Description of a New Method and Preliminary Results.

PURPOSE OF THE STUDY Fragility fractures of the pelvic ring in the elderly population are a serious problem in orthopaedics. The treatment options range from conservative treatment to diverse operative options. We present a balloon guided new technique of implanting cement augmented screws aiming at improved implant anchorage and reduced cement leakage. MATERIAL AND METHODS We describe a new technique of balloon- guided cement augmented iliosacral screws. After the balloon has been insufflated and contrast medium has been instillated for leakage detection, iliosacral screws can safely be placed with a relevant cement depot. RESULTS All patients (n = 8) treated in this way were allowed to weight bear on both legs and mobilisation was tolerated the next day after surgery. In the post-operative controls including X-ray and CT scan we noticed no cement leakage. Pain level as measured by the visual analog scale was significantly reduced to pre- surgery (mean 7.6 pre-operatively, mean 2.5 postoperatively). In addition pain medication could be reduced gradually soon after surgery. CONCLUSIONS The described procedure to address fragility fractures of the pelvic ring is a safe and easy to handle method. There are three advantages: First the osteoporotic S1 vertebral body can by stabilised by the amount of cement; second the cement leakage can be prevented by the balloon-compaction of the cancellous bone and the possibility to control the created cavity with contrast medium; third the bone - screw interface is much stronger compared to other procedures and is biomechanically superior against vertical shear stress. In contrast to sacroplasty, the cement application is guided by the previous use of a balloon. Key words:pelvic ring, fragility fracture, osteoporosis, elderly.

Delayed Fracture Healing in Diabetics with Distal Radius Fractures.

PURPOSE OF THE STUDY Diabetics may have an increased fracture risk, depending on disease duration, quality of metabolic adjustment and extent of comorbidities, and on an increased tendency to fall. The aim of this retrospective one-centre study consisted in detecting differences in fracture healing between patients with and without diabetes mellitus. Data of patients with the most common fracture among older patients were analyzed. MATERIAL AND METHODS Classification of distal radius fractures was established according to the AO classification. Inital assessment and followup were made by conventional x-rays with radiological default settings. To evaluate fracture healing, formation of callus and sclerotic border, assessment of the fracture gap, and evidence of consolidation signs were used. RESULTS The authors demonstrated that fracture morphology does not influence fracture healing regarding time span, neither concerning consolidation signs nor in fracture gap behavior. However, tendency for bone remodeling is around 70% lower in investigated diabetics than in non-diabetics, while probability for a successful fracture consolidation is 60% lower. CONCLUSIONS To corroborate the authors hypothesis of delayed fracture healing in patients with diabetes mellitus, prospective studies incorporating influencing factors like duration of metabolic disease, quality of diabetes control, medical diabetes treatment, comorbidities and secondary diseaseas, like chronic nephropathy and osteoporosis, have to be carried out. Key words: diabetes, delayed fracture healing, distal radius fractures, callus formation, blood glucose level, osteoblasts.

A comparative study of three signaling forms of the orange carotenoid protein.

Orange carotenoid protein (OCP) is a water-soluble photoactive protein responsible for a photoprotective mechanism of nonphotochemical quenching in cyanobacteria. Under blue-green illumination, OCP converts from the stable orange into the signaling red quenching form; however, the latter form could also be obtained by chemical activation with high concentrations of sodium thiocyanate (NaSCN) or point mutations. In this work, we show that a single replacement of tryptophan-288, normally involved in protein-chromophore interactions, by alanine, results in formation of a new protein form, hereinafter referred to as purple carotenoid protein (PCP). Comparison of resonance Raman spectra of the native photoactivated red form, chemically activated OCP, and PCP reveals that carotenoid conformation is sensitive to the structure of the C-domain, implicating that the chromophore retains some interactions with this part of the protein in the active red form. Combination of differential scanning fluorimetry and picosecond time-resolved fluorescence anisotropy measurements allowed us to compare the stability of different OCP forms and to estimate relative differences in protein rotation rates. These results were corroborated by hydrodynamic analysis of proteins by dynamic light scattering and analytical size-exclusion chromatography, indicating that the light-induced conversion of the protein is accompanied by a significant increase in its size. On the whole, our data support the idea that the red form of OCP is a molten globule-like protein in which, however, interactions between the carotenoid and the C-terminal domain are preserved.

