Stapled transanal rectal resection (STARR) was developed to correct intussusception causing obstructed defecation. Some patients, however, do not profit from this operation as anticipated. We aimed to study the relationship between functional outcome and rectal morphology after STARR.

Primary synovial chondromatosis (PSC) is a rare benign arthropathy affecting diarthrodial joints. It is more common in men than in women, with a ratio of 2:1, and usually occurs between the third and fifth decade of life. In two-thirds of reported cases, the knee joint is affected, followed by the hip, elbow, wrist, and shoulder. 9 Imhoff A. Schreiber A. [Synovial chondromatosis]. Orthopade. 1988; 17: 233-244 PubMed Google Scholar , 13 Milgram J.W. Synovial osteochondromatosis: a histopathological study of thirty cases. J Bone Joint Surg Am. 1977; 59: 792-801 PubMed Google Scholar Extraarticular localization is even less common, so PSC of the biceps tendon has only been reported a few times in the literature. 4 Covall D.J. Fowble C.D. Arthroscopic treatment of synovial chondromatosis of the shoulder and biceps tendon sheath. Arthroscopy. 1993; 9: 602-604 Abstract Full Text PDF PubMed Scopus (31) Google Scholar , 13 Milgram J.W. Synovial osteochondromatosis: a histopathological study of thirty cases. J Bone Joint Surg Am. 1977; 59: 792-801 PubMed Google Scholar , 26 Werner A. Wild A. Mueller T. Borys A. Gohlke F. Krauspe R. [Primary synovial chondromatosis of the shoulder]. Z Orthop Ihre Grenzgeb. 2002; 140: 404-408 Crossref PubMed Scopus (4) Google Scholar To our knowledge, there have only been 2 previous reports of an isolated chondromatosis of the biceps tendon sheath. 5 Covall D.J. Fowble C.D. Synovial chondromatosis of the biceps tendon sheath. Orthop Rev. 1994; 23: 902-905 PubMed Google Scholar , 8 Del Prete F. Extra-articular synovial chondromatosis. Description of a rare localization in the arm. Ital J Orthop Traumatol. 1992; 18: 111-115 Google Scholar We report the rare case of an isolated synovial chondromatosis of the biceps tendon sheath occurring in a pediatric patient and discuss the etiology, diagnosis, and treatment of this rare lesion based on current literature.

The ProblemThe failure rate after surgical acromioclavicular (AC) joint stabilization is of up to 10%. For revision, several techniques including modifications of the Weaver-Dunn procedure have been suggested. However, patients with failure of such revision techniques represent a special challenge due to the altered anatomic relationships and the lack of stabilizing structures.The SolutionIn this respect, a case of several failed AC joint reconstructions is reported in which a doubled semitendinosus graft was used. The use of either biological autograft or artificial material has been suggested in the literature. However, especially the use of an autograft or allograft tendon has been supported by biomechanical studies.Surgical TechniqueA semitendinosus graft was harvested, passed through a clavicular and a coracoid tunnel, and subsequently doubled around the medial clavicle and the medial coracoid hook. A second pair of tunnels in the distal part of the clavicle and the coracoid was used for tying a 2-mm Fiber-Wire (Arthrex Inc.) cerclage. Then, the tendon graft was sutured beyond itself with # 2 Ethibond (Ethicon Inc., Johnson & Johnson). Consecutively, the deltotrapezial fascia was doubled and closed up with inverted # 1 sutures. After skin closure the left arm was immobilized in a sling.Result12 months after surgery, the patient was free of pain, presenting with a Constant Score of 87/100 and a Neer Score of 94/100.

