Carpal tunnel syndrome, spinal canal stenosis, cardiomyopathy, renal insufficiency, enteropathy, and diffuse myopathy as an expression of systemic ATTR amyloidosis - diagnostics and therapy.

Systemic amyloidosis is an incurable multisystem disease, caused by fibrillar protein deposits with resulting dysfunction of affected organ systems. It mostly affects patients > 60 years. Diagnosis is often delayed because the symptoms are nonspecific and highly variable. We report on an elderly patient with multi-organ involvement with proven wild-type transthyretin amyloidosis. The initial manifestation involved bilateral carpal tunnel syndrome and lumbar spinal canal stenosis. The occurrence of ligament and tendon disorders, unexplained muscle pain and polyneuropathy in elderly patients should be considered as a possible first manifestation of systemic amyloidosis.

Successful treatment of a painful os peroneum using conservative measures, infiltration therapy, and shock waves.

Lateroplantar foot pain may be caused by various entities, whereby painful os peroneum syndrome should be included in the differential diagnosis. Physical examination and multimodal imaging enable a definitive diagnosis. We report on a 59-year-old man with severe, load-dependent pain, corresponding to an os peroneum syndrome, triggered by a pes planovalgus with consecutively induced focal inflammation and tendovaginitis of the tendon of the peroneus longus muscle. Multifactorial conservative measures including infiltration and shockwave therapy finally led to a restoration of the original condition.

Comparative outcome of different treatment options for fragility fractures of the sacrum.

BACKGROUND: Fragility fractures of the sacrum (FFS) have been detected more and more frequently in recent times, and the incidence will continue to increase due to increasing life expectancy. The aim of this study was to compare the clinical outcome of conservative, interventional and surgical treatment of FFS. METHODS: Retrospectively, 292 patients (276 women, 16 men) with confirmed FFS were followed up over a period of 2 years. The age of the women was Ø 81.2 (58 - 99) and that of the men Ø 78.1 (76 - 85) years. The pain was quantified using a VAS. Fractures were classified in accordance with the Rommens and Hofmann and with the Denis classification using conventional X-rays, CT and MRI. A QCT of the lumbar spine was performed to quantify bone mineral density. Concomitant diseases of every patient were recorded. An interdisciplinary case conference determined the individual treatment concept considering the age, type of fracture, pain level and comorbidities with classification into conservative, interventional (any type of sacroplasty) or surgical treatment. Over the course pain and independence were measured, complications and patient satisfaction were documented. A vitamin D determination was done, and existing comorbidities were included. RESULTS: Patients with a pain level of ≤5 benefited from the conservative therapy measures, with pain levels > 5 significantly delaying the development of mobility. After sacroplasty, the pain reduced significantly, which caused a rapid improvement in mobility without any significant difference being found between vertebro- (VSP), balloon (BSP), radiofrequency (RFS) and cement sacroplasty (CSP). In terms of pain reduction and mobilization, the surgical treated patients benefited from osteosynthesis, although more complex fracture types with lumbopelvic stabilization took longer. Overall, there were no deaths during the hospital stay. Mortality after 12 months was 21.7% for the conservative, 8.4% for the interventional and 13.6% for the surgical therapy group; the differences are significant. For patients in the conservative therapy group who were difficult to mobilize due to pain, the mortality increased to 24.3%. Over 24 months, patients achieved the best independence after sacroplasty. At 12 and 24 months, subjective satisfaction with the therapies was best after sacroplasty, followed by osteosynthesis and conservative measures. All patients had a pronounced vitamin D deficiency and manifest osteoporosis. Cardiovascular pathologies were the main concomitant diseases. CONCLUSIONS: Patients with FFS with a low level of pain benefit from conservative therapy measures, whereby complications and mortality increase significantly in the case of persistent immobilizing pain. Patients with an unacceptable level of pain resulting from non-dislocated fractures benefit significantly from sacroplasty. Patients with unstable and displaced fractures (Rommens and Hofmann type III and IV) should be operated on promptly. Different techniques are available for sacroplasty and osteosynthesis, which lead to an improvement of independence and a reduction in mortality.

