[Correction of kyphotic fixed lumbar segments and hypolordosis with the transforaminal lumbar interbody fusion technique]. / Erweiterte transforaminale lumbale intersomatische Fusion zur Korrektur kyphotisch fixierter lumbaler Segmente und lumbaler Hypolordosen.

OBJECTIVE: Correction of a segmental or global lumbar hypolordosis to improve a sagittal imbalance. INDICATIONS: Lumbar segments fixed in kyphosis; degenerative or posttraumatic hypolordotic deformity of the lumbar spine with sagittal imbalance. CONTRAINDICATIONS: Bechterew disease; extended adhesions in the retroperitoneum. SURGICAL TECHNIQUE: Segmental correction of a kyphotic fixed segment using a unilateral transforaminal approach to release the annulus and anterior longitudinal ligament. With an additional posterior V­shaped osteotomy, a segmental correction of more than 20° could be achieved to improve a global sagittal imbalance. POSTOPERATIVE MANAGEMENT: Back-friendly mobilisation starting the first day after surgery with support of a physiotherapist. No sports for 3-4 months. RESULTS: In all, 25 patients with 33 kyphotic fixed lumbar segments were treated using a complete anterior release of the annulus and anterior longitudinal ligament via a unilateral transforaminal approach. This enabled a lordosizing correction of the segment between 5° and 29° (mean 11.4°) without any neurological or vascular complications. A total of 10 patients treated with an additional posterior osteotomy were corrected 14-29° (mean 19°). There was a loss of reduction of the lordotic correction (mean 1°; range 0-3°) in the X­ray control at a minimum follow-up of 6 months (range 6-33 months).

[S2-Ala-iliac screws for extended pelvic fixation in longer lumbar instrumentations : Description of a freehand technique]. / S2-Ala-Iliumschrauben zur erweiterten pelvinen Fixation mehrsegmentaler lumbaler Spondylodesen : Beschreibung einer Freihandtechnik.

OBJECTIVE: To reduce the rate of implant failures at the lumbosacral junction in polysegmental lumbar fusions. INDICATIONS: Spinal fusion with deformity correction including L5/S1, revision surgery for pseudoarthrosis L5/S1, screw pull-out and pedicle fractures in S1, and S1/S2 fractures after polysegmental fusions. CONTRAINDICATIONS: Osteosynthesis of complex pelvic ring fractures, tumors of the ilium. Relative contraindication: infection, to avoid contamination of the iliosacral joint. SURGICAL TECHNIQUE: Conventional posterior approach to the lumbar spine. Positioning of the lumbar and S1 pedicle screws in common technique. Identification of the correct entrance point for one or two S2-Ala-iliac screws for each side and preparation of the drill holes in freehand technique. Connection of the lumbar and S1 pedicle screws and S2-Ala-iliac screws with one stress-free rod on each side without the use of connectors or special plates. POSTOPERATIVE MANAGEMENT: Back-friendly mobilization beginning on day 1 after surgery with support of a physiotherapist. No sports for 12 weeks. RESULTS: In all, 25 patients were treated with an extended pelvic fixation using S2-Ala-iliac screws. A primary deformity correction was performed in 11 patients, whereas 14 patients underwent revision surgery. A total of 24 patients were clinically and radiologically followed for a mean of 16 months. Two patients showed a loosening of the S2-Ala-iliac screws on one side, and one patient had broken screw as well only on one side without clinical symptoms. So far, no patient has undergone revision surgery because of S2-Ala-iliac screw-associated complications.

[Infections of the spine : Therapeutic strategies]. / Infektionen der Wirbelsäule : Therapiestrategien.

Spinal infections are relatively rare entities but the incidence is significantly increasing due to the rapidly growing numbers of interventions on the spine. Primary infections of intervertebral discs (spondylodiscitis) and vertebral bodies (spondylitis) are distinguished from secondary postinterventional infections. Treatment relies primarily on either conservative or surgical management. In the absence of indications for surgery, a conservative approach is indicated when the patient is neurologically intact and the bony destruction is minimal. Conservative therapeutic options are based on the microbiological diagnosis and use of antibiotics, immobilization, analgesics and orthotics. Indications for a surgical intervention are the presence of neurological deficits, intraspinal abscesses, extensive osseous destruction and failure of conservative management. Surgical therapy focusses on the decompression of neural structures, debridement and eradication of the focus of infection, pathogen identification, correction of the deformity and restoration of a physiological spinal profile. Following a postoperative infection a timely diagnosis including assessment of the extent of infection is crucial. In the case of a purely superficial infection, antibiotic prophylaxis and close monitoring is indicated. If findings are pronounced surgical revision, debridement together with antibiotic therapy and if necessary vacuum-assisted closure as well as revision ranging from exchange of implants to complete removal of osteosynthetic material are required. Spinal infections are severe conditions frequently with residual long-term sequelae, whether the patients are managed conservatively or surgically.

