M Tingart

University Hospital RWTH Aachen, Aachen, North Rhine-Westphalia, Germany

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Publications (178)175.71 Total impact

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    ABSTRACT: Objective To evaluate the usefulness of quantitative parameters obtained by optical coherence tomography (OCT) and magnetic resonance imaging (MRI) in the comprehensive assessment of human articular cartilage degeneration. Materials and methods Human osteochondral samples of variable degeneration (n = 45) were obtained from total knee replacements and assessed by MRI sequences measuring T1, T1ρ, T2 and T2* relaxivity and by OCT-based quantification of irregularity (OII, optical irregularity index), homogeneity (OHI, optical homogeneity index]) and attenuation (OAI, optical attenuation index]). Samples were also assessed macroscopically (Outerbridge classification) and histologically (Mankin classification) as grade-0 (Mankin scores 0–4)/grade-I (scores 5–8)/grade-II (scores 9–10)/grade-III (score 11–14). After data normalisation, differences between Mankin grades and correlations between imaging parameters were assessed using ANOVA and Tukey’s post-hoc test and Spearman’s correlation coefficients, respectively. Sensitivities and specificities in the detection of Mankin grade-0 were calculated. Results Significant degeneration-related increases were found for T2 and OII and decreases for OAI, while T1, T1ρ, T2* or OHI did not reveal significant changes in relation to degeneration. A number of significant correlations between imaging parameters and histological (sub)scores were found, in particular for T2 and OII. Sensitivities and specificities in the detection of Mankin grade-0 were highest for OHI/T1 and OII/T1ρ, respectively. Conclusion Quantitative OCT and MRI techniques seem to complement each other in the comprehensive assessment of cartilage degeneration. Sufficiently large structural and compositional changes in the extracellular matrix may thus be parameterized and quantified, while the detection of early degeneration remains challenging.
    No preview · Article · Jan 2016 · Skeletal Radiology
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    ABSTRACT: Introduction: The treatment of adult non-traumatic avascular necrosis of the femoral head (AVN; N-ANFH) within an estimated incidence of 5000-7000 cases per annum in Germany remains a challenge. Risk factors include steroids, alcohol abuse, chemotherapy and immunosuppressive medication, but a genetic predisposition has been suggested. Early diagnosis of this often bilateral disease process is essential for successful conservative or joint preserving surgical management. In this review, we present the update German consensus S3 guideline "diagnosis and management for N-ANFH" as a concise summary. Materials and methods: This systematic review is based on the published literature from January 1, 1970 to April 31, 2013 (German and English language). Inclusion criteria were systematic reviews, meta-analyses and relevant peer review publications. We identified a total of 3715 related publications, of which 422 were suitable according to the SIGN criteria, but only 159 fulfilled our inclusion criteria. Results and conclusions: Clinical suspicion of N-ANFH mandates radiographic evaluation. If radiographs are normal MRI scans are recommended, which should be evaluated according to the ARCO-classification. Differential diagnoses include transient osteoporosis, bone bruise, insufficiency fracture and destructive arthropathy. Untreated, subchondral fractures commonly occur within 2 years, during which the risk for contralateral involvement is high-thereafter unlikely. Conservative management with Ilomedin and Alendronat can be tried, but other pharmacological or physical treatments are inappropriate. No specific joint preserving procedure can be recommended, but core decompression should be considered in early stages if necrosis is <30 %. In ARCO stages IIIc or IV total hip arthroplasty (THA) should be contemplated, which offers similar outcome compared to osteoarthritis. Young age is the main risk factor for higher revision rates after THA for N-ANFH.