[Sacral fragility fractures: risk factors and outcomes after cement sacroplasty]. / Sakrale Fragilitätsfrakturen: Risikofaktoren und Ergebnisse nach Zementsakroplastie.

BACKGROUND: The objective of the present study on patients with fragility fractures of the sacrum (FFS) was to assess existing risk factors and clinical outcomes after cement sacroplasty (CSP). PATIENTS AND METHODS: 68 patients (64 women, 4 men) with previous FFS were followed up retrospectively. CT and MRI images were used to classify fractures according to Denis et al. and Rommens and Hofmann. Bone mineral content was determined by QCT in all patients. Concomitant diseases as well as central and peripheral fractures were recorded, considering the patient's medical history and X­ray images. Vitamin D levels were also determined. If conservative therapy was unsuccessful, CSP was performed. The results were documented on the basis of pain development, physical independence, patient satisfaction, complication rate and mortality. RESULTS: The age of the women in the study was Ø 83.2 (72-99) and that of the men Ø 77.8 (76-85) years. 42.4% had a Denis type 1, 4.2% a Denis type 2, 0% a Denis type 3, 43.3% a Denis type 1-2 and 10.1% a Denis type 1-2-3 fracture zone. FFP type II a to II c fractures were found in 88.2%, FFP type III c in 7.4% and FFP type IV b in 4.4%. Bilateral FFS were found in 68.8%. The average bone mineral content (BMC) was 35.4 (2-74) mg/ml, and the average vitamin D value was 8.8 (0-28) nmol/l. Other osteoporosis-associated fractures were found in around 50% of the patients. After CSP, patients showed a rapid and significant (p < 0.001) reduction in pain and sustained clinical improvement. CONCLUSION: FFS fracture risk factors were found to be female gender, advanced age, existing osteoporosis and severe vitamin­D deficiency. Patients with non-displaced FFS who could not be mobilised due to pain experienced sustained benefit from CSP.

[Clinical outcome and revenue situation after conservative, interventional and surgical/osteosynthetic treatment of sacral insufficiency fractures]. / Klinisches Outcome und Erlössituation nach konservativer, interventioneller und chirurgischer/osteosynthetischer Behandlung von sakralen Insuffizienzfrakturen.

BACKGROUND: Insufficiency fractures of the sacrum are being detected increasingly more frequently, whereby their incidence will no doubt increase further as a result of the rise in life expectancy. OBJECTIVE: The clinical appearance of sacral insufficiency fractures, the treatment approach taking into account the clinical outcomes and the DRG proceeds are discussed on the basis of clinical examples. PATIENTS AND METHODS: Three female patients (average age 78.3 years) with sacral insufficiency fractures were admitted for inpatient treatment due to increasing disabling pain. Taking into account the clinical symptoms and the recommendation of an interdisciplinary case conference, one patient was treated conservatively with short-term bed rest, accompanying analgesic medication and pain-adapted exercise measures. The second patient underwent computed tomography (CT)-guided balloon sacroplasty. Transsacroiliac screw fixation was performed on the third patient. Pain was documented over the course on a visual analogue scale (VAS) and the degree of independence on the Barthel scale. The fractures were classified according to Denis et al. and the classification of the FFP according to Rommens and Hofmann. The DRG revenue for the 2020 accounting period was then presented for each case. RESULTS: Patient No. 1: conservative therapy, unilateral Denis 1 fracture zone, corresponding to an FFP type IIa, baseline pain 7 score points, at discharge 4 score points, the Barthel scale increased from 55 to 75 points. After 6 days hospitalization, transferred to rehab. The DRG proceeds were €â€¯3817.95. Patient No. 2: balloon sacroplasty, bilateral Denis 1-2 fracture zone, corresponding to an FFP type IIa, baseline pain 9 score points, at discharge 2 score points, the Barthel scale increased from 35 to 95 points. After 4 days hospitalization, discharged to outpatient follow-up treatment. The DRG proceeds were €â€¯7409.44. Patient No. 3: osteosynthesis, bilateral Denis 1 fracture zone, corresponding to an FFP type IIa, baseline pain 7 score points, at discharge 2 score points, the Barthel scale increased from 40 to 90 points. After 5 days hospitalization, transferred to rehab. The DRG proceeds were €â€¯6714.30. CONCLUSION: The sacral insufficiency fracture is a strong indicator for the presence of manifest osteoporosis. Fracture risk factors are the female sex, advanced age, the presence of osteoporosis and vitamin D deficiency. Conservative therapy is the first step of the treatment cascade; however, in patients with persistent, disabling pain and no potential for mobilization, sacroplasty or osteosynthesis should be performed at an early stage. In patients treated with coordinated therapy processes and without clinical complications, all three treatment options are economically sufficient.

