Biomechanical evaluation of locked plating fixation for unstable femoral neck fractures.

AIMS: Evaluate if treating an unstable femoral neck fracture with a locking plate and spring-loaded telescoping screw system would improve construct stability compared to gold standard treatment methods. METHODS: A 31B2 Pauwels' type III osteotomy with additional posterior wedge was cut into 30 fresh-frozen femur cadavers implanted with either: three cannulated screws in an inverted triangle configuration (CS), a sliding hip screw and anti-rotation screw (SHS), or a locking plate system with spring-loaded telescoping screws (LP). Dynamic cyclic compressive testing representative of walking with increasing weight-bearing was applied until failure was observed. Loss of fracture reduction was recorded using a high-resolution optical motion tracking system. RESULTS: LP constructs demonstrated the highest mean values for initial stiffness and failure load. LP and SHS constructs survived on mean over 50% more cycles and to loads 450 N higher than CS. During the early stages of cyclic loading, mean varus collapse of the femoral head was 0.5° (SD 0.8°) for LP, 0.7° (SD 0.7°) for SHS, and 1.9° (SD 2.3°) for CS (p = 0.071). At 30,000 cycles (1,050 N) mean femoral neck shortening was 1.8 mm (SD 1.9) for LP, 2.0 mm (SD 0.9) for SHS, and 3.2 mm (SD 2.5) for CS (p = 0.262). Mean leg shortening at construct failure was 4.9 mm (SD 2.7) for LP, 8.9 mm (SD 3.2) for SHS, and 7.0 mm (SD 4.3) for CS (p = 0.046). CONCLUSION: Use of the LP system provided similar (hip screw) or better (cannulated screws) biomechanical performance as the current gold standard methods suggesting that the LP system could be a promising alternative for the treatment of unstable fractures of the femoral neck.Cite this article: Bone Joint Res 2020;9(6):314-321.

A rabbit humerus model of plating and nailing osteosynthesis with and without Staphylococcus aureus osteomyelitis.

The local mechanical environment at a fracture is known to influence biological factors such as callus formation, immune cell recruitment and susceptibility to infection. Infection models incorporating a fracture are therefore required to evaluate prevention and treatment of infection after osteosynthesis. The aim of this study was to create humane, standardised and repeatable preclinical models of implant-related bone infection after osteosynthesis in the rabbit humerus. Custom-designed interlocked intramedullary nails and commercially available locking plates were subjected to biomechanical evaluation in cadaveric rabbit humeri; a 10-week in vivo healing study; a dose response study with Staphylococcus aureus over 4 weeks; and finally, a long-term infection of 10 weeks in the plate model.Outcome measures included biomechanical testing, radiography, histology, haematology and quantitative bacteriology. Both implants offered similar biomechanical stability in cadaveric bones, and when applied in the in vivo study, resulted in complete radiographic and histological healing and osteotomy closure within 10-weeks. As expected in the infection study, higher bacterial doses led to an increasing infection rate. In both infected groups, there was a complete lack of osteotomy closure at 4 weeks. C-reactive protein (CRP), lymphocyte: granulocyte ratio and weight loss were increased in infected animals receiving IM nails in comparison with non-inoculated equivalents, although this was less evident in the plate group. In the 10-week infection group, healing does not occur in the plated rabbits. We have successfully developed a rabbit model that is suitable for further studies, particularly those looking into preventative strategies for post-traumatic implant-related osteomyelitis.

[The Postero-Lateral Approach--An Alternative to Closed Anterior-Posterior Screw Fixation of a Dislocated Postero-Lateral Fragment of the Distal Tibia in Complex Ankle Fractures]. / Der posterolaterale Zugang--eine Alternative zur geschlossenen anterior-posterioren Schraubenosteosynthese bei komplexen Sprunggelenkfrakturen.

