Cone-beam CT findings during prostate artery embolization for benign prostatic hyperplasia-induced lower urinary tract symptoms: a case report

Background

Cone-beam computed tomography (CBCT) is a new and useful technique for angiographic procedures. Prostatic artery embolization (PAE) has emerged as a promising treatment modality for lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH). CBCT can be helpful for PAE to determine the correct arteries for embolization, and to show any occlusion of these arteries.

Case presentation

Herein, we report on a patient who underwent CBCT-guided PAE as treatment for BPH-induced LUTS, present the imaging findings, and provide technical suggestions.

Conclusions

PAE is an effective, minimally invasive modality for the treatment of LUTS due to BPH, and contrast CBCT can help visualize and demonstrate occlusion of the prostatic arteries.

     

Novel Technique for Defogging and Cleaning the Laparoscope Lens uring Minimally Invasive Surgery

Background

Condensation on the lens of the laparoscope resulting from differences between room temperature and intra-abdominal temperature is a disturbing problem for laparoscopic surgeons. Anti lens condensation solutions prevent fogging in the intra-abdominal environment, but are troublesome to apply to the scope. We describe a technique that allows the antifogging solution to be applied to the endoscope without removing it from the patient.

Methods

A simple technique is described for cleaning the lens with anti-fogging solution without the need to remove the laparoscope from the abdomen, using a syringe and cheap plastic sheath introduced through a laparoscopic port.

Results

The technique described is a cost-effective and time-efficient way to maintain the correct laparoscope temperature while cleaning and de-fogging the lens as required throughout laparoscopic procedures.

Conclusion

The use of a syringe and cheap plastic sheath can allow application of antifog solution to the laparoscope lens without removing it from the body cavity, overcoming the main issues associated with maintaining lens clarity during laparoscopic surgery.

     

Radiation exposure using the O-arm<Superscript>®</Superscript> surgical imaging system

Purpose

This study was conducted to characterise the O-arm^® surgical imaging system in terms of patient organ doses and medical staff occupational exposure during three-dimensional thoracic spine and pelvic examinations.

Methods

An anthropomorphic phantom was used to evaluate absorbed organ doses during a three-dimensional thoracic spine scan and a three-dimensional pelvic scan with the O-arm^®. Staff occupational exposure was evaluated by constructing an ambient dose cartography of the operating theatre during a three-dimensional pelvic scan as well as using an anthropomorphic phantom to simulate the O-arm^® operator.

Results

Patient organ doses ranged from 30 ± 4 μGy to 20.0 ± 3.0 mGy and 4 ± 1 μGy to 6.7 ± 1.0 mGy for a three-dimensional thoracic spine and pelvic examination, respectively. For a single three-dimensional acquisition, the maximum ambient equivalent dose at 2 m from the iso-centre was 11 ± 1 μSv.

Conclusion

Doses delivered to the patient during a three-dimensional thoracic spine image acquisition were found to be significant with the O-arm^®, but lower than those observed with a standard computed tomography examination. The detailed dose cartography allows for the optimisation of medical staff positioning within the operating theatre while imaging with the O-arm^®.

     

Intraoperative radiation exposure in spinal scoliosis surgery for pediatric patients using the O-arm<Superscript>®</Superscript> imaging system

Purpose

The O-arm^® navigation system allows intraoperative CT imaging that can facilitate highly accurate instrumentation surgery, but radiation exposure is higher than with X-ray radiography. This is a particular concern in pediatric surgery. The purpose of this study is to examine intraoperative radiation exposure in pediatric spinal scoliosis surgery using O-arm.

Methods

The subjects were 38 consecutive patients (mean age 12.9 years, range 10–17) with scoliosis who underwent spinal surgery with posterior instrumentation using O-arm. The mean number of fused vertebral levels was 11.0 (6–15). O-arm was performed before and after screw insertion, using an original protocol for the cervical, thoracic, and lumbar spine doses.

Results

The average scanning range was 6.9 (5–9) intervertebral levels per scan, with 2–7 scans per patient (mean 4.0 scans). Using O-arm, the dose per scan was 92.5 (44–130) mGy, and the mean total dose was 401 (170–826) mGy. This dose was 80.2% of the mean preoperative CT dose of 460 (231–736) mGy (P = 0.11). The total exposure dose and number of scans using intraoperative O-arm correlated strongly and significantly with the number of fused levels; however, there was no correlation with the patient’s height.

