General, spinal or regional anaesthesia does not affect strength performance 6 months after ACL reconstruction.

PURPOSE: The recovery of strength is a key element in successfully returning to sports after ACL reconstruction. The type of anaesthesia has been suspected an influential factor in the post-operative recovery of muscle function. METHODS: In this retrospective analysis, n = 442 consecutive patients undergoing primary isolated ACL reconstruction using a hamstring autograft were analysed by pre- and post-operative isokinetic tests in a single orthopaedic centre. These were subdivided into four cohorts: (1) general anaesthesia (n = 47), (2) general anaesthesia with prolonged (48 h) on-demand femoral nerve block (n = 37), (3) spinal anaesthesia (n = 169) and (4) spinal anaesthesia with prolonged (48 h) on-demand femoral nerve block (n = 185). Primary outcome was the change from pre- to post-operative isokinetic strength during knee extension and flexion. RESULTS: Using one-way ANOVA, there was no significant influence of the type of anaesthesia. The main effect of anaesthesia on change in extension forces was not significant, and effect sizes were very small (n.s.). Similarly, the main effect of anaesthesia on change in flexion forces was statistically not significant (n.s.). CONCLUSIONS: The findings of this study support the interpretation that the type of anaesthesia has no significant effect on the ability to recover thigh muscle strength 6 months after isolated hamstring ACL reconstruction. With regard to the recovery of athletic performance and return-to-sports testing criteria, there is no reason to avoid regional anaesthesia. LEVEL OF EVIDENCE: III.

Relationship between pre- and post-operative isokinetic strength after ACL reconstruction using hamstring autograft.

BACKGROUND: Anterior cruciate ligament (ACL) ruptures are of major concern in sports. As mostly young and active individuals are affected there is an emphasis on the rapid and safe return to sports (RTS). Strengthening the ventral and dorsal thigh muscles is a prerequisite for a successful RTS after ACL reconstruction (ACLR), as persistent muscle weakness may increase the incidence for secondary injuries and impair performance. Aiming to increase evidence on the importance of preoperative muscle strength and the coaching of patients, the purpose of this study is to compare thigh muscle strength pre- and post-operatively after ACLR. METHODS: We performed a retrospective analysis of 80 patients with primary, isolated ACLR using a four-stranded hamstring autograft. We performed bilateral isokinetic concentric strength measurement (60°/s) before and six months after ACLR. Primary outcomes were the maximal knee extension and flexion torque, hamstrings-to-quadriceps ratio (H/Q ratio) and the corresponding limb symmetry indices (LSI). Pearson correlations were calculated for pre- and post-surgical values. RESULTS: The operated as well as the unaffected leg increased maximal knee extension (+ 18% ± 7% p < 0.05; + 11% ± 5% p < 0.05) and flexion torque (+ 9% ± 5% p < 0.05, + 10% ± 6% p < 0.05) throughout the 6 months of rehabilitation. The H/Q ratio remained unaffected (- 2% ± 3% p = 0.93; - 4% ± 4% p = 0.27). LSI of knee extension strength increased significantly (6% ± 3% p < 0.05), while flexion strength remained unaffected (+ 2% ± 4% p = 0.27). Positive correlations underline the interrelationship between the strength pre- and post-surgery for the knee extension (r = 0.788 p < 0.05) and knee flexion strength (r = 0.637 p < 0.05) after ACLR. CONCLUSIONS: Preoperative leg extension and flexion strength normalized to body mass are strongly correlated to postoperative strength performance after ACLR. Therefore, pre-operative quadriceps and hamstring muscle strength deficits may have a significant negative impact on functional performance following ACLR. This emphasizes the need for intensive preoperative screening and subsequent treatment to achieve the best possible preoperative leg strength before ACLR. TRIAL REGISTRATION: DRKS00020210 .

The effect of meniscal repair on strength deficits 6 months after ACL reconstruction.

