Marcel Dudda

ULTRASOUND ENHANCED ENDOCYTOTIC ACTIVITY OF HUMAN FIBROBLASTS

Although various in vitro studies have shown that low-intensity pulsed ultrasound influences cytoskeletal components and biochemical pathways, the exact biologic mechanisms are still not fully understood. In this study, we analysed the effect of therapeutic ultrasound on the endocytotic activity of human foreskin fibroblasts. Fibroblasts were incubated with two different endocytotic markers (transferrin Alexa 488 and Lucifer yellow; Sigma Bioprobes, Eugene, OR, USA). To evaluate the amount of internalized markers in sonicated and nonsonicated control cells, confocal microscopy and plate reader experiments were performed. Additionally, the structural integrity of the cell membrane was monitored by electron-microscopy. After ultrasound treatment a clear increase (1.6-fold/Lucifer yellow and 1.4-fold/transferrin Alexa 488) of fluorescent marker uptake was detected. Confocal microscopy and plate reader experiments revealed that whole populations of sonicated fibroblasts showed a significant higher fluorescence compared with cells not sonicated (p<0.05; t-test for unpaired samples). The electron microscopic analysis of the cells showed no signs of structural membrane damage or a loosening of the membrane integrity. However, an exceedingly high amount of endocytotic vesicles and clathrin coated pits were observed in the sonicated group.

Low-intensity pulsed ultrasound as a useful adjuvant during distraction osteogenesis: a prospective, randomized controlled trial.

BACKGROUND Low-intensity pulsed ultrasound (LIPUS) was proven to have a positive impact on bone healing in animal and clinical studies. METHODS In this prospective, randomized controlled trial the effect of LIPUS during distraction osteogenesis was investigated. Thirty-six patients who underwent distraction osteogenesis (>2 cm) were enrolled. Sixteen patients in the treatment group received LIPUS, and 20 patients as control group did not. Ultrasound treatment device was transcutaneously applied at the distraction gap for 20 minutes daily (frequency 1.5 MHz, signal burst with 200 μs, signal repetition frequency 1.0 kHz, intensity 30 mW/cm(2)). Evaluation of patients was performed by standard radiographs every 3 weeks to 4 weeks. RESULTS Average transport distance was 7.0 cm in the ultrasound group and 6.3 cm in the control group. Mean Paley index for the ultrasound group was 1.09 mo/cm and 1.49 mo/cm for the control group. Mean distraction consolidation index for the ultrasound group was 32.8 d/cm and 44.6 d/cm for the control group. The calculated indices indicated no significant statistical difference between the two groups (p < 0.116) but the fixator gestation period could be decreased for 43.6 days in the treatment group. CONCLUSIONS Therapeutic application of LIPUS during callus distraction constitutes a useful adjuvant treatment during distraction osteogenesis and has a positive effect on healing time with no negative effects.

Sakrumfrakturen und lumbopelvine Instabilitäten bei Beckenringverletzungen

Multiplanar posterior pelvic ring instabilities are severe injuries and typically occur in the os ilium, the sacroiliac joint, the sacrum and/or in a combination of these sites. They pose challenges to the orthopedic trauma surgeon during reconstruction, particularly when these injuries are associated with multiplanar sacral fractures and involvement of the lumbosacral junction. Due to the multidirectional forces affecting the pelvic ring, one has to have basic knowledge about the mechanism of injury, its biomechanics, and the various treatment options. In the following we give an overview on injury classifications, biomechanical aspects of the injuries and various types of operative treatments and osteosynthesis techniques.ZusammenfassungMultiplanare dorsale Beckenringinstabilitäten sind schwerwiegende Verletzungen und betreffen typischerweise das Os ilium, das Iliosakralgelenk, das Sakrum und/oder eine Kombination dieser anatomischen Strukturen. Sie stellen eine besondere Herausforderung für den behandelnden Chirurgen im Hinblick auf die anatomische Rekonstruktion und knöcherne Stabilisierung dar, insbesondere wenn mit einer multiplanaren Sakrumfraktur eine Involvierung des lumbosakralen Übergangs einhergeht. Aufgrund der mehrdimensionalen Kräfte, die auf den Beckenring einwirken, müssen grundlegende Kenntnisse der Verletzung, Biomechanik und verschiedener Versorgungsoptionen vorliegen. In der vorliegenden Arbeit soll ein Überblick über die Verletzungsklassifikationen und über biomechanische Aspekte verschiedener anerkannter standardisierter Osteosyntheseformen gegeben werden.AbstractMultiplanar posterior pelvic ring instabilities are severe injuries and typically occur in the os ilium, the sacroiliac joint, the sacrum and/or in a combination of these sites. They pose challenges to the orthopedic trauma surgeon during reconstruction, particularly when these injuries are associated with multiplanar sacral fractures and involvement of the lumbosacral junction. Due to the multidirectional forces affecting the pelvic ring, one has to have basic knowledge about the mechanism of injury, its biomechanics, and the various treatment options. In the following we give an overview on injury classifications, biomechanical aspects of the injuries and various types of operative treatments and osteosynthesis techniques.