    No preview · Article · Dec 2015 · Archives of Orthopaedic and Trauma Surgery
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    ABSTRACT: Optical Coherence Tomography (OCT) is an imaging technique that allows the surface and subsurface evaluation of semitransparent tissues by generating microscopic cross-sectional images in real time, to millimetre depths and at micrometre resolutions. As the differentiation of cartilage degeneration remains diagnostically challenging to standard imaging modalities, an OCT- and MRI-compatible indentation device for the assessment of cartilage functional properties was developed and validated in the present study. After describing the system design and performing its comprehensive validation, macroscopically intact human cartilage samples (n=5) were indented under control of displacement (δ1=202µm; δ2=405µm; δ3=607µm; δ4=810µm) and simultaneous OCT imaging through a transparent indenter piston in direct contact with the sample; thus, 3-D OCT datasets from surface and subsurface areas were obtained. OCT-based evaluation of loading-induced changes included qualitative assessment of image morphology and signal characteristics. For inter-method cross referencing, the device׳s compatibility with MRI as well as qualitative morphology changes under analogous indentation loading conditions were evaluated by a series of T2 weighted gradient echo sequences. Cartilage thickness measurements were performed using the needle-probe technique prior to OCT and MRI imaging, and subsequently referenced to sample thickness as determined by MRI and histology. Dynamic indentation testing was performed to determine Young׳s modulus for biomechanical reference purposes. Distinct differences in sample thickness as well as corresponding strains were found; however, no significant differences in cartilage thickness were found between the used techniques. Qualitative assessment of OCT and MRI images revealed either distinct or absent sample-specific patterns of morphological changes in relation to indentation loading. For OCT, the tissue area underneath the indenter piston could be qualitatively assessed and displayed in multiple reconstructions, while for MRI, T2 signal characteristics indicated the presence of water and related tissue pressurisation within the sample. In conclusion, the present indentation device has been developed, constructed and validated for qualitative assessment of human cartilage and its response to loading by OCT and MRI. Thereby, it may provide the basis for future quantitative approaches that measure loading-induced deformations within the tissue to generate maps of local tissue properties as well as investigate their relation to degeneration.
    No preview · Article · Dec 2015 · Journal of the Mechanical Behavior of Biomedical Materials
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    Preview · Article · Oct 2015 · Der Orthopäde
  • M Betsch · M Wild · B Rath · M Tingart · A Schulze · V Quack
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    ABSTRACT: Background: Scoliosis is a complex three-dimensional deformity of the spine, which usually occurs during childhood and adolescence. Up to now, whole spine X-rays have been the therapeutic gold standard in the diagnosis and follow-up of scoliosis. Aim: This review gives a brief overview of the history, technical background and possible fields of use for video-rasterstereography METHODS: Alternative measurement systems have been developed over the past few years for the treatment of scoliosis, because of the risk of radiation exposure of X-rays. The rasterstereographic system Formetric (Diers International GmbH, Schlagenbad) allows a radiation-free, three-dimensional analysis of the back surface and the spine. Outlook: Even dynamic measurements can now be conducted with this rasterstereographic system, which will help to further understand and analyze the human spine.
    No preview · Article · Sep 2015 · Der Orthopäde
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    ABSTRACT: Early diagnosis and treatment of cartilage degeneration is of high clinical interest. Loss of surface integrity is considered one of the earliest and most reliable signs of degeneration, but cannot currently be evaluated objectively. Optical Coherence Tomography (OCT) is an arthroscopically available light-based non-destructive real-time imaging technology that allows imaging at micrometre resolutions to millimetre depths. As OCT-based surface evaluation standards remain to be defined, the present study investigated the diagnostic potential of 3D surface profile parameters in the comprehensive evaluation of cartilage degeneration. To this end, 45 cartilage samples of different degenerative grades were obtained from total knee replacements (2 males, 10 females; mean age 63.8 years), cut to standard size and imaged using a spectral-domain OCT device (Thorlabs, Germany). 3D OCT datasets of 8 × 8, 4 × 4 and 1 × 1 mm (width × length) were obtained and pre-processed (image adjustments, morphological filtering). Subsequent automated surface identification algorithms were used to obtain the 3D primary profiles, which were then filtered and processed using established algorithms employing ISO standards. The 3D surface profile thus obtained was used to calculate a set of 21 3D surface profile parameters, i.e. height (e.g. Sa), functional (e.g. Sk), hybrid (e.g. Sdq) and segmentation-related parameters (e.g. Spd). Samples underwent reference histological assessment according to the Degenerative Joint Disease classification. Statistical analyses included calculation of Spearman's rho and assessment of inter-group differences using the Kruskal Wallis test. Overall, the majority of 3D surface profile parameters revealed significant degeneration-dependent differences and correlations with the exception of severe end-stage degeneration and were of distinct diagnostic value in the assessment of surface integrity. None of the 3D surface profile parameters investigated were capable of reliably differentiating healthy from early-degenerative cartilage, while scan area sizes considerably affected parameter values. In conclusion, cartilage surface integrity may be adequately assessed by 3D surface profile parameters, which should be used in combination for the comprehensive and thorough evaluation and overall improved diagnostic performance. OCT- and image-based surface assessment could become a valuable adjunct tool to standard arthroscopy.