INTRODUCTION: Ruptures of the anterior cruciate ligament (ACL) can be accompanied by meniscal lesions. Generally, the rehabilitation protocols are altered by meniscal repair. Therefore, the aim of this study was to investigate the effect of meniscal repair on the early recovery of thigh muscle strength in ACL reconstruction (ACLR). MATERIALS AND METHODS: We performed a matched cohort analysis of n = 122 isolated ACLR (CON) compared to n = 61 ACLR with meniscal repair (ACLR + MR). The subgroups of meniscal repair consisted of 30 patients who had undergone medial meniscus repairs (MM), 19 lateral meniscus repairs (LM) and 12 repairs of medial and lateral meniscus (BM). Isokinetic strength measurement was performed pre-operatively and 6 months post-surgery to perform a cross-sectional and a longitudinal analysis. All injuries were unilateral, and the outcome measures were compared to the non-affected contralateral leg. RESULTS: Six months postoperatively overall there is no significant difference between the groups (extension strength MR 82% vs. CON 85% and flexion strength 86% vs. 88%, resp.). Subgroup analysis showed that medial repairs exhibit a comparable leg symmetry while lateral repairs performed worse with leg symmetry being 76% in extension and 81% in flexion strength. Patients undergoing BM repair performed in between lateral and medial repairs (82% extension, 86% flexion). CONCLUSION: Generally, meniscal repair in conjunction with ACLR does not significantly alter the recovery of limb symmetry in strength at 6 months postoperatively. Interestingly, medial repairs seem to perform superior to lateral meniscal repair and repair of both menisci. Since the recovery of symmetric strength is a major factor in rehabilitation testing, these results will help to advise surgeons on appropriate rehabilitation protocols and setting realistic goals for the injured athlete. LEVEL OF EVIDENCE: III, retrospective cohort study.

[Sports activities after osteotomies around the knee]. / Sportfähigkeit nach kniegelenknaher Osteotomie.

In the current literature, the rate of return to sports following high tibial osteotomy is high. Patients are largely able to carry out the type of exercise done before the onset of symptoms and are satisfied with the clinical outcome. In general, however, a differentiated view of the sporting ability should be made, and the different requirements of the sport should be considered. A classification according to functional and biomechanical movement analysis seems to advisable. In addition, the recommendations of the treating physician seem to have a high impact on the postoperative level of the sports activities of the patients. A realistic assessment (by both the patient and the treating physician) that considers the sport, its requirements and the level of performance is necessary.

Benefit of Contrast-Enhanced Ultrasound (CEUS) in the Follow-Up Care of Patients with Colon Cancer: A Prospective Multicenter Study.

PURPOSE: According to the German guidelines on colorectal cancer, unenhanced ultrasound is recommended for follow-up. On the other hand, ultrasound and radiology societies specify the use of contrast-enhanced ultrasound for ruling out liver metastases. Studies focusing on the follow-up of cancer patients are lacking. The goal of this multicenter study initiated by the German Ultrasound Society (DEGUM) was to determine the potential benefit of contrast-enhanced ultrasound in the follow-up of patients with colon cancer. MATERIALS AND METHODS: Follow-up patients with colon cancer (UICC > IIa) were investigated. As scheduled according to the German guidelines, unenhanced ultrasound was performed followed by contrast-enhanced ultrasound. All liver lesions were recorded. In case of additional metastases detected on contrast-enhanced ultrasound, contrast-enhanced CT, MRI or biopsy was performed to confirm additional liver metastases. RESULTS: A total of 45 liver metastases were detected in 26/290 patients (= 9 %) using unenhanced ultrasound. A further 28 metastases were detected on contrast-enhanced ultrasound in these 26 patients. In 18 patients showing no liver metastases, 40 additional metastases were detected on unenhanced ultrasound. This means that 44 patients with a total of 113 liver metastases were detected on contrast-enhanced ultrasound (p = 0.0006). CONCLUSION: Contrast-enhanced ultrasound should be recommended in the follow-up of patients with colon cancer in addition to unenhanced ultrasound - the up-to-date standard.

Incidence of bleeding in 8172 percutaneous ultrasound-guided intraabdominal diagnostic and therapeutic interventions - results of the prospective multicenter DEGUM interventional ultrasound study (PIUS study).

