Three-dimensional assessment of patellofemoral anatomy: Reliability and reference ranges.

BACKGROUND: Three-dimensional (3D) imaging and analysis offer new possibilities in preoperative diagnostics and surgical planning. Simultaneous 3D analysis of the joint angles and the patellofemoral anatomy allow for a realistic assessment of bony pathologies in patients with patellofemoral complaints. This study aims to develop a standardized and validated assessment of the 3D patellofemoral morphology and to establish reference ranges. METHODS: Thirteen patellofemoral anatomic landmarks were defined on 3D bone models of the lower limbs based on computer tomography data and evaluated regarding inter- and intra-observer variability. Further, 60 3D models of the lower limbs of young subjects without any previous knee operation/injury were assessed and rescaled reference values for relevant patellofemoral indices were obtained. RESULTS: The mean inter- and intra-observer deviation of all landmarks was below 2.3 mm. The interobserver intraclass correlation coefficient (ICC) was between 0.8 and 1.0 and the intra-observer ICC between 0.68 and 0.99 for all patellofemoral parameters. The calculated reference ranges are: Insall-Salvati index 1.0-1.4; patella tilt 6-18°; patella shift -4 to 3 mm; patella facet angle 118-131°; sulcus angle 141-156°; trochlear depth 3-6 mm; tibial-tuberosity to trochlear groove distance(TT-TG) 2D 14-21 mm; TT-TG 3D 11-18 mm; lateral trochlear inclination 13-23°; trochlear facet angle 43-65°. CONCLUSION: The demonstrated 3D analysis of the patellofemoral anatomy can be performed with high inter- and intra-observer correlation. Applying the obtained reference ranges and using existing 3D assessment tools for lower limb alignment, a preoperative 3D analysis and planning for complex knee procedures now is possible.

[Recommendations for the perioperative use of dipyrone : Expert recommendation of the working group on acute pain of the German Pain Society, the scientific working group on pain medicine of the German Society for Anesthesiology and Intensive Care Medicine and the surgical working group on acute pain of the German Society for Surgery with participation of representatives of the Drug Commission of the German Medical Association]. / Empfehlungen zur perioperativen Anwendung von Metamizol : Expertenempfehlung des Arbeitskreises Akutschmerz der Deutschen Schmerzgesellschaft, des Wissenschaftlichen Arbeitskreises Schmerzmedizin der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin und der Chirurgischen Arbeitsgemeinschaft Akutschmerz der Deutschen Gesellschaft für Chirurgie unter Beteiligung von Vertretern der Arzneimittelkommission der deutschen Ärzteschaft.

BACKGROUND: Dipyrone (metamizole) is widely used for perioperative pain management in countries where it is marketed; however, uncertainty exists concerning the safe use of this drug, specifically considering the rare adverse event of an agranulocytosis. METHODS: As evidence from published studies was lacking, an expert panel developed recommendations for the perioperative use of dipyrone. After a formal, structured consensus process, the recommendations were approved by the involved medical societies. RESULTS: The panel agreed that blood cell counts shall not be standard for short-term perioperative use in patients unless they are at risk for neutropenia. The medical staff shall be aware of the symptoms and course of action when agranulocytosis is suspected. Patients shall be informed about the risks and benefits of dipyrone and about potential alternatives. The expert group concluded that dipyrone has a relatively positive risk-benefit ratio compared to other nonopioid analgesics. The group strongly recommended educating patients about the symptoms of agranulocytosis if they have received dipyrone over several days and/or treatment is to be continued after discharge, because agranulocytosis can occur several days after discontinuation of metamizole. Further recommendations refer to the information of the physician taking over the patient's care after discharge and the avoidance of re-exposure in patients having previously suffered from dipyrone-induced agranulocytosis. CONCLUSION: The group's recommendations shall be communicated in order to raise medical staff's and patients' awareness of the appropriate use of dipyrone in the perioperative period.

[Pharyngeal acid load and different functional endoscopy findings]. / Pharyngeale Säurebelastung bei unterschiedlichen Befunden der funktionellen Endoskopie.

