Icing the Pain-Ultrasound-Guided Cryoablation of Symptomatic Post-Amputation Stump Neuroma.

PURPOSE: To assess the feasibility and outcome of ultrasound-guided cryoablation in patients with a sensitized stump neuroma after limb amputation. MATERIAL AND METHODS: Seven patients (3 females, 4 males; mean age 42 years) were included in this retrospective study. Ultrasound-guided cryoablation of a previously identified painful stump neuroma was performed. Pain was assessed on the visual analogue scale (VAS) and compared before and after cryoablation (Wilcoxon Test). The degree of pain alleviation was correlated with patient age, duration of pain before ablation and time interval between amputation and ablation (Spearman correlation). A p-value less than 0.05 was deemed statistically significant. RESULTS: Nine cryoablations were performed for 8 neuromas. Technical success was 100%, there were no major complications. Mean follow-up was 27 months. There was a statistically significant decrease of pain from mean 8.3 / 10 (baseline) to 4 /10 (on day one), 2.1 / 10 (at one week) and 3 / 10 (at last follow-up) (p < 0.05). Patient satisfaction with cryoablation treatment was very high (median score 70 / 100). CONCLUSION: In our small population observational study, ultrasound-guided cryoablation of a sensitized stump neuroma was effective and safe for pain alleviation with very good long-term results. LEVEL OF EVIDENCE: Level 2, Observational study with dramatic effect.

[Injuries of the biceps-labrum complex : Principles, pathologies and treatment concepts]. / Verletzungen des Bizeps-Labrum-Komplexes : Grundlagen, Pathologien und Behandlungskonzepte.

BACKGROUND: The biceps-labrum complex is prone to acute lesions and degenerative changes due to its anatomical structure and the high load it has to endure. Pathological changes of these structures are common pain generators and can significantly impair shoulder function. Anatomically, the biceps-labrum complex can be divided into three zones: inside, junction and bicipital tunnel. DIAGNOSTIC PROCEDURE: Despite the focused physical examination and advancements in imaging techniques, the exact localization of pathologies remains challenging. Arthroscopy can be used to accurately diagnose inside and junctional pathologies but extra-articular changes in the region of the bicipital tunnel can only be partially visualized. TREATMENT: In cases of unsuccessful conservative treatment and correct indications, a high level of patient satisfaction can be surgically achieved. In young patients an anatomical reconstruction of inside lesions or tenodesis of the long head of the biceps tendon is performed; however, even tenotomy is a valuable option and can achieve equally satisfactory results. Unaddressed pathological changes of the bicipital tunnel can lead to persistence of pain. In clinical procedures performing tenodesis, both the different techniques and the implants used have been found to show similar results. This article describes the anatomical principles, pathological changes, the focused clinical instrumental diagnostics and discusses the different treatment philosophies as well as the outcome according to the recent literature.

[Typical alterations of frozen shoulder in MRI examinations]. / Typische Veränderungen bei der "frozen shoulder" in der bildgebenden MRT-Untersuchung.

Magnetic resonance imaging (MRI) is routinely used for the diagnostic assessment of diseases of the shoulder joint. Depending on the clinical presentation native imaging, intravenous (IV) or intra-articular injection of contrast medium can be performed (MR arthrography). Advances in imaging technology nowadays enable early detection of characteristic changes in the clinical picture of frozen shoulder. These changes typically include thickening of the coracohumeral ligament, the axillary pouch and the capsule at the rotator interval. Furthermore, obliteration of the subcoracoidal fat pad can also be observed. The MRI examinations also show a hyperintensity in the T2-weighted imaging and a contrast enhancement of the joint capsule. The alterations can show a temporal correlation with the clinical symptoms of the patient.

High-resolution flat panel CT versus 3-T MR arthrography of the wrist: initial results in vivo.