    No preview · Article · Sep 2015 · Physics in Medicine and Biology
  • V Quack · B Rath · H Schenker · A Schulze · Y El Mansy · M Tingart · M Betsch
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    ABSTRACT: Scoliosis is a complex, three-dimensional spinal deformity with various causes. Adolescent idiopathic scoliosis (AIS) is the most common form. Surgical treatment is indicated for curves greater than 45-50° meaured using the Cobb method. We can distinguish among posterior, anterior or combined surgical procedures. Today, the posterior, transpedicular approach has revolutionized scoliosis surgery. This review gives an overview of current surgical options in scoliosis treatment.
    No preview · Article · Sep 2015 · Der Orthopäde
  • A Schulze · S Schrading · M Betsch · V Quack · M Tingart
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    ABSTRACT: Scoliosis affects up to 6 % of the population. The resulting spine deformity, the increasing risk of back pain, cosmetic aspects, pulmonary disorders if the Cobb angle is > 80°, and the progress of the deformity to > 50° after the end of growth indicate non-operative or operative therapy. In daily clinical practice, the classifications of scoliosis allow the therapy to be adapted. Classifications consider deformity, topography of the scoliosis, and the age at diagnosis. This publication gives an overview of the relevant and most common classifications in the treatment of adolescent scoliosis. For evaluation, the deformity measurement on the coronary radiographic projection of the total spine (Cobb angle) is relevant to therapy. The classification of topography, form, and the sagittal profile of the deformity of the spine are useful for preoperative planning of the fusion level. Classifications that take into account the age at the time of the diagnosis of scoliosis differentiate among early onset scoliosis (younger than 10 years of age), adolescent scoliosis (up to the end of growth), and adult scoliosis. Early onset scoliosis is subdivided by age and etiology. Therapy is derived from the classification of clinical and radiological findings. Classifications that take into account clinical and radiological parameters are essential components of modern scoliosis therapy.
    No preview · Article · Sep 2015 · Der Orthopäde
  • U Maus · A Roth · M Tingart · C Rader · M Jäger · U Nöth · S Reppenhagen · C Heiss · J Beckmann
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    ABSTRACT: The present article describes the guidelines for the surgical treatment of atraumatic avascular necrosis (aFKN). These include joint preserving and joint replacement procedures. As part of the targeted literature, 43 publications were included and evaluated to assess the surgical treatment. According to the GRADE and SIGN criteria level of evidence (LoE), grade of recommendation (EC) and expert consensus (EK) were listed for each statement and question. The analysed studies have shown that up to ARCO stage III, joint-preserving surgery can be performed. A particular joint-preserving surgery currently cannot be recommended as preferred method. The selection of the method depends on the extent of necrosis. Core decompression performed in stage ARCO I (reversible early stage) or stage ARCO II (irreversible early stage) with medial or central necrosis with an area of less than 30 % of the femoral head shows better results than conservative therapy. In ARCO stage III with infraction of the femoral head, the core decompression can be used for a short-term pain relief. For ARCO stage IIIC or stage IV core decompression should not be performed. In these cases, the indication for implantation of a total hip replacement should be checked. Additional therapeutic procedures (e.g., osteotomies) and innovative treatment options (advanced core decompression, autologous bone marrow, bone grafting, etc.) can be discussed in the individual case. In elective hip replacement complications and revision rates have been clearly declining for decades. In the case of an underlying aFKN, however, previous joint-preserving surgery (osteotomies and grafts in particular) can complicate the implantation of a THA significantly. However, the implant life seems to be dependent on the aetiology. Higher revision rates for avascular necrosis are particularly expected in sickle cell disease, Gaucher disease, or kidney transplantation patients. Furthermore, the relatively young age of the patient with avascular necrosis should be seen as the main risk factor for higher revision rate. The results after resurfacing (today with known restricted indications) and cemented as well as cementless THA in aFKN are comparable for the appropriate indication to those in coxarthrosis or other diagnoses. Regardless of the underlying disease endoprosthetic treatment in aFKN leads to good results. Both cemented and cementless fixation techniques can be recommended. Georg Thieme Verlag KG Stuttgart · New York.
