Fluoroscopic imaging: New advances.

Today's orthopedic surgery could not be imagined without intraoperative x-ray-based imaging. This enables surgeons to assess operative interim steps as well as the result before wound closure and finishing the procedure. Although there have been mobile C-arms used for decades, there are recent advances that do not only affect the quality of the imaging itself but also the way, the information is processed and presented. These very exciting developments will change the integration of imaging into the surgical workflows, giving options of augmented reality, reduction of radiation dose, automatized acquisition and analysis of images and low-level guidance in procedures. This paper gives a review of current innovations and possible future trends in fluoroscopic 2D and 3D imaging.

Early Outcomes of Pelvic Trauma Patients - Complications, ICU Stay and Treatment Concepts in Two ATLS Compliant Trauma Centers: Germany and Qatar.

PURPOSE OF THE STUDY Pelvic trauma causes severe threats especially to polytraumatized patients. Not only it is in itself a possible cause for significant bleeding, but it also indicates a high risk for intra-abdominal injuries. The initial treatment of patients with pelvic trauma follows the ATLS principles of priority-oriented treatment. To examine the value of this highly standardized concept and to evaluate the effect of different patient collectives on early outcome parameters, two large collectives from Germany and Qatar were analyzed regarding injury parameters and early outcomes. MATERIAL AND METHODS Patients were recruited in Hamad General Hospital, Doha, Qatar (HGH) and BG Trauma Center Ludwigshafen, Germany (BG). All patients that were treated with a pelvic fracture between 2013 and 2016 were included in this retrospective analysis. Demographic parameters were collected as well as type of injury and the frequency of complication parameters as pneumonia, acute kidney failure, ARDS, sepsis and amount of blood transfusion. 1436 patients with pelvic fracture (645 from BG and 791 from HGH) were recruited. The mean age was 57.4 years in the BG and 33.6 years in the HGH group (p<0.000). The mean ISS was 17.81 in the BG and 15.88 in the HGH group (p=0.009). The mean pelvic AIS was 2.65 in the BG and 2.25 in the HGH group (p<0.000). RESULTS The mean frequency of complications was 9.3% in the BG and 9.9% in the HGH group (p=0.128). The mean frequency of ARDS was significantly higher in the BG group than in the HGH group (5.6% vs. 1.8%, p<0.000). The mean frequency of blood transfusion was significantly lower in the BG group than in the HGH group (28.8% vs. 39.2%, p<0.000). CONCLUSIONS Despite significant differences in the two collectives, this analysis shows comparable results regarding early outcome parameters in patients with pelvic injuries. In total, pelvic injuries are accompanied by a relatively high complication risk and need to be evaluated and treated according to priority-based algorithms. Key words: ATLS®, pelvic injury, complications, polytrauma.

Fracture reduction and screw position after 3D-navigated and conventional fluoroscopy-assisted percutaneous management of acetabular fractures: a retrospective comparative study.

BACKGROUND: Navigational techniques in orthopaedic trauma surgery have developed over the last years leaving the question of really improving quality of treatment. Especially in marginal surgical indications, their benefit has to be evident. The aim of this study was to compare reduction and screw position following 3D-navigated and conventional percutaneous screw fixation of acetabular fractures. The study hypothesis postulated that better fracture reduction and better screw position are obtained with 3D navigation. MATERIALS AND METHODS: Preoperative and postoperative CT scans of 37 acetabular fractures treated by percutaneous screw fixation (24 3D-navigated, 13 conventional) were evaluated. Differences in pre- and postoperative fracture gaps and steps were compared in all reconstructions as well as the screw position relative to the joint and the fracture. RESULTS: The differences in fracture gaps and fracture steps with and without 3D navigation were not significantly different. Distance of the screw from the joint line, angle difference between screw and ideal angle relative to the fracture line, length of the possible corridor used and position of the screw thread did not show any significant differences. CONCLUSION: Comparison of 3D-navigated and conventional percutaneous surgery of acetabular fractures on the basis of pre- and postoperative CTs revealed no significant differences in terms of fracture reduction and screw position.

Diagnostic accuracy of intraoperative CT-imaging in complex articular fractures - a cadaveric study.