The findings of functional endoscopy (upper esophageal sphincter insufficiency, cardia insufficiency, esophagitis, gastric heterotopia, axial sliding hernia, and visible aerosols) can be traced back to pharyngeal acid exposure by oropharyngeal pH measurement. Significantly increased pharyngeal acid loads are seen in gastric heterotopy and axial sliding hernia. For all measured statistics, the pharyngeal acid load is in the pathological or even very pathological range. The value of functional endoscopy in the context of laryngopharyngeal reflux diagnosis is clearly documented. The findings "heterotopic gastric mucosa" and "axial sliding hernia" may cause marked airway symptoms and a pathogenetic relationship with otorhinolaryngologic reflux-associated symptoms must be postulated for these entities.

[Recommendations for the perioperative use of dipyrone : Expert recommendation of the working group on acute pain of the German Pain Society, the scientific working group on pain medicine of the German Society for Anesthesiology and Intensive Care Medicine and the surgical working group on acute pain of the German Society for Surgery with participation of representatives of the Drug Commission of the German Medical Association]. / Empfehlungen zur perioperativen Anwendung von Metamizol : Expertenempfehlung des Arbeitskreises Akutschmerz der Deutschen Schmerzgesellschaft, des Wissenschaftlichen Arbeitskreises Schmerzmedizin der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin und der Chirurgischen Arbeitsgemeinschaft Akutschmerz der Deutschen Gesellschaft für Chirurgie unter Beteiligung von Vertretern der Arzneimittelkommission der deutschen Ärzteschaft.

BACKGROUND: Dipyrone (metamizole) is widely used for perioperative pain management in countries where it is marketed; however, uncertainty exists concerning the safe use of this drug, specifically considering the rare adverse event of an agranulocytosis. METHODS: As evidence from published studies was lacking, an expert panel developed recommendations for the perioperative use of dipyrone. After a formal, structured consensus process, the recommendations were approved by the involved medical societies. RESULTS: The panel agreed that blood cell counts shall not be standard for short-term perioperative use in patients unless they are at risk for neutropenia. The medical staff shall be aware of the symptoms and course of action when agranulocytosis is suspected. Patients shall be informed about the risks and benefits of dipyrone and about potential alternatives. The expert group concluded that dipyrone has a relatively positive risk-benefit ratio compared to other nonopioid analgesics. The group strongly recommended educating patients about the symptoms of agranulocytosis if they have received dipyrone over several days and/or treatment is to be continued after discharge, because agranulocytosis can occur several days after discontinuation of metamizole. Further recommendations refer to the information of the physician taking over the patient's care after discharge and the avoidance of re-exposure in patients having previously suffered from dipyrone-induced agranulocytosis. CONCLUSION: The group's recommendations shall be communicated in order to raise medical staff's and patients' awareness of the appropriate use of dipyrone in the perioperative period.

[Recommendations for the perioperative use of dipyrone : Expert recommendation of the working group on acute pain of the German Pain Society, the scientific working group on pain medicine of the German Society for Anesthesiology and Intensive Care Medicine and the surgical working group on acute pain of the German Society for Surgery with participation of representatives of the Drug Commission of the German Medical Association]. / Empfehlungen zur perioperativen Anwendung von Metamizol : Expertenempfehlung des Arbeitskreises Akutschmerz der Deutschen Schmerzgesellschaft, des Wissenschaftlichen Arbeitskreises Schmerzmedizin der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin und der Chirurgischen Arbeitsgemeinschaft Akutschmerz der Deutschen Gesellschaft für Chirurgie unter Beteiligung von Vertretern der Arzneimittelkommission der deutschen Ärzteschaft.

BACKGROUND: Dipyrone (metamizole) is widely used for perioperative pain management in countries where it is marketed; however, uncertainty exists concerning the safe use of this drug, specifically considering the rare adverse event of an agranulocytosis. METHODS: As evidence from published studies was lacking, an expert panel developed recommendations for the perioperative use of dipyrone. After a formal, structured consensus process, the recommendations were approved by the involved medical societies. RESULTS: The panel agreed that blood cell counts shall not be standard for short-term perioperative use in patients unless they are at risk for neutropenia. The medical staff shall be aware of the symptoms and course of action when agranulocytosis is suspected. Patients shall be informed about the risks and benefits of dipyrone and about potential alternatives. The expert group concluded that dipyrone has a relatively positive risk-benefit ratio compared to other nonopioid analgesics. The group strongly recommended educating patients about the symptoms of agranulocytosis if they have received dipyrone over several days and/or treatment is to be continued after discharge, because agranulocytosis can occur several days after discontinuation of metamizole. Further recommendations refer to the information of the physician taking over the patient's care after discharge and the avoidance of re-exposure in patients having previously suffered from dipyrone-induced agranulocytosis. CONCLUSION: The group's recommendations shall be communicated in order to raise medical staff's and patients' awareness of the appropriate use of dipyrone in the perioperative period.