    No preview · Article · Aug 2015 · Zeitschrift fur Orthopadie und Unfallchirurgie
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    ABSTRACT: Background: In Germany there are 5000 to 7000 new cases of atraumatic avascular necrosis of the femoral head in adults per year. It occurs mostly in middle age. An increased frequency of idiopathic cases can be observed. Chemotherapy, corticoids and kidney transplants are frequently associated with the disease. In most cases the disease occurs on both sides. Early diagnosis is of particular importance, since in early stages it is most likely to avoid late damage with joint destruction. Whereas previously the temporary operational joint preservation and subsequent joint replacement were often the only option of treatment, conservative and joint-preserving measures today play an increasing role. Material and Methods: After the AWMF guidelines for S3 guideline clinical questions were formulated. Over the period from 01/01/1970 to 31/05/2013 a literature search was conducted. Systematic reviews, metaanalyses, original papers and clinical trials of all designs were evaluated. There were a total of 3715 references, of which 422 for the assessment regarding SIGN were eligible and finally 180 were in accord with the defined inclusion and exclusion criteria. For the untreated course and the assessment of conservative measures, a total of 42 references was suitable. In formulating the recommendations the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system was used, which distinguishes A "shall", B "should" and 0 "can". Results and Conclusion: If left untreated, the aFKN within 2 years leads to a subchondral fracture and subsequent collapse. After the diagnosis of femoral head necrosis, the risk of a disease of the opposite side is high within the next 2 years, then unlikely. The sole conservative treatment brings no benefit for the treatment of atraumatic avascular necrosis in the adult. Although it improves function, less pain can be obtained, and surgical intervention can be delayed, the progression is not stopped. Conservative treatment must therefore always be part of the overall treatment. In ARCO stage I to II Iloprost may be considered as a pharmacological approach to reduce the pain and the bone marrow oedema. This also applies to alendronate. Since this is an off-label use, and thus a therapeutic trial, an appropriate patient education must take place. For the use of anticoagulants and statins, there is no recommendation. Also the hyperbaric oxygen therapy, shock waves and pulsating electromagnetic fields or electrical stimulation cannot be recommended. Georg Thieme Verlag KG Stuttgart · New York.
    No preview · Article · Aug 2015 · Zeitschrift fur Orthopadie und Unfallchirurgie
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    ABSTRACT: Posttraumatic osteoarthritis constitutes a major cause of disability in our increasingly elderly population. Unfortunately, current imaging modalities are too insensitive to detect early degenerative changes of this disease. Optical coherence tomography (OCT) is a promising nondestructive imaging technique that allows surface and subsurface imaging of cartilage, at near-histological resolution, and is principally applicable in vivo during arthroscopy. Thirty-four macroscopically normal human cartilage-bone samples obtained from total joint replacements were subjected to standardized single impacts in vitro (range: 0.25 J to 0.98 J). 3D OCT measurements of impact area and adjacent tissue were performed prior to impaction, directly after impaction, and 1, 4, and 8 days later. OCT images were assessed qualitatively (DJD classification) and quantitatively using established parameters ( OII, Optical Irregularity Index; OHI, Optical Homogeneity Index; OAI, Optical Attenuation Index ) and compared to corresponding histological sections. While OAI and OHI scores were not significantly changed in response to low- or moderate-impact energies, high-impact energies significantly increased mean DJD grades (histology and OCT) and OII scores. In conclusion, OCT-based parameterization and quantification are able to reliably detect loss of cartilage surface integrity after high-energy traumatic insults and hold potential to be used for clinical screening of early osteoarthritis.
    Full-text · Article · Aug 2015
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    ABSTRACT: Introduction: The aim of multidisciplinary rehabilitation after total knee replacement (TKA) is to reduce postoperative complications and costs and enable faster convalescence. The goals of fast-track rehabilitation, as a multidisciplinary concept, are to reduce the length of hospital stay and achieve early functional improvements by optimizing the perioperative setting. Method: A literature review was carried out for the years 1960-2013. The search terms were: "rehabilitation", "training", "physiotherapy", "physical therapy", "recovery", "exercise program", "knee surgery", "TKA", "total knee replacement", "arthroplasty", "intensive", "multidisciplinary", "accelerated", "rapid" or "fast track". Only randomized controlled trials and metaanalyses were included. A survey was also performed to assess care as actually offered in orthopaedic rehabilitation clinics in North Rhine-Westphalia. Results: A total of 729 articles were identified of which 11 studies were included. Fast-track rehabilitation can significantly reduce both the duration of hospital stay and costs after TKA. Current studies showed that a better short-/middle-term clinical outcome might be achieved with multidisciplinary rehabilitation. However, a difference in the long-term outcome could not be observed. Our survey shows that most patients are admitted to a rehabilitation clinic in a state of poor general condition as well as decreased mobility and knee range of motion. Conclusions: Fast-track rehabilitation facilitates a shortened hospital stay as well as cost saving. It probably can be used to optimize the condition of the patient before admission to a rehabilitation facility. © Georg Thieme Verlag KG Stuttgart · New York.