PURPOSE: To analyse the incidence of bleeding after percutaneous ultrasound guided diagnostic and therapeutic intraabdominal interventions in a prospective multicentre study (DEGUM percutaneous interventional ultrasound study). MATERIALS AND METHODS: Within a time period of 2 years diagnostic and therapeutic intraabdominal interventions (with the exclusion of ascites paracentesis) performed percutaneously under continuous ultrasound (US) guidance were prospectively assessed using a pseudonymized standardized web site entry form. Number and type of intervention, operator experience, patient characteristics, medication, lab data as well as technical aspects of the procedure and bleeding complications were analysed according to the interventional radiology standards. RESULTS: 8172 US-guided intraabdominal interventions (liver n = 5903; pancreas n = 501, kidney n = 434, lymph node = 272, biliary system n = 153, spleen n = 63, other abdominal organs and extra-organic targets n = 999) were analysed in 30 hospitals. The majority were diagnostic biopsies including 1780 liver parenchyma, 3400 focal liver lesions and 404 pancreatic lesions. 7525 interventions (92.1 %) were performed in hospitalized patients (mean age 62.6 years). Most operators were highly experienced in US-guided interventions (> 500 interventions prior to the study n = 5729; 70.1 %). Sedation was administered in 1131 patients (13.8 %). Needle diameter was ≥ 1 mm in 7162 punctures (87.9 %) with main focus on core needle biopsies (18 G, n = 4185). Clinically relevant bleeding complications with need of transfusion (0.4 %), surgical bleeding control (0.1 %) and radiological coiling (0.05 %) were very rare. Bleeding complications with fatal outcome occurred in four patients (0.05 %). The frequency of major bleeding complications was significantly higher in patients with an INR > 1.5 (p < 0.001) and patients taking a medication potentially interfering with platelet function or plasmatic coagulation (p < 0.0333). CONCLUSION: This prospective multicentre study confirms the broad spectrum of percutaneous US-guided intraabdominal interventions. However diagnostic liver biopsies dominate with the use of core needle biopsies (18 G). Percutaneous US-guided interventions performed by experienced sonographers are associated with a low bleeding risk. Major bleeding complications are very rare. A pre-interventional INR < 1.5 and individual medication risk assessment are recommended.

Importance of Abdominal Ultrasound in 17 Patients with Histologically Confirmed Autoimmune Pancreatitis (AIP).

PURPOSE: Autoimmune pancreatitis (AIP) is an independent, underdiagnosed, rare form of chronic pancreatitis. The goal of this study is to document ultrasound findings in histologically confirmed AIP in order to determine the diagnostic value of ultrasound. MATERIALS AND METHODS: 6 of 74 DEGUM instructors for internal medicine (level 3 and 2) provided anonymized clinical and sonographic data from 17 patients with histologically confirmed AIP. RESULTS: 9/17 patients had diffuse AIP, 8/17 had focal AIP, 14/17 suffered from upper abdominal pain, 9/17 had jaundice, and 3/9 had an elevated IgG4 level. Ultrasound showed diffuse hypoechoic organ enlargement in 9/17 cases and a hypoechoic tumor with an unclear border in 8/17 cases. AIP was verified by ultrasound-guided percutaneous core biopsy in 14 cases, by biopsy of the bile duct in 1 case, and by surgical biopsy in 2 cases. Involvement of the hepatobiliary system was present in 7/17 patients and autoimmune cholangitis was verified in 5 cases. All patients experienced remission after immunosuppressive treatment. The pancreatic duct had a normal width in 11 cases, was dilated in 5 cases, and was stenosed over a long stretch in 3 cases. Contrast-enhanced ultrasound did not show uniform signal increase but also no significantly reduced or absent perfusion. CONCLUSION: Ultrasound can be diagnostically useful if the clinical manifestations of AIP are known. While the diffuse form allows an ad-hoc suspected diagnosis, the focal form can only be suspected in the case of additional extrapancreatic involvement. Contrast-enhanced ultrasound (CEUS) contributes greatly to the differentiation from ductal adenocarcinoma in the case of focal AIP.

[Quantified TDI elastography of the patellar tendon in athletes]. / Quantifizierte TDI-Elastosonografie der Patellarsehne bei Sportlern.

