Radiographic parameter(s) influencing functional outcomes following angular stable plate fixation of proximal humeral fractures.

PURPOSE: Radiographic parameters which correlate with poor clinical outcome after proximal humeral fractures could be helpful indicators to answer the question which patients should be followed up closer. Moreover, during surgery, radiographic parameters correlating with unfavourable outcome should be avoided. The primary aim of the study was to compare radiographic measurements between the injured and the contralateral, uninjured shoulder. The secondary aim was to correlate these radiographic parameters with post-operative shoulder function. METHODS: Fifty-eight patients (age: 55.6 ± 14.4 years, age at surgery) following angular stable plate fixation of a proximal humeral fracture (2-part fractures according to Neer: 24, 3-part: 25, 4-part: 9) were included in this retrospective cohort study. All patients were followed up at least six years (7.9 ± 1.4 after surgical intervention). During follow-up examination, the Constant score (CS) was assessed, and radiographs of both shoulders were taken. Radiographs were analyzed regarding lateral humeral offset, distance between tuberculum and head apex, head diameter, head height, perpendicular height, perpendicular center, vertical height, and angles between head and humeral shaft (CCD and HSA). These parameters were compared between the injured and uninjured shoulder. The cohort was divided in two groups: patients with a CS category of excellent/good and satisfying/worse. Both groups were tested regarding differences of demographic and radiographic parameters. RESULTS: The distance between tuberculum and head apex (2.6 ± 3.4 mm vs. 4.3 ± 2.1 mm; p = 0.0017), the CCD (123.1 ± 12.9° vs. 130.1 ± 7.3°; p = 0.0005), and the HSA (33.1 ± 12.8° vs. 40.1 ± 7.3°; p = 0.0066) were significantly smaller on the treated shoulder compared to the uninjured side. Patients reached a Constant score of 80.2 ± 17.4 (95% CI 75.6-84.8) points. Regarding outcome categories of the Constant score, 46 patients had a good to excellent outcome, and 12 patients had a satisfying or bad outcome. The comparison of these groups revealed that patients with inferior outcome in the long-term follow-up were older, female, had a more complex fracture type (AO classification), smaller lateral humeral offset, smaller head diameter and height, lower perpendicular height, and lower CCD and HSA angles. CONCLUSION: If the abovementioned parameters cannot be restored sufficiently during surgery, (reversed) shoulder arthroplasty might be a better solution to reach good post-operative outcome. Moreover, patients presenting these radiographic characteristics in the follow-up, older patients, and patients with a more complex fracture type should be followed up closer to possibly prevent poor shoulder function. TRIAL REGISTRATION: 83 250/2011BO2.

Background parenchymal enhancement in pregnancy-associated breast cancer: a hindrance to diagnosis?

PURPOSE: The purpose of this study is to investigate the detectability of pregnancy-associated breast cancer (PABC) in lactating glandular tissue on magnetic resonance imaging (MRI) by using pre- and post-contrast acquisitions and their derived postprocessed images and compare these results to ultrasound (US) and mammography (MG). MATERIALS AND METHODS: We reviewed the electronic database for women with PABC and existing breast MRI. MR images (T2-weighted short inversion-recovery sequence [STIR], dynamic contrast-enhanced T1-weighted gradient echo sequence and postprocessed subtraction images [early post-contrast minus pre-contrast]) were retrospectively evaluated (image quality, parenchymal/tumour enhancement kintetics, tumour size and additional lesions). Supplemental subtraction images (latest post-contrast minus early post-contrast) to reduce plateau enhancement were additionally calculated and tumour conspicuity and size were measured. Findings were compared to US and MG reports. RESULTS: Nineteen patients (range 27-42 years) were included. Background parenchymal enhancement (BPE) was minimal (n=1), mild (n=3), moderate (n=7) and marked (n=8) with kinetics measured plateau (n=8), continuous (n=10) and not quantifiable (n=1). Tumour kinetics presented wash-out (n=17) and plateau (n=2). Eighteen of nineteen tumours were identified on the supplemental subtraction images. All tumours were visible on US; 12/19 were visible on MG (63.2%). MRI detected additional malignant lesions in two patients. CONCLUSION: Despite high BPE of the lactating breast, MRI securely detects carcinomas and identifies satellite lesions. By using supplemental subtraction images, background enhancement can be eliminated to facilitate diagnosis. US remains a reliable diagnostic tool, but additional MRI is recommended to rule out satellite/contralateral lesions. MG interpretations can be difficult due to high parenchymal density. KEY POINTS: • Despite high background enhancement, MRI of the breast confidently detects carcinomas and identifies further lesions in the lactating breast. • By using supplemental subtraction images, background enhancement in the lactating breast can be eliminated to facilitate diagnosis. • US remains a reliable diagnostic tool. Mammography can be limited due to extremely dense breast tissue related to lactation.