    No preview · Article · Aug 2015 · Die Rehabilitation
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    ABSTRACT: Loss of articular cartilage surface integrity is considered the earliest sign of osteoarthritis; however, its reliable detection has not been established by clinical routine diagnostics. This study comprehensively assesses a set of 11 algorithm-based 2-D Optical Coherence Tomography roughness parameters and investigates their clinical impact. Histology and manual irregularity quantification of 105 human cartilage samples with variable degeneration served as reference. The majority of parameters revealed a close-to-linear correlation with the entire spectrum of degeneration. Surface integrity should therefore be assessed by a combination of parameters to improve current diagnostic accuracy in the determination of cartilage degeneration.
    No preview · Article · Jul 2015 · Biomedical Optics Express

  • No preview · Article · Apr 2015 · Zeitschrift fur Orthopadie und Unfallchirurgie

  • No preview · Article · Apr 2015 · Zeitschrift fur Orthopadie und Unfallchirurgie
  • V Quack · M Betsch · H Schenker · J Beckmann · B Rath · C Lüring · M Tingart
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    ABSTRACT: Morphologically, bone marrow edema (BME) is an accumulation of fluid in the bone marrow. The BME is per se non-specific but can be identified at an early stage with magnetic resonance imaging (MRI). The underlying pathomechanism remains unclear. The BME can occur as an individual entity and as an accompanying condition of many diseases. The BME can be divided into three groups, ischemic, reactive and mechanical BME. Mechanical BME occurs after trauma or repetitive strain. Typical histological changes are present and there is no clear boundary between edema and microfracture. Some forms of trauma show BME in typical localizations. Both the trauma and the possible accompanying injuries can be indirectly indicated in this way in cases with an unknown trauma mechanism. The BME can be present as an isolated entity or as a comorbidity. For initiation of therapy, a comprehensive medical history and targeted diagnostics are indispensable. In some cases BME is indicative of the trauma mechanism and possible further accompanying injuries.
    No preview · Article · Mar 2015 · Der Unfallchirurg
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    ABSTRACT: Optical Coherence Tomography (OCT) is an evolving imaging technology allowing non-destructive imaging of cartilage tissue at near-histological resolution. This study investigated the diagnostic value of real time 3-D OCT in comparison to conventional 2-D OCT in the comprehensive grading of human cartilage degeneration. Fifty-three human osteochondral samples were obtained from eight total knee arthroplasties. OCT imaging was performed by either obtaining a single two-dimensional cross-sectional image (2-D OCT) or by collecting 100 consecutive parallel 2-D OCT images to generate a volumetric data set of 8 mm X 8 mm (3-D OCT). OCT images were assessed qualitatively according to a modified version of the DJD classification and quantitatively by algorithm-based evaluation of surface irregularity, tissue homogeneity and signal attenuation. Samples were also graded by Outerbridge and statistically analysed by one-way ANOVA, Kruskal Wallis and Tukey's or Dunn's post hoc tests. Overall, the generation of 3-D volumetric datasets and their multiple reconstructions such as rendering, surface topography, parametric and cross-sectional views proved to be of potential diagnostic value. With increasing distance to the mid-sagittal plane and increasing degeneration, score deviations increased, too. In conclusion, 3-D imaging of cartilage with image analysis algorithms adds considerable potential diagnostic value to conventional OCT diagnostics. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
    Full-text · Article · Jan 2015 · Journal of Orthopaedic Research
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    ABSTRACT: A consideration of the patient-specific biomechanical situation in the context of the surgical planning of total hip arthroplasty is highly recommended and may have a positive impact on the therapeutic outcome. In current clinical practice, surgical planning is based on the status of the individual hip and its radiographic appearance. Several authors proposed different biomechanical modeling approaches for the calculation of the resultant hip force R on the basis of parameters gathered from plain radiography. The comparative study presented in this paper shows that the biomechanical models by Pauwels, Debrunner, Blumentritt and Iglič provide a good approximation of the magnitude of R when compared to the in vivo data from instrumented prostheses. In contrast, the Blumentritt model resulted in abnormally high values. However, the computational results for the orientation of R show a high variability of all modeling approaches and seem to depend more on the model used than on patient-specific parameters. Georg Thieme Verlag KG Stuttgart · New York.
