Management of proximal femur fractures in the elderly: current concepts and treatment options.

As one of the leading causes of elderly patients' hospitalisation, proximal femur fractures (PFFs) will present an increasing socioeconomic problem in the near future. This is a result of the demographic change that is expressed by the increasing proportion of elderly people in society. Peri-operative management must be handled attentively to avoid complications and decrease mortality rates. To deal with the exceptional needs of the elderly, the development of orthogeriatric centres to support orthogeriatric co-management is mandatory. Adequate pain medication, balanced fluid management, delirium prevention and the operative treatment choice based on comorbidities, individual demands and biological rather than chronological age, all deserve particular attention to improve patients' outcomes. The operative management of intertrochanteric and subtrochanteric fractures favours intramedullary nailing. For femoral neck fractures, the Garden classification is used to differentiate between non-displaced and displaced fractures. Osteosynthesis is suitable for biologically young patients with non-dislocated fractures, whereas total hip arthroplasty and hemiarthroplasty are the main options for biologically old patients and displaced fractures. In bedridden patients, osteosynthesis might be an option to establish transferability from bed to chair and the restroom. Postoperatively, the patients benefit from early mobilisation and early geriatric care. During the COVID-19 pandemic, prolonged time until surgery and thus an increased rate of complications took a toll on frail patients with PFFs. This review aims to offer surgical guidelines for the treatment of PFFs in the elderly with a focus on pitfalls and challenges particularly relevant to frail patients.

Novel method for reduction of virus load in blood plasma by sonication.

BACKGROUND: Aim of the present study is the evaluation of ultrasound as a physical method for virus inactivation in human plasma products prior to transfusion. Our study is focused on achieving a high level of virus inactivation simultaneously leaving blood products unaltered, measured by the level of degradation of coagulation factors, especially in third world countries where virus contamination of blood products poses a major problem. Virus inactivation plays an important role, especially in the light of newly discovered or unknown viruses, which cannot be safely excluded via prior testing. METHODS: Taking into account the necessary protection of the relevant coagulation activity for plasma, the basis for a sterile virus inactivation under shielding gas insufflation was developed for future practical use. Influence of frequency and power density in the range of soft and hard cavitation on the inactivation of transfusion-relevant model viruses for Hepatitis-(BVDV = bovine diarrhea virus), for Herpes-(SFV = Semliki Forest virus, PRV = pseudorabies virus) and Parvovirus B19 (PPV = porcine parvovirus) were examined. Coagulation activity was examined via standard time parameters to minimize reduction of functionality of coagulation proteins. A fragmentation of coagulation proteins via ultrasound was ruled out via gel electrophoresis. The resulting virus titer was examined using end point titration. RESULTS: Through CO2 shielding gas insufflation-to avoid radical emergence effects-the coagulation activity was less affected and the time window for virus inactivation substantially widened. In case of the non-lipidated model virus (AdV-luc = luciferase expressing adenoviral vector), the complete destruction of the virus capsid through hard cavitation was proven via scanning electron microscopy (SEM). This can be traced back to microjets and shockwaves occurring in hard cavitation. The degree of inactivation seems to depend on size and compactness of the type of viruses. Using our pre-tested and subsequently chosen process parameters with the exception of the small PPV, all model viruses were successfully inactivated and reduced by up to log 3 factor. For a broad clinical usage, protection of the coagulation activities may require further optimization. CONCLUSIONS: Building upon the information gained, an optimum inactivation can be reached via raising of power density up to 1200 W and simultaneous lowering of frequency down to 27 kHz. In addition, the combination of the two physical methods UV treatment and ultrasound may yield optimum results without the need of substance removal after the procedure.

[Elbow dislocation fractures]. / Ellenbogenluxationsfrakturen.

The treatment of complex elbow dislocation fractures is a challenge to both the treating surgeon as well as to the patient due to the complex bony and soft tissue anatomy of the joint. In order to establish an expedient treatment algorithm, all osseous and ligamentous injuries need to be thoroughly assessed. Furthermore, a detailed knowledge of the joint-stabilizing structures, practicable surgical approaches as well as the possible techniques for fracture fixation and/or arthroplasty are essential to facilitate early rehabilitation of the elbow and avoid injury-related complications. Any unnecessary delay in treatment of this complex injury can result in posttraumatic functional disorders, recurrent instability and secondary arthrosis. In conclusion, the goals of surgical treatment must be the correct restoration of the joint anatomy and stability as the prerequisites for any successful treatment of elbow fracture dislocations in order to enable early motion of the joint.