Clinical Improvement and Cost-effectiveness of CT-guided Radiofrequency Sacroplasty (RFS) and Cement Sacroplasty (CSP) - a Prospective Randomised Comparison of Methods. / Klinische Verbesserung und Wirtschaftlichkeit nach CT-gesteuerter Radiofrequenzsakroplastie und Zementsakroplastie ­ ein prospektiver randomisierter Methodenvergleich.

INTRODUCTION: The objective of this study was a comparative analysis of cement augmentation by means of RFS and CSP with regard to outcome and cost-effectiveness. PATIENTS AND METHODS: CT-guided cement augmentation was performed on 100 patients with a total of 168 non-dislocated insufficiency fractures, 50 patients being treated with RFS and 50 patients with CSP. Leakages were detected by CT. Pain intensity was determined on a VAS before and after the intervention. The patients' self-sufficiency was assessed using the Barthel index. Patients were asked about any complications and their level of satisfaction. Costs incurred for carrying out the procedure were compared with the respective reimbursements received. RESULTS: Both procedures were technically fully feasible. No leakages were found in the RFS group, as opposed to 8.1% asymptomatic leakages in the CSP group. The mean value for pain before intervention was 8.8 in the RFS group and 8.7 in the CSP group. On the second postoperative day, there was a significant pain reduction with a value of 2.4 for both groups, which remained more or less constant over the follow-up period. The Barthel index increased significantly from an average of 30 before the intervention to 80 on the fourth postoperative day and 70 after 24 months. No differences were found between the two procedures with regard to pain, improvement in functional status and satisfaction. Taking into account the state-wide base rate used for calculating reimbursement, 3,834.75 € remained for RFS and 5,084.32 € for CSP. CONCLUSION: RFS and CSP are minimally invasive procedures that achieve equally good and sustained pain reduction, leading to markedly improved self-sufficiency of the patients. With regard to possible cement leakages, RFS is the safer method. A profit can be generated with both techniques.

CT-guided cement sacroplasty (CSP) as pain therapy in non-dislocated insufficiency fractures.

INTRODUCTION: In elderly patients with reduced bone quality, insufficiency fractures of the sacrum are relatively common and are typically associated with severe disabling pain. The objective of the present study was to examine the feasibility of cement augmentation by CSP, to determine post-interventional leakages and other complications, and to present the outcome of pain over the course of 18 months. MATERIALS AND METHODS: In 23 patients (20 women and 3 men) with an average age of 81.3 (71-92) years, a total of 41 sacral fractures were detected by MRI, 5 of them unilateral and 18 bilateral. Conservative treatment initially performed over a period of 3 weeks did not bring any satisfactory reduction in the severe disabling pain. The indication for intervention was established after an interdisciplinary case conference. The intervention was performed under intubation anaesthesia. Single-shot antibiotic prophylaxis was given routinely immediately prior to the intervention. Under sterile conditions, a Jamshidi needle was then advanced into the respective fracture zone in the sacrum from dorsal to ventral (short axis) or from lateral to medial transiliac (transiliac axis). After removing the inner needle, a flexible osteotome was inserted through the positioned hollow needle and used to extend the spongious space in the fracture zone and thus prepare a cavity for the cement filling. High-viscosity PMMA cement was then inserted discontinuously with the aid of a pressure gauge under low-dose CT control. Cement leakages were determined in the CT image on the day after the intervention, all cement outside of the cortical boundary being rated as a leakage. Pain was documented on a visual analogue scale (VAS) on the day before the intervention, on the second day, and 6, 12, and 18 months after the intervention. Additionally occurring complications were recorded, and the patients were asked to rate their satisfaction after 6 and 18 months. RESULTS: CSP was technically feasible in all patients. In the control CT scan, sufficient cement distribution and interlocking with vital bone were found along the course of the fracture in the sacrum. An average of 6.0 ± 0.83 ml of cement was inserted per fracture. Leakage was found in 5 of 41 (12.2%) of the fractures treated, although none were symptomatic. The mean pain score on the VAS was 8.8 ± 0.59 before the intervention, a significant pain reduction (p < 0.0005) was seen on the second post-operative day, with an average value of 2.1 ± 0.36, and this was stable at 2.2 ± 0.28 after 6, 2.3 ± 0.31 after 12, and 2.2 ± 0.41 after 18 months. Now that they no longer experienced disabling pain, all of the patients were fully remobilised and discharged back home. A high level of patient satisfaction was found after 6 and 18 months. CONCLUSION: As a minimally invasive procedure, CSP is an effective treatment method for rapid, significant, and sustained pain reduction.