Mid-term Functional Outcome and Return to Sports after Proximal Hamstring Tendon Repair.

Proximal hamstring tendon ruptures are commonly associated with a significant loss of function, and operative treatment is recommended in active patients. The objective was to evaluate objective/subjective functional results and return to sports following proximal hamstring tendon repair in the mid-term follow-up. 16 repairs of proximal hamstring ruptures were performed in 15 patients (9 males, 6 females). The average age at the time of injury was 47 years (range, 21-66). All patients were clinically examined at a mean follow-up of 56 months (range, 24-112 months). Validated patient-oriented assessment scores focussing on sports activity including the Lysholm Score, Tegner Activity Score, UCLA Activity Score, adapted WOMAC Score, and the VAS were evaluated as well as the return to sports. Isokinetic strength of both legs was tested using a rotational dynamometer. The Lysholm, Tegner, UCLA Activity Score and the adapted WOMAC demonstrated predominantly a return to a preinjury activity level at follow-up. Functional measurements of the operated leg showed similar results to the uninjured leg in knee extension and flexion strength (p>0.094). In return to sports, no signficant (p>0.05) differences concerning types or frequency were noted. The surgical repair of proximal hamstring tendon ruptures leads to constantly good functional results in the mid-term follow-up, where patients demonstrate similar isokinetic results in the healthy leg.

New Method for Monitoring Partial Weight Bearing (PWB) of Outpatients with an Independent Insole Sensor System.

UNLABELLED: PURPOSE OF THE STUDY Partial weight bearing (PWB) is commonly prescribed post operatively following lower limb fractures and compliance with the weight bearing protocol is an essential element of the rehabilitation. So far it is unknown to what extent patients do comply with PWB during the healing process as instructed by the surgeon. Our aim is to assess a new device for real-time feedback and long-term measurement of PWB of outpatients. The device offers the possibility to monitor the outpatient's activity. The applicability, reliability and validity of the new device should be evaluated. MATERIAL AND METHODS 20 young, healthy subjects complete a course of 500 m that contained several stairs, with a PWB of 15 kg. During the entire test, the axial load, the acceleration and the temperature were measured with a novel insole sensor system. The results were compared with reference measurements performed with a force plate. RESULTS Altogether, the 20 subjects performed 11,106 steps during the completion of the walking circuit. In 23.6% of the steps, the subjects applied a PWB of 10 to 20 kg. In 5.5% of all steps, PWB was superior to 60 kg. The mean bias of the insole was 11,58 N. Limits of agreement were +/- 125 N and the interclass correlation coefficient was r = 0.945. CONCLUSIONS The presented sensor sole might be a useful tool to obtain more precise insight of outpatients' activity and load to the injured limb during the healing process. Furthermore, these results demonstrate that even young and healthy subjects are not able to keep the prescribed PWB. This raises the question, if patients who have been recently operated are able to follow the instructions concerning the PWB. KEY WORDS: partial weight bearing (PWB), insole sensor system, sensor sole, monitoring, outpatients.

[Pertrochanteric femoral fractures in the elderly]. / Pertrochantäre Femurfrakturen beim geriatrischen Patienten.

Pertrochanteric fractures are one of the most common injuries in the elderly and due to the demographic changes the incidence and importance of this fracture entity will even increase in the future. The dynamic hip screw (DHS) has been used as the gold standard implant in the treatment of pertrochanteric femoral fractures for many years but recent studies have shown that cephalomedullary nails have some advantages. Due to the high incidence, operative treatment of these fractures is part of the standard repertoire of trauma surgeons and this article therefore provides an overview of existing knowledge and new trends in the treatment of pertrochanteric femoral fractures.