BACKGROUND: The dislocated posterolateral fragment of the distal tibia is considered as a key fragment for the successful reduction of comminuted ankle fractures. The reduction of this fragment can either be achieved indirectly by joint reduction using the technique of closed anterior-posterior screw fixation, or directly using the open posterolateral approach followed by plate fixation. The aim of this study was to compare the outcome after stabilization of the dislocated posterolateral tibia fragment using either closed reduction and screw fixation, or open reduction and plate fixation via the posterolateral approach in complex ankle fractures. PATIENTS/MATERIAL AND METHODS: In a prospective study between 01/2010 and 12/2012, all mono-injured patients with closed ankle fractures and dislocated posterolateral tibia fragments were assessed 12 months after osteosynthesis. Parameters included: size of the posterolateral tibia fragment relative to the tibial joint surface (CT scan, in %) as an indicator of injury severity, unreduced area of tibial joint surface postoperatively, treatment outcome assessed by using the "Ankle Fracture Scoring System" (AFSS), as well as epidemiological data and duration of the initial hospital treatment. RESULTS: In 11 patients (10 female, 1 male; age 51.6 ± 2.6 years [mean ± SEM], size of tibia fragment 42.1 ± 2.5 %) the fragment fixation was performed using a posterolateral approach. Impaired postoperative wound healing occurred in 2 patients of this group. In the comparison group, 12 patients were treated using the technique of closed anterior-posterior screw fixation (10 female, 2 male; age 59.5 ± 6.7 years, size of tibia fragment 45.9 ± 1.5 %). One patient of this group suffered an incomplete lesion of the superficial peroneal nerve. Radiological evaluation of the joint surface using CT scan imaging demonstrated significantly less dislocation of the tibial joint surface following the open posterolateral approach (0.60 ± 0.20 mm) compared to the closed anterior-posterior screw fixation (1.03 ± 0.08 mm; p < 0.05). Assessment of the treatment outcome using the AFSS demonstrated a significantly higher score of 97.4 ± 6.4 in the group with a posterolateral approach compared to a score of 74.4 ± 12.1 (p < 0.05) in the group with an anterior-posterior screw fixation. CONCLUSION: In comparison to the anterior-posterior screw fixation, open reduction and fixation of the dislocated, posterolateral key fragment of the distal tibia using a posterolateral approach resulted in a more accurate fracture reduction and significantly better functional outcome 12 months after surgery. In addition, no increased rate of postoperative complications, or extended hospital stay was observed but there was less severe post-traumatic joint arthritis. The results of this study suggest that in complex ankle factures the open fixation of the dislocated posterolateral fragment is recommended as an alternative surgical procedure and may be beneficial for both clinical and radiological long-term outcomes.

[Pyoderma gangrenosum after intramedullary nailing of tibial shaft fracture: A differential diagnosis to necrotizing fasciitis]. / Pyoderma gangraenosum nach Marknagelosteosynthese bei Tibiaschaftfraktur : Eine Differenzialdiagnose zur nekrotisierenden Fasziitis.

Pyoderma gangrenosum is a rare non-infectious neutrophilic dermatitis, whereas necrotizing fasciitis is a life-threatening bacterial soft tissue infection of the fascia and adjacent skin. As in the case described here after intramedullary nailing, the clinical appearance of both diseases can be similar. Because of the completely different therapeutic approach and a worse outcome in the case of false diagnosis, pyoderma gangrenosum should always be taken into consideration before treating necrotizing fasciitis.

[Effect of frequency compression in hearing aids on speech intelligibility and subjective sound quality]. / Wirkung von Frequenzkompression in Hörgeräten auf das Sprachverstehen und das subjektive Klangempfinden der Nutzer.

BACKGROUND: The acceptance of hearing aids by users with high frequency hearing loss still represents a problem. Processing algorithms that shift high frequency signal components into an audible frequency range are proposed as a solution. We looked into the issue of whether frequency compression becomes more beneficial with increasing high frequency hearing loss or/and for users with cochlear dead regions (DR). SUBJECTS AND METHODS: A total of 20 hearing aid candidates were assessed audiometrically and classified into two test groups in terms of their hearing loss and the presence of DR. The subjects then evaluated four hearing aid settings that differed solely in the degree of frequency compression. Speech recognition threshold measurements and subjective sound quality ratings were carried out for all four settings. RESULTS: Data showed that 15 of the 20 test subjects understood fricatives with a high frequency spectrum component better, since they were able to distinguish between the two logatomes "Afa" and "Asa". No correlation was found between the beneficial effect of frequency compression and the degree of high frequency hearing loss or the presence of DR. Subjective sound quality ratings indicated no clear preference, but excessive frequency compression was generally deemed counterproductive. CONCLUSION: Frequency compression may be appropriate for hearing aid users with high frequency hearing loss and can improve speech recognition. The degree of frequency compression required to achieve maximal benefit varies from case to case and has to be optimized on an individual basis.