Comparison of the 18-month outcome after the treatment of osteoporotic insufficiency fractures by means of balloon sacroplasty (BSP) and radiofrequency sacroplasty (RFS) in comparison: a prospective randomised study.

PURPOSE: The objective of this prospective, randomised study was to examine the feasibility and clinical outcome of balloon sacroplasty and radiofrequency sacroplasty. METHODS: In 40 patients with a total of 57 sacral fractures, CT-guided cement augmentation was performed by means of BSP or RFS. For BSP, the balloon catheter was inflated and deflated in the fracture zone, and the hollow space, thus, created was then filled with PMMA cement. For RFS, the spongious space in the fracture zone was initially extended using a flexible osteotome, and the highly viscous PMMA cement, activated by radiofrequency, was then inserted into the prepared fracture zone. Pain intensity was determined on a VAS before the intervention, on the second day, and 6, 12 and 18 months after the intervention. The results were tested for significance by means of paired Wilcoxon rank-sum tests and Mann-Whitney U tests. RESULTS: BSP and RFS were technically fully feasible in all patients. An average of 6.3 ml cement per fracture was inserted in the BSP group and an average of 6.1 ml per fracture in the RFS group. Leakage could be ruled out for both procedures. The mean pain score on the VAS before the intervention was 8.6 ± 0.55 in the BSP group and 8.8 ± 0.58 in the RFS group. On the second postoperative day, a significant pain reduction was seen (p < 0.001), with an average value of 2.5 (BSP ± 0.28, RFS ± 0.38) for both groups. After 6 (12; 18) months, these values were stable for the BSP group at 2.3 ± 0.27 (2.3 ± 0.24; 2.0 ± 0.34) and for the RFS group at 2.4 ± 0.34 (2.2 ± 0.26; 2.0 ± 0.31). With regard to pain, exceedance probability values of p = 0.86 (6 months), p = 0.94 (12 months) and p = 1 (18 months) were seen, so that neither treatment method leads to differences in results. CONCLUSIONS: BSP and RFS are interventional, minimally invasive procedures that enable reliable cement augmentation and achieve equally good clinical outcomes in the medium term.

Osseous Consolidation of an Aseptic Delayed Union of a Lower Leg Fracture after Parathyroid Hormone Therapy - A Case Report.

The absence of osseous consolidation of a fracture within the normal time period is defined as delayed union or non-union. Both for the patient and from a socio-economic point of view, impaired fracture healing represents a major problem. Risk factors for a delayed fracture healing are insufficient immobilisation, poor adaptation of the fracture surfaces, interposition of soft tissue in the fracture gap, as well as circulation disturbances, metabolic disease, smoking and infections. In animal studies, a positive effect of parathyroid hormone (PTH) on fracture healing has been shown. PTH has a direct stimulatory effect on osteoblasts and osteoclasts. In addition, it appears to influence the effect of osseous growth factors. Few cases with the empiric off-label use of PTH that showed a tendency to support delayed or non-union fractures have been published. We report about a patient with a fracture of the lower leg and no osseous consolidation after 7 months. Four Months after therapy with 20 µg teriparatide per day for 8 weeks the fracture was consolidated and the patient had regained full and pain free weight bearing capacity of the leg with no reported side effects.

Diagnosis and Treatment of Symptomatic Carpal Bossing.