Pseudoaneurysm of the anterior tibial artery after interlocking tibial nailing: an unexpected complication.

Anterior tibial pseudoaneurysm is a rare complication after interlocking screw insertion in tibial nailing. We present the case of a 28-year-old male patient with this complication with a 6-week delay after tibial nailing of a right tibial fracture type 42-A1 of the Association for the Study of Internal Fixation (AO/ASIF) classification. On presentation to our emergency department, the patient's complaints were solemnly intermittent pain and occasional swelling of his proximal lower leg. Deep vein thrombosis, compartment syndrome, and implant dislocation were ruled out, and the patient was discharged after his symptoms improved without further intervention. Four weeks later, the patient was readmitted for similar symptoms. A computed tomography (CT) angiography then revealed a pseudoaneurysm of the anterior tibial artery at the level of the proximal interlocking screw insertion. Aneurysmal sac excision with vessel repair was performed while reconstructing the additional dislocated proximal fibular fracture using standard AO/ASIF plating. Postoperatively, sufficient flow through the repaired vessel was documented using Doppler ultrasound and CT angiography. However, the patient sustained a temporal damage to the peroneal nerve after surgery. This case highlights the risk of a pseudoaneurysm of the anterior tibial artery after interlocking screw insertion as a rare but major complication of a routine surgical procedure. Early ultrasound diagnostics, CT angiography, or magnetic resonance (MR) angiogram should be performed to prevent the delay in diagnosis and treatment of such complications.

Simultaneous and coordinated rotational switching of all molecular rotors in a network.

A range of artificial molecular systems has been created that can exhibit controlled linear and rotational motion. In the further development of such systems, a key step is the addition of communication between molecules in a network. Here, we show that a two-dimensional array of dipolar molecular rotors can undergo simultaneous rotational switching when applying an electric field from the tip of a scanning tunnelling microscope. Several hundred rotors made from porphyrin-based double-decker complexes can be simultaneously rotated when in a hexagonal rotor network on a Cu(111) surface by applying biases above 1 V at 80 K. The phenomenon is observed only in a hexagonal rotor network due to the degeneracy of the ground-state dipole rotational energy barrier of the system. Defects are essential to increase electric torque on the rotor network and to stabilize the switched rotor domains. At low biases and low initial rotator angles, slight reorientations of individual rotors can occur, resulting in the rotator arms pointing in different directions. Analysis reveals that the rotator arm directions are not random, but are coordinated to minimize energy via crosstalk among the rotors through dipolar interactions.

[Fracture arthroplasty of femoral neck fractures]. / Frakturendoprothetik der medialen Schenkelhalsfraktur.

A paradigm shift in the treatment of elderly patients has recently taken place leading to an increase in joint replacement surgery. The aim of this article is to highlight new developments and to present a treatment algorithm for femoral neck fractures. The age limit must be individually determined considering the comorbidities and perioperative risk profile. Pertrochanteric femoral fractures are nearly exclusively treated by osteosynthesis regardless of age. The situation for femoral neck fractures is more complex. Patients younger than 65 years should generally be treated by osteosynthesis but patients older than 65 years benefit from hemiarthroplasty or total hip arthroplasty. In patients aged between 65 and 75 years with high functional demands and a justifiable perioperative risk, total joint replacement is the treatment of choice. In physically less active patients older than 75 years and poor general condition, preference should be given to hemiarthroplasty.

[Cardiac post-resuscitation care. An indication for trauma whole-body CT?]. / Zustand nach Reanimation. Eine Indikation für die "Traumaspirale"?

We report the case of a 51-year-old male patient who sustained a liver rupture following mechanical cardiopulmonary resuscitation (CPR) with the LUCAS® system. The patient was under anticoagulation and developed an abdominal compartment syndrome. Although the use of mechanical CPR devices, such as the LUCAS® system and the load distributing band (Autopulse®), is becoming more common, there are specific complications described in the literature, which are associated with mechanical CPR. It is important to differentiate between general complications associated with CPR and those which can be attributed to the application of mechanical CPR devices. Using the example of the presented case, this article outlines and discusses these points based on the currently available literature. It should also be noted that mechanical CPR can act in a similar way to chest trauma and can necessitate an investigation with contrast enhanced computed tomography.

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.

[Acute compartment syndrome after a bowling game]. / Kompartmentsyndrom nach Bowlingspiel.

