Therapy of aseptic nonunions with parathyroid hormone.

The absence of osseous consolidation of a fracture for 9 or more months with no potential to heal is defined as nonunion. Both for the patient and from a socioeconomic point of view, nonunions represent a major problem. Hypertrophic, vital nonunions are distinguished from atrophic avital ones. Risk factors for a delayed fracture healing are insufficient immobilisation, poor adaptation of the fracture surfaces or residual instability, interposition of soft tissue within the fracture gap, as well as circulation disturbances and infections. The incidence of nonunions after fractures of the long bones lies between 2.6 and 16% depending on the surgical technique used. In human and animal studies, a positive effect of parathyroid hormone (PTH) on fracture healing has been shown. PTH has a direct stimulatory effect on osteoblasts and osteoclasts. In addition, it appears to influence the effect of osseous growth factors. In this prospective study, 32 patients with nonunions were treated with teriparatide to investigate the effects of PTH on fracture healing. Definitive healing of the nonunions following PTH treatment could be observed in 95% of the cases.

Mesenteric Panniculitis (MP) in CT - A Predictor of Malignancy?

PURPOSE: The exact etiology of mesenteric panniculitis (MP) is still unknown and has been discussed in relation to different causes. The aim of this retrospective study was to evaluate a coherence between MP and malignancy. MATERIALS AND METHODS: Retrospective analysis of consecutive CT abdomen examinations of 5595 patients in terms of MP over a period of 3 years was performed. To make the diagnosis of MP, three of five typical signs were obligatory: hyperdense mass lesion with intercalated nodules, a "fat-ring sign" or halo sign, a hyperdense pseudocapsule and displacement of bowel loops. The patient cohort (mean age: 64.7 years) consisted of 1974 (35.2 %) patients with histologically confirmed cancer and 3621 patients (64.8 %) without known underlying oncological disease. RESULTS: A total of 143 cases were diagnosed with MP (2.55 %). The average age of patients was 69.9 years with a male to female ratio of 2:1. In this group oncological disease was confirmed in 107 patients (74.8 %). In 36 patients with MP (25.2 %), no malignancy was present. In the group of patients with an underlying oncological disease, the prevalence of MP was 5.42 % and was significantly higher (p < 0.005) than in the patients with MP and without an oncological disease. The highest prevalence of MP (29 cases) was observed in non-Hodgkin lymphoma (22.6 %). The statistically calculated risk of a tumor disease in this collective is about 5 times higher if MP was demonstrated (p < 0.001). CONCLUSION: Based on the data of the collective, the risk of malignancy is five times higher in the presence of MP than in an inconspicuous mesentery. MP seems to frequently occur with non-Hodgkin lymphoma. MP can be seen on the basis of typical morphological features on the CT image. MP must be differentiated from a wide range of benign and malignant diseases of the mesentery. KEY POINTS: • Mesenteric panniculitis can be diagnosed with CT.• In the case of accidentally diagnosed mesenteric panniculitis, a possible malignant cause should be ruled out in the differential diagnosis. Citation Format: • Scheer F, Spunar P, Wiggermann P et al. Mesenteric Panniculitis (MP) in CT - A Predictor of Malignancy?. Fortschr Röntgenstr 2016; 188: 926 - 932.

[Balloonsacroplasty: C-arm or CT controlled application? : Experience with 46 patients]. / Ballonsakroplastie: C-Bogen-kontrolliert oder CT-gesteuert? : Erfahrungen bei 46 Patienten.

INTRODUCTION: Sacral insufficiency fractures are often overlooked and lead to severe therapy-resistant pain. These fractures can be most sensitively detected with magnetic resonance imaging (MRI). Similar to balloon kyphoplasty, sacroplasty provides fixation of these fractures with cement. OBJECTIVES: This study was carried out to investigate whether pain is reduced using this method and whether computed tomography (CT)-guided cement application results in less cement extravasation and fewer complications than C-arm controlled application. MATERIAL AND METHODS: In a retrospective multicenter study, 46 patients (41 female, 5 male) with an average age of 75 years were treated by sacroplasty. The procedure was performed with CT-guidance for 25 patients and with C-arm control for 21 patients. Pain was evaluated using a visual analog scale. Patients were followed up for 6 months. RESULTS: The average operation time was 35 min and postinterventional hospital stay averaged 4 days. In the CT group pain decreased from an average score of 8.8 ± 0.7 preoperatively to 2.6 ± 0.6 postoperatively (p < 0.001) and in the C-arm group pain decreased from 8.2 ±1.0 to 2.2± 1.4 (p < 0.001). There were no cases of cement extravasation in the CT group (0 out of 25 = 0 %) and 8 asymptomatic cases in the C-arm group (8 out of 21 = 38 %). In addition, there were two injuries to the superior gluteal artery with hematoma in the area of puncture, one requiring operative treatment. There were two mortalities in the CT group from lung disease and stroke during the study but this was unrelated to the operation. CONCLUSION: Balloon sacroplasty results in a reliable and significant reduction in pain for sacral insufficiency fractures. The C-arm controlled cement application resulted in more frequent extravasation and complications than CT-guided application.

