The determination of skeletal age is essential in the management of patients with scoliosis. One of the most frequently used techniques to determine skeletal maturity is the method described by Risser. However, repeated X-ray exposure in the follow-up examinations of scoliosis patients may increase the risk of cancer. We compared conventional radiological evaluation of the Risser grade with ultrasound evaluation. For scoliosis patients routine application of ultrasound in the follow-up examinations may significantly reduce radiation exposure. 46 adolescent idiopathic scoliosis patients (median age, 14.5 years) were investigated. Sonographic and radiographic assessment of Risser sign was carried out by two independent senior staff skeletal radiologists. Agreement of Risser Grade between the two diagnostic methods was determined by Kappa statistics. Coefficients <0.21, 0.21-0.40, 0.41-0.60, 0.61-0.80, and >0.80 were rated as poor, fair, moderate, good, and very good agreement. For Risser Grades I-III 100% agreement was found between the two methods. Disagreement between radiographic and sonographic evaluation was found in Risser Grades IV and V. In five patients, X-ray evaluation yielded Risser Grade V while ultrasound showed Risser Grade IV. In one patient, radiographic examination resulted in Risser Grade IV while Grade V was detected in ultrasound. Overall, the Kappa value showed very good agreement between the two diagnostic methods. Our findings suggest that ultrasound can be applied as an alternative method to X-ray evaluation in Risser Grade determination. It should be routinely used in clinical practice to reduce the patients exposure to radiation.

To analyse the morphological appearance of horseshoe kidneys (HKs) and crossed fused ectopia (CFE) and to assess the frequency and clinical significance of associated anomalies and diseases.The findings and images of 209 patients with fused kidneys (FKs) were reviewed; in all, 244 scans from computed tomography (CT), 233 ultrasonograms and 89 micturition cysto-urethrograms, urograms, magnetic resonance images and angiograms were taken.HKs (found in one of 474 abdominal CT scans) and CFEs (found in one of 3078 CT scans) showed a high variability of vasculature that could not be classified. However, some generalized conclusions were possible about the renal vasculature (430 arteries in 103 kidneys). Variants of the most cephalad artery of both sides were rare. The second artery on the right had a pre-caval course. The origins of vessels located further caudal were more ventral. CFEs were anatomically different from HKs with respect to lower position, greater axial rotation, smaller pelvic width, more caudal origin, and fewer vessels, but not in accompanying anomalies. Severe anomalies or malformations were found in 23% of patients, with half of them in the urogenital system. Malformations were found considerably more often in children than in adults. There was no increased incidence of diseases such as stones or inflammation of the renal pelvis.Concomitant anomalies and diseases were equally frequent for HK and CFE, but less frequent than generally assumed. Individual cases of complex anatomical situations require special examination strategies, and CT appears to be the most reliable imaging method.

Ziele: Ziel dieser Studie war es, das Ergebnis von konservativ behandelten Patienten mit dem Ergebnis von interventionell behandelten Patienten zu vergleichen. Methode: Seit Juli 1996 wurden insgesamt 76 Patienten aufgrund einer Aortendissektion Stanford Typ B behandelt, wobei bei 37 Patienten die interventionelle Therapie (Gruppe A) und bei 39 Patienten die konservative Therapie (Gruppe B) bevorzugt wurde. Die Patienten wurden vor Austritt, nach 6 und 12 Monaten und anschließend jährlich verlaufskontrolliert. Neben einer klinischen Untersuchung wurden CT Untersuchungen durchgeführt. Mortalität, Morbidität, Komplikationen, Volumensänderungen von wahrem und falschen Lumen und Thrombosierung des falschen Lumens wurden evaluiert. Ergebnis: Die mittlere Verlaufsbeobachtungszeit betrug 34 Monate (0–97 Monate). Die Gesamtmortalität betrug in der Gruppe A 24.3% und in der Gruppe B 28.2%. Die dissektionsassozierte Mortalität betrug in der Gruppe A 16.2% und in der Gruppe B 17.9%. In der Gruppe A wurden Endoleaks bei 8 Patienten und eine retrograde Aortendissektion Typ A bei 4 Patienten beobachtet. In der Gruppe B war im Verlauf bei 2 Patienten eine interventionelle Therapie notwendig. Im Langzeitverlauf konnte sowohl in der Gruppe A als auch in der Gruppe B eine signifikante Volumezunahme des falschen Lumens beobachtet werden. Die interventionell behandelten Patienten zeigten ein stabileres wahres Lumen als die konservativ behandelten Patienten. Der Thrombosegrad war in der Gruppe A wesentlich besser als in der Gruppe B. Aortenrupturen wurden nur in Gruppe B (n=4) beobachtet. Schlussfolgerung: Die interventionelle Therapie ist bei Patienten mit einer akuten Dissektion Typ B und lebensbedrohlichen Komplikationen Therapie der Wahl. Die Indikationsstellung für dieses Verfahren sollte jedoch sehr eng gesetzt werden, da eine Progression des Krankheitsbildes mittels dieser Therapie nicht verhindert werden kann und eine relativ hohe Komplikationsrate in Kauf genommen werden muss.

