[Bisphosphonates in osteoporosis therapy. Standards and perspectives]. / Bisphosphonate in der Osteoporosetherapie. Standards und Perspektiven.

Bisphosphonates are potent inhibitors of bone resorption and approved agents for both the prevention and treatment of osteoporosis. Many clinical studies have shown a consistent reduction in the risk of vertebral fractures with the use of these drugs, while others have shown a clear reduction in the risk of hip and other non-vertebral fractures. The bisphosphonates are divided into three generations based on their potency and chemical structure. In general, as a substance group they are well tolerated and, when applied correctly, the toxicity is low. Alternative dosages, e.g. monthly, three times a month or yearly as an oral drug or i.v. would probably improve patient compliance. Clinical studies have also shown the safety and effectiveness of bisphosphonates over a period of 3-7 years.

False aneurysm of the left femoral artery and thrombosis of the left femoral vein after total hip arthroplasty.

We report a 75-year-old male patient with an aneurysm of the left femoral artery after cemented total hip arthroplasty. Two months after the operation, the patient showed a spherical resistance and pain in the left groin. Examination showed a big false aneurysm of the left femoral artery. After resection of the aneurysm, an endovascular stent graft vessel prosthesis was implanted. The aneurysm originated from a punctual lesion of the artery caused by a screw. Since the first description of vessel lesions in orthopaedic surgery in 1964, a total of 24 cases of aneurysm in hip surgery have been described. Therefore, a review of literature tries to explain causes and mechanisms of vessel injuries in hip surgery and the possibilities of repair.

[Contrast-enhanced diagnostics in orthopaedics]. / Kontrastmittelgestützte Diagnostik in der Orthopädie.

The diagnostic competence of the orthopaedist not only allows him to perform adequate therapy concepts, but also to meet the current structural challenges, both social and health related. In addition to clinical diagnosis, machine-aided diagnosis is becoming more important due to technical advances. In this context, contrast-enhanced examination has a special place, as it has an important diagnostic advantage in difficult or unclear cases. Current improvements in the areas of phlebography, myelography, arthrography and angiography are reviewed. Indications, risks and complications as well as the technical procedure are critically discussed.

Percutaneous vertebroplasty in the therapy of osteoporotic vertebral compression fractures: a critical review.

Percutaneous vertebroplasty has become an efficient technique for the treatment of painful vertebral fractures. Osteoporotic vertebral compression fractures are characterized by severe back pain and immobilization causing other complications like thrombosis or pneumonia. Vertebral cement augmentation provides increased strength of the vertebral body and an obvious pain relief. Between 1989 and 2004, 30 studies and a total of 2,086 treated patients have been published in literature. A review of these studies has been performed. The number and age of the patients, number of treated vertebrae, pre- and postoperative outcome of pain and complications of the different studies were assessed and analyzed. Percutaneous vertebroplasty is an efficient technique with low complication rates and a significant reduction in pain. It rapidly improves the mobility and quality of life of patients with vertebral compression fractures. With an increasing number of treated patients, experience with this interventional technique has become excellent. But still there are no randomized controlled trials available, showing that percutaneous vertebroplasty has a significantly better outcome than other treatment options, especially after a long-term follow-up.

CT-guided percutaneous vertebroplasty in the therapy of vertebral compression fractures.

The purpose of this study was to determine the efficacy and safety of CT-guided percutaneous vertebroplasty in the treatment of vertebral compression fractures. The primary objectives were pain reduction and bone-cement leakage during a long-term follow-up in patients with osteoporotic vertebral compression fractures. CT-guided percutaneous vertebroplasty was carried out in 61 patients (mean age 71.4 years; range 42-83; female ratio: 73.8%) with vertebral compression fractures. Treatment was carried out on an outpatient basis. Pain, bone-cement leakage and complications were monitored and recorded. The mean follow-up time was 19.8 months (range 3-52). Paired comparison procedures were used for the analysis of the results, which showed that all patients had a significant reduction of pain. The mean visual-analogue scale (VAS) before treatment was 8.8 points (range 6.5-9.8 points). The mean VAS score after treatment was significantly reduced to 2.6 points (range 1.5-4.1 points; p<0.01). No clinical or neurological complications were documented. Minor and asymptomatic bone-cement leakage was observed in 54% of the cases. Percutaneous vertebroplasty is an efficient and safe interventional procedure which rapidly improves the mobility and quality of life of patients with vertebral compression fractures. CT-guidance is a reasonable upgrade in the treatment procedure which reduces the amount of bone-cement leakage.