Breast tomosynthesis for the clarification of mammographic BI-RADS 3 lesions can decrease follow-up examinations and enables immediate cancer diagnosis.

Background The limited sensitivity of mammography in case of a high breast density often produces unclear or false-positive findings, so-called BI-RADS 3 lesions, which have to be followed up to prove benignity. Digital breast tomosynthesis (DBT) was developed to reduce such summation effects. Purpose To evaluate the influence of an additional DBT on the management of mammographic BI-RADS 3 findings and whether DBT can decrease the time to definitive diagnosis or not. Material and Methods We analyzed 87 patients with a mammographic non-calcified BI-RADS 3 lesion who underwent an additional DBT of the affected breast. A follow-up two-dimensional (2D) examination or a histological result of the lesion had to be available. The images were analyzed especially for the BI-RADS category and incremental diagnostic accuracy. Moreover, the inter-reader reliability and the radiation dose were evaluated. Results The BI-RADS category has been changed by the addition of DBT: 57.1% were assessed as BI-RADS 1 or 2, 4.6% as BI-RADS 4, and only 38.3% remained as BI-RADS 3. The intraclass correlation coefficient for the three readers showed a good agreement for inter-reader reliability. No false-negative examination was found in the follow-ups. Nine lesions were biopsied (seven benign, two malignant). Both malignant lesions were suspicious in the DBT (BI-RADS 4). A significant higher glandular dose was necessary for the DBT. Conclusion DBT has the potential to reduce the recall-rate of BI-RADS 3 lesions and to find and diagnose malignant lesions earlier than 2D mammography alone.

Contrast-enhanced spectral mammography in patients with MRI contraindications.

Background Contrast-enhanced spectral mammography (CESM) is a novel breast imaging technique providing comparable diagnostic accuracy to breast magnetic resonance imaging (MRI). Purpose To show that CESM in patients with MRI contraindications is feasible, accurate, and useful as a problem-solving tool, and to highlight its limitations. Material and Methods A total of 118 patients with MRI contraindications were examined by CESM. Histology was obtained in 94 lesions and used as gold standard for diagnostic accuracy calculations. Imaging data were reviewed retrospectively for feasibility, accuracy, and technical problems. The diagnostic yield of CESM as a problem-solving tool and for therapy response evaluation was reviewed separately. Results CESM was more accurate than mammography (MG) for lesion categorization (r = 0.731, P < 0.0001 vs. r = 0.279, P = 0.006) and for lesion size estimation (r = 0.738 vs. r = 0.689, P < 0.0001). Negative predictive value of CESM was significantly higher than of MG (85.71% vs. 30.77%, P < 0.0001). When used for problem-solving, CESM changed patient management in 2/8 (25%) cases. Superposition artifacts and timing problems affected diagnostic utility in 3/118 (2.5%) patients. Conclusion CESM is a feasible and accurate alternative for patients with MRI contraindications, but it is necessary to be aware of the method's technical limitations.

Quality of life and clinical-radiological long-term results after implant-associated infections in patients with ankle fracture: a retrospective matched-pair study.