The purpose of this study was to evaluate the presence and localization of intraabdominal adhesions using functional cine magnetic resonance imaging (MRI) and to correlate the MR findings with intraoperative results. In a retrospective study, patients who had undergone previous abdominal surgery with suspected intraabdominal adhesions were examined. A true fast imaging with steady state precession sequence in transverse/sagittal orientation was used for a section-by-section dynamic depiction of visceral slide on a 1.5-Tesla system. After MRI, all patients underwent anew surgery. A nine-segment abdominal map was used to document the location and type of the adhesions. The intraoperative results were taken as standard of reference. Ninety patients were enrolled. During surgery 71 adhesions were detected, MRI depicted 68 intraabdominal adhesions. The most common type of adhesion in MRI was found between the anterior abdominal wall and small bowel loops (n = 22, 32.5%) and between small bowel loops and pelvic organs (n = 14, 20.6%). Comparing MRI with the intraoperative findings, sensitivity varied between 31 and 75% with a varying specificity between 65 and 92% in the different segments leading to an overall MRI accuracy of 89%. Functional cine MRI proved to be a useful examination technique for the identification of intraabdominal adhesions in patients with acute or chronic pain and corresponding clinical findings providing accurate results. However, no differentiation for symptomatic versus asymptomatic adhesions is possible.

PURPOSE:The aim of the study was to evaluate the diagnostic accuracy of multi-slice-computed tomography (MDCT) for the detection of vertebral metastases in comparison to magnetic resonance imaging (MRI).MATERIALS AND METHODS:In a retrospective analysis, 639 vertebral bodies of 41 patients with various histologically confirmed primary malignancies were analysed. The MDCT-images were acquired on a 16/64-row-MDCT scanner (Siemens Somatom Sensation 16/64). MRI was performed on 1.5 T scanners (SIEMENS Symphony/Sonata). The MDCT- and MRI-images were evaluated separately by two experienced radiologists in a consensus reading. The combination of MDCT and MRI in an expert reading including follow-up examinations and/or histology as well as clinical data served as the gold standard.RESULTS:201/639 vertebral bodies were defined as metastatically affected by the gold standard. In MDCT 133/201 lesions, in MRI 198/201 lesions were detected. 68 vertebral bodies were false negative in MDCT, whereas 3 false negatives were found in MRI. 3 false positive results were obtained in MDCT, 5 in MRI. Sensitivity was significantly lower for MDCT (66.2%) than for MRI (98.5%) (p<0.0001). Specificity was not significantly different for both methods (MDCT: 99.3%; MRI: 98.9%). The diagnostic accuracy resulted in 88.8% for MDCT and 98.7% for MRI.CONCLUSION:Although 16/64-row-MDCT provides excellent image quality and a high spatial resolution in the assessment of bony structures, metastatic lesions without significant bone destruction may be missed. The diagnostic accuracy of MRI proved to be significantly superior to 16/64-row-MDCT for the detection of osseous metastases.

OBJECTIVEThe purpose of our study was to compare the detection rate of bone manifestations of multiple myeloma in whole-body MRI compared with MDCT and to assess accuracy in staging.SUBJECTS AND METHODSForty-one patients with histologically confirmed myeloma were prospectively examined with a whole-body MDCT protocol and whole-body MRI on a 1.5-T system. The MRI protocol consisted of T1-weighted spin-echo and STIR sequences. For data analysis, the entire skeleton was divided into 61 regions per patient. Image evaluation was performed in a consensus reading by two radiologists blinded to the patients' history, with separate evaluation of each technique. The patients were staged by MRI and MDCT data separately according to the Durie and Salmon PLUS staging system.RESULTSOn MRI, 15 patients showed no involvement. In 26 patients, 975 regions were affected: 21 patients were stage I, two were stage II, and 18 were stage III. On MDCT, 19 patients showed no involvement. In 22 patients, 462 regions were affected. For the detection rate, MRI was statistically superior to MDCT (p < 0.001, Wilcoxon's signed rank test). According to MDCT, 25 patients were stage I, seven were stage II, and nine were stage III. In 21 patients with involvement detected on both methods, MRI showed more extensive disease than MDCT. Eleven patients were understaged with MDCT compared with MRI, which was statistically significant (p < 0.001, chi-square test).CONCLUSIONWhole-body MDCT leads to a significantly lower detection rate and staging in patients with multiple myeloma.