Relationship between functional endoscopy and impedance-pH measurement.

Classic gastroenterological diagnostic tools have proven to be insufficient in identifying the causal relationship between extra-esophageal symptoms and presumed pathological reflux activity. Some new methodological approaches, such as functional endoscopy (video panendoscopy, VPE), are considered to be helpful. However, there are currently no data objectively verifying the success of this method. In a previous study, we found a good correlation between the reflux symptom index (RSI) according to Belafsky and endoscopic findings. Impedance-pH measurement is considered to be the gold standard in esophageal reflux disease diagnostics. Therefore, the relationship between endoscopic findings and the results of impedance-pH monitoring is now studied in patients with extra-esophageal reflux symptoms. The pathological findings of the VPE correlate with impedance-pH measurements regarding the parameters "number of reflux episodes," "fraction time," and "DeMeester score."

[Relationship between functional endoscopy and impedance-pH measurement. German version]. / Beziehung zwischen Funktionsendoskopie und Impedanz-pH-Metrie.

Classic gastroenterological diagnostic tools are proving increasingly insufficient for analyzing the complex causal relationship between extra-esophageal symptoms and presumed pathological reflux activity. Some new methodological approaches, such as functional endoscopy (videopanendoscopy, VPE), are considered to be helpful. However, there are currently no data objectively verifying the usefulness of this method. In a pilot study, a good correlation between the reflux symptom index (RSI) and endoscopic findings was shown. Impedance-pH measurement is considered to be the "gold standard" in esophageal reflux disease diagnostics. Therefore, the relationship between endoscopic findings and the results of impedance-pH monitoring are now studied in patients with extra-esophageal reflux symptoms. The investigation demonstrates that the pathological findings of VPE correlate well with impedance-pH measurements in terms of the parameters "number of reflux episodes", "fraction time", and "DeMeester score".

Pull-out stability of anchors for rotator cuff repair is also increased by bio-absorbable augmentation: a cadaver study.

INTRODUCTION: Osteoporosis is a highly focused issue in current scientific research and clinical treatment. Especially in rotator cuff repair, the low bone quality of patients suffering from osteoporosis is an important issue. In this context, non-biological solutions using PMMA for anchor augmentation have been developed in the recent past. The aim of this study was to evaluate whether augmentation of suture anchors using bio-absorbable osteoconductive fiber-reinforced calcium phosphate results in improved failure load of suture anchors as well. MATERIALS AND METHODS: Altogether 24 suture anchors (Corkscrew FT 1 Suture Anchors, Arthrex, Naples, FL, USA) were evaluated by applying traction until pullout in 12 paired fresh frozen human cadaver humeri using a servo-hydraulic testing machine. Inclusion criteria were an age of more than 64 years, a macroscopically intact RC and an intact bone. The anchors were evaluated at the anterolateral and posteromedial aspect of the greater tuberosity. 12 suture anchors were augmented and 12 suture anchors were conventionally inserted. RESULTS: The failure load was significantly enhanced by 66.8 % by the augmentation method. The fiber-reinforced calcium phosphate could be easily injected and applied. CONCLUSION: The bio-absorbable cement in this study could be a promising augmentation material for RC reconstructions, but further research is necessary-the material has to be evaluated in vivo.

Long-term effects of fundoplication in children with chronic airway diseases.