BACKGROUND: TDI elastosonography allows, in contrast to conventional methods, a quantitative-numerical evaluation of the quality of a tendon on the basis of so-called strain scores. Previous studies on elastosonography were mainly based on qualitative methods, which only allow for a graduated colour and optical-visual representation. The aim of this study was to assess the strain scores of non-symptomatic compared to symptomatic patellar tendons in order to estimate reference values. Furthermore, the correlation between the neovascularisation apparent in power Doppler sonography and the magnitude of the strain scores was investigated. METHODS: In total n = 75 athletes aged 33.2 ± 12.7 years were included in the study, with the ligamentum patellae diagnosed in n = 37 as being clinical non-symptomatic and in n = 38 as being symptomatic. After a detailed anamnesis and a clinical examination, all subjects underwent a conventional B-mode, a Dynaflow power Doppler and a TDI elastosonography of the ligamentum patellae using the Aplio MX (Toshiba Medical Systems, Corp.) in the longitudinal and cross-section planes, respectively. RESULTS: The strain scores of the non-symptomatic ligamentum patellae in the longitudinal section were on average 0.070 (± 0.039) depending on the measuring field. The symptomatic tendons showed significantly higher values in the longitudinal section with an average of 0.137 (± 0.052). Similar values were evident in the cross-section. In 58 % of the symptomatic tendons neovascularisation was detected. A correlation between the duration of the medical history and the presence of neovascularisation was thereby verified. CONCLUSIONS: The presented results show that TDI elastosonography in the hands of an experienced examiner is an appropriate method for quantifying the quality of the patellar tendon and gives additional information beyond that of B-mode, power Doppler sonography and MRI. To what extent the strain scores of the TDI elastosonography in addition to conventional sonography can influence the choice of the therapeutic procedure must be evaluated by conducting further studies.

A new approach to children's footwear based on foot type classification.

Current shoe designs do not allow for the comprehensive 3-D foot shape, which means they are unable to reproduce the wide variability in foot morphology. Therefore, the purpose of this study was to capture these variations of children's feet by classifying them into groups (types) and thereby provide a basis for their implementation in the design of children's shoes. The feet of 2867 German children were measured using a 3-D foot scanner. Cluster analysis was then applied to classify the feet into three different foot types. The characteristics of these foot types differ regarding their volume and forefoot shape both within and between shoe sizes. This new approach is in clear contrast to previous systems, since it captures the variability of foot morphology in a more comprehensive way by using a foot typing system and therefore paves the way for the unimpaired development of children's feet. Previous shoe systems do not allow for the wide variations in foot morphology. A new approach was developed regarding different morphological foot types based on 3-D measurements relevant in shoe construction. This can be directly applied to create specific designs for children's shoes.

Sex-related differences in foot shape.

The purpose of the study was to investigate sex-related differences in foot morphology. In total, 847 subjects were scanned using a 3-D-footscanner. Three different analysis methods were used: (1) comparisons were made for absolute foot measures within 250-270 mm foot length (FL); (2) and for averaged measures (% FL) across all sizes; (3) the feet were then classified using a cluster analysis. Within 250-270 mm FL, male feet were wider and higher (mean differences (MD) 1.3-5.9 mm). No relevant sex-related differences could be found in the comparison of averaged measures (MD 0.3-0.6% FL). Foot types were categorised into voluminous, flat-pointed and slender. Shorter feet were more often voluminous, longer feet were more likely to be narrow and flat. However, the definition of 'short' and 'long' was sex-related; thus, allometry of foot measures was different. For shoe design, measures should be derived for each size and sex separately. Different foot types should be considered to account for the variety in foot shape. Improper footwear can cause foot pain and deformity. Therefore, knowledge of sex-related differences in foot measures is important to assist proper shoe fit in both men and women. The present study supplements the field of knowledge within this context with recommendations for the manufacturing of shoes.

Foot morphology of normal, underweight and overweight children.