Ziel dieses Fortbildungsposters ist es, die Erfahrung eines „Single Centers“ in der endoluminalen Therapie der Aortendissektion Stanford Typ B in Zusammenschau mit der vorliegenden Literatur zu präsentieren. Seit 1996 wurden insgesamt 49 Patienten mit einer akuten (n=39)oder chronischen (n=10) Dissektion Stanford Typ B mit diesem neuen Therapieverfahren behandelt, die mittlere Beobachtungszeit beträgt 36 Monate (0–103 Monate). Es werden präinterventionelle Abklärung, Indikationen und Kontraindikationen, technische Überlegungen, intraoperative Komplikationen mit Vermeidungsstrategien, postinterventionelles Imaging, postinterventionelle Komplikationen, Strategien zur Behandlung von postinterventionellen Komplikationen, Erfahrungen mit verschiedenen Stent-Graft Designs, Volumensveränderungen des wahren und falschen Lumens im Kurz und Langzeitverlauf, Thrombosierung des falschen Lumens im Kurz und Langzeitverlauf und Mortalität bzw. Morbidität im Kurz und Langzeitverlauf präsentiert und diskutiert.

AIM:Endovascular treatment of infrarenal aortic aneurysms requires follow-up to rule out complications that would require renewed intervention. The aim of this study was to define those factors which, in the absence of such complications, could be relevant for the remaining risk.METHODS:The CT data sets of 55 patients (73.5+/-8 years; M: F ratio 49: 6) were evaluated volumetrically: immediately postinterventional, 6 months, and annually after the procedure. The median observation period was 30+/-19 months.RESULTS:Risk factors for a further increase in aneurysm volume were: short-term increase in volume >5%, medium-term growth >20%, one-time growth >20%, no decrease in volume, and an initial aneurysm volume >200 mL. Favorable factors were: a one-time decrease in volume >15% and no increase in volume at any follow-up visit. Indifferent factors were: initial decrease in volume, one-time growth <20%, one-time shrinkage <15%, and type II endoleak. Conclusion. Patients require particular attention whose aneurysm volume increased by more than 5% or increased medium-term or increased at once by more than 20%, and who either did not show a decrease in volume at any follow-up or who had a large initial volume. A one-time decrease in volume of more than 15% was positive, as was no increase in volume at any follow-up.

The aim of this retrospective study was to evaluate mid- and long-term results of endovascular stent-graft placement for emergency repair of acute traumatic thoracic aortic rupture. From 1996 through 2005, 22 consecutive patients (mean age: 38.7 years) underwent endovascular repair of acute traumatic thoracic aortic rupture located at the aortic isthmus in most cases. All patients were at high surgical risk due to severe associated injuries. The endografts were inserted via femoral or iliac artery access under fluoroscopic guidance. Follow-up was performed postinterventionally, at 6 and 12 months and yearly thereafter, and included clinical examination and computed tomography (CT) scans. Technical and clinical success rates were 86.3%. Mean follow-up was 31.7 months. Three patients developed early type I endoleak due to the inability of the rigid graft to adapt to the curved aortic contour. In two of them conversion to open surgery was necessary. One patient had late type I endoleak and died. No other complications were observed. The outcome was successful in most patients. The mid- and long-term results of our current study are promising. However, early type I endoleak represents a problem, especially in adolescent patients with a marked curvature of the aortic arch.