[Is the standard retention of syndesmotic positioning screws after ankle fracture fixation safe and feasible? A retrospective cohort study in 140 consecutive patients at a North American trauma centre]. / Ist das routinemäßige Belassen von Syndesmosenschrauben nach operativer Versorgung instabiler Sprunggelenksfrakturen gerechtfertigt? Erfahrung eines US-Traumazentrums an 140 konsekutiven Patienten.

BACKGROUND: Unstable ankle injuries with associated disruption of the distal-fibular syndesmosis are typically managed by adjunctive placement of temporary syndesmotic positioning screws. The widespread notion that positioning screws must be removed by default after healing of the syndesmosis remains a topic of debate which lacks scientific support. The present study was designed to test the hypothesis that syndesmotic positioning screws are safely retained per protocol in asymptomatic patients. PATIENTS AND METHODS: A retrospective analysis of an institutional prospective database was performed during a 5-year time-window at an academic level 1 trauma centre in the United States. All ankle fractures requiring surgical fixation were included in the analysis. The primary outcome parameter consisted of the rate of elective hardware removal for syndesmotic positioning screws within 6 months after surgical fixation. RESULTS: A total of 496 consecutive patients with 496 isolated ankle fractures managed by surgical fixation were included in this study. Of these, 140 injuries were managed by placement of syndesmotic positioning screws. Within 6 months follow-up, 17.1% of all syndesmotic screws were found to be radiographically broken, and 13.6% of syndesmotic screws revealed radiographic signs of loosening. Only 2 patients (1.4%) required the elective removal of symptomatic positioning screws within 6 months of surgical fracture fixation. CONCLUSION: Despite the high rate of radiographic complications related to breaking or loosening of syndesmotic screws in almost one third of all cases, more than 98% of all patients remain asymptomatic and do not require a scheduled hardware removal. The routine removal of syndesmotic positioning screws does not appear to be justified from a patient safety perspective.

[Challenging the dogma on inferiority of stainless steel implants for fracture fixation. An end of the controversy?]. / Das Dogma der Minderwertigkeit von Stahlimplantaten zur Frakturversorgung. Ein Ende der Kontroverse?

BACKGROUND: Titanium plates represent the predominant implants of choice for fracture care in Central Europe, based on the apparently favourable properties related to improved "biocompatibility". The present study was designed to test the hypothesis that the use of stainless steel implants for selected fractures represents a safe and efficient treatment modality, which is not associated with an increased rate of complications and surgical revisions. METHODS: We conducted a retrospective analysis of a prospective database during a 5-year study period (01/01/2006-12/31/2010) at an academic Level 1 Trauma Center on all fractures treated by stainless steel plates. Inclusion criteria consisted of all consecutive patients >15 years of age whose fractures were fixated with a stainless steel plate. All fractures were classified according to the AO/OTA system. Outcome parameters consisted of the rate of complications and surgical revisions, and the data were placed into context with the published complication rates for titanium plates. RESULTS: A total of 1,001 consecutive patients who underwent surgical fixation of fractures in the indication spectrum of this study were screened. Of these, 751 patients fulfilled the inclusion criteria. These patients had 774 fractures which were fixated with 859 stainless steel plates. Open fractures accounted for 9.6% of all injuries (n=74). The complication rate of the 774 fractures treated with stainless steel plates was 8.01% (n=62), with a surgical revision rate of 5.16% (n=40). These data are below the reported incidence of complications and surgical revisions for titanium plates in the identical indication spectrum in the pertinent literature published. CONCLUSIONS: The fixation of selected fractures with stainless steel implants represents a safe and efficient treatment option, which does not appear to be associated with increased complication rates. These data challenge the anecdotal superiority of titanium plates and should spur a new discussion on the use of stainless steel implants, particularly under the aspect of cost savings in the DRG era.