CONTEXT: Carpal bossing is an osseous formation at the dorsal portion of the quadrangular joint, which rarely becomes symptomatic. However, in some patients it causes pain, restricted mobility and can lead to complications like tendon rupture, inflammatory and degenerative joint disease. AIM: In this article, we present our experiences with this rare disorder in order to improve diagnostic and therapeutic proceedings. SETTINGS DESIGN: This is a multicenter and interdisciplinary observation made by orthopaedic surgeons and radiologists in the years 2010 to 2015. Retrospective observational study. The follow up period was 2 years. MATERIALS AND METHODS: In the observed time period, eight patients were diagnosed with symptomatic carpal bossing. Symptoms were pain at palmar flexion and limited mobility of the wrist in combination with a palpable protuberance over the quadrangular joint. All patients underwent X-ray, CT and MRI examinations. A conservative treatment strategy was initiated for 6 weeks in all patients, followed by a wedge resection when symptoms were persisting and disabling. RESULTS: After the conservative treatment schedule, five patients were asymptomatic. Three patients had persisting pain and were thus recommended for surgery. In the postoperative course, two patients were asymptomatic. One patient developed a type 1 complex regional pain syndrome (CRPS) in the first postoperative year, which was successfully treated with pain-adapted physiotherapy, pharmacotherapy with analgesics and calcitonin, and a triple CT-guided thoracic sympathetic nerve blockade. CONCLUSION: Carpal bossing is a mostly asymptomatic entity, which in our experience gets symptomatic due to direct trauma or repetitive stress, especially in competitive racket sports players. It can be diagnosed by thorough clinical examination and multimodal diagnostic imaging. Conservative treatment comprises an excellent prognosis, however surgery, either wedge resection or arthrodesis, must be considered if the response is not positive after 6 weeks.

Radiofrequency sacroplasty (RFS) for the treatment of osteoporotic insufficiency fractures.

INTRODUCTION AND OBJECTIVE: In elderly patients with reduced bone quality, insufficiency fractures of the sacrum are relatively common and are typically accompanied by severe, disabling pain. The objective of this study was to evaluate the feasibility of cement augmentation by RFS, as well as to determine postinterventional leakages and present the patients' outcomes. MATERIAL AND METHOD: In 20 patients (18 women, 2 men) with an average age of 80.4 (65-92) years, a fracture of the sacrum was detected by CT and MRI. Clinically manifest osteoporosis with QCT values of below 50 mg/ml was found in all patients. An initially performed conservative treatment over a period of 3 weeks did not achieve a satisfactory reduction in the severe, disabling pain. The cement augmentation was performed under CT guidance by means of RFS under intubation anaesthesia. A Jamshidi needle was advanced into the respective fracture zone in the sacrum from dorsal to ventral (short axis) or from lateral to medial transiliac (transiliac axis). After removing the inner needle, a flexible osteotome was inserted through the positioned hollow needle and used to extend the spongious space in the fracture zone and thus prepare a cavity for the cement filling. The highly viscous polymethyl methacrylate (PMMA) cement, activated by radiofrequency, was then inserted into the prepared fracture zone through a substituted screw cannula. Cement filling was performed discontinuously under instrumental guidance at 1.3 ml/min under CT guidance. Cement leakages were determined in CT images and conventional X-rays on the day after the intervention. Pain was documented on a visual analogue scale (VAS) on the day before the intervention, on the second day, and after 6 and 12 months after the intervention. Additionally occurring complications were recorded, and the patients were asked to state how satisfied they were after 12 months. RESULTS: RFS was technically feasible in all patients. In the control CT scans and X-rays, sufficient cement distribution and interlocking with vital bone was found along the course of the fracture in the sacrum. 7.2 (4-9) ml of cement were inserted per fracture. Leakage could be ruled out. The mean pain score on the VAS was 8.8 ± 1.2 before the intervention, and a significant reduction in pain (p < 0.001) was seen on the second postoperative day, with an average value of 2.3 ± 0.7, which was stable at 2.2 ± 1.3 after 6 months and 2.1 ± 1.1 after 12 months. All of the patients could be fully re-mobilised and discharged back home. A high level of patient satisfaction was found after 12 months, with 18 of the 20 patients stating that they would undergo the intervention again. One patient died of a stroke, another of cancer over the course. CONCLUSION: As a minimally invasive procedure, RFS is an effective and safe method of treatment for rapid, significant and sustained pain reduction.