BACKGROUND: Ankle fractures are frequently occurring injuries. Despite the relatively simple operative technique, patients often suffer from postoperative complications. Little is known about postoperative treatment of implant-associated infections of the ankle. Therefore, this study shows and evaluates a treatment algorithm in long- and short-term outcomes compared to infection-free patients. METHODS: Data from patients of over 20 years of a level 1 trauma center and university hospital was retrospectively analyzed including age, gender, comorbidities, smoking status, fracture classification, number of revisions, length of in-patient stay due to fracture and infection, and results of microbiological specimen with the length of antibiotic treatment. Moreover, present long-term outcome was evaluated by the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, the Ankle Osteoarthritis Score, and the Short Form 36 score and compared to a matched-pair infection-free patient cohort. RESULTS: Forty-four patients could be retrospectively evaluated (51% male, 49% women, mean age 46 ± 17 years). Most of the cases were Weber B fractures (38%) following an in-patient stay from 51 ± 4.3 days after primary treatment and 77 ± 10.0 days after secondary treatment in our hospital. Microbiological specimen showed in 77% Staphylococcus aureus with following intravenous antibiotic treatment for 13.9 ± 3.1 days in mean. Common comorbidities/risk factors were cardiovascular disease (28%), smoking (15%), and diabetes (18%). Cure of infection and clinical and radiographic osseous consolidation could be documented for all cases. Patients with implant-associated infections had significantly more risk factors than infection-free patients (1.1/0.33; p = .02 per patient). The matched-pair group showed significantly better long-term outcome in mean regarding the Ankle Osteoarthritis Score (2.0 ± 1.2/13.9 ± 4.7) and AOFAS hindfoot score (96.7 ± 1.9/87.3 ± 3.4). CONCLUSION: Immediate revision surgery with aggressive debridement, microbiological diagnostics, antibiotic therapy, and use of a drain until osseous consolidation is reached with following removal of the implant in patients with implant-associated infections after ankle fracture and open reduction internal fixation lead to cure of infection and fair long-term outcome in all cases. Special care must be taken of risk factors like diabetes and smoking. TRIAL REGISTRATION: 24/2008BO2.

BI-RADS® 3 lesions at contrast-enhanced breast MRI: is an initial short-interval follow-up necessary?

BACKGROUND: Magnetic resonance imaging (MRI) BI-RADS® 3 lesions should have a very high probability of being benign. To prove benignity most institutions do follow-up MRI. PURPOSE: To evaluate the necessity of initial short-interval follow-up after 6 months as it is suggested for mammographic BI-RADS®3 lesions. MATERIAL AND METHODS: We analyzed 163 consecutive MRI-BI-RADS® 3 lesions on follow-up MRI: 75 masses (46%), 67 foci (41.1%), and 21 (12.9%) non-mass-like enhancing lesions (NMLE). RESULTS: During MRI follow-up (mean time, 563 days) 20% of the lesions disappeared, 23% decreased, 52% did not change, and 4.9% showed increase. All increasing lesions were biopsied (5 benign, 2 ductal carcinoma in situ, 1 invasive carcinoma). The rate of malignancy was 1.8%. All malignant lesions (1 mass, 1 focus, 1 NMLE) showed increase at initial follow-up after a mean interval of 190 days. CONCLUSION: In this study the malignancy rate of MRI-BI-RADS® 3 lesions corresponded to mammographic BI-RADS® 3 lesions. Initial short-interval MRI should be suggested to identify malignant MRI-BI-RADS® 3 lesions.

Complication rates and outcomes stratified by treatment modalities in proximal humeral fractures: a systematic literature review from 1970-2009.