[Balloon osteoplasty as reduction technique in the treatment of tibial head fractures]. / Ballonaugmentation als Repositionstechnik bei der Versorgung von Tibiakopffrakturen.

BACKGROUND: Tibial plateau fractures requiring surgery are severe injuries of the lower extremities. Depending on the fracture pattern, the age of the patient, the range of activity and the bone quality there is a broad variation in adequate treatment.  AIM: This article reports on an innovative treatment concept to address split depression fractures (Schatzker type II) and depression fractures (Schatzker type III) of the tibial head using the balloon osteoplasty technique for fracture reduction. METHODS: Using the balloon technique achieves a precise and safe fracture reduction. This internal osteoplasty combines a minimal invasive percutaneous approach with a gently rise of the depressed area and the associated protection of the stratum regenerativum below the articular cartilage surface. This article lights up the surgical procedure using the balloon technique in tibia depression fractures. CONCLUSION: Using the balloon technique a precise and safe fracture reduction can be achieved. This internal osteoplasty combines a minimally invasive percutaneous approach with a gentle raising of the depressed area and the associated protection of the regenerative layer below the articular cartilage surface. Fracture reduction by use of a tamper results in high peak forces over small areas, whereas by using the balloon the forces are distributed over a larger area causing less secondary stress to the cartilage tissue. This less invasive approach might help to achieve a better long-term outcome with decreased secondary osteoarthritis due to the precise and chondroprotective reduction technique.

C-Reactive Protein in Orthopaedic Surgery.

C-reactive protein (CRP) is a common laboratory infection marker in blood-serum of patients. In all diverse medical departments CRP is often used, and also in orthopaedics CRP is proved to be very helpful in diagnosis and monitor of infections. CRP in most fields is superior to conventional and newer infection parameter and is a basic parameter for inflammation. Especially for detection of an early postoperative infection CRP can be very helpful as an objective parameter easy to obtain. In uneventful operative treatment a similar evolution in CRP concentrations was found: the peak level occurred on the second or third postoperative day and reflected the extent of surgical trauma. A second rise of CRP in the postoperative course indicates a complication. Highest levels are reached in bacterial infection after the forth postoperative day with a cut-off level about 10 mg/dl. CRP can also be used as a preoperative marker for risk stratification and newer times CRP is reported as an independent fracture-risk-factor. In general CRP is the basic inflammatory parameter in orthopaedic surgery and is more significant and common than WBC or ESR. But CRP is only a laboratory parameter and must always be correlated with clinical signs of infection.

Delayed Fracture Healing in Diabetics with Distal Radius Fractures.

PURPOSE OF THE STUDY: Diabetics may have an increased fracture risk, depending on disease duration, quality of metabolic adjustment and extent of comorbidities, and on an increased tendency to fall. The aim of this retrospective one-centre study consisted in detecting differences in fracture healing between patients with and without diabetes mellitus. Data of patients with the most common fracture among older patients were analyzed. MATERIAL AND METHODS: Classification of distal radius fractures was established according to the AO classification. Inital assessment and follow-up were made by conventional X-rays with radiological default settings. To evaluate fracture healing, formation of callus and sclerotic border, assessment of the fracture gap, and evidence of consolidation signs were used. RESULTS: The authors demonstrated that fracture morphology does not influence fracture healing regarding time span, neither concerning consolidation signs nor in fracture gap behaviour. However, tendency for bone remodeling is around 70% lower in investigated diabetics than in non-diabetics, while probability for a successful fracture consolidation is 60% lower. CONCLUSIONS: To corroborate the authors hypothesis of delayed fracture healing in patients with diabetes mellitus, prospective studies incorporating influencing factors like duration of metabolic disease, quality of diabetes control, medical diabetes treatment, comorbidities and secondary diseases, like chronic nephropathy and osteoporosis, have to be carried out.

[Traumatic elbow dislocations in bouldering]. / Ellenbogenluxationsverletzungen beim Trendsport Bouldern.