Conclusions

As the fused range became wider, several scans were required for O-arm, and the total radiation exposure became roughly the same as that in preoperative CT. Use of O-arm in our original protocol can contribute to reduction in radiation exposure.

     

Accuracy and evaluation of irradiation of novel localization devices with unique three-dimensional structures in microendoscopic spine surgery

Background

Although many reports are available on using a variety of instruments and techniques to prevent wrong-level spine surgery, the accurate localization of the correct spinal level remains problematic. At the same time, surgeons are also required to reduce radiation exposure to patients and operating room personnel. To solve these problems, we developed and used specially designed marking devices with a unique three-dimensional structure.

Purpose

To evaluate the accuracy of our novel devices for localization of the spinal level to prevent wrong-level surgery and reduce the amount and time of radiation exposure during surgery.

Study design

This was a retrospective cohort study.

Methods

In 8240 consecutive patients who underwent microendoscopic spine surgery between 1993 and 2012, the incidence of wrong-level surgery was studied. In addition, the amount of radiation exposure and total fluoroscopy time were measured in recent 100 consecutive patients using a digital dosimeter attached to the fluoroscope.

Results

Eight (0.097 %) patients had undergone wrong-level surgery. The average radiation exposure was 0.26 mGy (range 0.10–1.15 mGy), and the average total fluoroscopy time was 3.1 s (range 1–7 s).

Conclusions

Our novel localization devices and technique for their use in spine surgery are reliable and accurate for identifying the target level and contributed to reductions in preoperative localization error and radiation exposure to patients and operating room personnel.

     

Patellaformen

Background

Patella height is discussed as a possible factor in the development of osteoarthritis of the knee.

Methods

PubMed literature search

Results

Contradictory results are found in the literature.

Conclusion

According to the literature, there is currently no evidence that abnormal patella height can induce osteoarthritis of the knee.

     

No difference in flexion power despite iliopsoas fatty degeneration in healed hip fractures with large lesser trochanter displacement

Objective

To evaluate iliopsoas atrophy and loss of function after displaced lesser trochanter fracture of the hip.

Design

Cohort study.

Setting

District hospital.

Patients

Twenty consecutive patients with pertrochanteric fracture and displacement of the lesser trochanter of?>?20 mm.

Intervention

Fracture fixation with either an intramedullary nail or a plate.

Outcome measurements

Clinical scores (Harris hip, WOMAC), hip flexion strength measurements, and magnetic resonance imaging findings.

Results

Compared with the contralateral non-operated side, the affected side showed no difference in hip flexion force in the supine upright neutral position and at 30° of flexion (205.4 N vs 221.7 N and 178.9 N vs. 192.1 N at 0° and 30° flexion, respectively). However, the affected side showed a significantly greater degree of fatty infiltration compared with the contralateral side (global fatty degeneration index 1.085 vs 0.784), predominantly within the psoas and iliacus muscles.

Conclusion

Severe displacement of the lesser trochanter (>?20 mm) in pertrochanteric fractures did not reduce hip flexion strength compared with the contralateral side. Displacement of the lesser trochanter in such cases can lead to fatty infiltration of the iliopsoas muscle unit. The amount of displacement of the lesser trochanter did not affect the degree of fatty infiltration.

Level of evidence

II.

     

Computerassistierte Unterstützung der Diagnostik von kraniomandibulären Dysfunktionen

Background

A remarkable amount of the population is suffering from severe and painful craniomandibular dysfunctions (CMD). During the last decades, computer assisted procedures for diagnosis and therapy planning gained more and more acceptance in the clinical setting.

Material and methods

In this article, several recent computer assisted methods for CMD diagnosis support are presented. All methods are demonstrated based on data sets from the clinical routine.

Results

With regard to its good soft tissue contrast and its non-invasiveness, magnetic resonance imaging (MRI) has proved to be a suitable means for the diagnosis of craniomandibular soft tissue pathologies. By means of an MRI based computer assisted procedure, which was developed by the authors, diagnosis support for articular disc displacement is demonstrated. Additionally, the method can be applied to the evaluation of muscular structures. Computer aided assessment of data acquired by computer tomography (CT) or cone beam computer tomography (CBCT) is still prevalent for the examination of the skeletal anatomy and its pathologies. Inter alia because of the reduced radiation dose, the application of CBCT is increasing.