OBJECTIVE: Due to the fact that there is a global increase in obesity, knowledge about the impact of obesity on the development of a child's foot is of great importance for orthopaedic and paediatric physicians with regard to prevention, clinical treatment and management. Therefore, the purpose of this study was to investigate the influence of body mass on the development of a child's foot based on a foot type classification. METHODS: The feet of 1450 boys and 1437 girls aged 2-14 years were measured using a three-dimensional (3D) foot scanner (Pedus, Human Solutions Inc., Germany) in a bipedal upright position. Twelve relevant 3D foot measures were recorded, as well as the children's age, gender, height and mass. Factor analysis of principal components was used to obtain a smaller number of independent and standardized variables. The variables were used for cluster analysis to classify the children's feet. RESULTS: Five foot types were identified: flat, robust, slender, short and long feet. There were significant differences among foot types with respect to the children's body mass index. Normal weight children displayed an almost equal distribution of all foot types throughout childhood. Flat and robust feet were more common in overweight children, whereas underweight children showed more slender and long feet. CONCLUSION: The influence of excess, as well as deficient mass could be verified for the comprehensive foot morphology based on a foot type classification. Subsequently, foot discomfort as a result of various musculoskeletal disorders may develop. In turn, this might keep the children from being active and therefore reinforce the risk of developing obesity. However, there is still a lack of information regarding these relationships, which needs to be determined. This knowledge may help prevent orthopaedic foot problems and injuries.

[Sonographical diagnosis of pneumoretroperitoneum as a result of retroperitoneal perforation]. / Das sonografische Bild des Pneumoretroperitoneums als Folge einer retroperitonealen Perforation.

A retroperitoneal perforation is a rare incident. It can occur as a complication of ERCP with papillotomy (0.2-0.5%). Leakage of contrast agent during endoscopy raises the suspicion that this complication has occurred but doesn't always give sufficient information about the leakage extent. In the case of extreme gas emission, a plain abdominal X-ray shows classic pneumoretroperitoneum. The abdominal CT scan can display small amounts of free air which is why it is used for diagnosis in such cases. Ultrasonography also provides a reliable diagnosis and is a good method for monitoring the progression of the condition. Alternative causes of pneumoretroperitoneum can be: trauma, inflammation, infection, tumor as well as ERCP and other interventional procedures, especially endoscopies. Presacral retroperitoneal pneumoradiography was used for the diagnosis of retroperitoneal tumors in the 70 s but is no longer used today. Perforations into the retroperitoneal space come from several locations in the gastrointestinal tract. In the different types of lesions the gas can penetrate the compartments and reach as far as the mediastinum, the intraabdominal cavity, subcutaneum (cervical) or the scrotal compartment (compartment shift). Based on 11 cases (7 perforations during ERCP, 2 perforation during colonoscopy, 2 cases with damage of the distal esophagus), we show the most extensive presentation of the sonographical picture of pneumoretroperitoneum. Typical signs on abdominal ultrasound are an increased echogenicity around the right kidney ("overcasted" or "covered" kidney), air dorsal to the gallbladder, around the duodenum and the head of the pancreas and especially ventral to the great abdominal vessel which can lead to the picture of "vanishing" vessels. The extent of free air is easy to assess. Even very small amounts are detectable ventral to the right kidney. In most cases, a conservative approach with no oral intake, antibiotic coverage, and analgesia in close gastroenterological-surgical cooperation is indicated. Especially after ERCP abscess formation is repeatedly described, sometimes even with a lethal outcome. Sonography is a suitable method for detecting free air in the retro-peritoneum. Pneumoretroperitoneum following bowel-perforation can be effectively shown by ultrasound, it is possible to assess the extent of free air, and sonographic monitoring of the treatment is possible and successful.

Detection of therapeutically relevant diagnoses made by sonography of the upper abdomen: portable versus high-end sonographic units -- a prospective study.

