Real-life assessment of standardized contrast-enhanced ultrasound (CEUS) and CEUS algorithms (CEUS LI-RADS®/ESCULAP) in hepatic nodules in cirrhotic patients-a prospective multicenter study.

OBJECTIVES: Hepatocellular carcinoma (HCC) can be diagnosed non-invasively with contrast-enhanced ultrasound (CEUS) in cirrhosis if the characteristic pattern of arterial phase hyperenhancement followed by hypoenhancement is present. Recent studies suggest that diagnosis based on this "hyper-hypo" pattern needs further refinement. This study compares the diagnostic accuracies of standardized CEUS for HCC according to the current guideline definition and following the newly developed CEUS algorithms (CEUS LI-RADS®, ESCULAP) in a prospective multicenter real-life setting. METHODS: Cirrhotic patients with liver lesions on B-mode ultrasound were recruited prospectively from 04/2018 to 04/2019, and clinical and imaging data were collected. The CEUS standard included an additional examination point after 4-6 min in case of no washout after 3 min. The diagnostic accuracies of CEUS following the guidelines ("hyper-hypo" pattern), based on the examiner's subjective interpretation ("CEUS subjective"), and based on the CEUS algorithms ESCULAP and CEUS LI-RADS® were compared. RESULTS: In total, 470 cirrhotic patients were recruited in 43 centers. The final diagnosis was HCC in 378 cases (80.4%) according to the reference standard (histology 77.4%, MRI 16.4%, CT 6.2%). The "hyper-hypo" pattern yielded 74.3% sensitivity and 63% specificity. "CEUS subjective" showed a higher diagnostic accuracy (sensitivity, 91.5%; specificity, 67.4%; positive predictive value, 92%; negative predictive value, 66%). Sensitivity was higher for ESCULAP (95%) and "CEUS subjective" (91.5%) versus CEUS LI-RADS® (65.2%; p < 0.001). Specificity was highest for CEUS LI-RADS® (78.6%; p < 0.001). CONCLUSIONS: CEUS has an excellent diagnostic accuracy for the non-invasive diagnosis of HCC in cirrhosis. CEUS algorithms may be a helpful refinement of the "hyper-hypo" pattern defined by current HCC guidelines. KEY POINTS: • Contrast-enhanced ultrasound (CEUS) has a high diagnostic accuracy for the non-invasive diagnosis of hepatocellular carcinoma (HCC) in cirrhosis. • The CEUS algorithm ESCULAP (Erlanger Synopsis for Contrast-enhanced Ultrasound for Liver lesion Assessment in Patients at risk) showed the highest sensitivity, whereas the CEUS LI-RADS® (Contrast-Enhanced UltraSound Liver Imaging Reporting and Data System) algorithm yielded the highest specificity. • A standardized CEUS examination procedure with an additional examination point in the late phase, after 4-6 min in lesions with no washout after 3 min, is vital.

[H3F3A mutated multicentric giant cell tumor of bone : A very rare primary bone disease]. / H3F3A-mutierter multifokaler Riesenzelltumor des Knochens : Eine äußerst seltene primär ossäre Erkrankung.

This article presents the case of a metachronic multicentric giant cell tumor of bone (GCTB). The patient obtained his first diagnosis of GCTB in the left humerus at the age of 47 years. Furthermore, he suffered from a GCTB in the head of his 4th left metacarpal bone and from a recurrence of the latter. All tumors carried the characteristic H3F3A mutation, which was proven by Sanger sequencing and a mutation specific antibody. The case is the first description of a multicentric H3F3A mutated GCTB.

[Pathological fractures due to malignant bone tumors]. / Pathologische Frakturen bei malignen Knochentumoren.

