Dietrich Banzer

Imaging of hamate bone fractures in conventional X-rays and high-resolution computed tomography. An in vitro study.

RATIONALE AND OBJECTIVES To examine the ability to image fractures of the body and hook of the hamate bone in conventional X-rays and high-resolution computed tomography (HR-CT). MATERIALS AND METHODS In an in vitro experiment using 18 cadaver hands, the hamate bone was fractured at different places. Before and after fracture, conventional X-rays were taken in different planes (anteroposterior, lateral, oblique, and carpal tunnel), and HR-CT was performed with 2-mm layer thickness in the axial, sagittal, and coronal plane. RESULTS Taking into account all the conventional X-ray projections applied, the in vivo experiment revealed a sensitivity of 72.2%, a specificity of 88.8%, and an accuracy of 80.5%. For the HR-CT, the sensitivity was 100%, the specificity was 94.4%, and the accuracy was 97.2%. CONCLUSIONS Fractures of the body and hook of the hamate cannot always be detected with certainty in the conventional X-ray image, even if different projectional planes are used. The HR-CT is the imaging procedure of choice for further clarification, and an axial or sagittal plane should be selected.

Clinical results of TRAM flap delay by selective embolization of the deep inferior epigastric arteries.

Preoperative selective embolization of the deep inferior epigastric arteries constitutes a new technique in TRAM flap delay. Whereas surgical ligation of these vessels has proved to be an effective delay procedure in experimental and clinical settings, it requires an additional operative step under general anesthesia. Despite the introduction of the free TRAM leading to improved flap perfusion, this microsurgical technique is not always available because of the requirements of specialized equipment and staff, longer operating hours, and subsequently higher expenses. The search for a minimally invasive, easy, and inexpensive technique to improve perfusion of the pedicled TRAM flap led us to selective embolization of the deep inferior epigastric arteries by an angiographic procedure. After 4 years of experience with this technique, we now present the first clinical results. Breast reconstruction by a delayed pedicled TRAM flap was performed in 40 patients with a mean age of 48.4 years (range, 31 to 66 years). The mean interval between embolization and surgery was 3.6 months. Postoperative data concerning flap survival and complications were available for all patients. Embolization of the deep inferior epigastric arteries was performed bilaterally in 35 patients (87.5 percent) and unilaterally in 5 patients (12.5 percent). Radiotherapy had been applied in 21 patients (52.5 percent) before surgery. Postoperative flap complications consisted of partial necrosis in three (7.5 percent), fat necrosis in one (2.5 percent), impaired wound healing in five (12.5 percent), and postoperative bleeding in two patients (5 percent). Abdominal wound healing complications occurred in six patients (15 percent), abdominal wall weakness in eight (20 percent), and hernia formation in four (10 percent). Surgical corrections were performed at the breast (TRAM flap) in 22 patients (55 percent) and at the abdomen (donor site) in 9 (22.5 percent). Preoperative selective embolization of the deep inferior epigastric arteries constitutes an alternative delay procedure for the pedicled TRAM flap. It is superior to the conventional procedure without delay, offers several advantages compared with surgical ligation of these vessels, and represents an alternative to the free TRAM flap in selected cases. (Plast. Reconstr. Surg. 105: 1320, 2000.)

Ultrasound and Soft-Tissue Radiography to Monitor Local Interferon-α2B Treatment in Peyronie's Disease

Purpose: We attempted to assess objectively the response of Peyronies disease plaques to local interferon-α2B. Material and Methods: Twenty patients were treated with 5 local injections of 1 million units of IFN-α2B into a single designated plaque. Before treatment, and 4 weeks and 6 months after treatment, the plaques were examined ultrasonographically. Each time, a histogram profile was performed. All patients also underwent soft-tissue radiography in 2 planes using the mammography technique before and 6 months after treatment. Results: We found that with ultrasonography the plaques could be classified into 3 groups depending on degree of calcification, from nil to complete. Radiography detected calcifications better than ultrasonography but failed to detect plaques without calcification. The degree of calcification was negatively correlated with the response to treatment, since noncalcified plaques responded best, while fully calcified plaques failed to respond. Conclusion: In Peyronies disease, ultrasonography is an important tool for non-invasive monitoring treatment response and for preselecting patients for medical treatment.

BONE MINERAL DENSITY AND SPONGIOSA ARCHITECTURE IN CORRELATION TO VERTEBRAL BODY INSUFFICIENCY FRACTURES

Objective: the clinical value of spinal quantitative CT (sQCT) and the structural patterns of the vertebral bone were studied Material and Methods: sQCT was performed on 246 patients with a mean age of 57 years for whom conventional lateral radiographies of the thoracic and lumbar spine were available. All patients were suffering from back pain of unknown etiology. the bone mineral density (BMD) of the midvertebral section of 3 lumbar vertebral bodies was determined by means of single-energy-(SE)-weighted QCT (85 kV). Spongiosa architecture and density profile analyses were made in the axial images. This was contrasted to BMD values ascertained in SE QCT. the mean BMD was compared to the number of fractures and the patients were divided into three groups: group I — no fracture; group II — one fracture; and group III 1 fracture Results: the mean BMD was: 134.3 (74.1–187.5) mg hydroxyapatite (HA)/ml in group I; 79.6 (58.6–114.3) mg HA/ml in group II; and 52.4 (13.1–79.1)mg HA/ml in group III. A significant deterioration in spongiosa structure was found with increasing demineralization: strongly rarefied patterns predominated in the fracture groups II and III Conclusion: sQCT provides a good risk assessment of the occurrence of vertebral body insufficiency fractures

Die Reliabilität radiologischer Befunde zur Differentialdiagnose der vertebralen Osteoporose