After endovascular aortic aneurysm repair, stent graft migration and kinking or buckling of the stent graft can cause the perilous risk of rupture. In a previous paper we presented an approach to analyze the migration of the stent by defining the spinal canal as a reference object and by investigating the movements relative to it. In this paper, we quantify also non-rigid deformations of the stent. A procedure is used based on the segmentation and extraction of surface points for stent and spinal canal and on point set registration. The sensitivity of the quantified values with respect to the choice of segmentation parameters is investigated as well. Results for 6 patients show that the procedure allows us to distinguish benign cases from dangerous changes in morphology even if segmentation parameters vary within a reasonable bandwidth.

The endovascular repair of an abdominal aortic aneurysm is a minimal invasive therapy which has been established during the past 15 years. A stent-graft is placed inside the aorta in order to cover the weakened regions of its wall. During a time interval of one or more years the stent-graft can migrate and deform with the risk of the occlusion of one of its limbs or of the rupture of the aneurysm. In this work we developed several strategies to quantify the migration and deformation in order to assess the risk coming with these movements and especially to characterize appearing complications by them. We calculated the rigid movement of the stent-graft and the aorta relative to the spinal canal. For this purpose, firstly, we rigidly registered the spinal canals, extracted for the different points in time, in order to establish a fixed reference system. All objects have been segmented first and surface points have been determined before applying a rigid and non-rigid point set registration algorithm. The change in the residual error after registration of the stent-graft with an increasing number of degrees of freedom indicates the amount of change in the stent-graft's morphology. We investigated a sample of 9. Two cases could be clearly distinguished by the quantified parameters: a high global migration and a strong reduction of the residual error after non-rigid registration. In both cases, strong complications have been detected by the examination of clinical experts but only by means of the images acquired one year later.

OBJECTIVE:The aim of our retrospective study was to review our single-center experience with aortic abdominal aneurysm (AAA) repair retrospectively.MATERIAL AND METHODS:From 1995 to 2005, 70 consecutive patients affected by AAA were treated by endovascular stent-graft repair. Mean follow-up was 23.9 months. Follow-up investigations were performed at 6 and 12 months and yearly thereafter. Five different stent-graft designs were compared to each other. Primary technical success (PTS), assisted primary technical success (APTS), primary clinical success (PCS) and secondary clinical success (SCS) were evaluated.RESULTS:All over PTS was achieved in 94.3%, APTS in 97.1%, PCS in 61.4%, APCS in 64.3% and SCS in 70%. There were 3 type I endoleaks, 25 type II endoleaks, 4 type III endoleaks, 8 limb problems, 5 conversions to open surgery, 10 aneurysm sac expansions and 14 device migrations. Patients with newer generation devices showed better results than patients with first generation prosthesis. In addition results were better for grafts with suprarenal fixation (versus infrarenal fixation) and grafts with barbs and hooks (versus grafts without barbs and hooks). Patients with bad anatomic preconditions showed a higher complication rate.CONCLUSION:Contrary to first generation products, new stent-graft designs show acceptable technical and clinical results in endovascular AAA aneurysm repair. However, this therapy still should be reserved only for patients with significant comorbities and suitable anatomic conditions.

In this paper we present an approach to analyse the migration of stent grafts after endovascular aortic aneurysm repair. Stent graft migration and kinking or buckling of the graft can cause the perilous risk of rupture. Our approach allows describing the occurring movements quantitatively towards the aim to find common patterns related to different endograft devices or to dangerous changes in morphology. We proceed by defining the spinal canal as reference system and by investigating the movements of the graft relative to it. Here, we segment the spinal canal as well as the stent graft at different time points and we apply a point set registration algorithm in order to calculate the transformation to the spinal canal reference system and to determine the occurring motion of the stent. First results illustrate that essentially rigid motion occurs in case of thoracic aortic aneurysms.