BACKGROUND: Malignant bone tumors should be treated within interdisciplinary treatment concepts. The prognosis of pathological fractures is on the whole relatively poor because the fracture is indicative of a large and highly aggressive tumor and the hematoma associated with the fracture could possibly result in spreading of the tumor into the surrounding soft tissues. OBJECTIVES: This article summarizes the current interdisciplinary treatment concepts under special consideration of pathological fractures in primary bone tumors. METHODS: A selective literature search was carried out taking own experience into consideration. RESULTS: Due to the multimodal therapy approach for osteosarcoma and Ewing's sarcoma, the 5-year survival rate could be increased to 60-70 %. CONCLUSION: The therapeutic treatment should always be carried out within the framework of an interdisciplinary, oncological bone expert team, especially in cases of pathological fractures of malignant bone tumors.

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.

[Kyphoplasty update : What are the limits - what is possible?]. / Kyphoplastie Update : Wo liegen die Grenzen - was geht?

Kyphoplasty is an established procedure for the treatment of osteoporotic vertebral compression fractures. Developments in instrumentation and techniques have facilitated its use also for other localizations. In the hands of experienced practitioners smaller working cannulas and balloons have made successful treatment of high thoracic and cervical fractures and metastases possible. Balloon kyphoplasty performed for sacral insufficiency fractures in older patients plagued by chronic pain leads to marked pain reduction as well as faster weight-bearing. There are also early research results regarding the repair of tibial head defects and reinforcement with resorbable cement. These new procedures, which are currently applied by only a few surgeons, will be introduced and described in a case-specific manner.

[Preservative-free triamcinolone versus purified triamcinolone preparations]. / Primär konservierungsmittelfreies Triamcinolon im Vergleich zu aufgereinigten Triamcinolonpräparaten.

BACKGROUND: Intravitreal injections of triamcinolone are not only an important therapeutic tool for a variety of vitreo-retinal disorders, but can also be employed for visualisation of the vitreous during pars plana vitrectomy. Triesence® is a preservative-free triamcinolone suspension that has been approved for visualisation during vitrectomy via intravitreal administration and as intravitreal therapy for certain rare ocular diseases. However, the differences between Triesence® and purified (and thus also preservative-free) triamcinolones such as Volon A® or Kenalog® are not well specified, although the manufacturer of Triesence® advertises the product as "specifically formulated for the eye". METHODS: The publicly available FDA application material and information provided by the manufacturer for Triesence®, Kenalog® and Volon A® were analysed with respect to the differences between Triesence® and older triamcinolone preparations. RESULTS: According to the publicly available FDA documents the approval of Triesence mainly was based on studies that have been conducted with the older triamcinolone preparations Kenalog® or purified Volon A®. Apart from the absence of preservative the differences between Triesence® and the "older" triamcinolone preparation seem marginal. Published experimental or clinical studies in respect to the possible advantages of Triesence® compared to Kenalog® or Volon A® are lacking. Triesence® has been approved for sympathetic ophthalmia, temporal arteriitis, uveitis unresponsive to topical corticosteroids and for enhancing tissue visualisation during vitrectomy. Recently, the manufacturer of Kenalog® added a warning label ("not for intraocular use") on each vial of Kenalog®. The motifs for this re-labelling of Kenalog® remain unclear. CONCLUSION: Apart from the intraoperative use during vitrectomy Triesence® has only been approved for sympathetic ophthalmia, temporal arteriitis, and ocular conditions unresponsive to topical steroids. Consequently, the use of Triesence® like the older triamcinolone preparations (Kenalog® or Volon A®) for diabetic macular oedema, for Irivine-Gass syndrome, for neovascular AMD or after retinal vein occlusion is off-label.

Operative treatment of 733 patients with acute thoracolumbar spinal injuries: comprehensive results from the second, prospective, Internet-based multicenter study of the Spine Study Group of the German Association of Trauma Surgery.