Conclusions

Computer assisted techniques show high potential for a significant and efficient diagnosis support in the field of CMD. If adequately used, a remarkable increase in expertise can be gained. By the presented tools, the possibilities of craniomandibular diagnostics can be significantly extended, but it can never be replaced.

     

Management of skin and subcutaneous tissue in complex open abdominal wall reconstruction

Purpose

Open abdominal wall reconstruction is often a complex endeavor, usually performed on patients with multiple risk factors and co-morbidities.

Methods

In this article, we review soft tissue management techniques that can optimize the skin and subcutaneous tissue, with the goal of reducing surgical-site occurrences.

Results

Regardless of the hernia repair technique used, outcomes can be highly dependent on the appropriate management of the skin and subcutaneous tissue. Indeed, dehiscence and surgical-site infection can jeopardize the entire reconstruction, especially in cases where synthetic mesh might become exposed and/or infected, setting up a “vicious cycle” (Holihan et al. in J Am Coll Surg 221:478–485, 2015).

Conclusion

Multidisciplinary cooperation between the general and plastic surgeon is useful in cases of tenuous blood supply to the abdominal skin, in cases of redundant, marginal or excessive skin, and in cases of deficient skin.

     

Entzündlich-rheumatische Erkrankungen

Background

Inflammatory rheumatic diseases can lead to cartilage changes.

Methods

PubMed literature search

Results

The rheumatoid arthritis can produce degrading enzymes and cause cartilage damage; longitudinal studies do not exist.

Conclusion

There are no high level studies. The expert opinion is that infammatory rheumatic diseases can lead to osteoarthritis of the knee.

     

Komplikationsmanagement im Internet Marketing

Background

New patients come more and more often over the internet; therefore internet marketing plays an increasingly important role.

Question

How can physicians build an effective internet marketing strategy and avoid complications?

Method

Selection and authorization of a reputable agency.

Results

New customer acquisition through high visibility in the internet, at the same time increasing the image and awareness.

Conclusions

In the overall “marketing mix” internet marketing has become indispensable to physicians who want to be successful. Those who are well positioned in Google are well known by their target audience and thus receive a higher response.

     

Operative Behandlung der ulnaren Seitenbandläsion am Daumengrundgelenk

Objective

Reconstruction of the ruptured ulnar collateral ligament of the metacarpophalangeal (MP) joint of the thumb.

Indications

Ruptured ulnar collateral ligament of the thumb MP joint with instability: joint opening of more than 30° in flexion and more than 20° in extension, Stener lesion, displaced avulsion fractures.

Contraindications

Abrasions, wound-healing disturbance, skin disease, osteoarthritis.

Surgical technique

Curved skin incision dorsoulnar above the thumb MP joint. Protection of the branches of the superficial radial nerve. Incision of the adductor aponeurosis. Exposing the ulnar collateral ligament; opening and examination of the joint. Depending on the injury, primary suture repair, transosseous suture, repair with a bone anchor, osteosynthesis with K-wires or small screws in avulsion fracture, ligament reconstruction in chronic instability or older injury.

Postoperative treatment

Cast splint of the MP joint until swelling subsides; cast immobilization for 6 weeks; range-of-motion exercises, avoiding forced radial deviation of the MP joint for 3 months.

Results

Complete joint stability 3 months postoperatively in all 34 patients with rupture of the ulnar collateral ligament.

     

Endovaskuläre Augmentation der Shunt-Maturation

Background

Delayed maturation is a phenomenon that is observed in autologous arteriovenous shunts. Clinically, maturation of an autologous arteriovenous shunt primarily means that the diameter of the shunt vein becomes enlarged to the extent that it can be easily punctured. In addition, a mature shunt is characterized by a blood flow which is sufficient to perform hemodialysis.

Objective

Which diagnostic and therapeutic options are available for delayed maturation?

Material and methods

A literature search and evaluation of current study results on this topic were carried out.