BACKGROUND: Association between chronic airway diseases (CAD) and gastroesophageal reflux disease (GERD) is well described, but causality has not yet been conclusively established. This study evaluates the therapeutic significance of laparoscopic Thal fundoplication in children with CAD and diagnosed GERD. METHODS: We performed a retrospective analysis of 182 neurologically nonimpaired children, all with medically refractory CAD and GERD undergoing laparoscopic Thal fundoplication. The clinical response, ability to wean oral and inhaled medication and satisfaction with postoperative results were evaluated. RESULTS: Main symptoms disappeared completely in 68.7% of patients and were markedly improved in a further 22% of patients following surgery. Complete discontinuation of medication was achieved in 70.1-96.4% of cases and reduced in a further 1.8-23.5%. One intraoperative complication occurred (gastric perforation), however no conversion to laparotomy was necessary. Postoperative Dumping Syndrome occurred in 1% of cases and was managed dietetically. Prolonged postoperative dysphagia occurred in 4.3% of patients, but disappeared within 8 weeks in all but one case. CONCLUSIONS: Our study suggests that Thal fundoplication in neurologically nonimpaired children with CAD and documented GERD is effective and safe. Children unresponsive to preoperative medical management showed significant improvement in airway symptoms together with a marked reduction in the need for medication. We conclude that laparoscopic Thal fundoplication represents a significant treatment worthy of consideration in this group of patients.

[Importance of functional endoscopy for diagnostics of extraesophageal reflux : relationship of Belafsky's reflux symptom index and functional endoscopic data]. / Stellenwert der Funktionsendoskopie für die Diagnostik des extraösophagealen Refluxes : Beziehung des Reflux-Symptom-Index zu funktionsendoskopischen Daten.

BACKGROUND: Extraesophageal reflux exists as shown by scientific data. The underlying pathophysiology is not yet exactly known. Functional endoscopy seems to be a promising new diagnostic instrument. This study determined the relationship between functional endoscopy and Belafsky's reflux symptom index (RSI). METHODS: In this study 71 patients were prospectively included and underwent a functional endoscopic examination followed by 6 months of proton pump inhibitor (PPI) therapy. Symptoms were scored using Belafsky's RSI after endoscopic examination (before treatment) and after 3 and 6 months of PPI therapy. RESULTS: After 3 and 6 months of PPI-therapy significant decreases in the RSI were found. The functional endoscopy characteristics which were expected to remain constant were controlled after 6 months and found to be nearly 100 % reproducible. Patients profit from PPI- therapy when reflux is detected by endoscopy even when RSI was initally normal. Functional endoscopy seems to be a useful instrument to detect extraesophageal reflux.

[Traumatic elbow dislocations in bouldering]. / Ellenbogenluxationsverletzungen beim Trendsport Bouldern.

Bouldering is a new trend sport which has become popular in recent years. From April 2011 to June 2012 a total of 5 patients with elbow dislocations from bouldering were admitted to our level 1 trauma center. The injuries varied from simple elbow dislocations to complex fracture dislocations. Elbow dislocations occurred during falling backwards when patients tried to protect themselves by retroversion of both arms. In all cases the falling height was less than 4 meters. The bouldering injury pattern, the diagnostic and therapeutic management as well as the rehabilitation program are described in detail in this article. To the best of our knowledge this is the first report on the special danger of bouldering for complex elbow injuries.

[Arthroscopy-assisted management of wrist fractures]. / Arthroskopisch unterstützte Frakturversorgung am Handgelenk.

Distal radius fractures are the most common fractures in humans and early surgical intervention with modern plating systems is becoming increasingly more established to avoid secondary dislocation. Even fractures with slight dislocations are adequately stabilized and the affinity for surgical intervention and plating procedures is applied to secure these simple fractures. In this aspect the surgical indications are significantly dependent on X-ray examination results. Further diagnostics with respect to ligamentous and soft tissue injury are the exception although the impact energy which creates osseus fractures is sufficient by far to destroy functional soft tissue, cartilage and ligaments. The ongoing development of wrist arthroscopy enables new possibilities especially concerning concomitant articular involvement of distal radius fractures. Arthroscopy-assisted reduction and stabilization as well as minimally invasive soft tissue repair and loose body removal seem to be adequate methods to improve the surgical treatment of distal radius fractures.

Pacemaker placement and shoulder surgery: is there a risk?