BACKGROUND:This study aimed to evaluate the accuracy of functional cine-MRI in detecting abdominal adhesions.METHODS:For this study, 89 consecutive patients with adhesion-related complaints after previous abdominal surgery underwent preoperative workup including cine-MRI in transverse and sagittal orientations for a dynamic examination of an induced visceral slide. An abdominal map consisting of nine segments was created to document the location and extent of the adhesion. Cine-MRI and intraoperative findings were correlated.RESULTS:A total of 59 laparotomies and 30 laparoscopies were performed. Four cases required open surgery due to severe adhesions. The use of cine-MRI scan for the detection of adhesions showed an overall accuracy of 90%, a sensitivity of 93%, and a positive predictive value of 96%. The stronger the adhesions, the more accurate the scan findings. Of 44 patients with second-degree MRI scan findings, 50% had second-degree intraoperative findings. Of 35 patients with third- and fourth-degree adhesions on MRI scans, 74% had exactly the same intraabdominal findings at surgery. The MRI scan showed adhesions located in the small intestines (75%), large intestines (35%), abdominal cavity (42%), and reproductive organs (32%). Intraoperatively, adhesions were found in the small intestines (70%), large intestines (40%), abdominal cavity (42%), and reproductive organs (28%).CONCLUSIONS:Cine-MRI provides valid preoperative information with respect to extent, location, and strength of intraabdominal adhesions. Cine-MRI is a good alternative for diagnosing abdominal adhesions because objective findings of the scan and intraoperative findings correlate very well with each other.

Objective: Trauma is the foremost cause of death in young patients. Not only the patient but also the family experience the consequences of trauma. Interactions of medical staff with family members in the emergency situation may fait psychological and emotional needs. In this context the concept of family presence (FP) during resuscitation is controversial. Therefore, the aim of this study was to analyse the attitude of trauma surgeons towards FP during trauma resuscitation.Materials and methods: A questionnaire concerning beliefs and attitudes towards FP during trauma resuscitation was mailed to level I trauma centres of the Trauma Network of the German Trauma Society (DGU). Statistical difference was determined by Rank-Sum test to analyse ordinal variables, for analysing three groups Kruskal-Wallis and Dunn's testing were used. Data are given in mean S.D. or absolute percentage.Results: The questionnaire was answered by 464 of 545 (85%) trauma surgeons between July 2005 and September 2005. One hundred and sixty seven surgeons (37.9%) already knew about FP, 349 (75.2%) considered it a relevant topic, but 232 (50%) would never allow FP during trauma resuscitation. One hundred and sixty eight surgeons (36.2%) had experience of FP during trauma resuscitation with positive results in 56%. Female respondents tend to be better informed about FP and would promote FP more supportively. Those women with experience with FP reported predominantly positive experiences (87% versus 50%, p < 0.001).Conclusions: Our study investigated the factors affecting physicians' opinions towards FP. Any institutional FP programme will have to address physician objections to be successful, by recommending a well-designed, carefully structured protocol with a designated specially trained staff member to offer the family support and the option of entering the resuscitation room with permission of the staff. (C) 2007 Elsevier Ireland Ltd. All rights reserved.

Colon motility disorders are a very common problem. A precise diagnosis with current methods is almost unachievable. This makes it extremely difficult for the clinical experts to decide for the right intervention such as colon resection. The use of cine MRI for visualizing the colon motility is a very promising technique. In addition, if image segmentation and qualitative motion analysis provide the necessary tools, it could provide the appropriate diagnostic solution. In this work we defined necessary steps in the image processing workflow to gain valuable measurements for a computer aided diagnosis of colon motility disorders. For each step, we developed methods to deal with the dynamic image data. There is need for compensating the breathing motion since no respiratory gating could be used. We segment the colon using a graph cuts approach in 2D and 3D for further analysis and visualization. The analysis of the large bowel motility is done by tracking the extension of the colon during a propagating peristaltic wave. The main objective of this work is to extract a motion model to define a clinical index that can be used in diagnosis of large bowel motility dysfunction. We aim at the classification and localization of such pathologies.

