Lateral elbow tendinopathy: surgery versus extracorporeal shock wave therapy.

Lateral elbow pain caused by tendinopathy - tendinosis - or tennis elbow is a highly prevalent problem. Unfortunately, no treatment method can guarantee clinical success. Inspired by the lithotripsy technique used for kidney stones, extracorporeal shock wave therapy (ESWT) has been introduced as an alternative to surgical treatment 25 years ago. In a randomized prospective study, we compared 15 patients with lateral elbow tendinopathy who were operated and 14 who underwent ESWT. Almost all patients had good or excellent outcomes according to the criteria by Verhaar. Subjective improvement was 57% for the ESWT group and 76% for the surgery group. No significant differences between both groups were found (p = 0.07). We therefore recommend considering non-invasive techniques such as ESWT treatment prior to surgery in tennis elbow.

Non-uniformity in pre-insertional Achilles tendon is not influenced by changing knee angle during isometric contractions.

Achilles tendinopathy remains a prevalent condition among recreational and high-level athletes. Mechanical loading has become the gold standard in managing these injuries, but exercises are often generic and prescribed in a "one-size-fits-all" principle. The aim of this study was to evaluate the impact of knee angle changes and different levels of force production on the non-uniform behavior in the Achilles tendon during isometric contractions. It was hypothesized that a flexed knee position would lead to a more distinct non-uniform behavior, due to greater differential loading of soleus vs gastrocnemius, and that this effect would be attenuated by higher levels of force production. Contrary to the hypotheses, it was found that the non-uniform deformation, that is, superficial-to-deep variation in displacement with highest displacement in the deep layer, is consistently present, irrespective of the level of force production and knee angle (n = 19; mean normalized displacement ratio 6.32%, 4.88%, and 4.09% with extended knee vs 5.47%, 2.56%, and 6.01% with flexed knee, at 25%, 50%, and 75% MVC, respectively; P > .05). From tendon perspective, aside from the influence on muscle behavior, this might question the mechanical rationale for a change in knee angle during eccentric heel drops. Additionally, despite reaching high levels of plantar flexion force, the relative contribution of the AT sometimes appears to be decreased, potentially due to compensatory actions by agonist muscle groups. These results are relevant for optimizing AT rehabilitation as the goal is to reach specific local tendon loading.

Nasal symptoms, epithelial injury and neurogenic inflammation in elite swimmers.

BACKGROUND: A high burden of lower airway symptoms is found in elite swimmers. To what extent elite swimmers suffer from upper airway symptoms and how these associate with nasal inflammation is less clear. We here aimed to evaluate upper airway symptoms and nasal inflammation in elite athletes. METHODOLOGY: Elite swimmers, indoor athletes and age-matched controls were recruited. Upper airway symptoms were assessed by sino-nasal outcome test (SNOT)-22 questionnaire. Visual Analogue score (VAS) for nasal symptoms as well as neurogenic and inflammatory mediators in nasal fluid were assessed at baseline, immediately and 24-hours after sport-specific training. The effect of hypochlorite on nasal epithelial cells was evaluated in vitro. RESULTS: Baseline SNOT-22 and VAS for nasal itch and impaired smell were significantly higher in swimmers compared to controls. Nasal substance P and uric acid levels were increased in elite swimmers 24-hours after swimming compared to baseline. In elite swimmers, uric acid levels 24-hours post-exercise correlated with baseline SNOT-22. As increased symptoms and inflammation were found in swimmers but not in indoor athletes, we hypothesized that hypochlorite exposure might be the underlying mechanism. In vitro, the highest dose of hypochlorite decreased nasal epithelial cell integrity and induced release of uric acid. CONCLUSION: Upper airway symptoms are frequently reported in elite swimmers. Intensive swimming resulted in a delayed increase of epithelial injury and neurogenic inflammation.

[Stress fracture or osteochondral lesion of the navicular bone?] / Stressfractuur of osteochondraal letsel van het os naviculare?