Ziele: Retrospektive Studie zur Erfassung der klinisch-radiologischen Ergebnisse und Komplikationen im mittel – und langfristigen Verlauf nach endovaskulärer Therapie von akuten und chronischen traumatischen Aortenaneurysmen bzw. Dissektionen. Methode: 19 Patienten (2 Frauen, 17 Männer, Alter 14–82 Jahre) mit traumatischer Aortendissektion (akut n=15, chronisch n=4) wurden mittels Stentprothesen endovaskulär behandelt (Talent n=11, Vanguard n=5, Excluder n=3). Die Implantationen erfolgte in Allgemeinnarkose, wobei der Eingriff bei 15 Patienten notfallmäßig durchgeführt wurde. Bei einem Patienten wurde präinterventionell eine Ektasie der Aorta ascendens festgestellt, bei den restlichen Patienten konnte bis auf die Verletzung keine andere Aortenpathologie erhoben werden. Die Ergebniskontrolle erfolgte mittels Spiral-CT postinterventionell, nach 3, 6 und 12 Monaten und dann jährlich. Zusätzlich wurden die Patienten klinisch untersucht. Ergebnis: Die primäre technische Erfolgsrate betrug 95% (18/19). Bei einem Patienten war eine Reintervention aufgrund eines proximalen Endoleaks Typ I erforderlich. Die Nachbeobachtung betrug 4–108 Monate (mittel 36 Monate). Die sekundäre technische Erfolgsrate betrug 100%. Die 3o-Tage-Mortalität betrug 0%. Im Verlauf waren bei 2 Patienten aufgrund von Endoleaks Typ I Reinterventionen notwendig (18 und 28 Monate nach der primären Intervention), wobei ein Endoleak aúf Stentmigration und das andere auf eine Aneurysmenbildung der Aorta proximal des Stents zurückgeführt werden konnte. Eine sekundäre Intervention war bei beiden Patienten erfolgreich, wobei jedoch bei dem Patienten mit der Aneurysmenbildung 1 Monat nach der Sekundärintervention eine letale Aortendissektion Typ A diagnostiziert wurde. Schlussfolgerung: Die endovaskuläre Implantation von Stentprothesen ist eine vielversprechende Technik zur Behandlung von akuten und chronischen traumatischen Aneurysmen/Dissektionen der thorakalen Aorta.

Purpose: To evaluate the outcome of stent-graft placement in Stanford type B aortic dissection using contrast-enhanced spiral computed tomographic (CT) measurements of true and false lumen volumes and thrombus length. Methods: Among 18 consecutive patients (13 men; mean age 60 years, range 44–79) who underwent endovascular repair of Stanford type B dissection, 12 completed at least a 12-month follow-up, which included CT measurements of true and false lumen volumes and thrombus lengths prior to discharge and at 6 and 12 months postimplantation. Volumes were assessed in 3 different aortic segments (A1, A2, A3) extending from the proximal attachment site of the prosthesis to the aortic bifurcation. In addition, thrombus length was measured to evaluate the influence of clot formation on outcome of the false lumen volume. Results: Mean follow-up was 27 months (range 12–60). Within 12 months, mean true lumen volumes showed statistically significant increases in the A1 (p<0.001) and A2 (p=0.003) segments; false lumen volumes showed a significant decrease in the A1 segment (p=0.002) but an insignificant increase in the A2 segment. No substantial volume changes were observed in the A3 segment. Extension of clot formation in the false lumen varied among patients and over time. Length of stent-grafts, percentage of stented dissection length, or visceral arteries originating from the false lumen did not significantly influence thrombus development, nor did these parameters or thrombus formation distal to the prosthesis have a relationship to false lumen volumes. Conclusions: Volumetric analysis after endovascular repair of Stanford type B dissection shows optimal technical outcome in the stented segment, whereas the false lumen in the segment immediately adjacent to the stent-graft seems to be a vulnerable area. Extension of clot formation beyond the endograft seems to be no reliable predictor of outcome.

