Klinik und Poliklinik für Unfall-, Hand-, Plastische und Wiederherstellungschirurgie (Chirurgische Klinik II)
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- MRI (3)
- rotator cuff (3)
- joint instability (2)
- muscle degeneration (2)
- shoulder surgery (2)
- spectroscopy (2)
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- Institut für diagnostische und interventionelle Radiologie (Institut für Röntgendiagnostik) (13) (remove)
In this study, the impact of reconstruction sharpness on the visualization of the appendicular skeleton in ultrahigh-resolution (UHR) photon-counting detector (PCD) CT was investigated. Sixteen cadaveric extremities (eight fractured) were examined with a standardized 120 kVp scan protocol (CTDI\(_{vol}\) 10 mGy). Images were reconstructed with the sharpest non-UHR kernel (Br76) and all available UHR kernels (Br80 to Br96). Seven radiologists evaluated image quality and fracture assessability. Interrater agreement was assessed with the intraclass correlation coefficient. For quantitative comparisons, signal-to-noise-ratios (SNRs) were calculated. Subjective image quality was best for Br84 (median 1, interquartile range 1–3; p ≤ 0.003). Regarding fracture assessability, no significant difference was ascertained between Br76, Br80 and Br84 (p > 0.999), with inferior ratings for all sharper kernels (p < 0.001). Interrater agreement for image quality (0.795, 0.732–0.848; p < 0.001) and fracture assessability (0.880; 0.842–0.911; p < 0.001) was good. SNR was highest for Br76 (3.4, 3.0–3.9) with no significant difference to Br80 and Br84 (p > 0.999). Br76 and Br80 produced higher SNRs than all kernels sharper than Br84 (p ≤ 0.026). In conclusion, PCD-CT reconstructions with a moderate UHR kernel offer superior image quality for visualizing the appendicular skeleton. Fracture assessability benefits from sharp non-UHR and moderate UHR kernels, while ultra-sharp reconstructions incur augmented image noise.
Background
Dislocations of the elbow are the second most common dislocations of humeral joints following the shoulder. Besides numerous possible concomitant injuries of the collateral ligaments or the extensor or flexor apparatus, an accompanying disruption of the brachial artery is a rare occurrence. In the following, such a case is presented and discussed.
Method
A 70-year-old woman sustained a closed posterior elbow dislocation with accompanying disruption of the brachial artery due to a fall in a domestic environment. Pulselessness of the radial artery led to a computed tomography angiography being performed, which confirmed the diagnosis. Direct operative vascular reconstruction with a vein insert was carried out. Due to strong swelling of the soft tissue, other examinations of the elbow could not be performed initially. A redislocation a few days later led to an operative stabilization of the elbow joint.
Results
The final consultation 4 months postoperatively showed a stable, centered elbow joint and a normal perfusion of the affected arm. The elbow function was good with a range of motion of 0/0/110° of extension/flexion.
Conclusion
An elbow dislocation is a complex injury. An accurate clinical examination of possible concomitant injuries is important and should be repeated in the first few days after the occurrence. Vascular reconstruction should be performed immediately. In the case of persistent joint instability, an operative stabilization is indicated and may be supported by a hinged external fixator.
Background
Traumatic separation of the pubic symphysis can destabilize the pelvis and require surgical fixation to reduce symphyseal gapping. The traditional approach involves open reduction and the implantation of a steel symphyseal plate (SP) on the pubic bone to hold the reposition. Despite its widespread use, SP-fixation is often associated with implant failure caused by screw loosening or breakage.
Methods
To address the need for a more reliable surgical intervention, we developed and tested two titanium cable-clamp implants. The cable served as tensioning device while the clamp secured the cable to the bone. The first implant design included a steel cable anterior to the pubic symphysis to simplify its placement outside the pelvis, and the second design included a cable encircling the pubic symphysis to stabilize the anterior pelvic ring. Using highly reproducible synthetic bone models and a limited number of cadaver specimens, we performed a comprehensive biomechanical study of implant stability and evaluated surgical feasibility.