AIM: To compare the efficiency of a portable sonographic unit with a high-end unit used for sonographic examinations of the upper abdomen to detect therapeutically relevant diagnoses and to answer clinical questions. METHODS: Over a period of five years, 575 patients were examined by four examiners as part of the daily routine work. Patients without known diagnoses were examined first with the portable SonoSite 180 system, with documentation of the findings and diagnoses, and immediately thereafter with the high-end Philips HDI 5000 system. Subsequently, any discrepant findings and diagnoses were recorded. The assessment was confined to therapy-demanding diagnoses and to the resolution of the clinical question (major findings) as well as to other therapeutically relevant findings (minor findings). RESULTS: Of the 575 data sets (duplicated examinations), 574 could be evaluated. The major findings coincided in 447 (78 %) of 574 cases and were discrepant in 121 (22 %) cases in which the major findings were solely detected with the high-end Philips HDI 5000 system and missed with the portable SonoSite 180 system. Findings of the upper abdomen coincided in 252 (85 %) of 297 cases and were undetectable with the portable unit in 44 (15 %) cases. For 166 intestinal examinations, the proportion of coinciding major findings was 58 % (96 of 166 cases), with 42 % (71 of 166 cases) overlooked with the portable unit. For examinations of the pleura, the findings coincided in 99 (89 %) of 111 cases. The findings of emergency examinations coincided in 138 (75 %) of 185 cases, with 47 (25 %) findings exclusively detected with the HDI 5000 system. In emergencies without intestinal involvement, the findings coincided in 105 (89 %) of 118 cases. CONCLUSION: As expected, the high-end unit is markedly superior to the portable sonographic unit, especially for clinical questions requiring a high physical resolution, as needed for gastrointestinal structures, biliary system and pancreas. The portable unit provided its best results for examinations of the pleura and for emergency examinations as long as the gastrointestinal tract is excluded. For the routine use of portable sonographic units, it is important to know the limitation of the particular unit.

[Giant haemangioma of the liver - clinical and diagnostic problems - a case report]. / Riesenhämangiom der Leber - klinische und diagnostische Probleme - ein Fallbericht.

Typical echodense haemangiomas of the liver can easily be identified by B-scan ultrasound. Atypical or giant haemangiomas of the liver, however, need to be differentiated from secondary tumours or primary liver carcinomas and cholangiocarcinomas. Until recently, computed tomography or magnetic resonance tomography were required to confirm the diagnosis, and not so rarely even a fairly risky fine-needle puncture had to be performed. Contrast media-assisted sonography, in general, offers the same scope of differentiating liver tumours as the radiographic tomography methods. Contrast media-assisted sonography is not yet widely available and has not been sufficiently evaluated. One important limitation is thought to be the lack of echo depth. We demonstrate the diagnostic value of this method in the case of a liver haemangioma measuring more than 20 cm in diameter. The resulting clinical questions are being discussed.

Impact of a multimodal anti-emetic prophylaxis on patient satisfaction in high-risk patients for postoperative nausea and vomiting.

Postoperative nausea and vomiting (PONV) are frequent and unpleasant symptoms. This prospective study aimed to assess the efficacy of a multimodal approach to prevent PONV, and patient satisfaction using the willingness-to-pay method. Two validated risk scores were applied to forecast the individual risk for PONV in 900 consecutive patients of whom 108 were identified as high-risk patients (predicted risk: 79-87%). High-risk patients received multimodal anti-emetic prophylaxis: total intravenous anaesthesia with propofol, high fractional inspired oxygen (80%), omission of nitrous oxide, dexamethasone 8 mg, haloperidol 10 microg.kg(-1), and tropisetron 2 mg. Of the remaining patients with low or moderate risk for PONV, a random sample of 71 females received balanced propofol-desflurane anaesthesia without prophylactic anti-emetics. All patients were interviewed 2 and 24 h after surgery for occurrence of nausea and vomiting. Patient satisfaction was measured using the willingness-to-pay method. The incidence of PONV (95%-confidence interval) in the control-group was 41% (29-51%), slightly lower than predicted by the risk scores (53-57%). The multimodal anti-emetic approach reduced the predicted risk (79-87%) in the high risk-group to 7% (3-14%). This was associated with a high willingness-to-pay median (25th/75th percentile) of 84 UK pounds (33-184 UK pounds) in the multimodal anti-emetic group compared to 14 UK pounds (4-30 UK pounds) in the control group. A multimodal anti-emetic approach can considerably reduce the incidence of PONV in high-risk patients and is associated with a high patient satisfaction as measured by the willingness-to-pay method.

Nocardia paucivorans sp. nov.

Chemotaxonomic and 16S rDNA sequence analyses of an isolate from the sputa and bronchial secretions of a patient with chronic lung disease clearly demonstrated that it belongs to the genus Nocardia. DNA-DNA hybridization data, as well as the biochemical characteristics of the isolate, indicate that it belongs to a new species that differs from previously described members of the genus Nocardia. The name Nocardia paucivorans sp. nov. is proposed for this isolate and is represented by strain IMMIB D-1632T (= DSM 44386T).