OBJECTIVES: The objective of this study was to compare the diagnostic performance of direct C-arm flat panel computed tomography arthrography (FPCT-A) with direct magnetic resonance arthrography (MR-A) of the wrist in patients with clinically suspected pathologies. METHODS: Forty-nine patients underwent tri-compartmental wrist arthrography. FPCT-A was acquired using a high-resolution acquisition mode, followed by a 3-T MR exam using a dedicated wrist coil. Image quality and artifacts of FPCT-A and MR-A were evaluated with regard to the depictability of anatomical structures. The time stamps for the different image acquisitions were recorded for workflow assessment. RESULTS: Image quality was rated significantly superior for all structures for FPCT-A (p < 0.001) as compared to MR-A including intrinsic ligaments, TFCC, cartilage, subchondral bone, and trabeculae. The differences in image quality were highest for cartilage (2.0) and lowest for TFCC (0.9). The artifacts were rated lower in MR-A than in FPCT-A (p < 0.001). The procedure was more time-efficient in FPCT-A than in MR-A. CONCLUSIONS: FPCT-A of the wrist provides superior image quality and optimized workflow as compared to MR-A. Therefore, FPCT-A should be considered in patients scheduled for dedicated imaging of the intrinsic structures of the wrist. KEY POINTS: • FPCT arthrography allows high-resolution imaging of the intrinsic wrist structures. • The image quality is superior as compared to MR arthrography. • The procedure is more time-efficient than MR arthrography.

Thermoablation of Bone Tumors.

UNLABELLED: The aim of this article is to review the significance of percutaneous thermal ablation in the treatment of bone tumors. We describe available ablation techniques as well as advantages and disadvantages in specific settings. In detail, radiofrequency ablation (RFA), microwave ablation (MWA), laser ablation, high intensity focused ultrasound (HIFU) and cryoablation are presented. In the second part of this review curative and palliative indications for the treatment of benign and malignant bone tumors are discussed. This includes especially RFA, laser or cryoablation for the treatment of osteoid osteoma, as well as the palliative treatment of painful bone metastases, for example, by means of MWA or MR-guided HIFU. KEY POINTS: • The various thermoablative techniques demonstrate specific advantages and disadvantages.• Radiofrequency ablation is the evidence-based method of choice for treating osteoid osteoma.• Laser ablation is primarily suited for the treatment of small lesions of the hands and feet.• The intrinsically analgesic effect of cryoablation is advantageous when treating painful lesions.• Palliative treatment of painful bone metastases can for example be performed using MWA or MR-guided HIFU, by itself or combined with cementoplasty. Citation Format: • Ringe KI, Panzica M, von Falck C. Thermoablation of Bone Tumors. Fortschr Röntgenstr 2016; 188: 539 - 550.

Evaluation of the use of a tablet computer with a high-resolution display for interpreting emergency CT scans.

PURPOSE: Evaluation of the potential usability of an iPad 3 with a high-resolution display in CT emergency diagnosis compared to a 3 D PACS workstation. MATERIALS AND METHODS: 3 readers used a 5-point Likert scale to evaluate 40 CCT scans and 40 CTPA scans to determine the detectability of early signs of infarction in CCT or segmental and subsegmental pulmonary embolisms in CT angiography of the pulmonary arteries (CTPA) on the iPad 3 (Apple Inc., USA) using an application for image viewing (Visage Ease, Visage Imaging GmbH, Berlin) and on a 3 D PACS workstation (Visage 7.1, Visage Imaging, Berlin) using a certified monitor for image viewing. The results were compared using the Wilcoxon rank sum test, Spearman's correlation coefficient, and a kappa statistic. RESULTS: There was no significant difference in the median evaluations for the readings of both the CCT scans and the CTPA scans on the iPad 3 and on the workstation (p > 0.05) for all three readers. The mean Spearman's correlation coefficient for CCT and CTPA was 0.46 (± 0.2) and 0.69 (± 0.16), respectively, for the comparison iPad/PACS, 0.41 (± 0.16) and 0.68 (± 0.06), respectively, for the interobserver agreement on the iPad, and 0.35 (± 0.05) and 0.68 (± 0.10), respectively, for the interobserver agreement on the PACS. Mean kappa values for CCT of 0.52 (± 0.17) for the comparison iPad/PACS and 0.33 (± 0.16) and 0.32 (± 0.16), respectively, for the interobserver agreement on the iPad and the PACS were achieved. For CTPA average kappa values of 0.67 (± 0.19) were calculated for the comparison iPad/PACS and 0.69 (± 0.08) and 0.60 (± 0.14), respectively, for the interobserver concordance on the iPad 3 and the PACS. All differences were not statistically significant (p > 0.05). CONCLUSION: The variability of the interpretation of typical emergency scans on an iPad 3 with a high-resolution display and on a 3 D PACS workstation does not differ from the interobserver variability.