Results
We were able to demonstrate that the cable-clamp implants provide stability equivalent to that of a traditional SP-fixation but without the same risks of implant failure. We also provide detailed ex vivo evaluations of the safety and feasibility of a trans-obturator surgical approach required for those kind of fixation.
Conclusion
We propose that the developed cable-clamp fixation devices may be of clinical value in treating pubic symphysis separation.
Bone marrow lesions (BML) represent areas of deteriorated bone structure and metabolism characterized by pronounced water‐equivalent signaling within the trabecular bone on magnetic resonance imaging (MRI). BML are associated with repair mechanisms subsequent to various clinical conditions associated with inflammatory and non‐inflammatory injury to the bone. There is no approved treatment for this condition. Bisphosphonates are known to improve bone stability in osteoporosis and other bone disorders and have been used off‐label to treat BML. A randomized, triple‐blind, placebo‐controlled phase III trial was conducted to assess efficacy and safety of single‐dose zoledronic acid (ZOL) 5 mg iv with vitamin D 1000 IU/d as opposed to placebo with vitamin D 1000 IU/d in 48 patients (randomized 2:1) with BML. Primary efficacy endpoint was reduction of edema volume 6 weeks after treatment as assessed by MRI. After treatment, mean BML volume decreased by 64.53% (±41.92%) in patients receiving zoledronic acid and increased by 14.43% (±150.46%) in the placebo group (p = 0.007). A decrease in BML volume was observed in 76.5% of patients receiving ZOL and in 50% of the patients receiving placebo. Pain level (visual analogue scale [VAS]) and all categories of the pain disability index (PDI) improved with ZOL versus placebo after 6 weeks but reconciled after 6 additional weeks of follow‐up. Six serious adverse events occurred in 5 patients, none of which were classified as related to the study drug. No cases of osteonecrosis or fractures occurred. Therefore, single‐dose zoledronic acid 5 mg iv together with vitamin D may enhance resolution of bone marrow lesions over 6 weeks along with reduction of pain compared with vitamin D supplementation only.
Objectives
Triangular fibrocartilage complex (TFCC) injuries frequently cause ulnar-sided wrist pain and can induce distal radioulnar joint instability. With its complex three-dimensional structure, diagnosis of TFCC lesions remains a challenging task even in MR arthrograms. The aim of this study was to assess the added diagnostic value of radial reformatting of isotropic 3D MRI datasets compared to standard planes after direct arthrography of the wrist.
Methods
Ninety-three patients underwent wrist MRI after fluoroscopy-guided multi-compartment arthrography. Two radiologists collectively analyzed two datasets of each MR arthrogram for TFCC injuries, with one set containing standard reconstructions of a 3D thin-slice sequence in axial, coronal and sagittal orientation, while the other set comprised an additional radial plane view with the rotating center positioned at the ulnar styloid. Surgical reports (whenever available) or radiological reports combined with clinical follow-up served as a standard of reference. In addition, diagnostic confidence and assessability of the central disc and ulnar-sided insertions were subjectively evaluated.
Results
Injuries of the articular disc, styloid and foveal ulnar attachment were present in 20 (23.7%), 10 (10.8%) and 9 (9.7%) patients. Additional radial planes increased diagnostic accuracy for lesions of the styloid (0.83 vs. 0.90; p = 0.016) and foveal (0.86 vs. 0.94; p = 0.039) insertion, whereas no improvement was identified for alterations of the central cartilage disc. Readers' confidence (p < 0.001) and assessability of the ulnar-sided insertions (p < 0.001) were superior with ancillary radial reformatting.
Conclusions
Access to the radial plane view of isotropic 3D sequences in MR arthrography improves diagnostic accuracy and confidence for ulnar-sided TFCC lesions.