Anatomic reconstruction of articular fractures is one of the critical factors in later achieving good functional outcome. Intraoperative 3D imaging has been shown to offer better evaluation and therefore can significantly improve the results. The purpose of this study was to assess the difference between intraoperative three-dimensional fluoroscopy (3D) and intraoperative computed tomography (iCT) imaging regarding fracture reduction, implant placement and articular impressions in a distal humeral fracture model. AO type 13-B2 fracture pattern were created in upper extremity cadaver specimens. Articular step-offs, intra-articular screw placement and intraarticular impressions of different degrees of severity were created. All specimens had imaging performed. For each articular pattern 3D fluoroscopy in standard (3Ds) and high quality (3Dh) were performed (Arcadis Orbic, Siemens, Germany) as well as an intraoperative CT scan (iCT, Airo, Brainlab, Germany). Three observers evaluated all imaging studies regarding subjective and objective parameters. iCT is more precise than 3D fluoroscopic imaging for detection of articular impressions. Articular step-offs and intraarticular screw placement are similar for iCT and 3D. Subjective imaging quality is the highest for iCT and lowest for 3Ds. Intraoperative CT may be particularly useful in assessing articular impressions and providing a good subjective image quality for the surgeon.

2D projection-based software application for mobile C-arms optimises wire placement in the proximal femur - An experimental study.

PURPOSE: A new software application can be used without fixed reference markers or a registration process in wire placement. The aim was to compare placement of Kirschner wires (K-wires) into the proximal femur with the software application versus the conventional method without guiding. As study hypothesis, we assumed less placement attempts, shorter procedure time and shorter fluoroscopy time using the software. The same precision inside a proximal femur bone model using the software application was premised. METHODS: The software detects a K-wire within the 2D fluoroscopic image. By evaluating its direction and tip location, it superimposes a trajectory on the image, visualizing the intended direction of the K-wire. The K-wire was positioned in 20 artificial bones with the use of software by one surgeon; 20 bones served as conventional controls. A brass thumb tack was placed into the femoral head and its tip targeted with the wire. Number of placement attempts, duration of the procedure, duration of fluoroscopy time and distance to the target in a postoperative 3D scan were recorded. RESULTS: Compared with the conventional method, use of the application showed fewer attempts for optimal wire placement (p=0.026), shorter duration of surgery (p=0.004), shorter fluoroscopy time (p=0.024) and higher precision (p=0.018). Final wire position was achieved in the first attempt in 17 out of 20 cases with the software and in 9 out of 20 cases with the conventional method. CONCLUSIONS: The study hypothesis was confirmed. The new application optimised the process of K-wire placement in the proximal femur in an artificial bone model while also improving precision. Benefits lie especially in the reduction of placement attempts and reduction of fluoroscopy time under the aspect of radiation protection. The software runs on a conventional image intensifier and can therefore be easily integrated into the daily surgical routine.

[Three-dimensional correction of the thoraco-lumbar spine after sarcoma resection : An inter-disciplinary approach with free-tissue transfer]. / Dreidimensionale Korrektur der thorakolumbalen Wirbelsäule nach Resektion eines Sarkoms : Interdisziplinärer Ansatz mit freiem Gewebetransfer.

This article presents the case of a high-grade deformity of the thoraco-lumbar spine. The patient suffered from a sarcoma that was radically resected. Due to adjuvant radiation, the patient suffered from a radiation injury with chronic fistula. In a two-stage approach, the deformity was corrected by a closing-wedge osteotomy of L3 with elongation of the present dorsal spondylodesis (Th10-L4) to Th8 and the iliac bone. Soft-tissue reconstruction was achieved by a free latissimus dorsi flap that was anastomosed to an axillary arterio-venous loop. The presented interdisciplinary approach allowed an almost complete correction of the deformity and stable soft-tissue coverage.

An unusual birthmark case thought to be linked to a person who had previously died.

The following case report describes a Burmese subject with an unusual birthmark and birth defects thought by local people to be linked to events surrounding the death of his mother's first husband. The nature of the link is explored, including how the assumption of a linkage could have led to subsequent events.

Construction of a cassette enabling regulated gene expression in the presence of aromatic hydrocarbons.