Optimal table feed in run-off CT angiography in patients with abdominal aortic aneurysms.

OBJECTIVES: To assess the influence of different table feeds (TFs) on vascular enhancement and image quality in patients with an abdominal aortic aneurysm (AAA) undergoing computed tomography (CT) angiography of the lower extremities (run-off CTA). METHODS: Seventy-nine patients (71 ± 8 years) with an AAA (>30 mm) who underwent run-off CTA between January 2004 and August 2011 were included in this retrospective institutional review board-approved study. Run-off CTA was conducted using 16- and 64-row CT. The range of TFs was 30-86 mm/s and was categorised in quartiles TF1 (32.6 ± 1.9 mm/s), TF2 (38.9 ± 0.9 mm/s), TF3 (43.9 ± 3.1 mm/s) and TF4 (57.4 ± 10.5 mm/s). Image quality was rated independently by two radiologists and vessel enhancement was assessed. RESULTS: Image quality was diagnostic at all aortic, pelvic and almost all thigh levels. Below the knee, the number of diagnostic levels was highest for TF1 and decreased to TF4. Arterial enhancement between the aorta and fibular trunk was not different in all TF groups, P > 0.05. At the calf and foot strongest arterial enhancement was noted for TF1 and TF2 and decreased to TF4, P < 0.01. CONCLUSION: Results indicate that the highest image quality of run-off CTA in patients with an AAA may be obtained using table feeds measuring 30-35 mm/s. KEY POINTS: • CTA has become a key investigation for peripheral vascular disease. • Run-off CTA is more complex in patients with an abdominal aortic aneurysm. • Run-off CTA is feasible with a short bolus of intravenous contrast medium. • A constant 30-35 mm/s table feed provides the highest likelihood of diagnostic images.

Influence of rupture patterns of the medial patellofemoral ligament (MPFL) on the outcome after operative treatment of traumatic patellar dislocation.

PURPOSE: Patellar dislocation usually occurs to the lateral side, leading to ruptures of the medial patellofemoral ligament (MPFL) in about 90 % of all cases. Reliable prognostic factors for the stability of the patellofemoral joint after MPFL surgery and satisfaction of the patient have not been established as yet. METHODS: This multicentric study retrospectively included 40 patients with a mean age of 22.4 ± 8.1 years (range 9-48) from 5 German Trauma Departments with first-time traumatic patellar dislocation and operative treatment. Surgery was limited to soft tissue repairs, and a preoperative magnetic resonance imaging (MRI) was performed in all cases. Evaluation of the MRI included sulcus angle, dysplasia of the trochlea, depth and facet asymmetry of the trochlea, Insall-Salvati index, Tibial tuberosity to trochlear groove (TTTG) distance, and rupture patterns of the MPFL. Patients were interrogated after 2 years about recurrent dislocation, satisfaction, and the Kujala score. RESULTS: Trochlea facet asymmetry was significantly lower in patients with redislocation (23.5 ± 18.8) than in patients without redislocation (43.1 ± 16.5, p = 0.03). Patients with a patellar-based rupture were significantly younger (19.5 ± 7.2 years) than patients without patellar-based rupture (25.4 ± 8.1 years, p < 0.02). Patients with femoral-based ruptures were significantly older (25.7 ± 9.2 years) than patients without femoral-based rupture (19.7 ± 6.1 years, p < 0.02), and had a significantly higher TTTG distance (10.2 ± 6.9 vs. 4.5 ± 5.5, p < 0.02). Patients with incomplete ruptures of the MPFL had a significantly lower Insall-Salvati index (1.2 ± 0.2 vs. 1.4 ± 0.2, p = 0.05). The Kujala score in patients with redislocations was significantly lower (81.0 ± 10.5 points) than in patients without redislocation (91.9 ± 9.2 points, p < 0.02). CONCLUSION: Younger patients more often sustain patellar-based ruptures following first-time traumatic patella dislocation, while older patients more often sustain femoral-based ruptures of the MPFL. Incomplete MPFL ruptures are correlated with lower Insall-Salvati indices. Low trochlear facet asymmetry is correlated with higher rates of redislocation. These results may be of relevance for the operative and postoperative treatment in the future. LEVEL OF EVIDENCE: Prognostic study, Level IV.

