Authors: Persson, Jan | Peters, Sören | Haddadin, Simon | O'Loughlin, Padhraig F. | Krettek, Christian | Gaulke, Ralph
Article Type: Research Article
Abstract: OBJECTIVE: The current retrospective case-control study examines the prognostic value of radiologic parameters for long-term clinical outcome assessment after a calcaneus fracture. METHODS: In the authors' trauma department 262 adult patients with an isolated calcaneus fracture were treated from 1995 to 2005. Using conventional x-ray and computed tomography imaging. the calcaneal fractures were classified according to Sanders system. In addition, Boehler's and Gissane's angles were measured before and after therapy and the Larsen stage of subtalar arthrosis was determined. After a mean follow-up interval of 9.5 years, 44 patients were available for clinical and radiological assessment. RESULTS: At the time …of trauma the average age of the study group was 52 (range, 29-79) years. Thirty-seven patients were treated operatively and seven conservatively. Patients with a negative Boehler's angle, upon admission, exhibited significantly worse results using four of the five clinical scoring systems than patients with a preserved or slight reduced Boehler's angle. Operative treatment in patients whose Boehler's angle was elevated to normal range or beyond exhibited %worse better results than patients with an over-correction of Boehler's angle. In 11 cases, two primary and nine secondary subtalar arthrodeses were performed. The degree of subtalar arthrosis as per Larsen was increased 2.54 ± 1.14 in the course of hospital admission, arthrodesis and/or follow up examination. The results show no significant difference between operative and conservative treatment. CONCLUSIONS: Boehler's angle at time of admission appears to be a valuable prognosticator for functional long-term results after calcaneus fracture. An operative over-correction of a reduced Boehler's angle should be avoided. Show more
Keywords: Calcaneus fracture, long-term outcome, radiologic parameters, Boehler's angle, Gissane's angle
DOI: 10.3233/THC-140890
Citation: Technology and Health Care, vol. 23, no. 3, pp. 285-298, 2015
Authors: Stübig, Timo | Zeckey, Christian | Min, William | Citak, Musa | Krettek, Christian | Hüfner, Tobias | Gaulke, Ralph
Article Type: Research Article
Abstract: Background: Patient tracking helps improve workflow, decrease wait times, optimize costs, and enhance medical treatment in the outpatient setting. In that regard, real-time patient tracking may serve as a potential way to perform efficient patient care. In recent years, the increasing popularity of wireless local area networks (WLANs) has led to a growing number of devices utilizing wireless fidelity (WiFi) networks. This application has been used in various industries to enhance management processes. In that regard, we believe that this technology may enhance patient tracking, as the existing WLAN architecture in many clinics may allow for real-time tracking of patients. …However, current literature regarding the clinical applicability of these devices is sparse. The aim of this study is to analyze the developmental process and feasibility of our protytope model for real-time patient tracking, using WLAN in the outpatient setting of our Level I Trauma center. Methods: We performed the study in various stages. First, we analyzed our current patient workflow, and then devised a study protocol and prototype model that implemented both this workflow schematic and our current technology infrastructure. Second, we implemented our prototype model to determine the accuracy, feasibility, and safety of data transmission in our clinical setting. The factors examined during prototype implementation included the accuracy of patient localization and the time spent by each patient in the various areas of our clinic (as determined by patient tracking). Results: In our outpatient clinic, our prototype was capable of localizing and automating patient data with excellent accuracy and security. Conclusions: WLAN-based real-time patient localization systems can help overcome a number of common challenges and inefficiencies seen in the outpatient clinics. Real-time localization systems using WLAN technology performed adequately and safely in this pilot study. We believe that this will eventually lead to lower costs overall due to the improvements in efficiency. While the initial investment costs may be high, implemeting this system in a pre-existing WLAN and WiFi infrastructure should help minimize the start-up costs. Show more
Keywords: Patient tracking, WLAN, RTLS
DOI: 10.3233/THC-2012-0681
Citation: Technology and Health Care, vol. 20, no. 4, pp. 317-327, 2012
Authors: Gaulke, Ralph | Oszwald, Markus | Liodakis, Emmanouil | Stüber, Volker | Bachmann, Sören | Krettek, Christian