Balloon sacroplasty as a palliative pain treatment in patients with metastasis-induced bone destruction and pathological fractures.

PURPOSE: In the case of metastatic involvement of the sacrum with destruction and consecutive pathological fracture, intense disabling pain is one of the defining factors. The feasibility, safety and pain development with cement augmentation were to be investigated. MATERIALS AND METHODS: CT-guided balloon sacroplasty was conducted in 10 patients with metastasis-induced bone destruction of the sacrum. After establishment of the entry point, a K-wire was first introduced as far as the central tumor lesion via the short, or transiliac axis. A cannula was then positioned over the wire. Under CT guidance, a balloon catheter was introduced through the cannula and inflated and deflated several times. The PMMA cement was then injected into the preformed cavity. The procedure was completed by a spiral CT control using the thin-slice technique. Pain intensity was determined using a visual analog scale (VAS) before the procedure, on the 2nd postoperative day and 6 months after the intervention. Finally, the patients were asked to state how satisfied they were. RESULTS: Balloon sacroplasty was technically feasible in all patients. The control CT scan showed central distribution of the cement in the tumor lesion. On average 6 +/- 1.78 (4 - 10) ml of PMMA cement were introduced per treated lesion. A significant (p < 0.001) reduction in pain according to the VAS occurred in all patients from 9.3 +/- 0.67 (8 - 10) pre-operatively to 2.7 +/- 1.28 (1 - 5) on the 2nd postoperative day and 2.9 +/- 0.81 (2 - 5) 6 months after the intervention. All of the patients were re-mobilized after the procedure and underwent the further therapeutic measures as planned. CONCLUSION: Balloon sacroplasty is a helpful therapeutic option in the overall palliative treatment of patients with tumor-induced destruction. It is a safe and practicable procedure that markedly reduces disabling pain.

Single-phase percutaneous recanalization of malignant bile duct obstructions with a covered stent graft.

PURPOSE: The aim of this study was to evaluate the benefit of a percutaneous transhepatic biliary drainage (PTCD) endoprothesis in the case of patients with malignant occlusion of the common bile duct (CBD). MATERIALS AND METHODS: 32 patients (mean age 72 ±â€Š13 years) were treated with an endoprosthesis (VIABIL; M. L. GORE & ASSOCIATES, INC., USA) due to failed attempts of endoscopic retrograde cholangiopancreatography (ERCP) in the case of malignant occlusion of the CBD. RESULTS: The technical success rate was 96.9 %. In one patient the probing of an intrahepatic bile duct was impossible. Two major complications (bleeding, liver abscess) were successfully treated with appropriate measures. The bilirubin level did not significantly decrease immediately after intervention (13.2 ±â€Š6.5 mg/dl; p > 0.05). However, the follow-up displayed a highly significant decrease of bilirubin to 6.0 ±â€Š7.4 mg/dl; p < 0.05). The endoprosthesis was extended with bare metal NITINOL stents in 9 patients. The mean survival time of the patient group was 64 ±â€Š28 days (range 2 - 250  days). CONCLUSION: The implantation of an endoprosthesis proved to be an option with high technical success, a low complication rate and good benefit in our patients with malignant bile duct obstruction in palliative therapy situations. KEY POINTS: • The primary objective in the case of malignant bile duct obstruction is the treatment of jaundice.• After failed endoscopic recanalization of the bile ducts, transhepatic biliary drainage is desirable.• An ePTFE-FEP covered endoprothesis is a good treatment option in palliative situations.• A single-stage procedure shortens hospitalization time.

Experimental investigation of modern and established carotid stents.