Bouldering is a new trend sport which has become popular in recent years. From April 2011 to June 2012 a total of 5 patients with elbow dislocations from bouldering were admitted to our level 1 trauma center. The injuries varied from simple elbow dislocations to complex fracture dislocations. Elbow dislocations occurred during falling backwards when patients tried to protect themselves by retroversion of both arms. In all cases the falling height was less than 4 meters. The bouldering injury pattern, the diagnostic and therapeutic management as well as the rehabilitation program are described in detail in this article. To the best of our knowledge this is the first report on the special danger of bouldering for complex elbow injuries.

Functional results following titanium elastic-stable intramedullary nailing (ESIN) of mid-shaft clavicle fractures.

INTRODUCTION While plate fixation remains the gold standard for surgical treatment for displaced mid-shaft clavicle fractures (DMCF), intramedullary fixation has emerged as a promising alternative. However, due to its more demanding technique and depending on the fracture's nature, an open reduction can be necessary. Aim of this study was to compare the outcome of open reduction versus closed reduction of DMCF using ESIN. PATIENTS AND METHODS Titanium Elastic Nail (TEN) were used to treat 40 patients undergoing minimally invasive ESIN between December 2006 and July 2009. A total of 19 patients were treated with a closed reduction and 21 patients required open reduction. RESULTS Open reduction increases operative time and fluoroscopy time significantly versus closed reduction (open 80.8 ± 35.9 min; closed 30.5 ± 8.5 min). No significant differences were found regarding strength measurement (75.7 ± 22.0 N in the closed group and 74.2 ± 26.0 N in the open group), DASH score (5.1 ± 6.5 closed group vs. 5.8 ± 7.3 open group) and Constant score (87.4 ± 9 points closed group vs. 85.3 ± 7.2 points open group). No major complications were observed. CONCLUSION There was no significant difference comparing patients who were treated with an open versus a closed technique. If appropriately indicated we believe that using ESIN is an adequate and successful operative technique for DMCF. There were no significant differences in shoulder function after either procedure.

Anatomically precontoured LCP for delayed union of a medial third clavicle fracture. Case report with review of the literature.

BACKGROUND: Fractures of the medial clavicle third are rare injuries. Even in case of significant fracture displacement, their therapeutic management has been nonoperative. Recently, surgical intervention has become mandatory for displaced fractures types to prevent non-union and functional complaints, but the optimal operative strategy is being discussed controversially. CASE PRESENTATION: We describe the case of a 63-year-old male patient with a significantly displaced medial clavicle fracture after failed conservative treatment resulting in restricted, painful shoulder function. The patient underwent open reduction and osteosynthesis with an anatomically precontoured locking compression plate (LCP). One year after surgery the patient is free of complaints and has returned to his preinjury activity level without any functional restrictions. CONCLUSION: As a not yet reported operative approach, anatomically preshaped locking plating seems to be an effective fixation method for displaced fractures of the medial clavicle third. The operative management is described in detail and discussed with the current literature. Based on the presented case, we underline the statement that displaced medial clavicle fractures should be surgically addressed to avoid late damage.

Biosynthesis of a novel C30 carotenoid in Bacillus firmus isolates.