Pediatric and adolescent intra-articular fractures of the calcaneus.

Calcaneal fractures in childhood are very rare, whereas particularly intra-articular displaced fractures are not typical in skeletally immature children. Various techniques of osteosynthesis have been described. This study aimed to determine clinical and radiological outcome after surgical treatment of intraarticular calcaneal fractures. Fourteen intraarticular fractures of the calcaneus were included in this retrospective study. Eleven children (2 girls and 9 boys) aged 6-16 years (average age 11.5 years) underwent surgical treatment. One child sustained a Type II open fracture of both calcanei. All injuries occurred after a high-energy trauma; 3 patients had multiple additional fractures. The clinical and radiological postoperative follow up was an average 44 months. In 4 cases, a reduction through a minimally invasive approach and fixation with K-wires or screws could be achieved. Eleven fractures were treated with open reduction and internal fixation with plate osteosynthesis, K-wires or screws. In one case with open fractures of both heel bones, an additional external fixator was applied. The surgical treatment approach adopted enabled the pre-operative Böhler’s angle (average 16°) to be improved to an average 30°. In all cases, except for the patient with open fractures, a good functional result and outcome could be achieved. In calcaneal fractures in childhood, anatomical reduction is the determining factor, as in fractures in adults, whereas the surgical technique seems to have no influence on clinical outcome in children. The wound healing problems that have often been described were not observed in this age group.

[Sacrum fractures and lumbopelvic instabilities in pelvic ring injuries: classification and biomechanical aspects].

Multiplanar posterior pelvic ring instabilities are severe injuries and typically occur in the os ilium, the sacroiliac joint, the sacrum and/or in a combination of these sites. They pose challenges to the orthopedic trauma surgeon during reconstruction, particularly when these injuries are associated with multiplanar sacral fractures and involvement of the lumbosacral junction. Due to the multidirectional forces affecting the pelvic ring, one has to have basic knowledge about the mechanism of injury, its biomechanics, and the various treatment options. In the following we give an overview on injury classifications, biomechanical aspects of the injuries and various types of operative treatments and osteosynthesis techniques.ZusammenfassungMultiplanare dorsale Beckenringinstabilitäten sind schwerwiegende Verletzungen und betreffen typischerweise das Os ilium, das Iliosakralgelenk, das Sakrum und/oder eine Kombination dieser anatomischen Strukturen. Sie stellen eine besondere Herausforderung für den behandelnden Chirurgen im Hinblick auf die anatomische Rekonstruktion und knöcherne Stabilisierung dar, insbesondere wenn mit einer multiplanaren Sakrumfraktur eine Involvierung des lumbosakralen Übergangs einhergeht. Aufgrund der mehrdimensionalen Kräfte, die auf den Beckenring einwirken, müssen grundlegende Kenntnisse der Verletzung, Biomechanik und verschiedener Versorgungsoptionen vorliegen. In der vorliegenden Arbeit soll ein Überblick über die Verletzungsklassifikationen und über biomechanische Aspekte verschiedener anerkannter standardisierter Osteosyntheseformen gegeben werden.AbstractMultiplanar posterior pelvic ring instabilities are severe injuries and typically occur in the os ilium, the sacroiliac joint, the sacrum and/or in a combination of these sites. They pose challenges to the orthopedic trauma surgeon during reconstruction, particularly when these injuries are associated with multiplanar sacral fractures and involvement of the lumbosacral junction. Due to the multidirectional forces affecting the pelvic ring, one has to have basic knowledge about the mechanism of injury, its biomechanics, and the various treatment options. In the following we give an overview on injury classifications, biomechanical aspects of the injuries and various types of operative treatments and osteosynthesis techniques.

Vitiligo and allergic complications from orthopaedic joint implants: the role of benzoyl peroxide.

Orthopaedic joint implants and osteosynthetic materials are progressively being employed more often. Complications mainly include physical-mechanical problems and infections. Uncommonly, allergic reactions to an alloy metal or a bone cement component have been implicated. Less attention has been paid to the components of bone cement, such as acrylate, catalysers (e.g. peroxide), additive polymers or stabilisers. An important bone cement component is benzoylperoxide (BPO), an initiator of the process enhancement of the bone cement. Vitiligo is an acquired, progressive depigmenting disorder that can induce autoimmune diseases. The occurrence of vitiligo in combination with an infection or allergy is not well described, and this manuscript highlights the possibility of an occurrence of a vitiligo whenever the immunesystem is activated and T-cell activation is observed. The aim of this article was to analyze the diagnosis and management of vitiligo and allergic complications from orthopaedic joint implants due to benzoyl-peroxide and relevant patents.