A high-level expression cassette has been constructed from a TOL plasmid derived from Pseudomonas putida carrying all cis- and trans-acting regulatory elements necessary for transcriptional gene activation in the presence of aromatic hydrocarbons such as toluene. Foreign DNA can be inserted at unique KpnI, SacI, and EcoRI sites 7, 13, and 15 nucleotides downstream of a ribosome binding site. The cassette, flanked by BamHI and EcoRI restriction sites, was inserted into a broad-host-range vector and its efficacy demonstrated in various purple bacteria by monitoring the expression of a reporter gene spectrophotometrically and by SDS-PAGE. High-level induction (80- to 600-fold) was detected in Enterobacteriaceae and in Pseudomonas but was absent or low in Agrobacterium tumefaciens and Rhizobium leguminosarum.

[Dysfunction in connection with functional disorders of the cervical spine]. / Zu zahnärztlichen Funktionsstörungen mit Kopfschmerzen und funktionellen Störungen der Halswirbelsäule.

In pain patients with functional disorder you can often find a disharmonie in the cervical spine. The results of the examination from 74 patients (47 female, 27 male) shows that: 1. 86.5% of the patients told about neck pain. Those patients with hard neck pain, you can find five or more dolent masticatory muscles. 2. 50% of the patients have on block in the cervical spine, 36.5% have between two and four blocks. 3. In patients with low neck pain you can find less blocks, than in patients with hard neck pain. If there is a block the part of the patients with more than five dolent muscles is significantly higher. 4. 64 patients who have a block shows at the same time 56.8% a functional disorder. So everybody can see that it is really necessary to work together in the diagnosis, therapy and treatment in patients with functional disorders.

Molecular cloning and expression of a novel catechol 2,3-dioxygenase gene from the benzoate meta-cleavage pathway in Azotobacter vinelandii.

Azotobacter vinelandii strain 206 degrades benzoate via the meta-cleavage pathway. In a genomic library derived from this organism a clone was obtained which carried and expressed the gene for the third enzyme in this pathway, catechol 2,3-dioxygenase (EC 1.13.11.2), on a 5.9 kb SalI restriction fragment. The structural gene was more precisely mapped on an internal 1.6 kb EcoRI fragment which, after insertion into expression vectors, directed the synthesis of a 33 kDa polypeptide. The gene showed very little or no homology with isofunctional genes derived from Pseudomonas. Comprehensive substrate specificity analysis showed significant differences between the specific activities obtained from the cloned gene product and extracts derived from Azotobacter itself.

[Comparison investigation of non-precious metal-synthetic resin bond on basis of new adhesives and the non-precious metal-ceramic bond]. / Vergleichende Untersuchungen zwischen dem Nichtedelmetall-Kunststoffverbund auf der Basis neuer Haftvermittler und dem Nichtedelmetall-Keramikverbund.

The adhesive force was tested between the Silicoater and Sebond-MKV bonding systems and two Co Cr alloys. The tests were: The flexural strength-test, the tensile stress-test, the fracture test and the shear strength test. The ceramic veneering had worse results only in the flexural strength test compared with the two bonding systems. The bonding system Silicoater was in the tensile stress test and in the fracture test better than the Sebond MKV system. The bonding system Sebond-MKV showed better results in the flexural strength test and in the shear strength test than the Silicoater system. Differences in the results you could find between the test after dry air storing and saliva storing.

Molecular analysis of regulatory and structural xyl genes of the TOL plasmid pWW53-4.

pWW53-4 is a cointegrate between RP4 and the catabolic plasmid pWW53 from Pseudomonas putida MT53, which contains 36 kbp of pWW53 DNA inserted close to the oriV gene of RP4; it encodes the ability to grow on toluene and the xylenes, characteristic of pWW53, as well as resistance to tetracycline, kanamycin and carbenicillin, characteristic of RP4. A physical map of the 36 kbp insert of pWW53 DNA for 11 restriction enzymes is presented, showing that the relative positions of the two xyl operons are different from those on the archetypal TOL plasmid pWW0. The location of the genes for 4-oxalocrotonate decarboxylase (xylI) and 4-oxalocrotonate tautomerase (xylH) were shown by subcloning and enzyme assay to lie at the distal end of the meta pathway operon. Although 2-oxopent-4-enoate hydratase (xylJ) and 4-hydroxy-2-oxovalerate aldolase (xylK) could be detected on a large cloned HindIII fragment, they could not be accurately located on smaller subcloned DNA, but the only credible position for them is between xylF and xylI. The gene order in the meta pathway operon is therefore xylDLEGF(J,K)IH. The regulatory genes xylS and xylR were located close to and downstream of the meta pathway operon, and the restriction map of the DNA in this region, as has previously been shown for the two operons carrying the structural genes, shows similarities with the corresponding region on pWW0. Evidence is also presented for the existence of two promoters, termed P3 and P4, internal to the meta pathway operon which support low constitutive expression of the structural genes downstream in Pseudomonas hosts but not in E. coli.

