Spine surgery in a state-of-the-art hybrid operating room: an experience of 1745 implanted pedicle screws in the thoracolumbar spine.

Hybrid-operating rooms (hybrid-OR) combine high-resolution 2D images and 3D-scans with the possibility of 3D-navigation and allow minimal invasive pedicle screw placement even in the upper thoracic spine. The disadvantage of high cost and increased radiation needs to be compensated with high accuracy and safety. The hybrid operating room consists of a floor-based flat-panel robotic C-arm with 3D-scan capability (Artis Zeego, Siemens; Germany) combined with navigation (BrainLAB Curve, BrainLAB; Germany). Through a minimally invasive incision, a Jamshidi needle was advanced through the pedicle and a K-wire was placed. If 2D image quality did not allow safe placement 3D-navigation was used to place the K-wire. Position was controlled through a 3D-Scan and corrected if necessary before screw placement. Postoperative CTs evaluated screw perforation grade with grade I when completely within the pedicle, II < 2 mm, III 2-4 mm, and IV > 4 mm outside the pedicle. Overall, 354 screws were placed in T1-T6, 746 in the lower thoracic spine T7-T12 and 645 in the L1-L5. Navigation was mainly used in upper thoracic spine cases (31 of 57). In 63 out of 326 cases K-wire was corrected after the 3D-Scan. Overall, 99.1% of the screws showed perforation less than 2 mm. Mean radiation was 13.3 ± 11.7 mSv and significantly higher in the upper thoracic spine and in navigated procedures. Despite higher costs and radiation, the hybrid-OR allows highest accuracy and therefore patient safety in minimal invasive pedicle screw placement in the thoracic and lumbar spine.

Accuracy of screw stabilization of the dorsal pelvic ring using a hybrid operating room: 5 Year experience in a level 1 trauma center.

INTRODUCTION: Accuracy for screw placement in the dorsal pelvic ring can be enhanced using intraoperative 3D navigation. Advances in intraoperative imaging lead to benefits for pelvic surgery. New c-arms are equipped with flat panel detectors, which have a larger detector and assure higher image quality with accompanying dose reduction. A hybrid OR is defined by a fixed imaging system in an operating room providing the benefit of the surgical environment in combination with advanced intraoperative imaging. Aim of our investigation was to analyze the accuracy of navigated sacroiliac (SI) and transsacral transiliac (TSTI) screws in the dorsal pelvic ring, which were implanted with a hybrid OR in the first five years of use. MATERIAL AND METHODS: All percutaneous SI or TSTI screws implanted in the hybrid OR using intraoperative navigation in the first 5 years of utilization (between June 2012 to June 2017) were included. Intraoperative 3D-scans and postoperative computed tomography were examined for screw perforation. RESULTS: 210 SI and TSTI screws were implanted in 187 patients using intraoperative navigation in the hybrid-OR. 90.6 % of SI screws showed no cortical perforation. 6,3 % had a grade 1, 2.4 % a grade 2 and 0.8 % a grade 3 perforation. In 80.7 % of TSTI screws no perforation and in 13.3 % a grade 1 perforation was detected. 3.6 % showed a grade 2 and 2.4 % a grade 3 perforation. No significant difference between both screw types regarding the grade of cortical perforation could be seen. No significant relation between perforation rate and year of operation could be detected. CONCLUSION: Intraoperative navigation in a hybrid OR ensures a high accuracy for SI screws. Due to the large field of view and high image quality TSTI screws can be safely implanted in S1 and S2. Utilization of a hybrid-OR is accompanied with a steep learning curve.

Cement augmentation of the proximal femur nail antirotation: is it safe?