Computed tomography for preoperative planning in total hip arthroplasty: what radiologists need to know.

The number of total hip arthroplasties is continuously rising. Although less invasive surgical techniques, sophisticated component design, and intraoperative navigation techniques have been introduced, the rate of peri- and postoperative complications, including dislocations, fractures, nerve palsies, and infections, is still a major clinical problem. Better patient outcome, faster recovery and rehabilitation, and shorter operation times therefore remain to be accomplished. A promising strategy is to use minimally invasive techniques in conjunction with modular implants, aimed at independently reconstructing femoral offset and leg length on the basis of highly accurate preoperative planning. Plain radiographs have clear limitations for the correct estimation of hip joint geometry and bone quality. Three-dimensional assessment based on computed tomography (CT) allows optimizing the choice and positions of implants and anticipating difficulties to be encountered during surgery. Postoperative CT is used to monitor operative translation and plays a role in arthroplastic quality management. Radiologists should be familiar with the needs of orthopedic surgeons in terms of CT acquisition, post-processing, and data transfer. The CT protocol should be optimized to enhance image quality and reduce radiation exposure. When dedicated orthopedic CT protocols and state-of-the-art scanner hardware are used, radiation exposure can be decreased to a level just marginally higher than that of conventional preoperative radiography. Surgeons and radiologists should use similar terminology to avoid misunderstanding and inaccuracies in the transfer of preoperative planning.

High incidence of hamate hook fractures in underwater rugby players: diagnostic and therapeutic implications.

Hamate hook fractures are rare injuries but appear to occur frequently in underwater rugby, the reason for which was investigated in this study. High-level underwater rugby players with hook fractures diagnosed during a five-year interval (2005-2010) were studied retrospectively. Medical data on these patients were reviewed for information on the mechanism of injury, type of fracture, radiological imaging, treatment, and outcome. In ten patients, hook fractures of the leading hand were confirmed by computed tomography, all of which were associated with specific injuries during underwater rugby games. Conservative treatment resulted in delayed healing or non-union, wherefore fragment excision and open reduction and internal fixation was performed in ten and five patients, respectively, while two patients declined surgery. After surgery, all patients were able to play underwater rugby again. In underwater rugby, hook fractures occur frequently due to high and repeated forces applied to the leading hand during games.

Dorsal percutaneous cannulated mini-screw fixation for fractures of the hamate hook.

PURPOSE: Open fixation of acute fractures, delayed union and non-union of the hamate hook through a palmar approach has been reported. Minimal invasive fixation using a dorsal percutaneous approach and a headless cannulated mini-screw is another option not commonly considered. The authors present their case series of patients who underwent dorsal percutaneous fixation of acute fractures and delayed union of the hamate hook. METHODS: This study retrospectively reviewed six consecutive patients (five male patients and one female patient) with non-displaced acute fractures (< 8 weeks) and delayed union (8 to 12 weeks) of the hamate hook treated with dorsal percutaneous cannulated mini-screw fixation. The indications for surgery included wrist pain, patient refusal of conservative treatment, and prevention of non-union and hook excision. Exclusion criteria included displacement or inadequate size of the hamate hook, previous surgery, associated carpal injury, flexor tendon rupture, and median or ulnar nerve lesion in the carpal tunnel and Guyon's canal respectively. Each fracture was visualized by radiography and computed tomography before and after the intervention. RESULTS: Anatomically correct fixation of the hamate hook with central screw positioning was achieved in all patients. No displacement or disruption of the cortical shell of the hook was observed. The union rate was 100% with all patients being able to resume their pre-injury activities after an average of seven weeks from surgery. CONCLUSIONS: This pilot study demonstrates that non-displaced acute fractures and delayed union of the hamate hook can be treated successfully by dorsal percutaneous cannulated mini-screw fixation with minimal morbidity and complications.

Computed tomography for preoperative planning in minimal-invasive total hip arthroplasty: radiation exposure and cost analysis.