Introduction. Thoracic aortic aneurysms (TAA) are the most common condition of the thoracic aorta requiring surgical treatment. Despite significant improvement in anesthetic, surgical techniques and postoperative care, the mortality and morbidity rate in TAA-repair remains high. The aim of this study was to assess the morbidity and mortality rate after endovascular stem-graft treatment of atherosclerotic (non-dissecting) TAAs.Methods. Thirty-one patients, ASA-classification III-IV, with symptomatic or expanding atherosclerotic TAAs underwent endovascular stent-graft repair between May 1997 and August 2003. Procedures were performed on an emergency basis in 13 patients and elective in 18 patients. Patients were assessed postoperatively by routine CT-scan within 48 h. Further follow up investigations were performed after 3, 6, 12 months and annually thereafter.Results. Stent-graft placement was successful in all but one patient in whom the stem-graft procedure had to be postponed due severe hemodynamic instability. Perioperative mortality rate was 19% including three haemorrhages, two cardiac events and one respiratory failure (6/31). Technical success rate was 55% (17/31). Completion CT scans performed in 30 patients within 2 days of stent-graft procedure showed type I leaks in seven patients (23%), type II leaks in four patients (13%) and type III leaks in two patients (6%). Further complications included one stroke, one paralysis, one spinalis anterior syndrome and five relevant access related complications. New onset endoleaks, all type I, were observed in seven patients (23%) occurring after 3, 4, 7, 8, 17, 25 and 26 months. Mean follow-up was 15 months (range 2-69 months).Conclusion. Thoracic aortic atherosclerotic aneurysm stem-grafting is feasible but not without significant morbidity and mortality.

Infection is a serious complication of total hip replacement. It has been proposed that 6% of all infections after total hip arthroplasty may be of dental origin through hematogenous spread. However, no conclusive evidence that the mouth is a definitive source for infection of a total hip replacement has been reported. In the current case, Prevotella loeschii, a pigmented bacteroides species was identified in a total hip replacement. Prevotella loeschii is an organism which exclusively inhabits the dental region. Hematogenous spread of Prevotella loeschii may occur after penetration of the mucosal barrier in cases of endodontic or periodontic lesions, pericoronitis, or complications of tooth extraction. The involvement of Prevotella loescheii in an infection in a patient who had a total hip arthroplasty is strong evidence for the mechanism of a hematogenous infection from a dental source.

A 92 year old male patient was referred to our service because of gross hematuria. He had a history of numerous episodes of hematuria in the last year. A cystoscopy was performed as first measure. The bladder neck, the trigone and the ureteral orifices were normal. Inspection of the mucosa revealed a localized bleeding area three centimeter in diameter within the posterior wall of the bladder. This area was bulged by an extravesical solid tumor of unknown etiology. Local pressure had caused central necrosis, but no fistula could be observed. Plain radiographs of the pelvis were performed revealing severe osteolytic destruction of the right acetabulum, a proximal fracture of the right superior pubic ramus and central transpelvic dislocation of the prosthetic stem of a total hip replacement with the femoral head supporting at the contralateral sacroiliac joint (Figure 1). A computed tomography was performed demonstrating extravesical compression due to the dislocated prosthetic stem (Figure 3). Medical records revealed that the patient underwent total hip arthroplasty 22 years ago. Failure of the implant was reported but revision surgery was not performed. Revision surgery including removal of the intrapelvic prosthesis was initiated to avoid bladder rupture. Extraction of the stem was performed successfully, the patient recovered well and no further events of hematuria were recorded.

With the introduction of digital flat-panel detector systems into clinical practice, the still unresolved question of resolution requirements for picture archiving communication system (PACS) workstation monitors has gained new momentum. This contrast detail analysis was thus performed to define the differences in observer performance in the detection of small low-contrast objects on clinical 1K and 2K monitor workstations. Images of the CDRAD 2.0 phantom were acquired at varying exposures on an indirect-type digital flat-panel detector. Three observers evaluated a total of 15 images each with respect to the threshold contrast for each detail size. The numbers of correctly identified objects were determined for all image subsets. No significant difference in the correct detection ratio was detected among the observers; however, the difference between the two types of workstations (1K vs 2K monitors) despite less than 3% was significant at a 95% confidence level. Slight but statistically significant differences exist in the detection of low-contrast nodular details visualized on 1K- and 2K-monitor workstations. Further work is needed to see if this result holds true also for comparison of clinical flat-panel detector images and may, for example, exert an influence on the diagnostic accuracy of chest X-ray readings.