Rationale and Objectives. To evaluate the performance of a prototype computer-aided diagnosis (CAD) tool using artificial inteltigence techniques for the detection of pulmonary embolism (PE) and the possible benefit for general radiologists.Materials and Methods. Forty multidetector row computed tomography datasets (16/64- channel scanner) using 100 kVp, 100 mAs effective/slice, and 1-mm axial reformats in a low-frequency reconstruction kernel were evaluated. A total of 80 mL iodinated contrast material was injected at a flow rate of 5 mL/seconds. Primarily, six general radiologists marked any PE using a commercially available lung evaluation software with simultaneous, automatic processing by CAD in the background. An expert panel consisting of two chest radiologists analyzed all PE marks from the readers and CAD, also searching for additional finding primarily missed by both, forming the ground truth.Results. The ground truth consisted of 212 emboli. Of these, 65 (31%) were centrally and 147 (69%) were peripherally located. The readers detected 157/212 emboli (74%) leading to a sensitivity of 97% (63/65) for central and 70% (103/147) for peripheral emboli with 9 false-positive findings. CAD detected 168/212 emboli (79%), reaching a sensitivity of 74% for central (48/65) and 82%(120/147) for peripheral emboli. A total of 154 CAD candidates were considered as false positives. yielding an average of 3.85 false positives/case.Conclusions. The CAD software showed a sensitivity comparable to that of the general radiologists, but with more false positives. CAD detection of findings incremental to the radiologists suggests benefit when used as a second reader. Future versions of CAD have the potential to further increase clinical benefit by improving sensitivity and reducing false marks.

The aim of this pilot study was to evaluate a new, non-invasive examination method using MRI for the quantification of the colonic transit time after oral administration of gadolinium-saline solution filled capsules. Healthy volunteers without previous or acute symptoms of gastrointestinal disorders were enrolled. After a 3-day diet for the standardization of gastrocolonic content the volunteers swallowed five Gd-DTPA/saline 0.9%-filledcapsules. Seven different concentrations of Gd-DTPA/saline 0.9% solution between 1:0 and 0:1 were tested in a dilution series. Following ingestion of capsules, coronal Flash T1 and True Fisp sequences using a 1.5 Tesla system were obtained at 0 h, 3 h, 6 h, 12 h, 24 h, 36 h and 60 h. Sequences were analyzed by two independent experts for locating the capsules. Overall colonic transit time was separately analyzed for both genders. Fifteen healthy volunteers (7 females, 8 males; mean age 34 +/- 13 years) were enrolled. The phantom study provided the best contrast in both the T1-and T2-weighted sequences defining a ratio of 1:10 for Gd-DTPA/saline 0.9% solution. The mean transit time accounted for 41 +/- 9 h in women and for 31 +/- 10 h in men. MRI is an adequate method for the assessment of colonic transit time offering the advantages of no exposure to radiation, short examination time, possible dynamic evaluation of the transit and the practicability in terms of a future adoption to clinical routine.

The relation of heart rate and image quality in the depiction of coronary arteries, heart valves and myocardium was assessed on a dual-source computed tomography system (DSCT). Coronary CT angiography was performed on a DSCT (Somatom Definition, Siemens) with high concentration contrast media (Iopromide, Ultravist 370, Schering) in 24 patients with heart rates between 44 and 92 beats per minute. Images were reconstructed over the whole cardiac cycle in 10% steps. Two readers independently assessed the image quality with regard to the diagnostic evaluation of right and left coronary artery, heart valves and left ventricular myocardium for the assessment of vessel wall changes, coronary stenoses, valve morphology and function and ventricular function on a three point grading scale. The image quality ratings at the optimal reconstruction interval were 1.24±0.42 for the right and 1.09±0.27 for the left coronary artery. A reconstruction of diagnostic systolic and diastolic images is possible for a wide range of heart rates, allowing also a functional evaluation of valves and myocardium. Dual-source CT offers very robust diagnostic image quality in a wide range of heart rates. The high temporal resolution now also makes a functional evaluation of the heart valves and myocardium possible.