Article Type: Research Article
Abstract: The purpose of this prospective randomized comparative biomechanical study on four pairs of human cadaveric forearms was to discern whether primary stability following plate arthrodesis differs from the position of the screws. Four wrists were randomly assigned to either group such that one wrist of each pair was fixed via parallel screws and the other via an oblique screw crossing the radius and the lunate. Under fluoroscopic guidance, passive extension and flexion of each wrist was performed using a spring balance. Traction force increased by 5 N at each step, ranging from 0 N to a maximum of 100 N. …Fixation using a plate and oblique screw demonstrated lower recoverable deformation of the implant and a higher primary stability at the fusion site than parallel screws. The current investigators conclude that an oblique screw crossing radius and lunate increase primary stability which is consistent with the radiological results of comparable clinical trails. Show more
Keywords: Radiolunate arthrodesis, wrist biomechanics, implant loosening, cadaveric study
DOI: 10.3233/THC-2012-0671
Citation: Technology and Health Care, vol. 20, no. 3, pp. 225-232, 2012
Authors: Liodakis, Emmanouil | Liodaki, Eirini | Krettek, Christian | Citak, Musa | Gaulke, Ralph | Konstantinidis, Loukas | Kenawey, Mohamed
Article Type: Research Article
Abstract: Introduction: The importance of the vitality of a nonunion is crucial for the planning of the reconstructive procedure. Purpose of the present study is to analyze the role of single photon emission computed tomography (SPECT) in diagnosing and planning the treatment of atrophic nonunions in the upper and lower extremity. Patients and Methods: This study examined retrospectively the SPECT/CT scans of 10 patients (mean age = 44.5 ± 16.5 years, 9 males/1 female, 4 tibia/4 femur/1 radius/1 fibula) who underwent surgical exploration for suspected avital pseudarthrosis. Surgical and histopathological findings were compared with the radiologists' findings to assess the sensitivity …and specificity of SPECT in diagnosing avital nonunions. The average interval from the osteosynthesis until their SPECT scan was 18 months. All surgical findings have been documented electronically in the hospital computer system. Results of the radiologist's reading were then compared with surgical exploration and histopathological findings and specifity and sensitivity was calculated. Results: There were 4 vital and 6 nonvital pseudarthroses. SPECT scans identified all the vital pseudarthroses and 3 of the 6 nonvital pseudarthroses. The sensitivity of SPECT in diagnosing non-vital atrophic nonunions is 50% and the specifity 100%. Conclusions: SPECT/CT scan is a test with a low sensitivity but good specificity that excludes infection and confirms nonviability of the nonunion site. However, we shall wait for larger pool of research results in order to incorporate this test in routine clinical use. Show more
Keywords: Pseudarthrosis, vitality, SPECT/CT
DOI: 10.3233/THC-2011-0617
Citation: Technology and Health Care, vol. 19, no. 2, pp. 103-108, 2011
Authors: Citak, Musa | Koulalis, Dimitrios | Haentjes, Jonas | Suero, Eduardo M. | Gaulke, Ralph | Krettek, Christian | Hüfner, Tobias
Article Type: Research Article
Abstract: Introduction: In a complete dislocation of the talus, the talus is stripped of all its ligament connections in the triple articulated ankle joint. This case report describes the treatment and the 3-year follow-up of a complete dislocation of the talus with the use of intraoperative 3D imaging. Patients and methods: The 19-year-old patient was involved as a driver in a car accident. After the radiological diagnosis of a complete talus dislocation, an emergency operation was performed due to the critical soft tissue condition. The ISO-C3D fluoroscope from the company Siemens (Erlangen, Germany) was utilized for reduction control. Results: Follow-up evaluations …were completed three years after the treatment, the patient had no complaints. Discussion: Since these types of serious injuries are always combined with severe soft tissue damage, the main goals of this treatment have to be debridement and minimized iatrogenic surgical damage. By using intraoperative 3D imaging, immediate reduction control is available, so that revision operations can be avoided. Conclusion: Complete dislocation of the talus is an extremely rare injury, which may cause serious complications. A fast and careful reduction, whether open or closed, should be the goal of treatment. Successful reduction can be determined intraoperatively with the use of 3D imaging. Show more
Keywords: Complete dislocation, talus, 3D fluoroscopy, imaging, CAS
DOI: 10.3233/THC-2010-0574