BACKGROUND: An osteochondral lesion of the navicular bone in the foot is rare. Differentiation from a stress fracture is difficult, since both lesions usually present as vague pain in the midfoot in active young adults. However, the typical location differs. SPECT-CT allows an etiological diagnosis to be made. As management differs for the two lesions, a correct diagnosis is important. CASE DESCRIPTION: A 19-year-old male athlete had pain in the dorsal right midfoot on weight-bearing. A diagnosis of 'stress fracture of the navicular bone' was made on the basis of SPECT-CT. Since conservative therapy did not help, and because the location was atypical for a stress fracture, the diagnosis was revised to 'osteochondral lesion'. CONCLUSION: The key to the diagnosis of osteochondral lesion is its location in the central proximal third of the navicular bone. Patients with this type of lesion often undergo surgical treatment, whereas conservative therapy is sufficient in case of a stress fracture.

Feasibility to apply eucapnic voluntary hyperventilation in young elite athletes.

INTRODUCTION: Exercise-induced bronchoconstriction (EIB) is more common in athletes compared to the general population. The eucapnic voluntary hyperventilation test is used to detect EIB in adult athletes. It is however unclear whether this technique is also applicable to young athletes. METHODS: Young athletes (basketball (n = 13), football (n = 19), swimming (n = 12)) were recruited at the start of their elite sports career (12-14 years). Eight age-matched controls were also recruited. Eucapnic voluntary hyperventilation test was performed according to ATS guidelines in all subjects. A second (after 1 year, n = 32) and third (after 2 years, n = 39) measurement was performed in a subgroup of athletes and controls. RESULTS: At time of first evaluation, 3/13 basketball players, 4/19 football players, 5/11 swimmers and 1/8 controls met criteria for EIB (fall in FEV1≥10% after EVH). A ventilation rate of >85% of the maximal voluntary ventilation (MVV) is recommended by current guidelines (for adults) but was only achieved by a low number of individuals (first occasion: 27%, third occasion: 45%) However, MVV in young athletes corresponds to 30 times FEV1, which is equivalent to 85% of MVV in adults. A threshold of 70% of MVV (21 times FEV1) is feasible in the majority of young athletes. CONCLUSION: EIB is present in a substantial number of individuals at the age of 12-14 years, especially in swimmers. This underscores the importance of screening for EIB at this age. EVH is feasible in young elite athletes, however target ventilation needs to be adjusted accordingly.

Hospital- and community-based interventions enhancing (re)employment for people with spinal cord injury: a systematic review.

STUDY DESIGN: Systematic Review. OBJECTIVES: To investigate the effect of interventions enhancing (re)employment following spinal cord injury (SCI). SETTING: Studies from multiple countries were included. METHODS: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, PsycINFO and SPORTDISCUS databases were searched. Randomized controlled trials (RCTs) and non-randomized studies (NRSs) describing a hospital- or a community-based intervention aiming at employment in a SCI population were selected. Quality appraisal was done using the SIGN methodology, and the quality of evidence was graded using the Grade approach. Data extraction was performed according to the Cochrane Handbook. Employment rate and duration were primary outcomes. RESULTS: Only one RCT, including 201 patients describing an intervention over 1 and 2 years, was of sufficient quality. In this study, the employment rate was 26% after 1 and 31% after 2 years for competitive work, compared with 10% in the treatment as usual-intervention site (TAU-IS) control group and 2% in the treatment as usual observational site (TAU-OS) after 1 and 2 years. Other studies were of low quality and describe higher employment rates from 36 to 100%. CONCLUSIONS: Only one RCT was of sufficient quality and showed evidence that a vocational rehabilitation programme based on the principles of supported employment integrated in a multidisciplinary team enhances employment for SCI people. As the vast majority of studies included in this review are of low methodological quality, further research is needed.

Damage-associated molecular pattern and innate cytokine release in the airways of competitive swimmers.