Objectives
Trauma evaluation of extremities can be challenging in conventional radiography. A multi-use x-ray system with cone-beam CT (CBCT) option facilitates ancillary 3-D imaging without repositioning. We assessed the clinical value of CBCT scans by analyzing the influence of additional findings on therapy.
Methods
Ninety-two patients underwent radiography and subsequent CBCT imaging with the twin robotic scanner (76 wrist/hand/finger and 16 ankle/foot/toe trauma scans). Reports by on-call radiologists before and after CBCT were compared regarding fracture detection, joint affliction, comminuted injuries, and diagnostic confidence. An orthopedic surgeon recommended therapy based on reported findings. Surgical reports (N = 52) and clinical follow-up (N = 85) were used as reference standard.
Results
CBCT detected more fractures (83/64 of 85), joint involvements (69/53 of 71), and multi-fragment situations (68/50 of 70) than radiography (all p < 0.001). Six fractures suspected in radiographs were ruled out by CBCT. Treatment changes based on additional information from CBCT were recommended in 29 patients (31.5%). While agreement between advised therapy before CBCT and actual treatment was moderate (κ = 0.41 [95% confidence interval 0.35–0.47]; p < 0.001), agreement after CBCT was almost perfect (κ = 0.88 [0.83–0.93]; p < 0.001). Diagnostic confidence increased considerably for CBCT studies (p < 0.001). Median effective dose for CBCT was 4.3 μSv [3.3–5.3 μSv] compared to 0.2 μSv [0.1–0.2 μSv] for radiography.
Conclusions
CBCT provides advantages for the evaluation of acute small bone and joint trauma by detecting and excluding extremity fractures and fracture-related findings more reliably than radiographs. Additional findings induced therapy change in one third of patients, suggesting substantial clinical impact.
Hintergrund
Die Fotodokumentation von offenen Frakturen, Wunden, Dekubitalulzera, Tumoren oder Infektionen ist ein wichtiger Bestandteil der digitalen Patientenakte. Bisher ist unklar, welchen Stellenwert diese Fotodokumentation bei der Abrechnungsprüfung durch den Medizinischen Dienst der Krankenkassen (MDK) hat.
Fragestellung
Kann eine Smartphone-basierte Fotodokumentation die Verteidigung von erlösrelevanten Diagnosen und Prozeduren sowie der Verweildauer verbessern?
Material und Methoden
Ausstattung der Mitarbeiter mit digitalen Endgeräten (Smartphone/Tablet) in den Bereichen Notaufnahme, Schockraum, OP, Sprechstunden sowie auf den Stationen. Retrospektive Auswertung der Abrechnungsprüfung im Jahr 2019 und Identifikation aller Fallbesprechungen, in denen die Fotodokumentation eine Erlösveränderung bewirkt hat.
Ergebnisse
Von insgesamt 372 Fallbesprechungen half die Fotodokumentation in 27 Fällen (7,2 %) zur Bestätigung eines Operationen- und Prozedurenschlüssels (OPS) (n = 5; 1,3 %), einer Hauptdiagnose (n = 10; 2,7 %), einer Nebendiagnose (n = 3; 0,8 %) oder der Krankenhausverweildauer (n = 9; 2,4 %). Pro oben genanntem Fall mit Fotodokumentation ergab sich eine durchschnittliche Erlössteigerung von 2119 €. Inklusive Aufwandpauschale für die Verhandlungen wurde somit ein Gesamtbetrag von 65.328 € verteidigt.
Diskussion
Der Einsatz einer Smartphone-basierten Fotodokumentation kann die Qualität der Dokumentation verbessern und Erlöseinbußen bei der Abrechnungsprüfung verhindern. Die Implementierung digitaler Endgeräte mit entsprechender Software ist ein wichtiger Teil des digitalen Strukturwandels in Kliniken.