INTRODUCTION: Surgery to the anterior aspect of the shoulder is performed by many surgical specialties but the techniques used by our cardiology colleagues for insertion of cardiac pacemaker wires are often not appreciated by the surgical community. The deltopectoral approach has been used for open pacemaker wire insertion for many years by cardiologists. METHODS: We surveyed a group of subspecialty shoulder surgeons as well as orthopaedic trainees to see if this approach for pacemakers is well recognised. We tried to assess what level of knowledge exists regarding pacemaker placement in general as well as specific risks. RESULTS: There appears to be a paucity of knowledge regarding pacemaker placement and related patient safety issues in both surveyed groups. There was no difference between the two groups, suggesting that the level of knowledge does not increase with experience and specialisation. CONCLUSIONS: There is the potential to cause harm to patients if the insertion site and type of device is not identified before commencing surgery in this region and steps must be taken to minimise any intra-operative risk. There is a risk from direct injury to the pacemaker and/or leads as well as the hazards of using diathermy in close proximity to a pacemaker. There must be more widespread dissemination of this information in order to minimise risks to patients with pacemakers in situ.

[Gastroesophageal reflux diseases in childhood. Diagnosis and therapy]. / Extraösophageale Refluxerkrankungen bei Kindern. Diagnostik und Therapie.

Gastroesophageal reflux diseases represent a diagnostic challenge, not least since no single diagnostic procedure has been able to establish a causal link between pathological reflux and chronic upper and lower airway diseases. By combining a variety of procedures which point to a link (multi-channel pH measurement, impedance measurement of the esophagus, video panendoscopy, bronchoalveolar lavage, and quantification of lipid-laden alveolar macrophages) and careful differential and exclusion diagnoses, reflux-related diseases can be diagnosed with sufficient precision. In addition to initially successful PPI therapy, surgical intervention (hemifundoplication) is the method of choice in children.

Human BRCA1-associated breast cancer: no increase in numerical chromosomal instability compared to sporadic tumors.

BRCA1 is a major gatekeeper of genomic stability. Acting in multiple central processes like double-strand break repair, centrosome replication, and checkpoint control, BRCA1 participates in maintaining genomic integrity and protects the cell against genomic instability. Chromosomal instability (CIN) as part of genomic instability is an inherent characteristic of most solid tumors and is also involved in breast cancer development. In this study, we determined the extent of CIN in 32 breast cancer tumors of women with a BRCA1 germline mutation compared to 62 unselected breast cancers. We applied fluorescence in situ hybridization (FISH) with centromere-specific probes for the chromosomes 1, 7, 8, 10, 17, and X and locus-specific probes for 3q27 (BCL6), 5p15.2 (D5S23), 5q31 (EGR1), 10q23.3 (PTEN), and 14q32 (IGH@) on formalin-fixed paraffin-embedded tissue microarray sections. Our hypothesis of an increased level of CIN in BRCA1-associated breast cancer could not be confirmed by this approach. Surprisingly, we detected no significant difference in the extent of CIN in BRCA1-mutated versus sporadic tumors. The only exception was the CIN value for chromosome 1. Here, the extent of CIN was slightly higher in the group of sporadic tumors.

[Dice test--a simple method for assessment of visual acuity in infants with visual deficits]. / Würfel-Test--eine einfache Methode zur Visusbestimmung bei Sehbehinderung im Kleinkindalter.

PURPOSE: Determination of visual acuity in low vision infants or patients with additional cerebral retardation is difficult. In our low vision department we used dice of different sizes and colors as well as other defined objects to determine visual acuity (VA). In this study we compared the results of the dice test with conventional tests for measurement of visual acuity. METHODS: A total of 88 children with different causes of visual impairment e.g. albinism, retinal scars, retinopathy of prematurity (ROP), achromatopsia and optic atrophy etc., were included in this longitudinal study. Median follow-up time was 8.7 years (range 2.9-18.9 years). The first reliable examination was performed between the ages of 4 and 24 months (median 11 months). We estimated VA depending on the edge length of the dice, which were recognized at a distance of 30 cm, while 4 mm complied with VA 20/200. Best corrected binocular visual acuity was compared between the dice test, measurement with the Lea symbols and with numbers or Landolt rings. RESULTS: Estimation of visual acuity using the dice test was possible at the end of the first year of life (median 11 months, range 4-27 months). Although observation is limited to visual acuity results in the low vision range between light reaction and 20/120 there was nearly complete agreement between all three VA measurements. Visual acuity ranged from light perception to 20/20 with a median of 20/100. In 39 patients visual acuity was 20/200 or less at the end of the observation period. Visual acuity estimation overestimated visual acuity only in 5 out of the 88 patients, while in all of the patients with later acuity measurements better than 20/200, our best value of 20/200 was achieved. CONCLUSIONS: Using simple visual objects, such as dice with different colors and size down to an edge length of 4 mm, it is possible to estimate visual acuity in low vision infants within the first year of life. This option is also very helpful in patients who are not able to perform other visual acuity measurements or to give reliable answers using preferential looking, such as severely handicapped patients. In contrast to preferential looking with this dice test there is not only judgment of the reaction by the observer but also activity of the patient who grips the dice he can really see. This allows better counseling of families with low vision infants concerning current and later visual functions.