BACKGROUND: The optimal treatment of complex, displaced proximal humeral fractures is controversial. A systematic literature review of the time period from 1970 to 2009 was conducted. The purpose was to evaluate the clinical success and complications of the available treatment modalities to determine specific treatment recommendations for the different fracture patterns. METHODS: The databases (PubMed/EMBASE) were searched for the time period (01/1970-09/2009). Study quality, treatment modalities, classification, outcome scores and complications of 200 publications including 9377 patients were analyzed. Interventions were compared by analysis of variance with subsequent Tukey's-test. Complication rates among methods were compared by using Pearson's-chi-square-test and pairwise comparisons using Fisher's-two-tailed-exact-test. RESULTS: Hemiarthroplasty, angle-stable plate and non-operative treatment were used for 63% of the follow-up-patients. For 3- and 4-part fractures, patients with hemiarthroplasty [3-Part: 56.4 (lower/upper 95% confidence interval (CI): 43.3-68.7); 4-Part: 49.4 (CI: 42.2-56.7)] received a lower score than different surgical head-preserving methods such as ORIF [3-Part: 82.4 (CI: 76.6-86.9); 4-Part: 83.0 (CI:78.7-86.6)], intramedullary nailing [3-Part: 79.1 (CI:74.0-83.4)] or angle-stable plates [4-Part: 66.4 (CI: 59.7-72.4)].The overall complication rate was 56%. The most common complications were fracture-displacement, malunion, humeral head necrosis and malreduction. The highest complication rates were documented for conventional plate and hemiarthroplasty and for AO-C, AO-A, for 3- and 4-part fractures. Only 25% of the data were reported with detailed classification results and the corresponding outcome scores. DISCUSSION: Despite the large amount of patients included, it is difficult to determine adequate recommendations for the treatment of proximal humeral fractures because a relevant lack of follow-up data impaired subsequent analysis. For displaced 3- and 4-part fractures head-preserving therapy received better outcome scores than hemiarthroplasty. However, a higher number of complications occurred in more complex fractures and when hemiarthroplasty or conventional plate osteosynthesis was performed. Thus, when informing the patient for consent, both the clinical results and the possibly expected complications with a chosen treatment modality should be addressed.

Breast MRI of pure ductal carcinoma in situ: sensitivity of diagnosis and influence of lesion characteristics.

OBJECTIVES: The purpose of the study was to evaluate the sensitivity of breast MRI in the detection of pure DCIS and to analyze the influence of lesion type and nuclear grade. METHODS: 58 consecutive patients with pathologically proven pure DCIS and preoperatively performed breast MRI were retrospectively reviewed and analyzed. Sensitivities in the detection of DCIS were calculated for MRI and mammography (Mx). Influence of MRI lesion type and nuclear grading on DCIS diagnosis was evaluated. RESULTS: MRI detected pure DCIS with a sensitivity of 79.3%. The sensitivity of Mx was lower (69%), but the difference was not statistically significant (p=0.345). 46.2% of the DCIS presented as enhancing mass and 53.8% as non-mass-like enhancement (NMLE). None of the masses but 21.4% (n=6) of the NMLE were underestimated as probably benign (BI-RADS 3). MRI measured lesion sizes showed a moderate correlation (r=0.74) with histopathologically measured lesion sizes. MRI detection rate of DCIS decreased significantly (p=0.0458) with increasing nuclear grade. Calculated sensitivities were 100% for low-grade DCIS, 84.6% for intermediate-grade DCIS, and 66.7% for high-grade DCIS. CONCLUSIONS: In this study MRI could detect pure DCIS more sensitively than Mx. Despite of missing statistically significance preoperative MRI seems to be helpful in patients with DCIS who are eligible for breast conservation. This applies in particular to patients with non-high-grade DCIS because those were significantly more often positive on MRI and significantly more often negative on Mx. Misinterpretation occurs especially in cases of NMLE and high-grade DCIS and therefore a correlation with Mx is also recommended.

The complexity of proximal humeral fractures is age and gender specific.

BACKGROUND: Studies that investigated possible associations between the complexity of proximal humeral fractures and patient characteristics are rare. We hypothesized that the grade of fracture complexity may correlate with age and gender of hospitalized, adult patients. METHODS: Based on the Neer classification, we defined four radiological grades of fracture complexity. The data of adult patients that were treated during a 9-year period at a German hospital serving a town of 80,000 inhabitants was reviewed. RESULTS: Seven hundred and eighty fractures were evaluated [518 female/262 male (66.41/33.59 %), average age 64.2 years (range 17.4-99.2)]. During the study period, the number of fractures increased to 167 %. Almost two-thirds of the patients were females and older than 60 years. Of all fractures, 86 % were displaced fractures. In patients younger than 60 years, 1.99-fold more complex fractures occurred in males (32.4 %) than in females (16.2 %). In contrast, in patients older than 60 years, 1.72-fold more complex fractures occurred in females (54.1 %) than in males (31.5 %). There was a significant association between low-energy trauma and female gender older than 60 years. CONCLUSIONS: Our study demonstrated an overall increase of displaced proximal fractures. The vast majority of patients with more complex fractures consisted of female patients older than 60 years.