Gene organization of the first catabolic operon of TOL plasmid pWW53: production of indigo by the xylA gene product.

The entire operon coding for the enzymes responsible for conversion of toluenes to benzoates has been cloned from TOL plasmid pWW53 and the position of the genes accurately located. The coding region was 7.4 kilobase pairs (kbp) long, and the gene order was operator-promoter region (OP1)-a small open reading frame-xylC (1.6 kbp)-xylA (2.9 kbp)-xylB (1.8 kbp). Within the coding region there was considerable homology with the isofunctional region of the archetypal TOL plasmid pWW0. A central region of 2.9 kbp complemented an xylA (for xylene oxygenase) mutant of Pseudomonas putida mt-2 and was also capable of conferring the ability to convert indole to indigo on strains of Escherichia coli and P. putida. This reaction has been reported previously only for dioxygenases involved in aromatic catabolism but not for monooxygenases. It is proposed that the region encodes xylene oxygenase activity capable of direct monohydroxylation of indole to 3-hydroxyindole (oxindole), which then spontaneously dimerizes to form indigo.

[Effect of mitotic density on the probability of survival of patients with thin (less than or equal to 1.5 mm) melanomas]. / Der Einfluss der Mitosedichte auf die Uberlebenswahrscheinlichkeit von Patienten mit dünnem (less than or equal to 1,5 mm) Melanom.

Our studies dealt with the prognostic significance of the mitotic count for patients with thin (less than or equal to 1.5 mm) melanoma. We determined the mitotic rate of 50 patients who had died of melanoma thinner than 1.5 mm within 8 years (short-term survivors). The specimens were examined by means of a rectangular visual field; thus we could calculate the mitotic count to the square mm of the tumor surface. This outcome was compared to the mitotic rate of 50 long-term survivors who had not died within 8 years and who corresponded to the first group with regard to sex, tumor thickness, as well as tumor site. In both groups, at least 15% of the melanomas did not show any mitotic figure. With females, the average mitotic values were identical in both groups (1.1 vs. 1.15). In males, however, short-term survivors revealed a significantly (p less than 0.001) higher mitotic count (2.2) than long-term survivors (0.75).

Evolutionary conservation of genes coding for meta pathway enzymes within TOL plasmids pWW0 and pWW53.

Pseudomonas putida MT53 contains a TOL plasmid, pWW53, that encodes toluene-xylene catabolism. pWW53 is nonconjugative, is about 105 to 110 kilobase pairs (kbp) in size, and differs significantly in its restriction endonuclease digestion pattern and incompatibility group from the archetypal TOL plasmid pWW0. An RP4::pWW53 cointegrate plasmid, pWW53-4, containing about 35 kbp of pWW53 DNA, including the entire catabolic pathway genes, was formed, and a restriction map for KpnI, HindIII, and BamHI was derived. The entire regulated meta pathway genes for the catabolism of m-toluate were cloned into pKT230 from pWW53 on a 17.5-kbp HindIII fragment. The recombinant plasmid supported growth on m-toluate when mobilized into plasmid-free P. putida PaW130. A restriction map of the insert for 10 restriction enzymes was derived, and the locations of xylD, xylL, xylE, xylG, and xylF were determined by subcloning and assaying for their gene products in both Escherichia coli and P. putida hosts. Good induction of the enzymes by m-toluate and m-methylbenzyl alcohol but not by m-xylene was measured in P. putida, but little or no regulation was found in E. coli. The restriction map and the gene order showed strong similarities with published maps of the DNA encoding both the entire meta pathway operon (xylDLEGFJIH) and the regulatory genes xylS and xylR on the archetype TOL plasmid pWW0, suggesting a high degree of conservation in DNA structure for the catabolic operon on the two different plasmids.

TOL plasmid pWW15 contains two nonhomologous, independently regulated catechol 2,3-oxygenase genes.