[Five-year results following autogenous osteochondral transplantation to the femoral head]. / 5-Jahres-Ergebnisse nach autologer Knorpel-Knochen-Transplantation bei Hüftkopfnekrose.

The rationale for autogenous osteochondral grafting into necrotic areas of the femoral head is to provide hyaline cartilage for areas of main articular contact pressure. The aim of this study was to present our results of autogenous osteochondral grafting to the femoral head in the treatment of avascular necrosis. The mean follow-up of the five patients was 57 months following autogenous osteochondral grafting to the femoral head using DBCS (diamond bone-cutting system). The number of transplanted cylinders varied between one and three, and the diameter of the cylindrical transplants between 9 and 13 mm. Results were unsatisfactory in four of five hips and these underwent total hip replacement a mean of 49 months following DBCS of the hip. In our hands, osteochondral grafting to the femoral head using DBCS had proven technically possible in restoring the articular surface of the femoral head; however, this operation was associated with unsatisfactory results in four of five cases.

Management of haemophilic patients with inhibitors in major orthopaedic surgery by immunadsorption, substitution of factor VIII and recombinant factor VIIa (NovoSeven): a single centre experience.

Inhibitors of factor VIII or FIX in haemophilic patients are a common and serious complication associated with an increased risk of life-threatening bleeding during elective surgery. Substitution therapy fails to be effective, therefore an alternative treatment is needed. We have performed six major elective orthopaedic interventions in four patients with haemophilia A and inhibitors. A preoperative immunadsorbant therapy with Therasorb to eliminate inhibitors was successful in four cases, but during FVIII substitution inhibitors increased on day 4 to day 6 after surgery, leading to decreasing FVIII levels. Therefore, therapy was changed to recombinant FVIIa (rFVIIa; NovoSeven). Two interventions had to be covered with sole rFVIIa therapy as immunadsorbant therapy failed to be effective in one case and the need for acute intervention did not allow pretreatment in the other. We did not see increased bleeding during or after surgery when compared to our experience with non-inhibitor haemophilic patients. In conclusion, a preoperative decrease of inhibitors from immunadsorbant therapy, perioperative substitution of FVIII and changing treatment to rFVIIa when inhibitors are increased, is a safe and economic therapy for guaranteeing haemostasis in major elective orthopaedic surgery. On the contrary, sole therapy with rFVIIa allows immediate surgical intervention without a long hospital stay prior to surgery and a need for laboratory monitoring of inhibitor titres and FVIII levels. Our findings support data previously published.

[The role of stereotactic 11G vacuum biopsy for clarification of BI-RADS IV findings in mammography]. / Wertigkeit der stereotaktischen 11 G-Vakuumbiopsie zur Abklärung von Befunden der Kategorie BI-RADS IV in der Mammographie.

PURPOSE: To evaluate the potential of stereotactic vacuum breast biopsy in the histologic evaluation of suspicious mammographic findings ( BI-RADS IV). MATERIALS AND METHODS: In 221 patients with 227 probable mammographic lesions categorized as ( BI-RADS -IV), stereotactic biopsies were performed with an 11-gauge vacuum-assisted biopsy device (Mammotome). The evaluation included the histology of the specimens obtained with the Mammotome or with surgery, the time for the biopsy, the amount of bleeding, number of rotations and procured specimens, the extent of the resection and the complications. RESULTS: The biopsies were technically successful in 214 of the 227 probable mammographic lesions, with 176 lesions mostly resected and 34 lesions removed more than 50 %. No representative tissue was obtained from 4 lesions. All biopsies were performed without any clinically relevant complications and terminated after adequate material was obtained (O 28 specimens, 2.58 rotations). The mean time needed for performing the biopsy was 40.2 minutes. The histologic findings were DCIS (42 lesions), ADH (7 lesions), LCIS (3 lesions), ID-Ca (14 lesions, IL-Ca (3 lesions), and IDL-Ca (1 lesion). In 28 of 42 lesions with the initial DCIS histology, the surgical histology was also DCIS (n=28) or no residual tumor (n=10). In 4 lesions with an initial DCIS-histology, the surgical histology was invasive ductal cancer (9.5 %). The late follow-up examinations (up to 3 years) did not find any evidence of a false negative biopsy. CONCLUSION: Stereotactic vacuum breast biopsy ideally complements existing breast biopsy methods. The method is minimal invasive with a low rate of mostly minor complications.