The second, internet-based multicenter study (MCSII) of the Spine Study Group of the German Association of Trauma Surgery (Deutsche Gesellschaft für Unfallchirurgie) is a representative patient collection of acute traumatic thoracolumbar (T1-L5) injuries. The MCSII results are an update of those obtained with the first multicenter study (MCSI) more than a decade ago. The aim of the study was to assess and bring into focus: the (1) epidemiologic data, (2) surgical and radiological outcome, and (3) 2-year follow-up (FU) results of these injuries. According to the Magerl/AO classification, there were 424 (57.8%) compression fractures (A type), 178 (24.3%) distractions injuries (B type), and 131 (17.9%) rotational injuries (C type). B and C type injuries carried a higher risk for neurological deficits, concomitant injuries, and multiple vertebral fractures. The level of injury was located at the thoracolumbar junction (T11-L2) in 67.0% of the case. 380 (51.8%) patients were operated on by posterior stabilization and instrumentation alone (POSTERIOR), 34 (4.6%) had an anterior procedure (ANTERIOR), and 319 (43.5%) patients were treated with combined posteroanterior surgery (COMBINED). 65% of patients with thoracic (T1-T10) and 57% with lumbar spinal (L3-L5) injuries were treated with a single posterior approach (POSTERIOR). 47% of the patients with thoracolumbar junction (T11-L2) injuries were either operated from posterior or with a combined posterior-anterior surgery (COMBINED) each. Short angular stable implant systems have replaced conventional non-angular stable instrumentation systems to a large extent. The posttraumatic deformity was restored best with COMBINED surgery. T-spine injuries were accompanied by a higher number and more severe neurologic deficits than TL junction or L-spine injuries. At the same time T-spine injuries showed less potential for neurologic recovery especially in paraplegic (Frankel/AISA A) patients. 5% of all patients required revision surgery for perioperative complications. Follow-up data of 558 (76.1%) patients were available and collected during a 30-month period from 1 January 2004 until 31 May 2006. On average, a posterior implant removal was carried out in a total of 382 COMBINED and POSTERIOR patients 12 months after the initial surgery. On average, the rehabilitation process required 3-4 weeks of inpatient treatment, followed by another 4 months of outpatient therapy and was significantly shorter when compared with MCSI in the mid-1990s. From the time of injury until FU, 80 (60.6%) of 132 patients with initial neurological deficits improved at least one grade on the Frankel/ASIA Scale; 8 (1.3%) patients deteriorated. A higher recovery rate was observed for incomplete neurological injuries (73%) than complete neurological injuries (44%). Different surgical approaches did not have a significant influence on the neurologic recovery until FU. Nevertheless, neurological deficits are the most important factors for the functional outcome and prognosis of TL spinal injuries. POSTERIOR patients had a better functional and subjective outcome at FU than COMBINED patients. However, the posttraumatic radiological deformity was best corrected in COMBINED patients and showed significantly less residual kyphotic deformity (biseg GDW -3.8° COMBINED vs. -6.1° POSTERIOR) at FU (p = 0.005). The sagittal spinal alignment was better maintained when using vertebral body replacement implants (cages) in comparison to iliac strut grafts. Additional anterior plate systems did not have a significant influence on the radiological FU results. In conclusion, comprehensive data of a large patient population with acute thoracolumbar spinal injuries has been obtained and analyzed with this prospective internet-based multicenter study. Thus, updated results and the clinical outcome of the current operative treatment strategies in participating German and Austrian trauma centers have been presented. Nevertheless, it was not possible to answer all remaining questions to contradictory findings of the subjective, clinical outcome and corresponding radiological findings between different surgical subgroups. Randomized-controlled long-term investigations seem mandatory and the next step in future clinical research of Spine Study Group of the German Trauma Society.

[Classification of solid soft tissue tumours by ultrasonography]. / Sonografische Klassifikation solider Weichteiltumoren.