Purpose
The trauma centre of the Wuerzburg University Hospital has integrated a pioneering dual-room twin-CT scanner in a multiple trauma pathway. For concurrent treatment of two trauma patients, two carbon CT examination and intervention tables are positioned head to head with one sliding CT-Gantry in the middle. The focus of this study is the process of trauma care with the time to CT (tCT) and the time to operation (tOR) as quality indicator.
Methods
All patients with suspected multiple trauma, who required emergency surgery and who were initially diagnosed by the CT trauma protocol between 05/2018 and 12/2018 were included. Data relating to time spans (tCT and tOR), severity of injury and outcome was obtained.
Results
110 of the 589 screened trauma patients had surgery immediately after finishing primary assessment in the ER. The ISS was 17 (9–34) (median and interquartile range, IQR). tCT was 15 (11–19) minutes (median and IQR) and tOR was 96.5 (75–119) minutes (median and IQR). In the first 30 days, seven patients died (6.4%) including two within the first 24 h (2%). There were two ICU days (1–6) (median and IQR) and one (0–1) (median and IQR) ventilator day.
Conclusion
The twin-CT technology is a fascinating tool to organize high-quality trauma care for two multiple trauma patients simultaneously
Background:
Vascular damage in polytrauma patients is associated with high mortality and morbidity. Therefore, specific clinical implications of vascular damage with fractures in major trauma patients are reassessed.
Methods:
This comprehensive nine-year retrospective single center cohort study analyzed demography, laboratory, treatment and outcome data from 3689 patients, 64 patients with fracture-associated vascular injuries were identified and were compared to a control group.
Results:
Vascular damage occurred in 7% of patients with upper and lower limb and pelvic fractures admitted to the trauma room. Overall survival was 80% in pelvic fracture and 97% in extremity fracture patients and comparable to non-vascular trauma patients. Additional arterial damage required substantial fluid administration and was visible as significantly anemia and disturbed coagulation tests upon admission. Open procedures were done in over 80% of peripheral extremity vascular damage. Endovascular procedures were predominant (87%) in pelvic injury.
Conclusion:
Vascular damage is associated with high mortality rates especially in combination with pelvic fractures. Initial anemia, disturbed coagulation tests and the need for extensive pre-clinical fluid substitution were observed in the cohort with vascular damage. Therefore, fast diagnosis and early interventional and surgical procedures are necessary to optimize patient-specific outcome.
Background:
The amount of fatty degeneration (FD) has major impact on the clinical result and cuff integrity after rotator cuff repair. A quantitative analysis with magnet resonance imaging (MRI) spectroscopy was employed to analyze possible correlation of FD with tendon retraction, tendon thickness and patients’ characteristics in full thickness supraspinatus tears.
Methods:
Forty-two patients with full-thickness supraspinatus tears underwent shoulder MRI including an experimental spectroscopic sequence allowing quantification of the fat fraction in the supraspinatus muscle belly. The amount of fatty degeneration was correlated with tendon retraction, tendon thickness, patients’ age, gender, smoker status, symptom duration and body mass index (BMI). Patients were divided in to three groups of retraction (A) 0-10 mm (n=), (B) 11-20 mm (n=) and (C) < 21 mm (n=) and the means of FD for each group were calculated.
Results:
Tendon retraction (R = 0.6) and symptom duration (R = 0.6) correlated positively, whereas tendon thickness correlated negatively (R = − 0.6) with the amount of FD. The fat fraction increased significantly with tendon retraction: Group (A) showed a mean fat mount of 3.7% (±4%), group (B) of 16.7% (±8.2%) and group (C) of 37.5% (±19%). BMI, age and smoker-status only showed weak to moderate correlation with the amount of FD in this cohort.
Conclusion:
MRI spectroscopy revealed significantly higher amount of fat with increasing grade of retraction, symptom duration and decreased tendon thickness. Thus, these parameters may indirectly be associated with the severity of tendon disease.