Chronic neck pain is widely prevalent and a common source of disability in the working-age population. Etiology of chronic neck pain includes neck sprain, mechanical or muscular neck pain, myofascial pain syndrome, postural neck pain as well as pain due to degenerative changes. We report the case of a 42 year old secretary, complaining about a longer history of neck pain and limited movement of the cervical spine. Surprisingly, the adequate radiologic examination revealed a bilateral ossification of the stylohyoid ligament complex. Her symptoms remained intractable from conservative treatment consisting of anti-inflammatory medication as well as physical therapy. Hence the patient was admitted to surgical resection of the ossified stylohyoid ligament complex. Afterwards she was free of any complaints and went back to work. Therefore, ossification of the stylohyoid ligament complex causing severe neck pain and movement disorder should be regarded as a rare differential diagnosis of occupational related neck pain.

Outcome of patients suffering from traumatic brain injury (TBI) depends on the development of secondary brain damage. In this context, recent studies underlined the role of the natriuretic peptides- atrial natriuretic peptide and brain natriuretic peptide (BNP)-in aneurysmatic subarachnoidal hemorrhage (SAH). Especially BNP correlates with intracranial pressure and clinical outcome after SAH. Since its role in TBI remains unclear, the intracranial and systemic concentrations of N-terminal (NT)-proBNP were analyzed in patients suffering from severe TBI. We measured NT-proBNP levels in cerebrospinal fluid (CSF) and serum of 14 patients suffering from severe TBI (GCS15 mm Hg (n=6), the serum (800+/-150 pg/mL) and CSF levels (55+/-9 pg/mL) of NT-proBNP were significantly increased after 24 h, as compared to patients with ICP15 mm Hg. Further studies are currently performed to elucidate the physiologic role of NT-proBNP in TBI.

Background: The neuroprotein S100 released into the circulation has been suggested as a reliable marker for primary brain damage. However, safe identification of relevant traumatic brain injury (TBI) may possibly be hampered by S100 release from peripheral tissue. The objective of this study was to measure early S100 levels using the Elecsys((R)) S100 immunoassay for real-time assessment of severe TBI in multiple trauma.Methods: Consecutively admitted multiple trauma patients (injury severity score >= 16 points) were stratified according to the results of the initial cerebral computed tomography (CCT) examination. S100 serum levels were determined at admission and at 6, 12, 24, 48 and 72 h after trauma. Data were correlated to creatine phosphokinase (CK) and lactate dehydrogenase (LDH) serum levels. Using receiver operating characteristic (ROC) analysis, the discriminating power of S100 measurement was calculated for the detection of CCT+ findings.Results: Median S100 levels of CCT+ patients (n=9; 37 years) decreased from 3.30 mu g/L at admission to 0.41 mu g/L 72 h after trauma. They revealed no significant differences to CCT- patients (n=18; 44 years), but remained elevated compared to controls. Median CK and LDH levels correlated with the corresponding S100 levels during the first 24 h after trauma. ROC analysis displayed a maximum area under the curve of only 0.653 at 12 h after trauma. No significant difference was calculated for the differentiation between CCT+ and CCT- patients.Conclusions: Measurements of S100 serum levels using the Elecsys((R)) S100 immunoassay are not reliable for the real-time detection of severe TBI in multiple trauma patients. Due to soft tissue trauma or bone fractures, S100 is mainly released from peripheral sources such as adipocytes or skeletal muscle cells.

Objectives: We sought to assess large bowel motility, induced by 2 prokinetic agents, senna tea and erythromycin, using functional cine magnetic resonance imaging (MRI).Materials and Methods: Twelve volunteers underwent functional cine MRI before and after the administration of senna tea or erythromycin. The protocol consisted of 2 sets of repeated measurements using coronal T2-weighted HASTE sequences, adjusted to the course of the colon. For the assessment of large bowel motility, the changes of the luminal diameter were measured at 5 defined locations in the ascending, transverse, and descending colon.Results: In all examined volunteers after senna tea, the mean number of significant changes in the ascending colon was 8.6 and after erythromycin, 7.2. In the transverse colon, 9.6 diameters changed significantly for senna tea and 7.2 for erythromycin. In the descending colon, 6.6 diameters changed after senna tea and 7.2 after erythromycin.Conclusion: Senna tea and erythromycin proved to induce large bowel motility; senna tea was more effective. Functional cine MRI is a reliable, noninvasive method for the assessment of colonic motility.