Computed tomography (CT) was used for preoperative planning of minimal-invasive total hip arthroplasty (THA). 92 patients (50 males, 42 females, mean age 59.5 years) with a mean body-mass-index (BMI) of 26.5 kg/m(2) underwent 64-slice CT to depict the pelvis, the knee and the ankle in three independent acquisitions using combined x-, y-, and z-axis tube current modulation. Arthroplasty planning was performed using 3D-Hip Plan(®) (Symbios, Switzerland) and patient radiation dose exposure was determined. The effects of BMI, gender, and contralateral THA on the effective dose were evaluated by an analysis-of-variance. A process-cost-analysis from the hospital perspective was done. All CT examinations were of sufficient image quality for 3D-THA planning. A mean effective dose of 4.0 mSv (SD 0.9 mSv) modeled by the BMI (p<0.0001) was calculated. The presence of a contralateral THA (9/92 patients; p=0.15) and the difference between males and females were not significant (p=0.08). Personnel involved were the radiologist (4 min), the surgeon (16 min), the radiographer (12 min), and administrative personnel (4 min). A CT operation time of 11 min and direct per-patient costs of 52.80 € were recorded. Preoperative CT for THA was associated with a slight and justifiable increase of radiation exposure in comparison to conventional radiographs and low per-patient costs.

Cytokine-induced human IFN-gamma-secreting effector-memory Th cells in chronic autoimmune inflammation.

T-helper (Th) cells activated by cytokines in the absence of T-cell receptor ligation are suspected to participate in inflammatory processes by production of interferon-gamma (IFN-gamma). Still, the relevance of such a mechanism has not been addressed in humans. Here we demonstrate that a subset of human effector-memory Th cells expressing functional interleukin-12R (IL-12R), IL-18Ralpha, and CCR5 ex vivo can be induced to secrete IFN-gamma by cytokines signaling via the IL-2R common gamma-chain in combination with IL-12 and IL-18. Cytokine-driven IFN-gamma production depends on JAK3- and p38 mitogen-activated kinase signals and is sensitive to suppression by CD25(++) regulatory T cells. Contrary to IFN-gamma(+) Th cells induced upon antigen-specific stimulation, their cytokine-activated counterparts characteristically lack expression of costimulator 4-1BB (CD137). Strikingly, the majority of Th cells infiltrating inflamed joints of rheumatoid arthritis patients is equipped with receptors prerequisite for cytokine-induced IFN-gamma secretion. Among these cells, we detected a substantial fraction that secretes IFN-gamma directly ex vivo but lacks 4-1BB expression, indicating that cytokine-induced IFN-gamma(+) Th cells operate in autoimmune inflammation. Our data provide a rationale for how human effector-memory Thcells can participate in perpetuating inflammatory processes in autoimmunity even in the absence of T-cell receptor ligation.

Minimal Invasive Fixation of Hamate Hook Fractures Through a Dorsal Percutaneous Approach Using a Mini Compression Screw: An Experimental Feasibility Study.

PURPOSE: Isolated fractures of the hamate hook can be treated by conservative or surgical means. Because nonoperative treatment is associated with high nonunion rates, surgical treatment with open reduction and internal fixation through a palmar approach is often preferred. The aim of this study was to refine surgical treatment of hamate hook fractures using a cannulated mini compression screw through a dorsal percutaneous approach. METHODS: Artificial fractures of the hamate hook were created in five male cadaver hands under fluoroscopy. Using an ulnar approach, the hamate hook was fractured at the base (n = 3) and middle third (n = 2) of the hook using an osteotome. Each fracture was visualized by X-ray and computed tomography. Under fluoroscopy, the fracture was stabilized with a 1.1 mm K wire through a dorsal percutaneous approach which guided the introduction of a 3 mm diameter cannulated mini compression screw. The screw position was then controlled by X-ray and computed tomography. RESULTS: Percutaneous fixation of the fractured hook through the dorsal approach was achieved in all cases. Regardless of the fracture location, all fragments were adapted into anatomically correct positions. No displacement or disruption of the cortex of the hook was observed with central screw positioning. CONCLUSION: Minimal invasive repair of isolated hamate hook fractures through a dorsal percutaneous approach is feasible. The special properties of the cannulated mini compression screw allow optimal screw positioning and stable fixation without risk of diplacement or disruption of the hook fragment.