Citation: Technology and Health Care, vol. 18, no. 2, pp. 123-128, 2010
Authors: Gaulke, Ralph | O'Loughlin, Padhraig F. | Kendoff, Daniel | Oszwald, Markus | Hildebrand, Frank | Krettek, Christian
Article Type: Research Article
Abstract: Purpose: Traditional surgical techniques for radiolunate arthrodesis typically result in an unsatisfactory primary stability. Thus cast immobilisation is implemented until bone healing is complete. Nonunion and implant dislocation are frequent complications. Methods: Eighteen patients (20 wrists) with rheumatoid disease who had undergone a radiolunate arthrodesis procedure using a mini-titanium-T-plate with an oblique screw were examined. The high primary stability of this fusion depends on three point fixation. Results: Complete bone healing was achieved in all wrists. Dislocation of a screw occurred in one wrist which subsequently healed in mild dislocation. Grip strength improved in 12 hands with pain relief in …19 wrists. 18 patients rated the result of the operation as “very good” or “good” and would agree to have the operation again. Conclusion: The mini-titanium-T-plate with oblique screw achieves high primary stability via three point fixation of the lunate at the radius. Thus, postoperative immobilisation in a cast is unnecessary. The procedure is well tolerated by patients with a high satisfaction rating. Show more
Keywords: Radiocarpal arthrodesis, radiolunate arthrodesis, radiolunate nonunion, rheumatoid arthritis, rheumatoid wrist instability
DOI: 10.3233/THC-2009-0555
Citation: Technology and Health Care, vol. 17, no. 4, pp. 345-351, 2009
Authors: Oszwald, Markus | Westphal, Ralf | Bredow, Jan | Gaulke, Ralph | O'Loughlin, P.F. | Huefner, Tobias | Wahl, Friedrich | Krettek, Christian | Goesling, Thomas
Article Type: Research Article
Abstract: The main problems in intra-medullary nailing of femoral shaft-fractures are leg-length discrepancies and rotational differences with an incidence of 2–18% and 20–40% respectively. These may lead to severe postoperative sequelae such as additional correctional operations and difficult rehabilitation. Insufficient visualization can be considered the main reason for these complications. Finally, retention of the fragments in the correct alignment before nail insertion is difficult. To overcome these problems we established a robotic telemanipulator system to support the reduction process. It was evaluated in 30 fractures of embalmed human femora. Specially programmed software used an image-dataset which was acquired by an isocentric …3D fluoroscope. For visualization, a surface projection was generated. Localization and tracking of the fragments and the robot-arm as well as accuracy measurement was performed by using an optical navigation system. Manipulation was controlled via a force-feedback joystick. This way, collisions of the fragments were transmitted back to the surgeon. At the end of the reduction the robot could rigidly retain the fragments' position. Show more
DOI: 10.3233/THC-2009-0544
Citation: Technology and Health Care, vol. 17, no. 4, pp. 337-343, 2009
Authors: Oszwald, Markus | Westphal, Ralf | Calafi, Afshin | Stier, Rebecca | Müller, Christian W. | Gaulke, Ralph | Wahl, Friedrich | Krettek, Christian | Gösling, Thomas
Article Type: Research Article
Abstract: Fractures of the femoral bone are frequent injuries with a wide range of affected individuals. New treatment strategies and technologies are being explored permanently. Their quality is biomechanically judged by the accuracy of the anatomical reduction. Malalignment of the fragments would have an eminent impact on the overall outcome and rehabilitation. To establish a method for investigations of the reduction results of femoral fractures, we developed a model, using a navigation system for taking measurement. The dynamic reference bases (DRBs) where mounted to the intact femoral bone and registered as the reference position. A special construction allowed removal and reattachment …of the DRBs without provoking change in the DRB-bone system. The model was evaluated in it's constancy. Translational deviations remained below 0.9 mm and rotational deviations below 0.3° after 40 repetitive reattachments. The model could prove to be valid and reliable. An application in long-bone trauma research is reasonable. Show more
Keywords: Fracture model, femur, fracture reduction, navigation, robustness
DOI: 10.3233/THC-2010-0597
Citation: Technology and Health Care, vol. 18, no. 6, pp. 387-391, 2010
Authors: Oszwald, Markus | Westphal, Ralf | Klepzig, Daniel | Khalafi, Afshin | Gaulke, Ralph | Müller, Christian W. | Wahl, Friedrich | Krettek, Christian | Gösling, Thomas
Article Type: Research Article