[Biodegradable screw versus a press-fit bone plug fixation for ACL reconstruction: a prospective randomized study]. / Biodegradierbare Schraube vs. einer Press-fit-Verankerung für VKB-Rekonstruktionen : Eine prospektive randomisierte Studie.

BACKGROUND: Press-fit fixation of a tendon graft has been advocated in order to achieve tendon to bone healing. HYPOTHESIS: Fixation of a tendon graft with a porous bone scaffold limits bone tunnel enlargement compared with a biodegradable interference screw fixation. METHODS: Between 2005 and 2006, 20 patients (17 men, 3 women) were enrolled in this study for primary reconstruction of the ACL. Patients were randomized to either obtain graft fixation in the tibial tunnel by means of an interference screw (I) or a press-fit fixation with a porous bone cylinder (P). Three months after surgery, a CT scan of the knee was performed and tunnel enlargement was analysed in the coronal and sagittal planes for the proximal, middle and distal thirds of the tunnel. After 6 months, 1 and 2 years, International Knee Documentation Committee (IKDC), Tegner and Lysholm scores of both groups were compared. RESULTS: The bone tunnel enlargement was 106.9±10.9% for group P and 121.9±9.0% for group I (P<0.02) in the AP plane and 102.8±15.2% vs 121.5±10.1% in the coronal plane (P<0.01). IKDC, Tegner, and Lysholm scores improved in both groups from pre- to postoperative assessment without significant differences between the two groups. There was a trend to higher knee stability in group P after 3 months (0.6±1.4 mm vs 1.81±.5 mm, P=0.08). CONCLUSIONS: Both interference screw and a press-fit fixation lead to a high number of good or very good outcomes after ACL reconstruction. Tibial press-fit fixation decreases the amount of proximal bone tunnel enlargement. Press-fit fixation decreases the amount of proximal bone tunnel enlargement and improves bone to tendon contact.

Post transplant lymphoproliferative disease in pediatric solid organ transplant patients: a possible role for [18F]-FDG-PET(/CT) in initial staging and therapy monitoring.

Post transplant lymphoproliferative disease (PTLD) is a severe complication after solid organ or bone marrow transplantation. In pediatric transplant recipients PTLD is the most common malignancy. The aim of this study was to evaluate a possible role for positron emission tomography with [18F]-2-fluoro-2-desoxy-glucose (FDG) in the initial staging and in therapy monitoring of pediatric patients suffering from biopsy-proven CD20-positive PTLD after solid organ transplantation. Seven pediatric patients were included. All available imaging studies - CT (n=15), MRI (n=16) and PET/PETCT (n=16) - were reviewed on a lesion by lesion base. The performance of FDG-PET in the initial staging and during therapy with a chimeric anti-CD20 antibody was compared to conventional cross sectional imaging and correlated with the clinical outcome. FDG-PET identified all sites of disease as shown by CT/MRI and helped to clarify the significance of equivocal findings. The initial stage of disease was correctly identified by FDG-PET alone when compared to CT/MRI. During therapy, FDG-PET was superior to conventional cross-sectional imaging in the early evaluation of response.

Hepatic resection using heat coagulative necrosis. First report of successful trisegmentectomy after hypertrophy induction.

INTRODUCTION: Intraoperative blood loss has been identified as one of the major mortality predictors for liver surgery. Different strategies have been used in the past to minimize blood loss during resection. A new method using heat coagulative necrosis in healthy tissue at the resection plane to achieve a bloodless resection has been described 3 years ago and has already gained acceptance for peripheral resections. A further developmental stage of this method is now available with the so-called Habib 4x sealer. So far, only resections ranging from segmentectomies to hemihepatectomies are reported. MATERIALS AND METHODS: In the case reported here, the new method was challenged to perform an extended hepatic resection in a patient suffering from colorectal liver metastases. The resection was performed in a hybrid technique of regular hilar preparation and parenchymal dissection using the sealer. CONCLUSION: The method showed to be safe and efficient even for an extended resection.