Long-term pathological gait pattern changes after talus fractures - dynamic measurements with a new insole.

PURPOSE: The aim of the current study was to describe long-term gait changes after talus fractures, identify patterns associated with poor outcome and discuss possible treatment options based on dynamic gait analysis. METHODS: Twenty-seven patients were followed-up clinically and via gait analysis after talus fracture osteosynthesis. Continuous dynamic pedobarography with a gait analysis insole was performed on a standardized parcours consisting of different gait tasks and matched to the outcome. RESULTS: Mean follow-up was 78.3 months (range 21-150), mean AOFAS and Olerud-Molander scores 66 (range 20-100) and 54 (range 15-100). Significant correlations between fracture classification and osteoarthritis (Hawkins: rs = 0.67 / Marti-Weber: rs = 0.5) as well as several gait differences between injured and healthy foot with correlations to outcome were seen: decreased step load-integral/maximum-load; associations between centre-of-pressure displacement and outcome as well as between temporospatial measures and outcome. Overall, pressure-distribution was lateralized in patients with subtalar joint injury (Δ: 0.5765 N/cm2, p = 0.0475). CONCLUSIONS: Talus fractures lead to chronic gait changes and restricted function. Dynamic pedobarography can identify patterns associated with poor results. The observed gait patterns suggest that changes can be addressed by physical therapy and customized orthoses to improve overall outcome. The presented insole and measurement protocol are immediately feasible as a diagnostic and rehabilitation aid.

Weight-bearing recommendations after operative fracture treatment-fact or fiction? Gait results with and feasibility of a dynamic, continuous pedobarography insole.

PURPOSE: Rehabilitation after lower-extremity fractures is based on the physicians' recommendation for non-, partial-, or full weight-bearing. Clinical studies rely on this assumption, but continuous compliance or objective loading rates are unknown. The purpose of this study was to determine the compliance to weight-bearing recommendations by introducing a novel, pedobarography system continuously registering postoperative ground forces into ankle, tibial shaft and proximal femur fracture aftercare and test its feasibility for this purpose. METHODS: In this prospective, observational study, a continuously measuring pedobarography insole was placed in the patients shoe during the immediate post-operative aftercare after ankle, tibial shaft and intertrochanteric femur fractures. Weight-bearing was ordered as per the institutional standard and controlled by physical therapy. The insole was retrieved after a maximum of six weeks (28 days [range 5-42 days]). Non-compliance was defined as a failure to maintain, or reach the ordered weight-bearing within 30%. RESULTS: Overall 30 patients were included in the study. Fourteen (47%) of the patients were compliant to the weight-bearing recommendations. Within two weeks after surgery patients deviated from the recommendation by over 50%. Sex, age and weight did not influence the performance (p > 0.05). Ankle fracture patients (partial weight-bearing) showed a significantly increased deviation from the recommendation (p = 0.01). CONCLUSIONS: Our study results show that, despite physical therapy training, weight-bearing compliance to recommended limits was low. Adherence to the partial weight-bearing task was further decreased over time. Uncontrolled weight-bearing recommendations should thus be viewed with caution and carefully considered as fiction. The presented insole is feasible to determine weight bearing continuously, could immediately help define real-time patient behaviour and establish realistic, individual weight-bearing recommendations.

Predictive value of clinical scoring and simplified gait analysis for acetabulum fractures.