PURPOSE: The design and material determine the mechanical properties of stents. In vitro parameters such as radial force, flexibility and wall adaptation of different stents were investigated in order to obtain evidence for clinical use. MATERIALS AND METHODS: A total of 8 stents, including 2 hybrid stents with a combination of closed/open-cell design (Sinus Carotid RX, Cristallo Ideale), 3 closed-cell stents (Adapt, Carotid Wallstent, Xact Carotid) and 3 open-cell stents (Vivexx Carotid, Protégé Rx and Precise) with a diameter of 8 mm and a length of 40 mm, were investigated. The radial force, the bending stiffness of the stent system and of the stent, and the collapse pressure were measured. The wall adjustment of the stents was documented by fluoroscopy and assessed in a step and curve model. RESULTS: The bending stiffness of the stent systems declined significantly in the expanded state, whereby the Xact Carotid stent showed the highest value (291.1 N/mm2) in contrast to 31.6-39.4 N/mm2 for the Sinus Carotid and Cristallo Ideale. The radial force on expansion of the stents to 7 mm was lowest for the Adapt (0.009 N/mm) and highest for the Precise (0.068 N/mm). The collapse pressure was highest for the Carotid Wallstent (0.48 bar), compared with the other stents (0.1 - 0.2 bar). The best wall adjustment in the curve model was shown by the Precise, the Sinus Carotid Rx and the Vivexx Carotid Stent. The diameter change from 5 to 7 mm was smoothly adapted by the Cristallo Ideale and the Carotid Wallstent. The Adapt showed poor vessel wall adaptation in both step and curved vessels. CONCLUSION: As a result of their design, the Sinus Carotid Rx and the Cristallo Ideale show the best wall adjustment, with comparable radial force and high flexibility, whereby the Cristallo Ideale has the advantage that it has a closed-cell design in the middle third of the stent. The other stents should be taken into consideration with their specifications in individual cases. KEY POINTS: The investigation of carotid stents provides an objective comparison of mechanical properties. Conclusions about the respective optimum uses of stents can be drawn from this. The hybrid stents show a good balance of properties for wide applicability. Citation Format: • Wissgott C, Schmidt W, Behrens P et al. Experimental Investigation of Modern and Established Carotid Stents. Fortschr Röntgenstr 2014; 186: 157 - 165.

Combination of rotational atherothrombectomy and Paclitaxel-coated angioplasty for femoropopliteal occlusion.

OBJECTIVE: The rotational atherothrombectomy with Straub Rotarex(®) is a safe and efficient treatment of acute/subactute vascular occlusions. The purpose of this study was to evaluate the benefit of paclitaxel-coated angioplasty after rotational atherothrombectomy over an observation period of six months. MATERIALS AND METHODS: Overall, 29 patients were treated with the Rotarex catheter in combination with paclitaxel-coated angioplasty. All patients had acute/subacute and chronic occlusions of the superficial femoral artery (SFA) and/or popliteal arteries. The ankle-brachial index (ABI) was detected before the intervention, after the procedure, and after six months. Also clinical examination and ultrasound scans were done in the observation period. RESULTS: There were no technical failures. The ABI shows a significant increase from 0.52 ± 0.17 to 0.91 ± 0.25 in the follow-up. By ultrasound examination, there were found two (6.9%) restenoses during the follow-up. There was one dissection during the intervention (3.5%). CONCLUSION: The rotational atherothrombectomy in combination with paclitaxel-coated angioplasty might be an effective and safe method with a promising low rate of restenosis at six months.

Percutaneous Vascular Closure System Based on an Extravascular, Bioabsorbable Polyglycolic Plug (ExoSeal): Results from 1000 Patients.

PURPOSE: The objective of this prospective study was to evaluate the effectiveness and safety of a percutaneous closure system based on a polyglycolic acid plug for achieving hemostasis. MATERIAL AND METHODS: In this study from 2011 to 2014, a percutaneous vascular closure system (ExoSeal) was used in 1000 patients (mean age 70.6 ± 10.2 years), using antegrade and retrograde techniques within the context of an angiographic intervention. The system was used in conjunction with transfemoral approaches with a sheath size of 6F. Post the intervention (on the following day and after 6 weeks), follow-up was conducted clinically and using color-coded duplex ultrasound. RESULTS: Immediate hemostasis was achieved in 939/1000 patients (93.9%). In the remaining 61 cases, a correct positioning of the polyglycolic acid plug was not possible because of malfunctioning of the device, massive vascular wall calcifications, postoperative scar tissue, or too steep a puncture angle. In these cases, manual compression was successful. There was one retroperitoneal bleeding requiring transfusion. Minor complications were observed (7.4% in total) with 10 pseudoaneurysm (1%), 63 inguinal hematomas (up to 3 cm; 6.3%), and 1 stenosis (0.1%). CONCLUSION: Safe and effective hemostasis is possible with the percutaneous ExoSeal closure system at puncture sizes of 6F.

Solitary breast cancer metastasis to the esophagus - a multimodal diagnostic approach.

We present a case of late breast cancer metastasis over 15 years since the initial diagnosis which was highly unusual because of its solitary aspect with no other evidence of the disease and its uncommon localization in the esophagus. With a history of breast cancer, several differential diagnoses for suspicious space-occupying masses need to be considered, like radiation-induced cancer or multiple neoplasm. A multimodal diagnostic approach can lead to the correct diagnosis. Endoscopy, endoscopic ultrasound (EUS) including EUS-guided fine-needle aspiration (FNA), CT and PET/CT findings are provided.