PURPOSE: Malignant soft tissue tumours appear infrequently in comparison to benign lesions. Clinical misdiagnosis leads to inadequate or delayed therapy in many cases of soft tissue sarcoma. The present study explores the question if ultrasonography as a widely-used diagnostic tool allows for a discrimination of benign and malignant soft tissue tumours. MATERIALS AND METHODS: In a prospective study over a period of 8 years 224 histologically ascertained solid soft tissue tumours, thereof 120 sarcomas and 27 aggressive benign lesions were investigated by B-mode and colour Doppler sonography. The echotexture was analysed computer-based using the parameters echogenicity, homogeneity and vascularisation in all lesions. RESULTS: Different tumour groups showed typical patterns of echotexture, which enabled a classification using 6 categories, distinguishing homogenous hyperechoic, heavily inhomogeneous and homogenous hypoechoic lesions, each group linked to an elevated or low vascularisation. Implementation of the proposed classification revealed a sensitivity in the detection of soft tissue sarcomas and aggressive benign lesions of 94.4 % with a specificity of 79.7 % and an accuracy of 89.7 %. CONCLUSION: Ultrasonography allows for a determination of the diagnostic and therapeutic procedure in soft tissue tumours. Due to the fact that soft tissue sarcomas present hypervascularised almost exclusively, predominantly homogenous hypoechoic, rarely homogenous hyperechoic, and aggressive benign tumours present homogenous hypoechoic predominantly, such patterns require a biopsy prior to further surgical therapy. However, in homogenous hyperechoic lesions displaying a low blood flow either a primary resection or a conservative treatment with follow-up examinations can be discussed depending on clinical findings and history of the patient. Although the group of heavily inhomogeneous tumours within our collective consisted of benign lesions exclusively, biopsy should be recommended in theses cases in order to exclude a soft tissue sarcoma.

[The juvenile bone cyst: treatment with continuous decompression using cannulated screws]. / Die juvenile Knochenzyste: Behandlung durch kontinuierliche Dekompression mit kanülierten Schrauben.

BACKGROUND: A unicameral bone cyst (UBC) may be caused by an intraosseous venous obstruction with the accumulation of interstitial fluid. Therefore, continuous decompression of the fluid using cannulated screws would represent a causal therapeutic approach. MATERIALS AND METHODS: The clinical and radiographic follow-up of 17 patients with UBCs treated by curettage and mechanical decompression using cannulated screws was evaluated retrospectively. RESULTS: Radiographic examination revealed the following results: complete healing of the lesion (n=2), persistent defect after healing (n=6), persistent lesion (n=6), and recurrent cyst after temporary remodeling (n=3). No pathologic fracture was subsequently observed in the group of lesions that had a persistent defect after healing. A persistent lesion occurred in the proximal femur in 75% of the cases and in the proximal humerus in 50% of the cases. CONCLUSION: Continuous decompression using cannulated screws can be applied in UBCs of the proximal humerus in patients with recurrent fractures and subjective complaints. However, treatment failures are common and comparable to other therapeutic approaches. Therefore, conservative treatment must be discussed critically. Healing with residual defect must be regarded as a good treatment result, and additional operative procedures with the objective of radiographic cosmetics should not be done. Because of poor results and long-term disability related to weight bearing, treatment of UBCs with cannulated screws cannot be recommended in lesions located in the proximal femur. In these cases, immediate surgical stabilization is the appropriate procedure.

[Operative treatment of traumatic fractures of the thoracic and lumbar spinal column. Part I: epidemiology]. / Operative Behandlung traumatischer Frakturen der Brust- und Lendenwirbelsäule: Teil I: Epidemiologie.

The Spine Study Group (AG WS) of the German Trauma Association (DGU) has now been in existence for more than a decade. Its main objective is the evaluation and optimization of the operative treatment for traumatic spinal injuries. The authors present the results of the second prospective internet-based multicenter study (MCS II) of the AG WS in three consecutive parts: epidemiology, surgical treatment and radiologic findings and follow-up results. The aim of the study was to update and review the state-of-the art for treatment of spinal fractures for thoracic and lumbar spine (T1-L5) injuries in German-speaking countries: which lesions will be treated with which procedure and what differences can be found in the course of treatment and the clinical and radiological outcome? This present first part of the study outlines the new study design and concept of an internet-based data collection system. The epidemiologic findings and characteristics of the three major treatment subgroups of the study collective will be presented: operative treatment (OP), non-operative treatment (KONS), and patients receiving a kyphoplasty and/or vertebroplasty without additional instrumentation (PLASTIE). A total of 865 patients (OP n=733, KONS n=52, PLASTIE n=69, other n=7) from 8 German and Austrian trauma centers were included. The main causes of accidents in the OP subgroup were motor vehicle accidents 27.1% and trivial falls 15.8% (KONS 55.8%, PLASTIE 66.7%). The Magerl/AO classification scheme was used and 548 (63.3%) compression fractures (type A), 181 (20.9%) distraction injuries (type B), and 136 (15.7%) rotational injuries (type C) were diagnosed. Of the fractures 68.8% were located at the thoracolumbar junction (T11-L2). Type B and type C injuries carried a higher risk for concomitant injuries, neurological deficits and additional vertebral fractures. The average initial VAS spine score, representing the status before the trauma, varied between treatment subgroups (OP 80, KONS 75, PLASTIE 72) and declined with increasing patient age (p<0.01).