BACKGROUND: Fractures of the acetabulum show a high, long-term complication rate. The aim of the present study was to determine the predictive value of clinical scoring and standardized, simplified gait analysis on the outcome after these fractures. METHODS: Forty-one patients with acetabular fractures treated between 2008 and 2013 and available, standardized video recorded aftercare were identified from a prospective database. A visual gait score was used to determine the patients walking abilities 6-m postoperatively. Clinical (Merle d'Aubigne and Postel score, visual analogue scale pain, EQ5d) and radiological scoring (Kellgren-Lawrence score, postoperative computed tomography, and Matta classification) were used to perform correlation and multivariate regression analysis. RESULTS: The average patient age was 48 y (range, 15-82 y), six female patients were included in the study. Mean follow-up was 1.6 y (range, 1-2 y). Moderate correlation between the gait score and outcome (versus EQ5d: rs = 0.477; versus Merle d'Aubigne: rs = 0.444; versus Kellgren-Lawrence: rs = -0.533), as well as high correlation between the Merle d'Aubigne score and outcome were seen (versus EQ5d: rs = 0.575; versus Merle d'Aubigne: rs = 0.776; versus Kellgren-Lawrence: rs = -0.419). Using a multivariate regression model, the 6 m gait score (B = -0.299; P < 0.05) and early osteoarthritis development (B = 1.026; P < 0.05) were determined as predictors of final osteoarthritis. A good fit of the regression model was seen (R2 = 904). CONCLUSIONS: Easy and available clinical scoring (gait score/Merle d'Aubigne) can predict short-term radiological and functional outcome after acetabular fractures with sufficient accuracy. Decisions on further treatment and interventions could be based on simplified gait analysis.

Surfactant protein A mediates pulmonary clearance of Staphylococcus aureus.

Surfactant protein A has been shown to enhance opsonization and clearance of Staphylococcus aureus in vitro. Here, the phagocytosis of alveolar S. aureus was investigated in vivo using intravital microscopy. Fluorescence labelled S. aureus Newman cells were intratracheally administered to anesthetized mice and the alveolar surface was observed for fifteen minutes. Confirming previously reported in vitro data, surfactant protein A-deficient mice showed a significantly reduced uptake of bacteria compared to wild-type mice.

Experiences in the Use of Motorized Intramedullary Nails after Complex Injuries to the Extremities. / Erfahrungen bei der Anwendung motorisierter Marknägel nach komplexen Extremitätenverletzungen.

The treatment of complex injuries of the extremities after comminuted fractures or non-unions is a challenging area in the field of trauma surgery. Internal, motorized implants nowadays enable a patient-oriented and progressive treatment of these cases. The present article aims to present modern treatment strategies of complex injuries of the extremities, support the use of novel, motorized intramedullary nails and provide experiences for the handling with lengthening nails or transport nails. For this purpose, the preoperative planning including selection of patients, presentation of internal lengthening and transport systems and the most important factors during preparation of the surgery are described. Moreover, critical steps during the implantation of motorized nails and also during potential follow-up interventions are highlighted and the postoperative protocol including precise recommendations for the transport und consolidation phase are provided. Finally, the experiences are illustrated by presentation of the four different cases. The use of internal, motorized implants represents the latest step in the treatment of complex injuries of the extremities. These implants improve the quality of life and the authors recommend its use. However, these implants require a high expertise and adaption of established treatment protocols in these challenging trauma cases. Follow-up analyses with a considerably large number of cases are necessary and the research on implants to solve persisting problems in the area of complex injuries of the extremities has to be pursued intensively.

Occurrence, resistance patterns, and management of carbapenemase-producing bacteria in war-wounded refugees from Ukraine.

We analyzed consecutive clinical cases of infections due to carbapenemase-producing gram-negative bacteria detected in war-wounded patients from Ukraine who were treated at one university medical center in southwest Germany between June and December 2022. The isolates of multiresistant gram-negative bacteria were subjected to a thorough microbiological characterization and whole genome sequencing (WGS). We identified five war-wounded Ukrainian patients who developed infections with New Delhi metallo-ß-lactamase 1-positive Klebsiella pneumoniae. Two isolates also carried OXA-48 carbapenemases. The bacteria were resistant to novel antibiotics, such as ceftazidime/avibactam and cefiderocol. The used treatment strategies included combinations of ceftazidime/avibactam + aztreonam, colistin, or tigecycline. WGS suggested transmission during primary care in Ukraine. We conclude that there is an urgent need for thorough surveillance of multiresistant pathogens in patients from war zones.