[Sports-related injuries of the spine]. / Sportverletzungen und -schäden der Wirbelsäule.

Different sports show different patterns and frequencies of injuries, which are discussed in this paper. About 3% of all sports accidents relate to the spine. These injuries often have far-reaching consequences for the patients. A very early and extensive diagnosis of all changes is decisive for the start of an adequate therapy and thus for the prognosis of the injury. Radiological diagnosis is also of decisive importance for the documentation of late injuries and in the question of rehabilitation. Here special focus is put on MRT and CT diagnostics.A healthy spine of humans is normally able to resist all static and dynamic strains of the usual sports. However, anomalies and dysfunctions of the spine can reduce its capacity to resist strain. The recommendations of sporting activities are given according to the extent of deflection and the expected growth. The importance of radiology in primary diagnosis and in the follow-up due to typical changes like scoliosis, Morbus Scheuerman, spondylolysis and spondylolisthesis is discussed here as well.

CT-guided intratumoural administration of cisplatin/epinephrine gel for treatment of malignant liver tumours.

To analyze prospectively the interventional and clinical aspects of computed tomography-guided direct intratumoural injection of a novel chemotherapeutic administration and the parenchymal changes of tumour and necrosis in malignant liver tumours. Eight patients with 17 colorectal liver metastases were treated with a mean of 5.1 injections and nine patients with 13 hepatocellular carcinoma nodules with a mean of 3.1 treatments with computed tomography guided local applications of a novel cisplatin/epinephrine gel. This application provides a higher local and lower systemic drug concentration. Volumes of tumour and necrosis prior and after treatment were measured by computer generated volumetric analysis. Contrast enhanced studies verified pretherapeutic viable tumour volumes with a value of 77.4 ml in the metastases and 29.2 ml in the hepatocellular carcinoma nodules. Intratumoural drug application resulted in a significant increase of necrosis and a decrease in viable tumour volume to be 68.3 ml in metastases and 14.5 ml in hepatocellular carcinoma. Local therapy control rate for the follow up to 6 months was 38 and 71% for the group of metastases and hepatocellular carcinoma, respectively. Direct intratumoural injection of cisplatin/epinephrine injectable gel is a feasible and good tolerated method and results in the development of a statistically significant increase in necrosis in malignant liver tumours. For hepatocellular carcinoma a higher local therapy control rate compared to colorectal metastases can be reported.

Reconstructed anterior cruciate ligaments using patellar tendon ligament grafts: diagnostic value of contrast-enhanced MRI in a 2-year follow-up regimen.

We analyzed prospectively the diagnostic efficacy of contrast-enhanced MRI following anterior cruciate neoligament (ACL) reconstruction. One hundred fifty-six MR examinations were performed 2, 12, 52, 76, and 104 weeks post-operatively on 68 patients with ACL transplants. Sagittal, parasagittal, and coronal images using unenhanced T1- and T2-weighted spinecho sequences, and post-contrast images utilizing T1-weighted spinecho and fat-saturated sequences, were acquired. Results were correlated with those of the pivot shift, Lachman, and a mechanical test. The MR examination criteria included morphological analysis, signal intensity, transplant contrast enhancement, secondary signs (e.g., elongation of normal ligaments), and comparison with clinically standardized test results. Two weeks post-operatively all neoligaments showed homogeneous low signal intensity on T1- and T2-weighted spinecho sequences indistinguishable from that of normal cruciate or patellar ligaments [contrast-to-noise ratio (C/N) on T1: 1.6], with a 9% percentile enhancement. At 12-52 weeks, signal intensity increased (C/N: 6.7), with a mean 50% percentile enhancement. The 1-year follow-up allowed no definite assessment of the neoligament's course. At 76 and 104 weeks, significant decrements in signal intensity (C/N: 3.0) and ligamentous percentile enhancement (25%) occurred. All patients tested displayed stable transplants 2 years post-operatively. Contrast-enhanced MRI allows accurate evaluation of morphology and function up to 3 months postoperatively and 1-2 years following ACL reconstructive surgery.