AIMS: Pigmented Bacillus spp. with probiotic properties have been isolated. In the yellow-/orange-coloured strains, the carotenoid pigments present have been characterized. In contrast, the carotenoids present in the Bacillus isolates coloured red await identification. The present article reports progress on the elucidation of the pigment biosynthetic pathway in these red-pigmented Bacillus firmus strains. METHODS AND RESULTS: A combination of UV/Vis, chromatographic and mass spectrometry (MS) has revealed the properties of the predominant pigment and the end-point carotenoid of the pathway to be methyl 4,4'-diapolycopene-dioate after transmethylation. The diglycosyl ester of 4,4'-diapolycopene-dioate persists in vivo prior to chemical treatment. Different mutants and inhibitor treatment were employed to establish the C30 biosynthesis pathway with all precursors and intermediates to 4,4'-diapolycopene-dioate detected, which include 4,4'-diapophytene and all desaturation intermediates to 4,4'-diapolycopene and 4,4'-diapolycopene-dialdehyde. To cultures synthesizing the 4,4'-diapolycopene-dioate derivative and those in which its formation was inhibited, oxidative stress was induced by peroxide treatment. Conditions that decreased the growth rate of the pigmented cells by only 30% caused a complete growth inhibition of the culture devoid of the 4,4'-diapolycopene-dioate derivative. CONCLUSION: This finding demonstrates the diversity of C30 carotenoid biosynthesis in Bacillus species and the antioxidative function of the 4,4'-diapolycopene-dioate derivative in B. firmus cells. SIGNIFICANCE AND IMPACT OF THE STUDY: It could be shown that the C30 4,4'-diapolycopene-dioate derivatives protect pigmented B. firmus from peroxidative reactions. Under oxidative conditions, this can be an ecological advantage over nonpigmented (=noncarotenogenic) strains that are equally abundant.

[Recurrent hematomas of the iliopsoas muscle after total hip replacement as a differential diagnosis for chronic groin pain: case series report]. / Rezidivierende Iliopsoaseinblutungen als Differenzialdiagnose bei Chronischen Leistenschmerzen nach Hüfttotalendoprothesenimplantation: Eine Fallserie.

BACKGROUND: Chronic and atraumatic groin pain may be due to a variety of pathologies local to and distal from the hip joint. Aside from frequent entities, such as inguinal hernia, impingement of the iliopsoas muscle by the anterior rim of the acetabular component leading to a hematoma can be a potential cause after total hip replacement (THR). MATERIAL AND METHODS: This article presents three cases of delayed groin pain after THR received due to osteoarthrosis of the hip joint several years prior to the onset of symptoms. In all three cases the patient suffered from chronic groin pain aggravated by active flexion without direct trauma. After thorough clinical, laboratory and radiological (ultrasound, x-ray, computed tomography) examination a hematoma of the iliopsoas muscle was detected. Furthermore, in all three cases the acetabular component appeared to be slightly malpositioned. Considering the least invasive procedure all cases were treated with an excavation of the hematoma. After recurrence the indications for revision of the malpositioned acetabular component were present. RESULTS: All patients clearly showed a reduction of pain after operative revision. There have been no further hematomas and the patients could be easily and rapidly remobilized. CONCLUSIONS: Persistent atraumatic groin pain connected to a deficit in hip flexion after THR needs thorough investigation by the treating physician. The differential diagnosis of a delayed hematoma due to impingement of the iliopsoas muscle is a rare but more complex entity. After careful consideration of the perioperative risks an early indication for revision of a malpositioned acetabular component is promising.

Carotenoids found in Bacillus.

AIMS: To identify the diversity of pigmented aerobic spore formers found in the environment and to characterize the chemical nature of this pigmentation. MATERIALS AND RESULTS: Sampling of heat-resistant bacterial counts from soil, sea water and the human gastrointestinal tract. Phylogenetic profiling using analysis of 16S rRNA sequences to define species. Pigment profiling using high-performance liquid chromatography-photo diode array analysis. CONCLUSIONS: The most commonly found pigments were yellow, orange and pink. Isolates were nearly always members of the Bacillus genus and in most cases were related with known species such as Bacillus marisflavi, Bacillus indicus, Bacillus firmus, Bacillus altitudinis and Bacillus safensis. Three types of carotenoids were found with absorption maxima at 455, 467 and 492 nm, corresponding to the visible colours yellow, orange and pink, respectively. Although the presence of other carotenoids cannot be ruled out, these three predominant carotenoids appear to account for the pigments obtained in most pigmented bacilli, and our analysis reveals the existence of a C30 biosynthetic pathway. Interestingly, we report the presence of a water-soluble pigment that may also be a carotenoid. The function of carotenoids is photoprotection, and carotenoid-containing spores exhibited significantly higher levels of resistance to UV radiation than non-carotenoid-containing Bacillus species. SIGNIFICANCE AND IMPACT OF THE STUDY: This study demonstrates that pigmented bacilli are ubiquitous and contain new carotenoid biosynthetic pathways that may have industrial importance.