[Operative treatment of traumatic fractures of the thorax and lumbar spine. Part II: surgical treatment and radiological findings]. / Operative Behandlung traumatischer Frakturen der Brust- und Lendenwirbelsäule. Teil II: Operation und röntgenologische Befunde.

The Spine Study Group (AG WS) of the German Trauma Association (DGU) presents its second prospective Internet-based multicenter study (MCS II) for the treatment of thoracic and lumbar spinal injuries. This second part of the study report focuses on the surgical treatment, course of treatment, and radiological findings in a study population of 865 patients. A total of 158 (18,3%) thoracic, 595 (68,8%) thoracolumbar, and 112 (12,9%) lumbar spine injuries were treated. Of these, 733 patients received operative treatment (OP group). Fifty-two patients were treated non-operatively and 69 patients were treated with kyphoplasty/vertebroplasty without additional instrumentation (Plasty group). In the OP group, 380 (51.8%) patients were instrumented from a posterior (dorsal) position, 34 (4.6%) from an anterior (ventral) position, and 319 (43.5%) cases with a combined posteroanterior procedure. Angular stable internal spine fixator systems were used in 86-97% of the cases for posterior and/or combined posteroanterior procedures. For anterior procedures, angular stable plate systems were used in a majority of cases (51.1%) for the instrumentation of mainly one or two segment lesions (72.7%). In 188 cases (53,3%), vertebral body replacement implants (cages) were used and were mainly implanted via endoscopic approaches (67,4%) to the thoracic spine and/or the thoracolumbar junction. The average operating time was 152 min in posterior-, 208 min in anterior-, and 298 min in combined postero-anterior procedures (p<0,001). The average blood loss was highest in combined operations, measuring 959 ml vs. 650 ml in posterior vs. 534 ml in anterior operations (p<0,001).Computer-assisted intraoperative navigation systems were used in 95 cases. At the time of hospital admission, 58,7% of the patients had spinal canal narrowing of an average of 36% (5-95%) at the level of their injury. The average spinal canal narrowing in patients with a complete spinal cord injury (Frankel/ASIA A) was calculated to be 70%, vs. 50% in patients with incomplete neurologic deficits (Frankel/ASIA B-D), and 20% in patients without neurologic deficits (Frankel/ASIS E; p<0,001). The average procedure in the plasty treatment subgroup was 50 min (18-145 min) to address one (n=59) or two (n=10) injured vertebral bodies. In patients with nonoperative treatment mainly three-point-corsets (n=36) were administered for a duration of 6-12 weeks. During their hospital stay 93 of 195 (44,7%) patients with initial neurologic deficits improved at least one Frankel/ASIA grade until the day of discharge. Two patients (0,2%) showed a neurologic deterioration. The highest rate of complete spinal cord injury (n=36, 23%) was associated with thoracic spine injuries. Nine (1%) patients died during the initial course of treatment. A total of 105 (14,3%) cases with intraoperative (n=56) and/or postoperative complications (n=69) were registered. The most common intraoperative complication was bleeding (n=35, 4,8%). A higher relative frequency of intraoperative complications was noticed in combined (n=34, 10,7%) vs. isolated posterior (n=22, 5,9%; p=0,021) procedures. The most common postoperative complication was associated with wound healing problems in 14 (1,9%) patients. Except in the non-operative treatment subgroup, a correction of the posttraumatic measured radiological deformity was achieved to a different extent within every treatment subgroup. There were no statistically significant differences between the postoperative radiological results of the treatment subgroups (dorsal vs. combination), taking into consideration the influence of relevant parameters such as different fracture types, patient age, and the amount of posttraumatic deformity (p=0,34, ANOVA).