Pediatric pelvic ring injuries: How benign are they?

INTRODUCTION With an incidence of less than 0.2% of all pediatric fractures, pelvic ring injuries are rare. Historically they were conservatively treated, but because malunion and long-term morbidity are associated with unstable injuries, a trend towards operative treatment can be observed. The purpose was to determine clinical and radiographic outcomes following these complex pediatric pelvic ring injuries. PATIENTS AND METHODS This Level IV retrospective analysis was completed at a private orthopaedic practice in association with a Level One teaching trauma center. There were 33 children with pelvic ring injuries with a mean age of 12.6 years (4-16) and an average follow up of 28.6 months (range 6-101). Injuries were 2 A2, 3 B1, 16 B2, 10 B3, and 2 C2 according to OTA/AO classification. Group 1 had 16 unstable, operatively treated injuries and Group 2 had 17 stable, non-operatively treated injuries. Radiographic deformity, leg length discrepancy, low back, and SI joint pain were evaluated. RESULTS For Group 1, 10 of 15 patients (67%) had a permanent ischial height difference >5mm compared to Group 2, in which 5 of 12 (42%) had an ischial height difference of >5mm. Group 1 had more pelvic asymmetry (12.3mm vs. 6.6mm) and ring width difference (6.9mm vs. 3.9mm) on final X-rays as compared to Group 2. Children with 5-10mm posterior sacral displacement had significantly more pain than children with 0-4mm displacement (p=0.034). Thirteen children (39%) had residual low back/SI joint pain; the rate was significantly higher in the Group 1 (3/17 vs. 10/16, p=0.008). In three (9%) children with 2 B2 and 1 B3 injury, leg length discrepancy between 5mm to 15mm occurred. DISCUSSION AND CONCLUSION In pediatric patients with pelvic ring injuries, radiographic deformity persisted and did not remodel. Pelvic ring deformity occurred more commonly with complex unstable ring injuries. The complex displaced injuries have higher rates of operative intervention, residual deformity, and low back and SI joint pain.

Fulminant necrotizing fasciitis of the thigh, following an infection of the sacro-iliac joint in an immunosuppressed, young woman

Necrotizing soft tissue infection of an extremity is a rare but life-threatening disease. The disease is an infection that involves the soft tissue layer and is characterized by rapidly spreading inflammation (especially of the fascial planes and the surrounding tissues) with a high mortality. Early diagnosis is essential for the outcome of the patients. Radical surgical debridement is the treatment of choice. The predisposing factors are immunosuppression, diabetes mellitus and drug abuse. This report presents a case of necrotizing fasciitis in the thigh, following an abscess of the sacro-iliac joint, as a rare complication in a young, immunosuppressed woman. The patient’s history revealed intravenous drug abuse and hepatitis C. After immediate diagnosis by magnetic resonance imaging, radical surgical debridement was required and performed. Prior to soft tissue coverage with a split skin graft, five additional sequential debridements were necessary. During her hospital stay, the patient experienced further cerebral and pulmonary septic embolisms and an infection of the elbow. Six months after admission, the patient was discharged in good condition to a rehabilitation center. Necrotizing fasciitis is a life-threatening complication following an abscess of the sacro-iliac joint. Physicians must be vigilant to inflammatory signs and pain in immunosuppressed patients. An abscess of the sacro-iliac joint is rare, but complications of an untreated abscess can be fatal in these patients.

[Blunt force injuries due to martial arts in children--a diagnostic problem? Delayed diagnosis of an infected hematoma].