BACKGROUND: Cement augmentation of the proximal femur nail antirotation (PFNA; Fa. DePuy Synthes) showed good biomechanical and clinical results regarding increased stability and functional outcome [Linden et al. in J Orthop Res 24:2230-2237, 2006;Kammerlander et al. in Injury 49:1436-1444, 2018;]. Cement-associated complications are well known in orthopedic procedures like hip arthroplasty, vertebra- and kyphoplasty. This study investigates outcome and safety of augmentation of the proximal femur nail blade. MATERIALS AND METHODS: The retrospective review of the 299 patients (mean age 80 ± 13 years; 205 women and 94 men) focused on perioperative complications after augmentation which was performed with Traumacem V+ Cement (Fa. DePuy Synthes) in 152 cases. The decision for augmentation of the blade was made by the attending surgeon and based on the factors age, bone quality, and fracture pattern. Primary outcome measures were changes in blood pressure, heart rate or oxygen saturation, and the number of needed vasoactive drugs during augmentation. Secondary outcome measures where the rate of cement leakage into the joint, mechanical failure, and perioperative complications like pulmonary embolism, stroke, or heart attack. RESULTS: In 152 augmented cases, no leakage of cement into the joint could be detected. No signs of mechanical failure like cut-out of the blade were seen after 6 weeks and 3 months. Also, augmentation did not show a higher rate of mortality or postoperative complications like stroke, heart attack, embolism, or infection. 57 of 152 augmented cases received an intraoperative intervention with vasoactive medication at the time of augmentation either prophylactically or because of a blood pressure fall. Out of the non-augmented cases, 21 of 147 needed vasoactive medication in the second half of the operation. The difference between these groups was significant (p < 0.05). In the cases without an intervention, there was a significant blood pressure fall of about 8 ± 7.4 mmHg during the augmentation (p < 0.001). Still, none of the augmented cases showed a change in heart rate or oxygen saturation. CONCLUSION: The augmentation of the PFNA blade proved to be a safe procedure. Cement augmentation will not increase postoperative complications or mortality. The risk for leakage of cement into the joint is low and mechanical cut-out might be prevented. The decision for augmentation should be made carefully and always be declared loud and in advance to allow the anesthetist to prepare, because blood pressure changes can occur.

Impact of oral anticoagulation on proximal femur fractures treated within 24 h - A retrospective chart review.

BACKGROUND: About one third of all patients with proximal femur fractures take oral anticoagulation like aspirin (ASS), direct platelet aggregation inhibitors like Clopidogrel and Ticagrelor (PAI), vitamin-K-antagonists like Warfarin (VKA) and direct oral anticoagulants like Rivaroxaban, Dabigatran and Apixaban (DOAC). The management and timing of fracture stabilization of these patients is a rising challenge in orthopedic trauma. Our objective was to determine the effect of oral anticoagulation on patients with proximal femur fractures, which received a proximal femur nail antirotation (PFNA) within 24 h after trauma. MATERIAL AND METHODS: A retrospective chart review of 327 patients (mean age 80 ± 13 years; 223 women and 104 men) with sub- or intertrochanteric fractures between January 2013 and December 2017 was performed. All patients underwent surgery in the first 24 h after admission. Solely patients without or with only one type of oral anticoagulation were included. There were 74 patients with ASS, 30 with PAI, 52 with DOAC and 25 with VKA medication. All patients taking VKA received high dose Vitamin K or coagulation factors to normalize INR prior to surgery. Primary outcome measures were transfusion rate and pre- and postoperative hemoglobin (Hb) difference. Secondary outcome measures were mortality and complications like infection, hematoma and acute cardiovascular events. RESULTS: Patients undergoing treatment with DOAC had a 3.4-fold increased risk for intraoperative blood transfusion. The risk for blood transfusion for patients taking ASS, PAI or VKA did no differ from the control group. Patients without an intraoperative blood transfusion on oral anticoagulation showed no increase in pre- and postoperative Hb-difference compared with controls. Anticoagulation showed no significant effect on complication rates and mortality in patients operated within the first 24 h. CONCLUSION: Early surgical care of proximal femur fractures is safe even in patients with anticoagulant medication. All patients should be preoperatively prepared for possibly intraoperative transfusion, especially patients on DOAC.

Radiation exposure for the surgical team in a hybrid-operating room.