[Operative treatment of traumatic fractures of the thoracic and lumbar spinal column: Part III: Follow up data]. / Operative Behandlung traumatischer Frakturen der Brust- und Lendenwirbelsäule: Teil III: Nachuntersuchung.

In this third and final part, the Spine Study Group (AG WS) of the German Trauma Association (DGU) presents the follow-up (NU) data of its second, prospective, internet-based multicenter study (MCS II) for the treatment of thoracic and lumbar spinal injuries including 865 patients from 8 trauma centers. Part I described in detail the epidemiologic data of the patient collective and the subgroups, whereas part II analyzed the different methods of treatment and radiologic findings. The study period covered the years 2002 to 2006 including a 30-month follow-up period from 01.01.2004 until 31.05.2006. Follow-up data of 638 (74%) patients were collected with a new internet-based database system and analyzed. Results in part III will be presented on the basis of the same characteristic treatment subgroups (OP, KONS, PLASTIE) and surgical treatment subgroups (Dorsal, Ventral, Kombi) in consideration of the level of injury (thoracic spine, thoracolumbar junction, lumbar spine). After the initial treatment and discharge from hospital, the average duration of subsequent inpatient rehabilitation was 4 weeks, which lasted significantly longer in patients with persistent neurologic deficits (mean 10.9 weeks) or polytraumatized patients (mean 8.6 weeks). Following rehabilitation on an inpatient basis, subsequent outpatient rehabilitation lasted on average 4 months. Physical therapy was administered significantly longer to patients with neurologic deficits (mean 8.7 months) or type C injuries (mean 8.6 months). The level of injury had no influence of the duration of the inpatient or outpatient rehabilitation. A total of 382 (72.2%) patients who were either operated from posterior approach only or in a combined postero-anterior approach had an implant removal after an average 12 months. During the follow-up period 56 (8.8%) patients with complications were registered and of these 18 (2.8%) had to have surgical revision. The most common complications reported were infection, loss of correction, or implant-associated complications. Clinical data showed a 2.9 higher relative risk for smokers compared to non-smokers to suffer from wound healing problems. The neurologic status of 81 (60.4%) out of 134 patients with neurologic deficits at the time of injury improved until follow-up. Neurologic deterioration was documented in 8 (1.3%) cases. Complete neurologic deficits after injury to the thoracic spine improved in 9% of the cases, whereas 59% of the cases with complete neurologic deficit improved after injury to the thoracolumbar junction. The surgical approach (posterior or combined postero-anterior) had no significant influence on neurological results at follow-up. Patient age, sex and neurologic deficits showed a statistically significant influence (p<0.05) on the fingertip-floor distance (FBA) at follow-up. Patient back function improved during the follow-up period. More than 2 years after the time of injury 32.2% of the patients had no complaints with respect to back function. The relative frequency of patients with unrestrained back function was greater after posterior surgery (24.2%), than anterior surgery (13.8%), or combined surgery (17.3%) (p=0.005; chi(2)-test). At follow-up there were no statistically significant differences of unrestrained back function between different levels of injury (thoracic spine 17.4%, TL junction 22.5% and lumbar spine 13.6%). The relative frequency of patients with injury to the thoracolumbar junction who reported "no complaints from the anterior approach" at follow-up, was calculated to be 55.6% after open versus 63.8% after endoscopic approaches with no significant differences. Of the patients 56.3% reported no donor site morbidity following iliac crest bone harvesting. The VAS spine score at follow-up was calculated within different treatment subgroups: OP 58.4 points, KONS 59.8 points, and PLASTIE 59.7 points. Statistically significant differences of the VAS spine score between posterior (64.9 points) versus combined surgery (47.8 points) were only verified at the level of injury of the thoracic spine (p=0.004). The relative frequency of patients regaining at least 80% of the initial score level was OP (posterior 60.4%, anterior 61.1%, combined 51.4%), 52.9% KONS and 67.6% PLASTIE. After surgery the mean period of incapacity from work was 4 months. Patients with a sedentary occupation before the time of injury were fully reintegrated into work in 71.1% of the cases. Patients with a physical occupation were fully reintegrated in 38.9% of the cases at follow-up. At follow-up 87 (31.2%) patients after posterior and 50 (20.1%) after combined surgery had no restrictions to their recreational activities (p=0.001). Treatment subgroups PLASTIE and KONS show a similar radiological result at follow-up with a bisegmental kyphotic deformity (GDW) of -9 degrees and -8.5 degrees, respectively. With all operative methods it was possible to correct or partly correct the posttraumatic kyphotic deformity. Until follow-up there was a loss of correction depending on the surgical approach and level of injury. Combined postero-anterior stabilization gave statistically significant better radiological results with less kyphotic deformity (-3.8 degrees) than posterior stabilization alone (-6.1 degrees) (p=0.005; ANOVA). Thus combined surgery was superior in its capability to restore spinal alignment within the observational period. At follow-up the use of titanium vertebral body replacement implants (cages) to reconstruct and support the anterior column showed significantly better radiological results with less kyphotic deformity and loss of correction (GDW 0.3 degrees) than the use of iliac bone strut grafts (-3.7 degrees ) (p<0.001). Neither additional anterior plates nor the combination of anterior plates with a cage or bone graft had a statistically significant influence on the kyphotic deformity measured at follow-up. A matched-pair analysis of anterior surgery alone versus combined surgery for the treatment of compression fractures (type A) at the thoracolumbar junction showed a significantly greater intraoperative blood loss but better radiological results in terms of monosegmental and bisegmental kyphotic deformity after combined surgery (p<0.05). A matched-pair analysis of treatment results between non-operative and operative treatment for burst fractures (type A3.1-2) showed a period of inability to work (6 months) which was twice as long for the non-operative treatment group. At the same time significantly better radiological results at follow-up were achieved after operative treatment of these fractures (p<0.05).