[Contrast medium enhanced magnetic resonance tomography of liver metastases: positive versus negative contrast media]. / Kontrastmittelverstärkte Magnetresonanztomographie von Lebermetastasen: Positive versus negative Kontrastmittel.

The development in oncologic liver surgery as well as modified interventional therapy strategies of the liver have resulted in improved diagnostic imaging. The evolution of contrast agents for MR imaging of the liver has proceeded along several different paths with the common goal of improving liver-lesion contrast. In MRI contrast agents act indirectly by their effects on relaxation times. Contrast agents used for hepatic MR imaging can be categorized in those that target the extracellular space, the hepatobiliary system, and the reticuloendothelial system. The first two result in a positive enhancement, the last one in a negative enhancement. Positive enhancers allow a better characterization of liver metastases using dynamic sequence protocols. Detection rate of liver metastases is increased using hepatobiliary contrast-enhanced MRI compared to unenhanced MRI. Negative enhancers, iron oxide particles, significantly increase tumor-to-liver contrast and allow detection of more lesions than other diagnostic methods. Iron-oxide enhanced MRI enables differential diagnosis of liver metastases comparing morphologic features using T2 and T1-weighted sequences.

Phase I trial of gemcitabine (Gemzar), 24 h infusion 5-fluorouracil and folinic acid in patients with inoperable pancreatic cancer.

Gemcitabine (Gemzar) has a significant impact upon survival and quality of life for patients with pancreatic cancer, compared with 5-fluorouracil (5-FU). This phase I study was initiated to define the recommended dose of 5-FU delivered as a 24 h infusion in combination with gemcitabine (1000 mg/m2) and folinic acid (200 mg/m2) in patients with inoperable pancreatic cancer, treated on an outpatient basis. Drugs were administered weekly for 4 weeks out of 6 weeks. Sixteen chemonaive patients (median age 59 years, range 51-66) were enrolled, 15 had stage IV and one stage III disease. The median Karnofsky performance score (KPS) was 70 (range 60-80). Six patients received 5-FU 750 mg/m2, eight received 5-FU 1000 mg/m2 and two received 5-FU 1250 mg/m2. The maximum tolerated dose of 5-FU was 1000 mg/m2. Hepatotoxicity was dose limiting. One patient who received 5-FU 1250 mg/m2 died as a result of hepatorenal failure. There was one partial response, nine patients had stable disease for more than 3 months and 13 patients had improved KPS. The median time to progressive disease was 31 weeks (range 5-50 weeks). A phase 11 trial is underway to further assess the activity of this combination at the recommended dose of 750 mg/m2 5-FU.

Cardiovascular autonomic dysfunction and hemodynamic response to anesthetic induction in patients with coronary artery disease and diabetes mellitus.

UNLABELLED: Autonomic neuropathy is a major complication of diabetes mellitus and is reported to be associated with increased perioperative hemodynamic instability. We investigated the relationship between autonomic dysfunction and hemodynamic response to anesthetic induction in diabetic and nondiabetic patients with coronary artery disease. We studied 60 patients scheduled for coronary artery surgery, 30 suffering from diabetes mellitus. Preoperative evaluation included traditional cardiovascular autonomic function tests (coefficient of variation of 150 beat-to-beat intervals in heart rate at rest, heart rate response to deep breathing, and heart rate and arterial blood pressure response to standing), spectral analysis of blood pressure and heart rate variability (HRV), and the computation of spontaneous baroreflex sensitivity. After premedication with clorazepate, anesthesia was induced with sufentanil (0.5 microg/kg), etomidate (0.1-0.2 mg/kg), and vecuronium (0.1 mg/kg). Heart rate and blood pressure before anesthetic induction and before and after tracheal intubation were compared between groups. Autonomic function tests, spectral analysis of HRV, and spontaneous baroreflex sensitivity revealed significant differences between patient groups. Most diabetic patients (n = 23) had one or more abnormal test results, in contrast to most nondiabetic patients, who did not show signs of autonomic neuropathy (n = 23). There was no relationship between cardiovascular autonomic function and hemodynamic behavior during anesthetic induction. The blood pressure response to anesthetic induction was not different between patient groups, even when comparing the subgroups with and without abnormal autonomic function tests. These findings indicate that increased hemodynamic instability during anesthetic induction is not obligatory in patients with diabetes mellitus and autonomic dysfunction. IMPLICATIONS: This study indicates that increased hemodynamic instability during anesthetic induction is not obligatory in patients with coronary artery disease and autonomic dysfunction.