Hybrid-operating rooms enable the surgeon to acquire intraoperative high-resolution 2- and 3D images and use them for navigation. The radiation dose of the operating personal and the patient remains the major concern. In 9 months, 109 pelvic and spine cases were performed using a hybrid operating room. Radiation dose of the surgeon and the assisting nurse was recorded using real-time dosimeters. Lower radiation doses for the main surgeon in navigated dorsal instrumentations of the thoracic spine were recorded. Standing between the C-arm during screw placement increased the radiation dose sixfold. Lumbar dorsal instrumentation showed a similar radiation dose compared to the previous studies in traditional operating room settings. The use of a hybrid-operating room for dorsal spine instrumentation showed no increase in radiation dose compared to traditional settings. Intraoperative navigation can help to reduce the radiation dosage for the operating personnel.

Correction to: Radiation exposure for intraoperative 3D scans in a hybrid operating room: how to reduce radiation exposure for the surgical team.

The original version of this article unfortunately contained a mistake. In abstract, results section should read.

Radiation exposure for intraoperative 3D scans in a hybrid operating room: how to reduce radiation exposure for the surgical team.

BACKGROUND: Hybrid operating rooms are used in different fields of surgery. In orthopedic surgery, the possibility of a 3D scan of difficult anatomical regions (spine, pelvis) showed promising results not only in navigated screw placement. The associated exposure to radiation raises questions regarding potential risks for the operating room personal and the patient. The present study focuses on scatter radiation during 3D scans in a hybrid operating room, the adjacent rooms, and methods to reduce radiation exposure. MATERIAL AND METHODS: [Formula: see text] i2 dosimeters were used to measure scatter radiation during 3D scans of different anatomical regions in different distances and heights in a hybrid operating room. The 3D scans were performed with a floor-based flat-panel robotic C-arm with 3D scan capability (Artis Zeego, Siemens; Germany). The 3D scans were performed using a human cadaver. The 3D scans were performed using a standard and a dose reduction protocol (DRP). RESULTS: The highest scatter radiation was measured during 3D scans of the pelvis on the side of the surgical assistant (39.5 µSv in height of 1 m) compared to the side of the main surgeon (23 µSv in height of 1 m). Scatter radiation was less on the position of the scrub nurse (6.8 µSv in height of 1 m) and during 3D scans of the other anatomical regions. The radiation dosage was about 66% less with the DRP. Low values of scatter radiation were measured behind a radiation protection wall and with open doors in the adjacent rooms. CONCLUSION: While performing a scan scatter radiation was measured everywhere in the operating room especially during 3D scans of the pelvic girdle. Therefore, settings with lower dosage should be used whenever possible. Personnel should stand behind a radiation safety wall or leave the operating room and close the doors. For this study, six behavioral rules to avoid radiation in a hybrid operating room were established.

Improving biliary stent patency by the use of stent coating - a prospective randomized porcine study.

BACKGROUND: Endoscopic stenting of the bile duct is a standard procedure for almost 35 years. In the case of long-term stenting occlusion of the stent is a major concern. Therefore optimizing biliary stents with respect to their patency is of great importance. We tested in an in animal study if coating of self-expanding metal stents with hydrophobin alone or hydrophobin with heparin reduces stent clogging as there were promising results in an in vitro study with this approach. MATERIAL AND METHODS: In a randomized prospective animal study we implanted self-expanding metal stents either native or coated with hydrophobin alone or coated with hydrophobin and heparin into the bile duct of 15 pigs. After a survival period of 6 weeks we measured which part of the stent surface (%) was covered with clogging material using a commercially available image editing program on scanning electron microscopic images. RESULTS: We found no differences between the native self-expanding metals stents and those coated with hydrophobin alone or hydrophobin and heparin. CONCLUSION: There are important differences in the clogging process between in vitro and in vivo models. Coating with hydrophobin with or without heparin is not able to inhibit the clogging process in an animal model.

[Impact of Spinal Fractures in Horseback Riding]. / Verletzungsfolgen nach Wirbelsäulenfrakturen im Reitsport.