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.

Treatment with proton pump inhibitors is associated with increased mortality in patients with pyogenic liver abscess.

BACKGROUND: Proton pump inhibitors (PPI) are often used in patients with gastro-esophageal reflux and peptic ulcer disease. A higher risk for infectious diseases and for pyogenic liver abscess has been reported in patients with prolonged PPI intake. Although many patients have ongoing PPI treatment after diagnosis of liver abscess, there are no data available that focus on the prognostic impact of PPI treatment in these patients. AIM: To analyse the effect of PPI treatment on mortality in patients with pyogenic liver abscesses. METHODS: Between January 2005 and March 2017, one hundred and eighty-one patients with pyogenic liver abscess were retrospectively included in this analysis. Medical records including PPI treatment, microbiological and imaging data were reviewed. The primary endpoint was index mortality and predictive factors were analysed using uni- and multivariate logistic regression models. RESULTS: One hundred patients with pyogenic liver abscess (55.2%) were treated with PPI compared to 81 patients (44.8%) without PPI treatment. In both patient cohorts, enterococcus spp. and streptococcus of the anginous group were the most common pathogens identified. Patients with PPI treatment had significantly higher index mortality compared to patients without PPI treatment (30.0% vs 11.1%, P = 0.003). After adjusting for comorbidities PPI remained an independent predictive factor with an OR of 2.56 (1.01-6.46, P = 0.036). CONCLUSIONS: PPI treatment is associated with higher index mortality in patients with pyogenic liver abscess. Therefore, critical evaluation of the indication for PPI treatment is particularly important in patients at high risk for pyogenic liver abscess.

[Therapy indications and options for skeletal metastases]. / Therapieindikationen und -optionen bei ossären Metastasen.

Pathological fractures are dreaded complications due to skeletal metastasis. Modern oncological therapies and more sophisticated new radiological techniques such as MRI and positron emission tomography have improved multimodal treatment concepts. Surgical intervention is determined by the primary disease, general condition and life expectancy of the patient. The goals of surgical treatment are improvement of life quality, pain relief and maintenance of mobility.