How to detect a dwarf: in vivo imaging of nanoparticles in the lung.

Nanotechnology is a rapidly developing field in science and industry. The exposure to nanoparticles (NPs) will steadily grow in the future and there is thus an urgent need to study potential impacts of the interaction between NPs and the human body. The respiratory tract is the route of entry for all accidentally inhaled NPs. Moreover, NPs may intentionally be delivered into the lung as contrast agents and drug delivery systems. The present review provides an overview of currently used techniques for the in vivo imaging of NPs in the lung, including x-ray imaging, computed tomography, gamma camera imaging, positron emission tomography, magnetic resonance imaging, near-infrared imaging, and intravital fluorescence microscopy. Studies based on these techniques may contribute to the development of novel NP-based drug delivery systems and contrast agents. In addition, they may provide completely new insights into nanotoxicological processes. FROM THE CLINICAL EDITOR: Nanoparticles are rapidly gaining ground in various therapeutic and diagnostic applications. This review provides an overview of current in vivo imaging techniques of NPs in the lung, including x-ray, CT, gamma camera imaging, PET, MRI, near-infrared imaging, and intravital fluorescence microscopy, aiding the development of novel NP-based techniques and nanotoxicology.

Experimental induction of blunt chest trauma in mice: A modified approach with evaluation in dummies and cadavers.

Experimental chest trauma or blunt thoracic trauma using a blast wave mechanism is well established in animal models. The aim of the present study was to establish a complementary, murine experimental chest trauma model precisely defined by physical data and calculations. For this purpose, a device was developed using a dropped weight and physical properties, including velocity, energy and impact, were calculated. The device allowed for the maximum depth of impression to be measured. The device was first tested using blocks of modelling clay and was then applied to mouse cadavers. X-ray and dissection were performed to check for bone fractures and organ injuries following blunt chest traumas of increasing impact. Lesions and hemorrhages were observed in mouse cadavers which sustained a force equivalent to the energy of ~1 J.

Stabilization of a Type B1.1 Injury in a Morbidly Obese Patient Using an Internal Fixator in a Minimally Invasive Technique: A Case Report.

CASE: In this case report, we present a novel stabilization technique of the pubic symphysis using an internal spinal fixator in a 78-year-old morbidly obese woman having a pelvic disruption type B1.1 (AO classification). We treated the disruption using an internal fixator to reduce the extent of the incision and soft-tissue damage. CONCLUSIONS: The use of an internal fixator, known from percutaneous spinal fixation, for the stabilization of the pubic symphysis in cases of disruption ("open book" injuries) may be an alternative to the standard plate fixation as a novel minimally invasive stabilization technique.

Helping prometheus: liver protection in acute hemorrhagic shock.

Acute hemorrhagic hypovolemic shock is caused by a significant high blood loss and leads to hemodynamic instability. The decrease in intravascular volume results in cellular hypoxia and finally in damage to organs such as the liver and the kidney. The liver plays a decisive role in the development or prevention of multiple organ failure after hemorrhagic shock. Despite the large number of experimental studies, the knowledge of pathophysiological mechanisms in the liver after hemorrhagic shock is incomplete. The aim of this mini review was to provide an overview of the pathophysiological changes in liver function after acute hemorrhagic shock and to address treatment options to improve liver perfusion.

A novel tool for continuous fracture aftercare - Clinical feasibility and first results of a new telemetric gait analysis insole.