[Surgical treatment of ankle fractures as an outpatient procedure. A safe and resource-efficient concept?]. / Ambulante Versorgung operativer Spunggelenkfrakturen an einem US-Traumazentrum. Ein valides Modell im DRG-Zeitalter?

BACKGROUND: In many European countries, patients requiring surgical treatment of ankle fractures are generally hospitalized for an average of 8-11 days. This anecdotal concept is largely based on the premise that the inpatient monitoring of soft tissue conditions may lead to a decreased complication rate. The present study was designed to test the hypothesis that the surgical care of isolated ankle fractures as an outpatient procedure represents a safe and feasible concept which is not associated with an increased complication rate. METHODS: A retrospective analysis was performed of a prospective database during a 5-year period (01/01/2005-12/31/2009) at a US academic level 1 trauma center with an institutional protocol of outpatient surgery for isolated ankle fractures. All fractures were classified according to the AO/OTA system. Outcome parameters consisted of the rate of postoperative complications and frequency of unplanned surgical revisions outpatient isolated versus inpatient isolated with surgical fixation of ankle isolated fractures. RESULTS: Among 810 consecutive patients with ankle fractures during the study period, 476 met the inclusion criteria. Of these, 256 patients (53.8%) were treated as outpatients. The average length of stay of patients who were admitted as inpatients was 1.5±0.8 days (range 1-5 days). The age distribution was in a similar range for inpatients and outpatients (39±14.1 vs 35±12.8 years), and the injury severity based on the AO/OTA fracture classification revealed a similar distribution of fracture patterns in both groups. The rate of postoperative complications (9.1 vs 3.1%) and of unplanned surgical revisions (3.6 vs 1.2%) was significantly increased in the hospitalized group, compared to patients with ambulatory surgery (P<0.05). CONCLUSION: The surgical treatment of isolated ankle fractures as an outpatient procedure represents a safe and resource-efficient concept which is not associated with an increased complication rate. Cultural differences in the domestic environment of individual patients may have to be taken into consideration.

[Bariatric surgery and associated complications: radiological imaging]. / Adipositaschirurgie und ihre Komplikationen : Radiologische Bildgebung.

Obesity is an increasing problem faced by the healthcare system. In managing obesity, bariatric surgery is becoming more important with evidence showing a reduction in long-term morbidity and mortality. There are special challenges faced by the radiology department in providing an imaging service for this population of patients, from technical requirements through to the interpretation of post-surgical images. This article provides an overview of the most frequently performed procedures, normal postoperative imaging findings and the appearance of common complications.

Comparison of a new whole-body continuous-table-movement protocol versus a standard whole-body MR protocol for the assessment of multiple myeloma.

OBJECTIVES: To evaluate a whole body (WB) continuous-table-movement (CTM) MR protocol for the assessment of multiple myeloma (MM) in comparison to a step-by-step WB protocol. METHODS: Eighteen patients with MM were examined at 1.5T using a WB CTM protocol (axial T2-w fs BLADE, T1-w GRE sequence) and a step-by-step WB protocol including coronal/sagittal T1-w SE and STIR sequences as reference. Protocol time was assessed. Image quality, artefacts, liver/spleen assessability, and the ability to depict bone marrow lesions less than or greater than 1 cm as well as diffuse infiltration and soft tissue lesions were rated. Potential changes in the Durie and Salmon Plus stage and the detectability of complications were assessed. RESULTS: Mean protocol time was 6:38 min (CTM) compared to 24:32 min (standard). Image quality was comparable. Artefacts were more prominent using the CTM protocol (P = 0.0039). Organ assessability was better using the CTM protocol (P < 0.001). Depiction of bone marrow and soft tissue lesions was identical without a staging shift. Vertebral fractures were not detected using the CTM protocol. CONCLUSIONS: The new protocol allows a higher patient throughput and facilitates the depiction of extramedullary lesions. However, as long as vertebral fractures are not detectable, the protocol cannot be safely used for clinical routine without the acquisition of an additional sagittal sequence.

Evaluation of malignant liver tumors: biphasic MS-CT versus quantitative contrast harmonic imaging ultrasound.