OBJECTIVE:The aim of this study was to determine the accuracy of CT arterioportography and hepatic digital subtraction angiography, separately and combined, for the detection of hepatocellular carcinoma in the cirrhotic liver by using thin-section liver explant histopathologic findings.SUBJECTS AND METHODS:Fifty-nine patients with liver cirrhosis were examined with CT arterioportography and digital subtraction angiography as a part of preoperative diagnostic workup for liver transplantation. Before liver explantation, CT arterioportograms and digital subtraction angiograms were prospectively evaluated in a blinded manner, separately by two CT radiologists and two angiographers, respectively, and combined by two reviewer teams, each including a CT radiologist and an angiographer. In addition, each examination was retrospectively evaluated using direct comparison with the corresponding thin-section liver explant specimensRESULTS:There were 39 histologically confirmed hepatocellular carcinomas. In both prospective and retrospective assessments, the reviewers achieved the best performance with CT arterioportography and digital subtraction angiography combined (area under the curve [A(z)] 0.82). The diagnostic confidence in the detection of hepatocellular carcinoma was higher with digital subtraction angiography (A(z), 0.81) than that with CT arterioportography (A(z), 0.68). Prospectively, sensitivity and specificity were 75% and 60% for CT arterioportography, 77% and 80% for digital subtraction angiography, and 84% and 81% for CT arterioportography and digital subtraction angiography combined, respectively. Retrospectively, sensitivity and specificity were 80% and 62% for CT arterioportography; 82% and 79% for digital subtraction angiography; 87% and 81% for CT arterioportography and digital subtraction angiography combined, respectively. Five hepatocellular carcinomas, one poorly and four well differentiated, with a mean size of 1.4 cm were not detectable on the CT arterioportography and digital subtraction angiography combination. False-positive findings were 20, 11, and 10 on CT arterioportography, digital subtraction angiography, and the CT arterioportography and digital subtraction angiography combination.CONCLUSION:Combining CT arterioportography with digital subtraction angiography enabled reliable detectability of moderately and poorly differentiated hepatocellular carcinomas in cirrhotic livers but was less sensitive for the detection of well-differentiated hepatocellular carcinomas and resulted in a relatively high rate of false-positive findings.

For assessment of total knee arthroplasty outcome, various scoring systems have been introduced. The current study assessed the interobserver correlation of four commonly used total knee arthroplasty outcome scores. One hundred eighteen total knee arthroplasties were investigated by two independent observers, using the Hungerford score, the Hospital for Special Surgery score, the Knee Society score, and the Bristol score. Each score consisted of three subscores: pain, knee, and function. For the highest interobserver correlation was computed for the Bristol score (interobserver correlation coefficient, 0.88). For knee range of motion, flexion contracture, and extension lag there was high interobserver correlation (interobserver correlation coefficient > 0.8 each). For walking distance and walking aids, there also was a high interobserver correlation (interobserver correlation coefficient > 0.7 each). For clinical assessment of total knee arthroplasty, pain should be measured on a four-step system, the knee should be assessed by measurement of range of motion, extension lag, and flexion contracture, and function should be measured on a separate score assessing walking distance and walking aids.

Zusammenfassung Stressfrakturen stellen eine diagnostische Herausforderung für den Radiologen dar, da sie nativradiologisch mitunter schwer zu diagnostizieren sind und mit knöchernen Neubildungen verwechselt werden können. Stressfrakturen wurden erstmals bei Militärrekruten und Hochleistungssportlern beobachtet, sie treten jedoch auch immer häufiger bei Freizeitsportlern auf. Stressfrakturen betreffen hauptsächlich die unteren Extremitäten, v. a. die Tibia, die Knochen des Tarsus und des Metatarsus, den Femur und die Fibula. In den oberen Extremitäten kommen sie insbesondere am Humerus, am Radius und an der Ulna vor. Meistens lässt sich eine Korrelation zwischen Lokalisation der Stressfraktur und der ausgeübten Sportart feststellen. Bei Langstreckenläufer ist z. B. meistens die Tibia betroffen. Stressfrakturen der oberen Extremität sind seltener und zeigen keine so eindeutige sportspezifische Lokalisation. Grundlage für eine korrekte Diagnose ist eine sorgfältige klinische Anamnese. Das initiale konventionelle Röntgen kann negativ ausfallen. Eine weitere Abklärung erfolgt meistens mittels Computertomographie, MR-Tomographie und der Knochenszintigraphie. Die MR-Tomographie und die Knochenszintigraphie haben einen besonderen Stellenwert in der Initialdiagnostik, da mit diesen beiden Techniken die korrekte Diagnose früh gestellt werden kann.