Weight bearing after lower extremity fractures still remains a highly controversial issue. Even in ankle fractures, the most common lower extremity injury no standard aftercare protocol has been established. Average non weight bearing times range from 0 to 7 weeks, with standardised, radiological healing controls at fixed time intervals. Recent literature calls for patient-adapted aftercare protocols based on individual fracture and load scenarios. We show the clinical feasibility and first results of a new, insole embedded gait analysis tool for continuous monitoring of gait, load and activity. Ten patients were monitored with a new, independent gait analysis insole for up to 3 months postoperatively. Strict 20 kg partial weight bearing was ordered for 6 weeks. Overall activity, load spectrum, ground reaction forces, clinical scoring and general health data were recorded and correlated. Statistical analysis with power analysis, t-test and Spearman correlation was performed. Only one patient completely adhered to the set weight bearing limit. Average time in minutes over the limit was 374 min. Based on the parameters load, activity, gait time over 20 kg weight bearing and maximum ground reaction force high and low performers were defined after 3 weeks. Significant difference in time to painless full weight bearing between high and low performers was shown. Correlation analysis revealed a significant correlation between weight bearing and clinical scoring as well as pain (American Orthopaedic Foot and Ankle Society (AOFAS) Score rs=0.74; Olerud-Molander Score rs=0.93; VAS pain rs=-0.95). Early, continuous gait analysis is able to define aftercare performers with significant differences in time to full painless weight bearing where clinical or radiographic controls could not. Patient compliance to standardised weight bearing limits and protocols is low. Highly individual rehabilitation patterns were seen in all patients. Aftercare protocols should be adjusted to real-time patient conditions, rather than fixed intervals and limits. With a real-time measuring device high performers could be identified and influenced towards optimal healing conditions early, while low performers are recognised and missing healing influences could be corrected according to patient condition.

Polytrauma in the elderly: a review.

Although the field of geriatric trauma is - ironically - young, care for the elderly trauma patient is increasingly recognised as an important challenge, considering the worldwide trend towards increasing longevity.Increasing age is associated with physiological changes and resulting comorbidities that present multiple challenges to the treating physician.Even though polytrauma is less likely with increasing age, lower-energy trauma can also result in life-threatening injuries due to the reduced physiological reserve.Mechanisms of injury and resulting injury patterns are markedly changed in the elderly population and new management strategies are needed. From initial triage to long-term rehabilitation, these patients require care that differs from the everyday standard.In the current review, the special requirements of this increasing patient population are reviewed and management options discussed. With the increase in orthogeriatrics as a speciality, the current status quo will almost certainly shift towards a more tailored treatment approach for the elderly patient. Further research expanding our current knowledge is needed to reduce the high morbidity and mortality rate. Cite this article: Braun BJ, Holstein J, Fritz T, Veith NT, Herath S, Mörsdorf P, Pohlemann T. Polytrauma in the elderly: a review. EFORT Open Rev 2016;1:146-151. DOI: 10.1302/2058-5241.1.160002.

The importance of surfactant proteins-New aspects on macrophage phagocytosis.

Surfactant and its components have multiple functions. The so called collectins are surfactant proteins which opsonize bacteria and improve pulmonary host defense via the phagocytosis and clearance of microorganisms and particles. In this special issue of the Annals of Anatomy a new surfactant protein, Surfactant Associated 3, is highlighted. As outlined in this mini review Surfactant Associated 3 is regarded as an enhancer of phagocytosis. In addition, the role played by SP-A is updated and open research questions raised.

Blood loss in pelvic ring fractures: CT-based estimation.

BACKGROUND: The main cause of mortality after pelvic ring fractures is the acute haemorrhagic shock. The aim of the study was to estimate blood loss using CT and to correlate estimated blood loss to the mortality. METHODS: A retrospective analysis of 42 patients with AO/OTA C-type pelvic ring fractures was performed. In total 29 AO/OTA C1-type, 4 C2-type and 9 C3-type fractures were analysed. A CT-volumetric analysis was developed to estimate the early blood loss in the different compartments. The results were correlated to the mortality of the patients. RESULTS: Significant increases in interstitial free blood volume (392±502.8 vs. 888±663; P<0.05) and total blood loss (476±535 vs. 1,005±649; P<0.05) were seen when comparing C1 to C3-type fractures. Early blood loss significantly correlated to mortality. No significant difference was seen between all groups with respect to systolic blood pressure, haemoglobin concentration and the Injury Severity Score (ISS). CONCLUSIONS: In pelvic ring fractures the CT-estimated blood loss correlates to mortality.