Abstract: Introduction: The insertion site for an antegrade femoral intramedullary nail in the treatment of a femoral shaft fracture has traditionally been performed using a free-hand technique. An inappropriate starting point can result in suboptimal nail insertion leading to malreduction, or iatrogenic fracture. Furthermore, repeated attempts to establishthe optimal starting point cancause additional soft tissue trauma and radiation exposure. In the following study we compared a robot-guided technique with the standard free-hand technique for establishing the entry point of an antegrade femoral nail. We hypothesized that the robot-guided technique is more reliable and efficient. Methods: A custom-made drill-guide was mounted onto …the arm of an industrial robot. Two orthogonal fluoroscopic images were acquired from the proximal femur of five cadaveric human specimens. Images were processed with a specialsoftwarein order to create an enhanced contour-recognition map from which the bone axes were automatically calculated. The drilling trajectory was computed along the extension of the bone-axis. The robot then moved the drill-guide on this trajectory toward the entry point. The drilling was then performed by the surgeon. In the control group, five cadaveric human femora were utilized to manually establish the starting pointusing the free-hand technique. Results: 100% of the intramedullary cavities were successfully accessed with both the robot-guided and the manual techniques. In the manual technique repositioning of the drill was necessary in three out of five cases. The mean number of acquired fluoroscopic images was significantly reduced from 11.6 (manual) to 4 (robot-guided). Conclusion: Robot-assisted drilling ofthe entry-point in antegrade femoral nailingis more reliable and requires fewer radiographic images than the free hand technique. Yet, based on economical and logistical considerations, its application will probably only be accepted when a concomitant application for fracture reduction is available. Show more
DOI: 10.3233/THC-2010-0580
Citation: Technology and Health Care, vol. 18, no. 3, pp. 173-180, 2010
Authors: Oszwald, Markus | Westphal, Ralf | Klepzig, Daniel | Stier, Rebecca | Gaulke, Ralph | Calafi, Afshin | Müller, Christian W. | Wahl, Friedrich | Krettek, Christian | Gösling, Thomas
Article Type: Research Article
Abstract: Introduction: Intramedullary nailing has become the gold standard in the treatment of femoral shaft fractures. This procedure involves the placement of distal interlocking bolts using the freehand technique. Accurate placement of distal interlocks can be a challenging task, especially in inexperienced hands. Misplacement of distal interlocking bolts can lead to iatrogenic fracture, instability of the bone-implant construct, or even malalignment of the extremity. Repeated drilling attempts increase radiation exposure and can cause additional bony and soft tissue trauma. We hypothesize that robot-guided placement of distal interlocks is more accurate, precise, and efficient than the freehand technique. Methods: A custom-designed drill …guide was mounted onto the arm of an industrial robot. We developed a special device to secure a generic block (Synbone, Malans, Switzerland) into which an intramedullary nail could be inserted in a standardized way. A metric scale allowed later measurements of the drillings. Digital images were taken from each side of the block for analysis of the drilling trajectories. The fluoroscope was adjusted to obtain perfect circles of the distal interlocking holes. The number of images necessary to achieve this was recorded. The axis was recognized automatically by using the differences in contrast between the matrix of the generic bone and the implant (intramedullary nail). The drill trajectories were then computed. The robot with the mounted drill-guide automatically moved onto the calculated trajectory. The surgeon then executed the drilling. We performed 40 robot assisted drillings in generic blocks. Freehand drilling served as our control group. Results: Analysis of the digital images revealed a mean deviation of 0.94 mm and 2.7° off the ideal trajectory using robotic assistance. In 100% of the cases (n=40), the distal locking hole was hit. A mean of 8.8 images was acquired. After manual drilling, 92.5% of the distal interlocks were hit. A mean deviation of 3.66 mm and 10.36° was measured. A mean of 23.4 fluoroscopic images were needed. The differences between the two methods were statistically significant. Conclusion: Robot-guided drilling increases the accuracy and precision of distal interlocking while reducing irradiation. Considering economical and logistical aspects, this application should be integrated with robot-guided fracture reduction. Show more
DOI: 10.3233/THC-2010-0596
Citation: Technology and Health Care, vol. 18, no. 4-5, pp. 325-334, 2010