BACKGROUND: Injuries to the spinal cord are not only dreaded because of the high risks existing during the acute phase, but also because of their potential long-term sequelae. Horseback riding also poses a high risk of spinal injuries. We therefore evaluated the most frequent characteristics of accidents leading to long-term sequelae, the primary long-term discomfort resulting from such injuries caused by horseback riding accidents and the way injured persons changed their behaviour after the accidents. PATIENTS: Our study included all cases of horseback riding injuries registered in the Department of Trauma, Hand, Plastic and Restorative Surgery at the University Hospital of Ulm between May 2005 and October 2012. Sequelae of the accidents were examined via follow-up interviews by phone. These included questions about protective gear worn during the accident as well as behavioural changes after the injury. In addition, a spine-specific questionnaire based on the Visual Analogue Scale (VAS) was used to assess long-term complications. RESULTS: Overall, we recorded 50 cases of spinal injuries caused by horseback riding accidents over a time span of 7 years and 5 months. 41 (82 %) of the patients were female and 9 (18 %) were male. The average patient age was 32.0 ±â€Š15.2 years. All in all, the 50 patients sustained 84 injuries: 59 fractures and 25 other injuries such as distorsions or discoligamentous injuries. Most injuries were located in the lumbar spine (n = 43), corresponding to 51 % of all recorded injuries, followed by 32 % in the thoracic spine (n = 27) and 17 % in the cervical spine (n = 14). After sustaining a fracture to the spine, 9 out of 24 patients quit horseback riding. All patients used a helmet after the accident, but only 7 out of 15 used back protection. 11 out of 24 patients suffer from back pain while resting with a mean VAS score of 3.4 ±â€Š1.9. More than half (17 out of 24) have back pain while working with a VAS score of 4.8 ±â€Š2.2. CONCLUSION: The frequency and severity of back injuries sustained by horseback riders increases with age. This can be due to various reasons such as biomechanical factors. The low acceptance of back protection is remarkable.

[Diverticulitis--conservative therapy]. / Divertikulitis--Konservative Therapie.

BACKGROUND: Diverticulitis due to diverticulosis of the colon is a common clinical problem with a high morbidity and socio-economic consequences. Frequent clinical signs are flatulence, abdominal pain, stool problems which may often be misinterpreted as the symptoms of an irritable bowel or a colitis. Accordingly, the diagnostic work-up must be adequate to allow for the stage-adapted planning and performance of the therapy. MATERIAL AND METHODS: The following questions will be addressed in this review: What do we need to clarify diagnosis? Which antibiotics should be used? What is the best conservative approach for treatment? RESULTS AND CONCLUSIONS: Basic conservative therapy consists of systemic antibiosis which can be extended by a topical antibiosis, and administration of aspirin as well as probiotics. The indications for a specific therapy is made on an individual basis according to stage (Hansen and Stock). Above all, a "team approach" and close communication between gastroenterologists and surgeons are mandatory for adequate treatment of these patients.

[Radical cystectomy and ileal neobladder reconstruction in elderly female patients over 70 years old: morbidity, functional and oncological long-term results]. / Zystektomie mit Anlage einer Ileumneoblase bei der über 70-jährigen Frau : Morbidität, funktionelle und onkologische Ergebnisse.

BACKGROUND: As life expectancy is increasing the incidence and therefore the number of elderly female patients with bladder cancer is also increasing. The aim of this study was to assess long-term clinical, functional and oncological outcome in elderly women (≥70 years) who were treated by radical cystectomy and ileal neobladder reconstruction for invasive bladder cancer. MATERIAL AND METHODS: A total of 121 women with clinically organ-confined invasive urothelial carcinoma underwent radical cystecomy with an orthotopic ileal neobladder in Ulm between 1995 and 2010. The clinical course, functional, pathological, and oncological outcome of these women were analyzed retrospectively and compared between patients ≥70 (n=24) and <70 years of age (n=97). All complications which occurred during the first 90 days after surgery were analyzed in detail, defined and classified according to the modified Clavien system. RESULTS: The overall 90 day complication rates were 66.7 % and 62.5 % for patients ≥70 and <70 years, respectively. Of these 54.2% and 44.8% were minor complications and 12.5 % and 17.7 % were major complications, respectively. Infections were the most frequent cause of complications with 36.7 %. Univariate analyses revealed that neither age nor comorbidity (ASA score) were significant predictors of perioperative complications. The daytime continence rates were comparable in both age groups (71% versus 82%, p=0.64); however, younger patients showed significantly higher night time urinary continence rates (43% versus 89%, p=0.013). Neither univariable nor multivariable analyses indicated that age ≥70 years had a significant impact on tumor-specific survival. CONCLUSIONS: Chronological age per se does not seem to be a contraindication for the creation of an orthotopic ileal neobladder; however, the risk of postoperative incontinence seems to increase with age.