A preliminary study on the changes in some potential markers of muscle-cell degradation in sub-maximally exercised horses supplemented with a protein and amino acid mixture.

In this preliminary study, time-dependent changes in plasma CK and AST activity, tyrosine (Tyr), 3-methyl-histidine (3mHis), glucose and lactate concentrations were analysed in nine horses under two different conditions. Furthermore, intramuscular concentrations of Tyr, 3mHis and activities of cathepsin B, acid phosphatase (ACP), glucose-6-phosphate dehydrogenase (G6PDH) and mRNA expression of ubiquitin were determined at the same time. After studying the effects of exercise alone, the effects of exercise and feeding of an experimental protein/amino acid (AA) supplement were analysed. Horses were submitted to a total of four standardised exercise tests (SETs) of high intensity. Potential markers of muscle break down were determined prior to, immediately after, 4 and 18 h after exercise. The experiment was subdivided into two consecutive periods of 3 weeks. In each period, two SETs were performed. In the second period, horses were fed with the protein/AA supplement within 1 h after exercise. Significant changes in plasma, intramuscular Tyr levels and mRNA expression of ubiquitin were caused both by time in relation to exercise and by treatment with the protein/AA supplement. The experimental supplement significantly decreased the 4-h post-exercise expression of ubiquitin mRNA in muscle. Only a borderline increase of markers of lysosomal involvement was seen and CK and AST activity generally showed their normal post-exercise patterns. A clear post-exercise reduction of this CK activity, however, was not observed after supplementation with the protein/AA mixture. The current findings indicate that horses might benefit from protein and AA supplementation directly after training by decreasing post-exercise proteolysis. The results support that further studies should be performed to characterize changes in equine protein metabolism caused by exercise including underlying molecular mechanisms.

Changes in intramuscular amino acid levels in submaximally exercised horses - a pilot study.

The time-dependent changes in intramuscular amino acid (AA) levels caused by exercise and by feeding a protein/AA supplement were analysed in nine horses. Horses were submitted to a total of four standardized exercise tests (SETs). Amino acid concentrations were determined prior to, immediately after, 4 and 18 h after exercise. The experiment was subdivided into two consecutive periods of 3 weeks. In each period two SETs were performed. In the second period, horses were given a protein/AA supplement within 1 h after exercise. Significant changes in mean plasma AA levels similar to previous studies were noted to be time-dependent and to be associated with feeding the supplement. The intramuscular concentrations of the free AA in relation to pre-exercise levels showed significant time-dependent changes for alanine, asparagine, aspartate, citrulline, glutamine, glycine, isoleucine, leucine, methionine, serine, taurine, threonine, tyrosine and valine. Feeding the supplement significantly increased the 4 h post-exercise intramuscular concentration of alanine, isoleucine, methionine and tyrosine. At 18 h after exercise, apart from isoleucine and methionine, levels were still increased and also those of asparagine, histidine and valine in relation to none treatment. Hence, it was concluded that AA mixtures administered orally to horses within 1 h after exercise increased intramuscular AA pool.

The effects of short intensive exercise on plasma free amino acids in standardbred trotters.

The aim of this study was to investigate the effect of short intense exercise on plasma amino acid concentrations in trotters and to test the repeatability of plasma amino acids concentration in samples obtained on two independent days under field conditions. Plasma amino acid concentrations were analysed in blood samples of 36 standardbred trotters before and after intense exercise over a distance of 2000 m. Sampling was repeated in 20 horses after 35 days. Exercise intensity was estimated from post-exercise lactate levels. Horses were divided in two groups according to a cut-off lactate concentration at 15 mmol/l. The plasma concentrations of alanine, aspartate, glutamate, isoleucine, leucine, lysine and taurine increased and arginine, asparagine, citrulline, glutamine, glycine, histidine, methionine, serine, tryptophan and 3-methylhistidine decreased after exercise. Ornithine, threonine, tyrosine, phenylalanine and valine concentrations remained constant. Higher intensity of exercise significantly decreased tryptophan and increased taurine concentrations. Sampling day had a significant effect on the absolute pre- and post-exercise amino acid concentrations. Exercise had a significant influence on the concentrations of most plasma amino acids in trotters. These changes could reflect shifts between the free amino acid compartments, but there were also some indications for muscle catabolism. The amino acid supply of sporting horses could be of specific significance for maintaining muscle integrity and for the improvement of post-exercise recovery of competition horses.