Magnetic resonance imaging in the diagnosis of acute injured distal tibiofibular syndesmosis.

RATIONALE AND OBJECTIVES: This study assessed the diagnostic potential of magnetic resonance imaging for the evaluation of the tibiofibular syndesmosis. METHODS: A total of 38 patients with an acute ankle trauma and clinical suspicion of a syndesmotic tear were prospectively studied with conventional plain film radiography and magnetic resonance imaging. Magnetic resonance imaging studies included plain T1-weighted (T1-w) and T2-weighted (T2-w) sequences and contrast-enhanced T1-w sequences 0 to 3 days after trauma. All images were read by two independent radiologists before surgical intervention. Sensitivity and specificity were determined for the two observers and the concordance of the two observers were calculated using the interobserver analysis (Kappa-Test). Intraoperative inspection (n = 21) revealed rupture of the anterior tibiofibular ligament (ATIF) in 15 patients, intact ATIF in 6 patients, and intact posterior tibiofibular ligament (PTIF) in 21 cases. Clinical and follow-up examinations revealed an intact syndesmotic complex in another 17 patients. RESULTS: Primary diagnostic criteria for diagnosing a ligamentous tear included tibiofibular diastasis in conventional plain films; nonvisualization of the ATIF; an abnormal course, a wavy, irregular contour of the ligament; increased signal intensity of the ligament in T2-w sequences, in plain T1-w sequence, and marked enhancement in T1-w after contrast. Important secondary signs were defined as joint fluid in the tibiofibular space and prolapse of interspace fat. Highest diagnostic accuracy was achieved if three or more diagnostic criteria could be visualized. Both readers performed best with the enhanced T1-weighted and the T2-weighted images in transverse orientation. The interobserver analysis resulted in high concordance: Kappa = 0.9 (confidence interval: 0.76 to 1.00) for all patients, and in Kappa = 0.76 (confidence interval: 0.45 to 1.0) for surgically treated patients. CONCLUSIONS: Magnetic resonance imaging of the syndesmotic complex is a highly sensitive and specific tool for the pretherapeutic-evaluation of syndesmotic injury.

Heart rate variability in patients with daytime sleepiness suspected of having sleep apnoea syndrome: a receiver-operating characteristic analysis.

1. Periodic breathing is known to be associated with cyclic fluctuations in heart rate. The purpose of this study was to evaluate the capability of spectral analysis of heart rate variability to identify episodes with periodic breathing in patients suspected of having sleep apnoea syndrome. 2. Forty-eight subjects complaining of chronic day-time sleepiness were studied using polysomnography and additional monitoring of Holter-ECG and synchronized pulse oximetry. The recordings were divided into 20 min episodes which were identified as recordings registered during normal breathing, periodic breathing, and periods of both normal and abnormal breathing. Power spectral analysis was performed on episodes which met the criteria of stationary of data (313 episodes with normal breathing, 264 episodes with continuous periodic breathing, 80 episodes with both normal and periodic breathing patterns). 3. The ability of parameters, derived from analysis of heart rate variability, to discriminate between episodes with normal and periodic breathing was assessed by receiver-operating characteristic analysis. 4. The spectral power component in the frequency range 0.01-0.07 Hz revealed the greatest accuracy for discriminating between normal and periodic breathing (area under the receiver-operating characteristic curve = 0.929; standard error = 0.009). The analysis of the episodes classified as false-positive at a given test sensitivity of 90% and a corresponding specificity of 77% revealed that half of these episodes had been recorded during transient central nervous arousal reactions related to periodic leg movements or heavy snoring. 5. We concluded that power spectral analysis of heart rate variability offers a possible means of identifying episodes of sleep-related breathing disorders or periodic leg movements. Therefore, analysis of heart rate variability may be a valuable additional diagnostic tool in patients undergoing Holter-ECG recording.