PURPOSE: It was the aim of our study to establish the extent to which contrast enhancement with SonoVue(R) in combination with quantitative evaluation of contrast-medium dynamics facilitates the detection of malignant hepatic tumors. MATERIALS AND METHODS: One hundred patients with histologically confirmed malignant or benign hepatic tumors (maximum size 5 cm) were analyzed. We used a high-end ultrasound machine (Logic 9, GE Healthcare, Milwaukee, WI, USA), with a multifrequency curved array transducer (2.5 - 4 MHz), Contrast-enhanced ultrasound (bolus injection 2.4 mL SonoVue(R)) was carried out with the intermittent breath-holding technique. Native vascularization was analyzed with power Doppler sonography. The contrast-enhanced dynamic ultrasound investigation was carried out with contrast harmonic imaging in the true detection mode during the arterial, portal venous and late phases. The mechanical index was set at 0.15. Perfusion analysis was performed by post-processing of the raw data (time intensity curve [TIC] analysis). Biphasic 16- or 64-slice multislice computed tomography served as reference method in nearly all cases. RESULTS: One hundred patients with 59 malignant (43 colon, 5 breast, 2 endocrine metastases, 7 hepatocellular carcinomas and 2 kidney cancers) and 41 benign (12 circumscribed fatty changes, 2 abscesses, 7 focal nodular hyperplasias, 5 complicated cysts and 15 hemangiomas) tumors were included. The CT classification was true positive in 71 of 92 patients, false negative in 8 cases, and in 13 cases no final diagnosis was possible; sensitivity was 96.7 % and specificity was 71.4 % for CT. The quantitative contrast harmonic imaging ultrasound classification was true positive in 98 of 100 patients and false negative in 2 cases; the sensitivity was 98.6 % and the specificity was 96.6 %. The Fisher test showed a significant difference at p < 0.05. No investigator-dependency was noted. CONCLUSION: In our study contrast-enhanced ultrasound was more accurate than multislice computed tomography in the prediction of malignancy and benignity of liver tumors.

[Osteoathritis after SLAP Lesion? Clinical and arthro-MRI evaluation after arthroscopic SLAP refixation]. / Die SLAP-Läsion als Präarthrose? Klinische und MR-Arthrografie-Ergebnisse nach arthroskopischer Refixation einer SLAP-II-Läsion.

INTRODUCTION: The development of glenohumeral osteoarthritis is sufficiently described after instability and rotator cuff pathologies. The purpose of this work was to evaluate a coherency between glenohumeral osteoarthritis and SLAP lesions by means of MR arthrography which has not been described up to now in the literature. MATERIAL AND METHODS: 20 patients with a SLAP lesion type II were treated with arthroscopic SLAP repair. MR arthrography was performed after intra-articular administration of diluted gadolinium (after positive vote of the ethics committee) after a mean FU of 36 months (26 to 54 months). The MR arthrography data were analysed by 3 investigators (two radiologists, one orthopaedic surgeon) in consensus. Osteoarthritis was graded according to the modified Outerbridge classification for MRI. Besides image quality and artifacts, adhesions from the tendon to the bone and the rotator cuff were evaluated. Intraoperative documented findings were used for comparison. The clinical investigation encompassed Roweand Constant score, clinical investigation of instability and SLAP lesion (O'Brian test, SLAP apprehension test) as well as the subjective contentment. The statistical evaluation was performed with SAS reverse. RESULTS: In 12 of 20 cases an increase of glenohumeral osteoarthritis was seen, in 4 cases a circumscribed entire cartilage defect appeared in the MRI. Osteoarthritis did not correlate with the subjective and objectively collected clinical results or the aetiology of the SLAP lesion at the time of the re-examination. Results of the MR arthrography revealed that, in six cases, the biceps anchor did not show proper bony ingrowth. Nonetheless, these cases do not correlate with a poorer clinical result. CONCLUSION: Due to the small case number a correlation between SLAP lesion and osteoarthritis cannot be postulated statistically, however, the results still indicate a trend which should be pursued in the long-term course.

Multislice computed tomography versus contrast-enhanced ultrasound in evaluation of complex cystic renal masses using the Bosniak classification system.