A 28-year-old male patient was initially conservatively treated by a general physician for muscle strain of the right calf after a bowling game. Due to increasing pain and swelling of the lower leg 5 days later, the differential diagnosis of a deep vein thrombosis was considered. Furthermore, the onset of neurological deficits and problems with raising the foot prompted inclusion of compartment syndrome in the differential diagnosis for the first time. Admission to hospital for surgical intervention was scheduled for the following day. At this point in time the laboratory results showed a negative d-dimer value and greatly increased C-reactive protein level. On day 6 a dermatofasciotomy was performed which revealed extensive muscular necrosis with complete palsy of the peroneal nerve. In the following lawsuit the patient accused the surgeon of having misdiagnosed the slow-onset compartment syndrome and thus delaying correct and mandatory treatment. The arbitration board ruled that the surgeon should have performed fasciotomy immediately on day 5 at the patient's consultation. The clinical presentation of progressive pain, swelling of the lower leg in combination with peroneal palsy must lead to the differential diagnosis of compartment syndrome resulting in adequate therapy. The delay of immediate surgery, therefore, was assessed to be faulty as this knowledge is to be expected of a surgeon.

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.

Gene expression changes in cancellous bone of type 2 diabetics: a biomolecular basis for diabetic bone disease.

PURPOSE: Diabetes mellitus type 2 (2DM) is associated with altered bone quality. In order to analyze associated changes on a molecular level, we investigated the gene expression of key factors of osteoblast metabolism in type 2 diabetics. METHODS: Total mRNA and protein of bone samples from 2DM patients and non-diabetic patients were isolated, and subsequently, reverse transcription polymerase chain reaction (RT-PCR) or Western blot was performed. Furthermore, pro- and anti-inflammatory serum cytokine levels were determined using a cytokine array. RESULTS: Expression of runt-related transcription factor 2 (RUNX2) was increased by 53 %. Expression of the bone sialoproteins, secreted phosphoprotein 1 (SPP1; osteopontin), and integrin-binding sialoprotein (IBSP), was elevated by more than 50 %, and activating transcription factor 4 (ATF4) expression was 13 % lower in the investigated diabetes group compared to the control group. Similarly, the expression of versican (VCAN) and decorin (DCN) was upregulated twofold in the diabetic group. At the same time, 2DM patients and controls show alterations in pro- and anti-inflammatory cytokine levels in the serum. CONCLUSIONS: This study identifies considerable changes in the expression of transcription factors and extracellular matrix (ECM) components of bone in 2DM patients. Furthermore, the analysis of key differentiation factors of osteoblasts revealed significant alterations in gene expression of these factors, which may contribute to the dysregulation of energy metabolism in 2DM.

[Foreign body retention after soft tissue laceration. A case of insufficient inspection and documentation]. / Augenbrauenplatzwunde mit übersehenem Fremdkörper. Unzureichende Inspektion und Dokumentation.

A 52-year-old man sustained a laceration to his left eyebrow after a fall in his bathroom. His plastic glasses shattered upon impact. The patient was referred to a local emergency department. After a quick exploration by the physician on call, the wound was closed by a nurse using the Steri-Strip Wound Closure system. No further exploration or imaging was performed. Four weeks after the incident the patient presented to a dermatologist with a "foreign body sensation" at the site of the laceration. Assuming a foreign body granuloma, he was referred to a maxillofacial surgeon who removed plastic debris (parts of the glasses worn by the patient). The wound subsequently healed without further complications.The patient filed a complaint for inadequate treatment in the emergency department. No detailed patient and accident history had been obtained, the wound exploration performed by the physician was superficial, and the wound closure was performed by a nurse. The expert opinion of the arbitration board ascertained a medical malpractice in terms of insufficient history, examination, and a lack of documentation. Specific questioning of the accident history would have led to the suspicion of possible foreign bodies, thus, leading to a more thorough exploration and likely further imaging. The arbitration board concluded that obtaining a detailed accident history and an accurate examination would have revealed the foreign bodies and/or led to further imaging. Complying with this, the patient could have been spared further harm and secondary surgery would have been unnecessary.

[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.

[Fractures of the lower extremity in the emergency room. Analysis of a new immobilization and x-ray splint]. / Frakturen der unteren Extremität in der Notaufnahme. Anwendungsanalyse einer Lagerungs- und Röntgenspezialschiene.