[Diagnostic approach in cases of herbal hepatotoxicity]. / Diagnostisches Vorgehen bei Lebererkrankungen durch pflanzliche Mittel.

BACKGROUND: Herb-induced liver injuries are rare and often lack careful evaluation by physicians and regulatory agencies, with the consequence that alternative diseases with specific therapeutic modalities are missed. Other shortcomings are low data quality that additionally complicates adequate evaluation. METHODS: Based on our own experience and a selective literature search, recommendations are presented that will substantially improve data acquisition and causality evaluation. RESULTS: Important diagnostic criteria include clinical manifestation, dechallenge, type of liver injury, (unintentional) reexposure, comedication, risk factors, primary disease, and definitive exclusion of alternative causes. Concomitantly, the data quality in cases of primarily assumed herbal hepatotoxicity may be substantially improved merely by strict data acquisition using a liver specific form. To establish the diagnosis of hepatic adverse drug reaction, a liver specific causality assessment method is available, which has been proven valuable for physicians and regulatory agencies for pharmacovigilance issues, and should be used more often. Using additional diagnostic steps, care should be taken that alternative diseases are recognized in time and treated adequately. CONCLUSION: In hospital and outpatient settings, primarily assumed herb-induced liver injury is a particular challenge for physicians and regulatory agencies that requires substantially improved case data quality and causality evaluation.

[Endoscopic therapy for tumours of the papilla of vater]. / Endoskopische Interventionsmöglichkeiten bei Tumoren der Papille.

BACKGROUND: Ampullary tumours are rare and can be separated in benign and malignant lesions. There are non-invasive diagnostic methods in order to detect ampullary tumours like abdominal ultrasound, computed tomography and MRCP (magnetic resonance cholangiopancreaticography) as well as invasive methods, e. g., gastroscopy, duodenoscopy, endosonography, intraductal ultrasound, ERCP and cholangioscopy. Endoscopy is the method of choice for this indication, whereas a combination of the different diagnostic methods is common. MATERIAL AND METHODS: A selective literature research with descriptive survey has been carried out. RESULTS: The standard method to treat benign tumours of the papilla is endoscopic papillectomy. For malignant tumours surgery is preferred. But in some certain circumstances it is also possible to treat carcinomas of the papilla endoscopically. DISCUSSION: This overview should assist surgeons and endoscopists to choose the right diagnostic approach and to treat adenomas as well as carcinomas of the Papilla of Vater appropriately. CONCLUSION: The treatment of papilla tumours depends primarily on the dignity, the morphology of the findings and the extension of the tumour (extraductal vs. intraductal).

Optimizing biliary stent patency by coating with hydrophobin alone or hydrophobin and antibiotics or heparin: an in vitro proof of principle study.

PURPOSE: Although a wide range of biliary plastic and metal stents is on offer nowadays, the ideal cost-effective stent that functions permanently and that is easy to handle regarding its exchange is still not available. Therefore we tested in an in vitro model if the coating of plastic stents with hydrophobin alone or with hydrophobin and antibiotics or heparin in combination leads to an inhibition of the clogging process. METHODS: We coated commercially available biliary plastic stents with hydrophobin alone, as well as with hydrophobin and antibiotics or heparin in combination. After an incubation period of 28 days in human bile, we examined the stents by scanning electron microscopy to see whether the clogging material on its surface was reduced. RESULTS: Coating of plastic stents with hydrophobin led to a reduction in the amount of adherent material on the surface of the stents. Coupling of ampicillin/sulbactam or levofloxacin did not lead to a further reduction of the clogging material, whereas coupling with highly concentrated heparin did reduce the adherent material. CONCLUSIONS: The coating of biliary plastic stents with hydrophobin or with hydrophobin and heparin in combination seems to be a promising option to delay the clogging process.