    Full-text · Article · Dec 2014 · Zeitschrift fur Orthopadie und Unfallchirurgie
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    ABSTRACT: Spondylodiscitis is a rare disease which is associated with high mortality. No guidelines for treatment exist and the available studies are not homogeneous. Attempts have been made in recent years to structure therapy using algorithms. Early recognition of the disease is above all important for its later outcome. Therapy takes place in not only orthopaedic/trauma surgery clinics but also in neurosurgical clinics. We sent an online survey on this subject to orthopaedic clinics, trauma surgery and neurosurgery clinics in Germany. The aim was to ascertain current care strategies in Germany. A further objective was to elicit differences between the specialist fields. A total of 164 clinics responded to the survey. The response rate was 16 % of the orthopaedic/trauma surgery clinics and 32 % of the neurosurgical clinics. Differences between the two specialist fields can be found particularly in the use of systemic and local antibiotics, in the choice of surgical access to the thoracic spine and the lumbar spine and in post-operative imaging. In both specialist fields, patients with neurological dysfunctions are treated primarily in clinics with high case numbers. In terms of surgery, 2/3 of the responding clinics choose a one-stage operative treatment. Minimally invasive procedures and the use of cages are widespread. The participants estimate that, on the whole, a better outcome and higher patient satisfaction tend to exist after operative treatment. The lack of homogeneity regarding treatment strategies which is indicated here clearly shows the need for therapy guidelines as an aid to orientation. This will be a challenge for the future due to the low incidence and the situation regarding currently available studies. Georg Thieme Verlag KG Stuttgart · New York.
    No preview · Article · Dec 2014 · Zeitschrift fur Orthopadie und Unfallchirurgie
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    ABSTRACT: Optical Coherence Tomography (OCT) yields microscopic cross-sectional images of cartilage in real time and at high resolution. As yet, comprehensive grading of degenerative cartilage changes based on OCT has rarely been performed. This study investigated the potential of quantitative OCT using algorithm-based image parameters such as irregularity (OII – Optical Irregularity Index), homogeneity (OHI – Optical Homogeneity Index) and attenuation (OAI – Optical Attenuation Index) in the objective grading of cartilage degeneration. Therefore, OCT was used to image and assess 113 human osteochondral samples obtained from total knee replacements. Processing included the analysis of OII (by calculation of the standard deviation with regards to a fitted surface), of OHI (by edge detection of tissue signal changes) and of OAI (by analysis of relative imaging depth). Additionally, samples were subject to macroscopic (Outerbridge grading), biomechanical (elastic stiffness), qualitative OCT and histological evaluation (Modified Mankin grading). Significant correlations were found between all outcome measures. OII and OHI were effective in assessing cartilage surface, integrity and homogeneity, while OAI could discriminate between unmineralized and mineralized cartilage, respectively. Therefore, quantitative OCT holds potential as a diagnostic tool for more reliable, standardized and objective assessment of cartilage tissue properties. © 2014 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res
    Full-text · Article · Oct 2014 · Journal of Orthopaedic Research

Publication Stats

2k Citations
175.71 Total Impact Points

Institutions

  • 2011-2016
    • University Hospital RWTH Aachen
      • Department of Orthodontics
      Aachen, North Rhine-Westphalia, Germany
  • 2011-2015
    • RWTH Aachen University
      Aachen, North Rhine-Westphalia, Germany
  • 2004-2014
    • Universität Regensburg
      • Department of Orthopaedics
      Ratisbon, Bavaria, Germany
  • 2012-2013
    • University Hospital Regensburg
      • Klinik und Poliklinik für Innere Medizin I
      Ratisbon, Bavaria, Germany
  • 2007
    • University of Wuerzburg
      Würzburg, Bavaria, Germany
  • 2006
    • Asklepios Klinikum Bad Abbach
      Abach, Bavaria, Germany
  • 2002-2004
    • Orthopädische Universitätsklinik Friedrichsheim
      Frankfurt, Hesse, Germany
  • 2001
    • Harvard University
      Cambridge, Massachusetts, United States
  • 1999
    • University of Cologne
      • Center for Experimental Medicine
      Köln, North Rhine-Westphalia, Germany