Individual differences and repeatability of post-prandial changes of plasma-free amino acids in young horses.

Few data are available on post-prandial changes of plasma amino acids (AAs) in horses and on the repeatability and the individual variance on different sampling days. The objective of the present study was to measure pre- and post-prandial concentrations of plasma AA in 10 yearling horses. Blood samples were taken on days 1 and 40 of the study before feeding of hay, oats and soya meal and over an 8 h post-prandial period in 2-h intervals. The plasma AAs were measured by high-pressure liquid chromatography after ortho-phthalaldehyde derivatization. Mean fasting concentrations of the AAs were not significantly influenced by the individuum and sampling day. Repeatability of the fasting AA levels in the individual horses on two different sampling days was only found for histidine, 3-methylhistidine, methionine, tryptophan and taurine. While the absolute post-prandial AA concentrations differed between sampling days, the relative changes were comparable. All AA concentrations except 3-methylhistidine increased after feeding by 13% to more than 200% of their fasting values if the combined data of both days were analysed. Four hours after feeding the concentrations of arginine, asparagine, lysine, leucine, isoleucine and threonine, decreased more than 20%. Histidine, methionine, phenylalanine, valine, tryptophan, glutamine, glycine, tyrosine and taurine concentrations decreased by less than 20%. Concentrations of aspartic acid, glutamic acid, ornithine, serine and citrulline remained elevated. Most AA approached the fasting concentrations at 8 h, only glycine increased between 6 and 8 h after meal and 3-methyl-histidine concentrations were constant throughout the entire period. In conclusion, the pre-prandial plasma AA in horses appeared less influenced by individuum or sampling day than post-prandial plasma AA concentrations. Therefore, plasma AA concentrations should be interpreted only under well-defined conditions, especially regarding the feeding regimen.

Multi-microphone technology for severe-to-profound hearing loss.

In this study the potential benefit of hearing instruments with multi-microphone technology was investigated in laboratory and in field tests for users with severe-to-profound hearing loss. Twenty-one experienced hearing aid users were fitted with high-power multi-microphone hearing instruments (Phonak PowerZoom P4 AZ). The following evaluations were performed: (i) adaptive speech test (SRT for HSM sentence test) in quiet and in noise with their own instrument and the test instrument in the omnidirectional (basic program) and directional mode (party noise profound+zoom algorithm). (ii) Paired comparisons of loudness, sound quality and speech intelligibility for both the omni and zoom program. (iii) Questionnaires on satisfaction and self-assessment of communication in different listening conditions (Oldenburg Inventory). Only 10 subjects achieved 50% correct (SRT) on the sentence test in noise (speech 0 degrees/noise 180 degrees) with both their own instrument and the test instrument in the omnidirectional mode. However, 15 subjects succeeded in the SRT measurement in the directional mode. The average SRT improvement of the directional over the omnidirectional mode was 13.7 dB. Loudness was judged 'medium loud' for both listening programs. Sound quality and intelligibility were rated significantly better for the zoom program. Compared to their own instrument users' satisfaction with the test instrument was significantly higher, especially in noisy listening situations.

Comparison of two digital hearing instrument fitting strategies.

Two different hearing instrument fitting strategies were compared in the laboratory and in a field test with regard to the benefit for hearing aid users and their satisfaction with the fitting. DSL [input/output (i/o)] fittings based on hearing threshold and uncomfortable levels for the subject were evaluated vs a prescriptive fitting method based on unaided loudness scaling. Twenty-one subjects were fitted diotically with both fitting strategies implemented in a digital hearing instrument (Siemens Prisma). The patients tested both fitting strategies sequentially in a 4 + 4-week field trial using a crossover study design. Speech recognition threshold measurements, sound quality ratings and paired comparisons of sound quality were performed for all conditions (unaided, DSL[i/o] fitting and loudness-based fitting). In addition, subjective benefit and preference were assessed with questionnaires. Speech audiometry did not reveal significant differences between the two fittings. DSL[i/o] fittings showed superior results in most sound quality tests and in the self-assessment of communication abilities while the loudness-based approach was slightly preferred in noisy environments. The results seemed to be influenced by the higher gain predicted by DSL[i/o]. This study provides no evidence that effort spent on loudness scaling leads to improved fitting results.