Novel hydroxycarotenoids with improved antioxidative properties produced by gene combination in Escherichia coli.

We have used combinatorial biosynthesis to synthesize novel lipophilic carotenoids that are powerful cellular antioxidants. By co-expressing three different carotenoid desaturases in combination with a carotenoid hydratase, a cyclase, and a hydroxylase on compatible plasmids in Escherichia coli, we synthesized four novel carotenoids not previously detected in biological material or chemically synthesized. Their identification was based on their relative retention times on HPLC, spectroscopic properties, molecular weights, number of hydroxy groups, and 1H-NMR spectra. The carotenoids were designated as 1-HO-3', 4'-didehydrolycopene, 3, 1'-(HO)2-gamma-carotene, 1,1'-(HO)2-3, 4, 3', 4'-tetradehydrolycopene, and 1, 1'-(HO)2-3, 4-didehydrolycopene. These novel acyclic derivatives differ from structurally related compounds by extension of the conjugated polyene chain as well as additional hydroxy groups at position C-1'. We determined their antioxidative activity in a liposome-membrane model system, which showed that their ability to protect against photooxidation and radical-mediated peroxidation reactions was linked to the length of the conjugated double-bond system and the presence of a single hydroxy group. The protection of membrane degradation was superior to the related 1-HO and 1, 1'-(HO)2 lycopene derivatives, making them interesting pharmaceutical candidates.

Genetic manipulation of carotenoid biosynthesis: strategies, problems and achievements.

Carotenoids, some of which are provitamin A, have a range of diverse biological functions and actions, especially in relation to human health. For example, carotenoids are known to be crucial for normal vision and have been associated with reducing the risk of several degenerative diseases including cancer. The putative advantage of modifying and engineering the carotenoid biosynthetic pathways is obvious: to provide sources for the isolation of desired carotenoids or to generate food plants with increased carotenoid content. This article reviews the studies of carotenoid production in heterologous microorganisms and the engineering of crop plants using manipulated carotenoid biosynthesis.

[Surgical treatment of posterosuperior impingement (PSI)]. / Operative Therapie des posterosuperioren Impingements (PSI).

OBJECTIVE: To restore the physiologic anterior and posterior capsular volume to achieve an anatomic central contact point of the glenohumeral articulation and treatment of concomitant glenohumeral injuries due to posterosuperior impingement (PSI). INDICATIONS: Plateauing of clinical improvement despite adequate nonsurgical treatment (for at least 6-12 months). CONTRAINDICATIONS: General contraindications for elective arthroscopic surgery. SURGICAL TECHNIQUE: Diagnostic arthroscopy of the glenohumeral joint through the posterior portal to assess stability of the biceps-labral complex even in the Abduction and External Rotation (ABER) position to confirm the diagnosis of PSI and to detect concomitant glenohumeral injuries. In most cases posterosuperior SLAP (superior labrum anterior posterior) repair or tenodesis of the long head of the biceps. POSTOPERATIVE MANAGEMENT: Arm sling for 6 weeks with limited range of motion. Free active range of motion of elbow and wrist. Limited shoulder external rotation for 6 weeks. Free shoulder range of motion from week 7, full daily life activities after 12 weeks. Modification of the postoperative management according to intraoperative findings. RESULTS: At our hospital 18 overhead athletes (6 women, 12 men, mean age 31 years) with PSI without SLAP lesion or rotator cuff tear underwent isolated plication of the anteroinferior capsule after primary nonsurgical treatment. At a mean period of 9 months, 16 patients returned to their pre-injury sports activity level, 2 patients had to give up their sports due to persisting shoulder problems. At a mean follow-up of 27 months (range 12-55 months) the Walch Duplay score was on average 82.9 ± 8.3 for men and 73.8 ± 5.9 for women.