Summary□Background: Radiologically identified vertebral deformities, e. g. wedge-, fish-, or crush-vertebrae are not always a consequence of local osteoporosis. Other frequent pathomechanisms include Morbus Scheuermann, degenerative changes, overt trauma, and congenital dysplasia. This requires differential diagnosis of vertebral deformities. Radiological classification criteria have to satisfy various methodological requirements to ensure reliability of the results.□Methods: Inter-rater reliability of more than 30 radiological findings was assessed in 4 German centres of the European Vertebral Osteoporosis Study (EVOS). One hundred randomly selected EVOS cases from the West-Berlin population, each contributing 2 lateral X-rays from the thoracic and lumbar spine respectively, were independently evaluated by 7 observers. All observers were medical doctors, 4 of them heads or members of clinical radiological departments. Thus each observer read 200 radiographs. Radiological alterations in the form and structure of 13 vertebrale which were considered to be relevant for the differential diagnosis of osteoporosis were recorded in a standardized documentation form. Additionally global judgements (e. g. “osteoporotic spine” yes/no) were required. To quantify agreement Fleiss’ kappa (κ) for nominal data and multiple observers was used.□Results: Only 4% of all vertebral columns were stated as “normal”, 25% as “osteoporotic”. This last figure exceeded more than 2-fold the prevalence of significant vertebral deformities, as based on semiautomatic morphometry (about 10%). Wedge deformities were found on average in 39% of all thoracic and 5% of all lumbar X-rays with ranges of 20% to 53% and 2% to 10% respectively among 7 observers. For both variables, agreement (κ) between the observers was below 0.40. The highest agreement was found for the assessment of fractures of the upper and/or lower lamina of lumbar vertebrae (κ=0.58). Agreement did not vary between radiologists and non-radiologists. Higher κ-values were recorded for observers working in the same centre (0.50 to 0.90).□Conclusion: There is an urgent need for the differential diagnosis of vertebral deformities which in half of all cases may be caused by vertebral osteoporosis. The low inter-rater reliability of 30 radiological characteristics seriously interferes with this task. Moderate to good agreement was seen only among observers coming from the same centre. It may be concluded that a more intensive training is likely to lead to better agreement. However, this is a time and resource consuming option. It may be equally appropriate to include further information from other sources such as bone mass measurement to identify osteoporosis related vertebral deformities. In the meantime, prevalence estimations and case control studies based solely on vertebral morphometry have to be interpreted with caution.

Erectile Dysfunction due to Single Vessel Failure: Diagnosis and Surgical Treatment

We report on the successful surgical treatment of venous single vessel disease in a patient presenting with erectile dysfunction. We stress the necessity of accurate diagnostic workup which enables the identification of rare cases that can be cured surgically.

Computerized analysis of gray-value profiles in spongy and cortical bone. Clinical experience.

RATIONALE AND OBJECTIVES Osteoporosis is characterized by a loss of bone mineral density and deterioration of structure. The authors present a structural parameter for the quantitative assessment of osteoporotic changes in vertebral bone. METHODS In 40 patients without or with known osteoporotic fractures, spongiosa and cortical bone mineral density was measured in lumbar vertebrae 1 to 3 by quantitative CT. Additional axial high-resolution CT slices were obtained for the structural analysis. In the spongiosa, the gray-value profile along a horizontal line in the CT slice was used, whereas in the cortical shell a profile was obtained from the cortical ridge. Both profiles were intersected with a horizontal line of variable position, and the maximum number of intersections was determined. RESULTS The maximum number of intersections is significantly higher in cases with fractures (spongiosa 48.6, cortical shell 77.3) than in cases without fractures (spongiosa 42.1, cortical shell 62.4). It also correlates with bone mineral density and age. CONCLUSIONS The presented method shows significantly different numeric results for patients with and without osteoporotic fractures. The analysis is easy to perform and provides additional information on the bone structure that may be used in combination with bone mineral density measurements.

Knochendichte von Spongiosa und Kortikalis der Lendenwirbelsäule

BACKGROUND AND METHOD In an additional bone density measurement protocol to the European Vertebral Osteoporosis Study (EVOS) separate spongious and cortical density measurements (sQCT) were carried out at the first 3 lumbar vertebrae in 293 volunteers (92 men and 201 women) in 3 Berlin regional centers. RESULTS The spongious mineral density decreases from proximal to distal (L1 to L3), the cortical density increases from proximal to distal, mainly in men. Men showed no significant decrease of cortical density and a lower decrease of spongious density with age compared to women. A comparison of bone mineral density with vertebral height indices of McCloskey/Kanis, Eastell/Melton and Felsenberg showed significant differences of spongious density between a group with normal vertebral height and a group with at least one pathologically degraded vertebra. Individuals with osteoporosis according to the WHO-definition showed a higher prevalence of vertebral deformities. No significant loss of cortical density was observed in these people.Summary□Background and Method: In an additional bone density measurement protocol to the European Vertebral Osteoporosis Study (EVOS) separate spongious and cortical density measurements (sQCT) were carried out at the first 3 lumbar vertebrae in 293 volunteers (92 men and 201 women) in 3 Berlin regional centers.□Results: The spongious mineral density decreases from proximal to distal (L1 to L3), the cortical density increases from proximal to distal, mainly in men. Men showed no significant decrease of cortical density and a lower decrease of spongious density with age compared to women. A comparison of bone mineral density with vertebral height indices of McCloskey/Kanis, Eastell/Melton and Felsenberg showed significant differences of spongious density between a group with normal vertebral height and a group with at least one pathologically degraded vertebra. Individuals with osteoporosis according to the WHO-definition showed a higher prevalence of vertebral deformities. No significant loss of cortical density was observed in these people.