Pseudomonas putida MT15 contains a 250-kilobase-pair (kbp) TOL plasmid pWW15, encoding toluene and xylene catabolism, which undergoes large spontaneous deletions to give two classes of mutants with altered catabolic phenotypes (H. Keil and P. A. Williams, J. Gen. Microbiol, 131:1023-1033, 1985). Two structural genes for catechol 2,3-oxygenase (C23O) were cloned from pWW15. The gene for C23OI was located on the 2.1-kbp XhoI fragment Xh, whereas that for C23OII was found on the 11.5-kbp BamHI fragment BJ. The two restriction fragments and the subcloned regions of them showed no similarity in the pattern of restriction digestion, nor did they hybridize with each other. The substrate specificities of the two enzymes were also substantially different. The two structural genes were separated on pWW15 by about 100 kbp. In plasmid pWW15-510 of a B5 mutant, the 90-kbp deletion in the plasmid removed most of the intervening DNA, but it also deleted 80% of the gene for C23OI from its 3' end. Thus, only C23OII was expressed in the host MT15-510. Conversely, in RP4::pWW15 cointegrate plasmid pWW15-1003, only the C23OI gene was present. The expression of C23O activity from these two derivative plasmids and from the wild-type pWW15 showed that only C23OI was induced by growth in the presence of m-toluate, whereas both activities were induced in the only C23OI was induced by growth in the presence of m-toluate, whereas both activities were induced in the presence of m-xylene. These findings cast doubt on the earlier hypothesis that the deletions in B3 and B5 mutants remove a regulatory gene by which m-toluate induces the enzymes necessary for its own catabolism.

Prognostic significance of the patient's sex, tumor site, and mitotic rate in thin (less than or equal to 1.5 mm) melanoma.

Patients who died of a melanoma thinner than 1.5 mm within 96 months (group 1, n = 60) were compared with those having a tumor of the same thickness who had not died in this time period (Group 2, n = 300). Both groups were investigated with respect to differences in patient sex and age and to thickness, diameter, exophytic growth, and site of the melanoma as well as the number of mitoses/mm2 of tumor area. Relatively speaking, more men than women died of a thin melanoma: in Group 1 (deceased) there were 32 men and 28 women, in Group 2 (alive) 58 men and 242 women. The better survival rate of females did not depend on the difference in the predominating melanoma locations (female face and legs; male trunk): In both sites, on the legs and on the trunk, women had a significantly higher 8-year survival rate than men with equally thick tumors. Furthermore, melanomas on the arms and legs of females had a better prognosis than those on the trunk and face. Both the patient's sex and the tumor site seem to influence the survival of melanoma patients. Only in men was the median of mitoses/mm2 of tumor area found to be higher in the first group (2.2) than in the second group (0.75). In women, no marked difference in the mitotic count was found (Group 1:1.1; Group 2:1.15).

Degradation of aromatic carboxylic acids by acinetobacter.

The degradation of the aromatic carboxylic acids 3-phenylpropionic acid, cinnamic acid and L-phenylalanine was investigated in several strains of Acinetobacter calcoaceticus var. lwoffii. Evidence is presented for the conversion of 3-phenylpropionic acid into the cis-2,3-dihydrodihydroxy-derivative, which is further metabolized to 3-(2,3-dihydroxyphenyl-)propionic acid, followed by cleavage of the aromatic ring in meta-proximal position. When pre-grown on 3-phenylpropionic acid, cinnamic acid as well as L-phenylalanine were metabolized under resting cell conditions via the same degradation pathway. When cultivated with cinnamic acid as sole carbon source 4-hydroxycinnamate, together with 4-hydroxybenzoate and protocatechuate were found as metabolites. L-phenylalanine, when provided as the only carbon source, is converted via phenylacetic acid to 2-hydroxyphenyl-acetic acid. All metabolites were identified by conventional chemical techniques. Enzymatic studies yielded further support for the proposed pathways. In 14 of 15 Acinetobacter strains the presence of plasmid DNA could be detected. The number of plasmids varied between 1 and 7. Regarding the number and size of the plasmids considerable variations within the different bacterial strains were observed. No extended homology among the plasmids could be shown by restriction endonuclease digestion. One strain exhibiting a high spontaneous mutation rate to the 3-phenylpropionic acid-negative phenotype did not show any change in its plasmid pattern. The results lead us to conclude that a correlation between the degradative properties of these strains and the presence of plasmid DNA is unlikely.