INTRODUCTION Blunt force injuries in martial arts occur frequently but isolated hematoma of muscles in the extremities is rare. Even minor trauma of the lower extremities due to throwing techniques in judo and other forms of Asian martial arts can lead to major pathologies. METHODS A 9-year-old girl presented with an unclear swelling and soreness of the calf muscle. The patient could not remember an obvious traumatic event. She was admitted 4 days later because of increased swelling, pain and erythema. The parents reported a minor trauma at judo training 1 week ago. Further investigation was performed with MRI and confirmed a massive hematoma much greater than previously shown by sonography. RESULTS Histologic and microbiologic evaluation demonstrated florid inflammation and proof of Staphylococcus aureus was found intra-operatively. DISCUSSION The diagnosis of blunt force injuries due to martial arts is difficult in childhood because often children do not remember a traumatic event. Therefore, it is important to obtain a thorough history from caregivers. Because sonography depends highly on the experience of the investigator MRI is considered to be a better diagnostic modality to diagnose and guide treatment in this age group.ZusammenfassungEinleitungVerletzungen im Kampfsport sind häufig. Oftmals handelt es sich um stumpfe Traumata, gerade im Judo und anderen asiatischen Kampfsportarten. Isolierte Muskellogenhämatome in der Wadenmuskulatur sind hingegen selten.MethodeBerichtet wird über ein 9-jähriges Mädchen mit unklarem Schmerz und Schwellung der Wade. Initial war ein Trauma nicht erinnerlich. Vier Tage später erfolgte eine Wiedervorstellung mit einem geröteten, geschwollenen Unterschenkel. Sport- und Spielanamnese ergab eine Bagatellverletzung im Judotraining eine Woche zuvor. Das MRT-Bild zeigte ein Weichteilhämatom mit deutlicher Größenzunahme im Vergleich zur vorherigen Sonographie.ErgebnisHistologisch waren eine floride Entzündungsreaktion des Hämatoms sowie der Nachweis von Staphyloccocus aureus intraoperativ nachweisbar.DiskussionDiagnosen stumpfer Verletzungen durch Kampfsport im Kindesalter sind häufig schwierig, die Fremd-, Sport- und Spielanamnese äußerst wichtig. Da die Sonographie stark untersucherabhängig ist, bietet die MRT bei nicht eindeutigem klinischem Befund und unklarer Anamnese einen dominanten Stellenwert in der Diagnostik, da Weichteilstrukturen mit entsprechenden Sequenzen in kürzester Zeit gut und ohne Strahlenbelastung dargestellt werden können.AbstractIntroductionBlunt force injuries in martial arts occur frequently but isolated hematoma of muscles in the extremities is rare. Even minor trauma of the lower extremities due to throwing techniques in judo and other forms of Asian martial arts can lead to major pathologies.MethodsA 9-year-old girl presented with an unclear swelling and soreness of the calf muscle. The patient could not remember an obvious traumatic event. She was admitted 4 days later because of increased swelling, pain and erythema. The parents reported a minor trauma at judo training 1 week ago. Further investigation was performed with MRI and confirmed a massive hematoma much greater than previously shown by sonography.ResultsHistologic and microbiologic evaluation demonstrated florid inflammation and proof of Staphylococcus aureus was found intra-operatively.DiscussionThe diagnosis of blunt force injuries due to martial arts is difficult in childhood because often children do not remember a traumatic event. Therefore, it is important to obtain a thorough history from caregivers. Because sonography depends highly on the experience of the investigator MRI is considered to be a better diagnostic modality to diagnose and guide treatment in this age group.

Low complication rate of elastic stable intramedullary nailing (ESIN) of pediatric forearm fractures: A retrospective study of 202 cases

Abstract Elastic stable intramedullary nailing (ESIN) has been established as state of the art treatment for forearm fractures in children, if operative stabilization is required. Their use has been expanded to single bone shaft fractures, and also more complex injuries such as Monteggia fractures or Monteggia-like lesions. A wide range of complications has been reported in the literature, up to 70% in certain investigations. The purpose of this study was to assess the complication rate after ESIN treatment of forearm fractures in children and adolescents in a representative cohort of patients from a level 1 trauma center in Germany. Between 2000 and 2015, we retrospectively analyzed all patients, up to the age of 16 years, with forearm fractures, who were operatively treated using ESIN in our department of general and trauma surgery. The main outcome measurements were the rates of postoperative complications after ESIN such as re-fracture, malunion, nonunion, tendon lesion, wound infection, and limited range of motion. In all, 201 consecutive patients with 202 forearm fractures were included in this study. Age averaged 9.7 years (range 3–16 years). Fifteen (7.4%) fractures were open. Fractures were 82.2% diaphyseal both-bone forearm fractures. Follow-up averaged 10.2 months (range 0.7–176.3 months). Complications were 10 re-fractures, 2 malunions, 3 extensor pollicis longus tendon ruptures, 1 superficial wound infection, and 2 limited range of motions. Fourteen (6.9%) children required a secondary operative intervention for their complication. Time to implant removal averaged 3.8 months (range 0.4–16.3 months). Elastic stable intramedullary nailing is a minimally invasive and reliable technique with a low complication rate. Both-bone forearm fractures and single bone fractures, and also Monteggia and Monteggia-equivalent fractures can be successfully treated with this method. As a major complication, re-fractures are frequently seen, even with ESIN in situ.