Initial Host Response to Bacteria in the Murine Lung Differs Between Pseudomonas aeruginosa, Staphylococcus aureus and Streptococcus pneumoniae.

Phagocytosis of bacteria is an important process during early host defence. It has been directly observed only ex vivo or in vitro. Here, we report on the observation of phagocytosis under in vivo conditions by using intravital microscopy in the murine lung. Suspensions of fluorescently labelled Streptococcus pneumoniae, Staphylococcus aureus and Pseudomonas aeruginosa cells were each instilled intratracheally to anaesthetized mice. After thoracotomy, the alveolar surface was observed for 30 min. Alveolar phagocytes exhibiting ingested bacteria could be detected and counted. The highest numbers were found after the infection with P. aeruginosa. By using intravital microscopy, cellular host defence could be observed in living mice lungs. The initial phagocytic reaction crucially depends on the species of applied bacteria invading the lung.

Validation and reliability testing of a new, fully integrated gait analysis insole.

BACKGROUND: A new tool (OpenGo, Moticon GmbH) was introduced to continuously measure kinetic and temporospatial gait parameters independently through an insole over up to 4 weeks. The goal of this study was to investigate the validity and reliability of this new insole system in a group of healthy individuals. METHODS: Gait data were collected from 12 healthy individuals on a treadmill at two different speeds. In total, six trials of three minutes each were performed by every participant. Validation was performed with the FDM-S System (Zebris). Complete sensor data were used for a within test reliability analysis of over 10000 steps. Intraclass correlation was calculated for different gait parameters and analysis of variance performed. RESULTS: Intraclass correlation for the validation was >0.796 for temporospatial and kinetic gait parameters. No statistical difference was seen between the insole and force plate measurements (difference between means: 36.3 ± 27.19 N; p = 0.19 and 0.027 ± 0.028 s; p = 0.36). Intraclass correlation for the reliability was >0.994 for all parameters measured. CONCLUSION: The system is feasible for clinical trials that require step by step as well as grouped analysis of gait over a long period of time. Comparable validity and reliability to a stationary analysis tool has been shown.

Plantar fibromatosis--topical review.

Morbus Ledderhose is a rare hyperproliferative disease of the plantar fascia, leading to the formation of nodules. Its origin is unknown. No causal therapy is available, and treatment remains symptomatic. Various therapeutic strategies to alleviate symptoms are available and are adapted to the severity of the disease. In early stages, conservative therapy including nonpharmacological, physical, and pharmacological treatments is applied. If the disease progresses, irradiation of the plantar surface, injections of steroids, shock wave therapy, and partial or complete fasciectomy as an ultimate therapy may be indicated. Novel experimental treatment options including application of fibrinolytic agents are currently being tested, but no controlled, randomized long-term studies are available. This review aims to provide a systematic overview of current established procedures and outlines novel experimental strategies for the treatment of morbus Ledderhose, including future avenues to treat this rare disease.

Direct visualisation of microparticles in the living lung.

Microparticles (MP) and fibres can be inhaled and cause inflammatory lung diseases. So far MP and fibres have not observed directly in the lung of living animals. A direct visualisation of particles and fibres would be important to study interactions with local and immigration host cells. In this methodical report latex beads were used as model particles for, e.g. nanoparticles, dusts, pollen or bacteria and were investigated using intravital fluorescence microscopy. Intravital fluorescence microscopy of the lung periphery is challenging because of the constant movement of the lung tissue and the heart. Chest window techniques have been described for investigation of lung vessels. For investigation of MP in larger areas of the lung surface this study presents an open chest-technique. Fluorescent MP were instilled into the trachea and could be observed in the alveoli of the right lung. Abundant numbers of MP were found within alveolar macrophages indicating that they are actively engulfed. Using the same setup also fluorescence labelled bacteria and its phagocytosis could be observed as shown in preliminary experiments. In conclusion, we present a method to analyse MP/fibres and its interaction with local and immigrating host cells in the living lung.