BACKGROUND: Fractures of the lower extremity are a common reason for presentation to an emergency room. The aim of this study was to evaluate a new immobilization and x-ray splint (Andante®, ForMed) in the emergency room. METHODS: From April 2010 to August 2010 all patients presenting with a fracture of the lower extremity were included in the study. Pain perception (visual analog scale; VAS) was measured before and after splint application. The handling of the splint during radiography was assessed and the quality of the diagnostic x-ray was evaluated. RESULTS: The study comprised 61 patients. Subjective pain perception was reduced significantly (3.96±1.9 vs. 6.38±2.2; p<0.001). The handling of the splint was graded at 1.73±0.96 (1, very good; 5, poor). There was no difference in the diagnostic quality of the x-rays between the Andante® and the control group; however, significantly poorer results were found for x-rays of ankle fractures (p<0.038). CONCLUSION: The Andante® splint is a useful tool in the emergency room that combines simple handling and pain relief due to immobilization. However, the quality of the diagnostic x-rays was not better compared with the control group.

[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.

Superconductivity in just four pairs of (BETS)2GaCl4 molecules.

How small can a sample of superconducting material be and still display superconductivity? This question is relevant to our fundamental understanding of superconductivity, and also to applications in nanoscale electronics, because Joule heating of interconnecting wires is a major problem in nanoscale devices. It has been shown that ultrathin layers of metal can display superconductivity, but any limits on the size of superconducting systems remain a mystery. (BETS)2GaCl4, where BETS is bis(ethylenedithio)tetraselenafulvalene, is an organic superconductor, and in bulk it has a superconducting transition temperature Tc of approximately 8 K and a two-dimensional layered structure that is reminiscent of the high-Tc cuprate superconductors. Here, we use scanning tunnelling spectroscopy to show that a single layer of (BETS)2GaCl4 molecules on an Ag(111) surface displays a superconducting gap that increases exponentially with the length of the molecular chain. Moreover, we show that a superconducting gap can still be detected for just four pairs of (BETS)2GaCl4 molecules. Real-space spectroscopic images directly visualize the chains of BETS molecules as the origin of the superconductivity.

Charge transfer in the TCNQ-sexithiophene complex.

Molecular crystals from thiophene molecules can be doped with TCNQ-F4 molecules for use in all-organic optoelectronic and semiconductor devices. The charge transfer and the molecular orbital energy level formation in between these two organic molecules are investigated here by density functional theory calculations. The isolated molecules are calculated nonbonded and bonded together, forming a charge transfer complex (CTC). The relaxed structure of the complex shows essentially coplanar and centered molecules with the alpha-sexithiophene rings tilted alternatingly by 4.8 degrees. The bond formation of these molecules results in a charge transfer of approximately 0.4 e from the alpha-sexithiophene to the TCNQ-F4 molecule. The highest occupied molecular orbital-lowest unoccupied molecular orbital gap width is reduced as compared to the isolated molecules due to the newly formed orbitals in the CTC. Upon adsorption on a Au(111) surface, electrons are transferred onto the molecule complex, thereby causing the molecular levels to align asymmetric with respect to the charge neutrality level. The theoretical results for the single molecule and CTC layer are compared to experimental photoemission and scanning tunneling spectroscopy results.

Investigating molecular charge transfer complexes with a low temperature scanning tunneling microscope.

Electron donor-acceptor molecular charge transfer complexes (CTCs) formed by alpha-sexithiophene (6T) and tetrafluoro-tetracyano-quinodimethane (F4TCNQ) on a Au(111) surface are investigated by scanning tunneling microscopy, spectroscopy, and spectroscopic imaging at 6 K. New hybrid molecular orbitals are formed in the CTCs, and the highest occupied molecular orbital of the CTC is mainly located on the electron accepting F4TCNQ while the lowest unoccupied molecular orbital is predominantly positioned on the electron donating 6T. We observed the conductance switching of F4TCNQ inside CTCs, which may find potential applications in novel molecular device operations.

Decompositional incommensurate growth of ferrocene molecules on a Au(111) surface.

Deviating from the common growth mode of molecular films of organic molecules where the adsorbates remain intact, we observe an essentially different growth behavior for metallocenes with a low temperature scanning tunneling microscope. Ferrocene molecules adsorb dissociatively and form a two layer structure. The top layer unit cell is composed of two tilted cyclopentadienyl (cp) rings, while the first layer consists of ferrocene molecules and cp-Fe complexes. Surprisingly a fourfold symmetry is observed for the top layer while the first layer displays threefold symmetry elements. It is this symmetry mismatch which induces an incommensurability between these layers in all except one surface direction. The top layer is weakly bonded and has an antiferromagnetic ground state as calculated by local spin density functional approximation.