[Optimization of conventional X-ray images for the detection of hook of hamate fractures]. / Optimierung von konventionellen Röntgenaufnahmen zur Erkennung von Hamulus ossis hamati Frakturen.

Fractures of the hook of the hamate are a rare event. The fracture cannot always be detected clinically and standard radiographs do not always provide an overlap-free image of the hook of the hamate, so that fractures can easily be overlooked. The objective of the present study was to examine if the sensitivity of detecting hamulus ossis hamati fractures can further be improved by a modified conventional radiographic projection. After dissection of the hook of the hamate on 10 cadaver hands, a fracture was produced close to the base using a surgical chisel. Conventional radiographs were then performed in four different projections (dorso-palmar, lateral, carpal-tunnel and oblique view). The oblique view was obtained in a 45 degrees supination position, slight extension and radial duction, with the tube tilted from distal to proximal by 30 degrees. An axial spiral CT was used as a reference for detection of the fracture. The highest sensitivity of the conventional radiographs, with 8/10 identified fractures (80%), was achieved by the oblique view. The carpal-tunnel view with 4/10 (40%) and the dorso-palmar projection with 3/10 (30%) were much lower. All fractures were missed in the lateral projection. If all of the conventional radiographic projections are taken into account, the sensitivity is increased to 90%. All of the fractures were reliably detected in the axial CT-image. If a hamulus ossis hamati fracture is suspected clinically, in addition to the dorso-palmar and carpal-tunnel view, the special oblique view described here should be performed as a third projection plane, while the lateral view can be dispensed with. However, even if all projections are taken into account, a negative finding in the conventional radiographic imaging does not exclude a fracture with absolute certainty. In such cases, a CT or MRI should be performed to exclude a fracture.

Therapeutic alternatives in nonunion of hamate hook fractures: personal experience in 8 patients and review of literature.

Symptomatic nonunion frequently results after conservative treatment of hamate hook fractures, emphasizing the need of appropriate surgical strategies. A retrospective analysis of 8 patients with nonunions treated by fragment excision or open reduction and internal fixation (ORIF) at 3 centers was performed. The literature was reviewed for treatment options, as bone grafting and low-intensity pulsed ultrasound. Although fragment excision is advocated as the "gold standard" in nonunion, reports on functional results are controversial, and recent anatomic and biomechanical studies of the hook challenge this opinion. In our patients, complete relief of symptoms and comparable functional results were observed after ORIF or fragment excision. Bone grafting could supplement ORIF in selected cases. Low-intensity pulsed ultrasound may evolve as a conservative treatment option. Several alternatives to hook excision are available aiming at complete anatomic and functional recovery of hamate hook nonunion. Further experience is needed before general recommendations can be formulated.

Hook of hamate fractures: critical evaluation of different therapeutic procedures.

The treatment of choice in nondisplaced hook of hamate fractures is conservative, with lower arm splinting. Displaced fractures should be treated operatively, whereby excision of the fragment or open reduction and internal fixation are described. A hamulus ossis hamati fracture was verified in 14 patients (mean age, 42 years; range, 21 to 73 years) including 11 men and three women. In six patients (42.9 percent), conservative treatment was initiated immediately after trauma with a lower arm cast for 6 weeks, and eight patients (57.1 percent) were operated on primarily. In five patients (35.7 percent), the fragment was excised, and in three patients (21.4 percent), an open reduction and internal fixation was performed using a screw. In five of six patients treated conservatively, nonunion of the fracture with persisting clinical symptoms developed. All of those patients were treated operatively, whereby three patients underwent excision and two patients underwent screw fixation, which led to elimination of the symptoms. One patient was asymptomatic despite nonunion of the fracture and rejected surgery. All of the eight patients operated on primarily were asymptomatic 3 months after surgery. Therefore, the success rate of primary surgical treatment (eight of eight) was significantly higher compared with conservative treatment(one of six). Finally, all 14 patients were asymptomatic at late postoperative follow-up. The clinical outcome of patients with hook of hamate fractures treated conservatively was disappointing. Therefore, primary surgical treatment is recommended. In our patients, excision and open reduction and internal fixation led to comparable results.