[Beyond staging, typing and grading. New challenges in breast cancer pathology]. / Jenseits von Staging, Typing und Grading. Herausforderungen und Perspektiven für die Tumorpathologie der Mamma.

Tumor biological parameters for the prediction and prognosis of invasive breast cancer are gaining in importance compared to traditional pathological categories. The immunohistochemically determined steroid hormone receptor status is not only the decisive factor influencing whether endocrine therapy (which is indicated in cases of even slight expression) is given or not, but also whether chemotherapy is considered. The Her2 status is of similar importance and needs to be analysed in every case of invasive carcinoma, whereby reproducibility, which requires greater efforts than with steroid hormone receptors, has to be assured. Probably only a small portion of breast cancers will benefit from chemotherapy. Since traditional pathological categories are not sufficient for the identification of this subgroup, there has been an intense search for alternative prognostic parameters, whereby gene expression profiling has emerged as the most promising tool. Despite minimal concordance with regard to single genes, the various profiles available converge in the identification of the proliferative signature as the prognostically most relevant. Whether histopathological grading and immunohistochemical determination of the growth fraction with Ki-67 or genetic profiling will be more reliable in the identification of the aggressive subtype has yet to be clarified in clinical studies which encompass central pathological review.

[BRCA1- and BRCA2- associated breast carcinomas]. / BRCA1- und BRCA2-assoziierte Mammakarzinome.

Breast cancers with a genetic BRCA1-/BRCA2 background differ from each other and sporadic cases. A specific pathological surrogate marker, however, does not exist. In this study the results of a German reference centre are reported. BRCA1 associated cancers are predominantly high grade (G3), triple negative, highly proliferative (median Ki-67 55%) and only exceptionally accompanied by lobular intraepithelial neoplasia. Cancers with a BRCA2 germ line mutation are less frequent and resemble sporadic cases with a comparably higher proliferative activity and a lack of Her2 overexpression.

Dynamic ultrasound assessment in the diagnosis of intra-articular entrapment of the biceps tendon (hourglass biceps): A preliminary investigation.

BACKGROUND: The hourglass biceps, an intra-articular entrapment of the long head of the biceps (LHB), is a possible diagnosis in cases of shoulder pain associated with loss of passive elevation. PURPOSE: The objective of this study is to investigate the role of dynamic ultrasound (U/S) in determining the diagnosis of the hourglass biceps lesion. MATERIALS AND METHODS: A prospective cohort of 16 patients with the clinical suspicion of an hourglass lesion, a preoperative ultrasound, and a confirmed hourglass LHB at surgery, were included in the study. Eight patients had preoperative dynamic ultrasound assessment of the LHB, and eight had standard ultrasound investigations and served as a control group. RESULTS: Dynamic ultrasound accurately diagnosed an hourglass biceps in three out of eight cases. LHB hypertrophy was demonstrated in five out of eight cases with U/S and three out of eight cases with standard U/S. All patients were treated by excision of the intra-articular portion of the LHB, 15 by bipolar tenotomy, and one by LHB tenodesis. CONCLUSIONS: Dynamic ultrasound shows promise in improving the accuracy in diagnosis of LHB hypertrophy and the Hourglass lesion. LEVEL OF EVIDENCE: III (Consecutive case-control study investigating a diagnostic test).