Results

In the literature three main reasons for delayed maturation are given: problems with arterial inflow, problems with venous outflow and accessory veins. The early diagnosis and treatment of the underlying problem help to minimize the use of catheters. The most important tool in the diagnosis of delayed maturation is the physical examination, which then allows the underlying problem that prevents maturation to be identified with targeted imaging. Using sonography, patients who fulfill the criteria for delayed maturation can be identified. Digital subtraction angiography (DSA) and magnetic resonance imaging (MRI) complete the imaging diagnostics.

Conclusion

The majority of autologous shunts with delayed maturation can be brought to maturity using endovascular techniques.

     

Beinachsen- und Fußfehlstellung

Background

Varus and valgus malalignment as well as foot malalignment can change the load applied to the knee.

Methods

PubMed literature search

Results

Inconsistent results for leg axis and the incidence of osteoarthritis of the knee are reported in the literature.

Conclusion

Leg axis and foot malpositioning are not causative factors.

     

Harnröhrenrekonstruktion bei vorausgegangener Hypospadieoperation

Background

The tasks involved in reconstructing the urethra after failed hypospadias repair range from correction of a trivial meatal stenosis to reconstruction of the entire anterior urethra.

Objectives

To describe pathological findings in the urethra after failed hypospadias repair and the respective surgical methods used for their correction.

Materials and methods

The various pathological findings after unsuccessful hypospadias surgery are classified according to their location and complexity.

Results

The general rules of reconstruction that should be applied in each particular situation are described.

Conclusions

Successful reconstruction of the urethra in patients with failed hypospadias surgery requires experience and good knowledge of the anatomy of the normal and hypospadic urethra and penis. Mastery of plastic surgical techniques and profound knowledge of the various surgical methods of hypospadias surgery are essential.

     

Tibiakopffrakturen

Background

Tibial plateau fractures represent 1–2?% of all human fractures. Complex fractures affecting the tibial joint surface and accompanying injuries of the soft tissue covering can be a special challenge for surgeons. This paper provides the current state of treatment options.

Classification

In German-speaking countries the classification of the Working Group for Osteosynthesis (Arbeitsgemeinschaft für Osteosynthesefragen, AO) is accepted as the gold standard but in English-speaking countries the classification by Schatzker is preferred.

Diagnostics

The severity of the soft tissue injury is the main factor for determining the time of operation and for perioperative decision making. The gold standards in imaging diagnostics are conventional x-ray photographs in two planes and computed tomography plus 3D reconstruction. Magnetic resonance imaging plays the most important role in evaluating concomitant injuries of ligaments and menisci.

Therapy

One of the main goals is to avoid posttraumatic arthritis of the knee joint. Time and fracture management depend on the so-called personality of the fracture. Screws and locking plates are most commonly used as implants. The importance of arthroscopically assisted surgery is increasing. For filling bone defects artificial bone graft substitutes are inserted more frequently.

Conclusion

The long-term outcome of surgically treated younger patients with low energy trauma seems to be good. Poorer results can be expected in cases with high energy trauma and higher degrees of destruction of the tibial joint surface. The ongoing research on operation techniques, implants and bone graft substitutes aims at improving the results in the future.

     

Adjacent intervertebral space infection after lumbar fusion

Background

Surgical site infection is a catastrophic complication after spinal surgery, which seriously affects the progress of rehabilitation and clinical outcome. Currently the clinical reports on spinal surgical site infections are mostly confined to the surgical segment itself and there are few reports on adjacent segment infections after spinal surgery.

Study design

Case report.

Objective

To report a clinical case with adjacent level infection after spinal fusion.

Methods

We report the case of a 68-year-old woman who underwent posterior lumbar 4?5 laminectomy, posterolateral fusion and internal fixation. The patient showed signs of surgical site infection, such as surgical site pain, high fever and increase of the inflammatory index 1 week after the operation. Magnetic resonance imaging (MRI) confirmed the diagnosis of adjacent intervertebral disc infection. The patient received early combined, high-dose anti-infection treatment instead of debridement.

Results

After the conservative treatment, the infection was controlled and the patient subsequently enjoyed a normal daily life.

Conclusion

Adjacent level infections can occur after spinal surgery. Early diagnosis and anti-infection treatment played an important role in the treatment of this kind of complication.