title: Dynamic Contrast-Enhanced Sonography and Dynamic Contrast-Enhanced Magnetic Resonance Imaging for Preoperative Diagnosis of Infected Nonunions.
abstract: Bone regeneration depends on perfusion of the fracture tissue, whereby hypervascularity is associated with infection, which itself causes nonunions. To date, nonunion perfusion has not been assessed with contrast-enhanced sonography. The aim of this study was to evaluate the potential of contrast-enhanced sonography in the analysis of nonunion tissue perfusion.
  
  
  
  Nonunion vascularity of 31 patients before revision surgery was prospectively examined with qualitative contrast-enhanced sonography and dynamic contrast-enhanced magnetic resonance imaging (MRI). Time-intensity curves from 2-minute contrast-enhanced sonographic video clips were generated, and parameters such as wash-in rate, rise time, and peak enhancement were quantified. On dynamic contrast-enhanced MRI, the initial area under the enhancement curve was quantified. Preoperative radiographs, computed tomograms, the clinical nonunion score, laboratory infection features, as well as contrast-enhanced sonographic and dynamic contrast-enhanced MRI perfusion were correlated with microbiological results from the nonunion tissue.
  
  
  
  Both qualitative and quantitative contrast-enhanced sonography showed significant differences between infected and aseptic nonunions (P = .015 and .020). The qualitative dynamic contrast-enhanced MRI analysis was not significant (P= .244), but after quantification, a strong correlation (P = .007) with microbiological results was noted. A receiver operating characteristic analysis calculated ideal cutoff values for quantitative contrast-enhanced sonography and dynamic contrast-enhanced MRI so that their combination detected infected nonunions with sensitivity and specificity of 88.9% and 77.3%, respectively. Clinical, radiologic, and laboratory examinations did not correlate with microbiological results (P > .05).
  
  
  
  Contrast-enhanced sonography can visualize the vascularity of nonunions in real time, while quantification software allows for a semiobjective evaluation of bone perfusion. The correlations of both quantitative contrast-enhanced sonography and dynamic contrast-enhanced MRI with microbiological results show their high value for differentiation of infected from aseptic nonunions.
authors.affiliation: Center for Orthopedics, Trauma Surgery, and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany. christian.fischer@med.uni-heidelberg.de.
authors.forename: Christian
authors.initials: C
authors.lastname: Fischer
authors.affiliation: Center for Orthopedics, Trauma Surgery, and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: Eva-Maria
authors.initials: EM
authors.lastname: Preuss
authors.affiliation: Center for Orthopedics, Trauma Surgery, and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: Michael
authors.initials: M
authors.lastname: Tanner
authors.affiliation: Institute of Medical Biometry and Informatics, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Bruckner
authors.affiliation: Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Krix
authors.affiliation: Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: Erick
authors.initials: E
authors.lastname: Amarteifio
authors.affiliation: Center for Orthopedics, Trauma Surgery, and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: Matthias
authors.initials: M
authors.lastname: Miska
authors.affiliation: Center for Orthopedics, Trauma Surgery, and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: Arash
authors.initials: A
authors.lastname: Moghaddam-Alvandi
authors.affiliation: Center for Orthopedics, Trauma Surgery, and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: Gerhard
authors.initials: G
authors.lastname: Schmidmaier
authors.affiliation: Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: Marc-André
authors.initials: MA
authors.lastname: Weber
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001424:Bacterial Infections / Q000150:complications / Q000000981:diagnostic imaging*; D003287:Contrast Media; D005260:Female; D050723:Fractures, Bone / Q000000981:diagnostic imaging* / Q000382:microbiology; D006801:Humans; D007089:Image Enhancement / Q000379:methods*; D007090:Image Interpretation, Computer-Assisted / Q000379:methods; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011300:Preoperative Care / Q000379:methods*; D011446:Prospective Studies; D012372:ROC Curve; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D014463:Ultrasonography / Q000379:methods*; D055815:Young Adult
chemical_list: D003287:Contrast Media
keywords: contrast-enhanced sonography; dynamic contrast-enhanced magnetic resonance imaging; infection; musculoskeletal ultrasound; nonunion; perfusion; quantification