To assess the diagnostic performance of multislice computed tomography (MS-CT) in the classification of atypical or complex cystic renal masses using the Bosniak system in comparison to contrast-enhanced ultrasound (CEUS) and, in unclear cases, to the surgery findings.Thirty-two consecutive patients (14 women, 18 men; age range 39-72 years) with 37 atypical or complex cystic renal masses at MS-CT underwent conventional ultrasound (US) and CEUS. CEUS employed a low-MI technique using 1.6-2.4 ml SonoVue (Bracco, Italy) i.v. and a 2-4 MHz multifrequency transducer (Siemens, Sequoia, Acuson). Fourteen masses were resected, the remaining 23 lesions were followed up for periods ranging from 3 months to 2 years. Images and digital cine clips of all lesions were evaluated by blinded readers. On the basis of MS-CT appearance the lesions were assigned to the Bosniak classification. Similar criteria modified for US imaging were used to score atypical cysts at CEUS. In the Bosniak classification at MS-CT the lesions were scored as category II (n=15), IIF (n=7), III (n=8) and IV (n=7). At CEUS, masses were classified as Bosniak classification II (n=8), IIF (n=12), III (n=8) or IV (n=9). All type IV and 6/8 type III and 1/8 type IIF lesions were removed surgically. All category IV and 3/8 category III lesions of the surgical group were malignant, the one type IIF lesion was benign. All class II and IIF cysts except one were stable after a follow-up period ranging from 3 months to 2 years. In 7/37 lesions (19%) the MS-CT and CEUS scores were different, while in 30/37 (81%) they were equivalent. CEUS depicted more thin septa than MS-CT, or upgraded wall thickness, resulting in a Bosniak score upgrade from category II to IIF in 5 lesions. Two cystic renal masses could not be clearly assigned by MS-CT but were considered malignant due to the additional information from CEUS, which was confirmed by surgical removal (small cystic renal cancer).CEUS with SonoVue allows an early evaluation of atypical or complex cystic renal masses. It is an additional examination to MS-CT. Due to the dynamic examination, additional information about perfusion of the cystic septa or cystic renal cancer can be gained.

[Vascular and parenchymal diseases of the kidney]. / Vaskuläre und parenchymale Erkrankungen der Nieren.

Diseases of the kidney often progress to end-stage renal failure over a period of several years and might lead to life-long dialysis. To avoid loss of renal function, kidney disease should be diagnosed as early as possible in order to initiate therapeutic measures in time. Several invasive and non-invasive radiological imaging techniques for the detection and characterization of renal disease are available. Particularly, non-invasive computed tomography (CT) and magnetic resonance imaging (MRI) have seen substantial technical advances in recent years. Today, both modalities offer a comprehensive diagnostic evaluation of renal diseases in a single examination, comprising detailed information of the parenchyma as well as of arterial and venous vasculature. This review article describes the most important vascular and parenchymal kidney diseases and their radiological characteristics with a focus on MRI and CT.

[Screening in cardiovascular diseases]. / Screening bei Herz- und Gefässkrankheiten.

Cardiovascular disease still ranks number one in the mortality statistics in the industrialized world. In Germany the five most common causes of death are all associated with arteriosclerotic changes of the arterial vasculature. As the treatment often extends over long periods and it can be impossible for patients to work, peripheral arterial occlusive disease (PAOD) constitutes a not inconsiderable economic factor. Thus, screening for arteriosclerotic disease seems to be reasonable, because the potential for influencing arteriosclerotic changes is known to be higher in an early stage of the disease even before symptoms become apparent. Not every case can be cured, but progression can frequently be slowed down. The need for invasive procedures, some of them associated with ionizing radiation, limited the use of imaging of the arterial vasculature for a long time. Noninvasive clinical examinations such as the "ankle brachial index" (ABI) can indicate the presence of PAOD, though exact localization of the pathologic changes is not possible except with imaging methods. In contrast to these, MRI is a noninvasive imaging modality that does not involve ionizing radiation but offers high spatial resolution arterial imaging.

[A 19-year-old patient with acute promyelocytic leukemia and knee swelling]. / 19-jährige Patientin mit akuter Promyelozytenleukämie und Knieschwellung.

We report on a case of a 19-year-old female patient with acute promyelocytic leukemia suffering from febrile monarthitis of the right knee during neutropenia after consolidation chemotherapy caused by Geotrichum capitatum. Apparently this infection occurred due to a hematological reactivation since the patient had already developed Geotrichum capitatum fungemia during induction therapy. Under antimycotic therapy with voriconazole, flucytosine, and caspofungin as well as after two arthroscopic synovectomies with cleansing of the right knee, the infection could be controlled and the full clinical function of the knee joint could be preserved.