BACKGROUND: Daily intensive exercise by elite athletes can result in exercise-induced asthma especially in elite swimmers and this may be linked to epithelial damage. OBJECTIVE: To study airway epithelial damage and release of damage-associated molecular patterns (DAMPs) after intensive exercise in elite athletes and controls. METHODS: We recruited competitive swimmers (n = 26), competitive indoor athletes (n = 13) and controls (n = 15) without any history of asthma. Lung function was measured before, immediately after and 24 h after a 90-min intensive exercise protocol. Sputum induction was performed at baseline and 24 h after exercise. Exercise-induced bronchoconstriction (EIB) was assessed by the eucapnic voluntary hyperventilation test. RESULTS: Baseline sputum uric acid, high mobility group box-1, CXCL8 mRNA, sputum neutrophils and serum Clara cell protein-16 (CC-16) were significantly higher in competitive swimmers compared with controls. Intensive swimming for 90 min resulted in an increase of sputum IL-1ß, IL-6 and TNF mRNA in competitive swimmers, and of sputum IL-6 mRNA and sputum neutrophils in controls. Although all participants were asymptomatic, seven competitive swimmers, one indoor athlete and one control met the criteria for EIB. CONCLUSION: Our findings show that the intensive training combined with exposure to by-products of chlorination induces airway epithelial damage in competitive swimmers. This is associated with increased damage-associated molecular patterns, innate cytokine release and neutrophilic airway inflammation.

Permanent mechanical deformation of an intrathecal baclofen pump secondary to scuba diving: a case report.

STUDY DESIGN: Case report. OBJECTIVES: To describe the case of a spinal cord injury patient that went scuba diving resulting in a mechanical deformation of his intrathecal baclofen pump. SETTING: University Hospitals Leuven, Belgium. METHODS: Case report. RESULTS: Diving below 10 meters of depth can result in irreversible mechanical damage of the drug reservoir of an intrathecal baclofen pump. CONCLUSION: Patients with an intrathecal baclofen pump should be warned for the risks associated with scuba diving and should not dive more than 10 meters below sea level.

Muscle rupture after minimal trauma of the spastic muscle: three case reports of patients with spinal cord injury.

STUDY DESIGN: Retrospective study of three cases. OBJECTIVES: To report three cases of muscle rupture caused by minimal trauma in spinal cord injury (SCI) patients with severe spasticity and a literature review of the underlying mechanisms. SETTING: Department of Physical and Rehabilitation Medicine, University Hospitals Leuven, Belgium METHODS: Retrospective study of three cases of muscle ruptures in SCI patients with severe spasticity. All muscle lesions were diagnosed by ultrasound. Literature review (Pubmed) was performed to identify extrinsic and intrinsic risk factors. RESULTS: According to the literature and our clinical findings, several structural and mechanical alterations of the spastic muscle in combination with specific stretching during therapy or a transfer can cause a muscle rupture after minimal trauma. CONCLUSION: To the authors' knowledge, this is the first report of muscle rupture due to spasticity in SCI patients. Altered mechanical properties of the spastic muscle in combination with extreme stretching may cause partial or complete ruptur. Although this is a rare complication of spasticity, medical staff and therapists should be aware of the risk factors in order to prevent and quickly identify muscle lesions.

Etiology of spinal cord injuries in Sub-Saharan Africa.

STUDY DESIGN: Review. OBJECTIVES: The aim is to highlight the epidemiology of spinal cord injuries (SCIs) in Sub-Saharan Africa in order to improve prevention strategies. SETTING: University Hospitals Leuven, Belgium. METHODS: Pubmed was searched over August and September 2010. A combination of the following MeSH-terms was used: 'Africa South of the Sahara', 'Spinal Cord Diseases', 'Paraplegia' and 'Spinal Cord Injuries'. Limits were set on articles published as from 1990. The World Health Organization database was also consulted. RESULTS: We obtained 243 hits of which 13 articles were relevant to the case. These papers covered seven countries: Ethiopia, Ghana, Nigeria, Senegal, Sierra Leone, South Africa and Zimbabwe. In traumatic SCIs, motor vehicle accidents are the most frequent cause of injury followed by falling from a height and thirdly violence, being the most important cause of SCI in South Africa. In the Plateau State of Nigeria, collapsing tunnels in illegal mining are the most prevalent cause. For the non-traumatic SCIs, tuberculosis appeared to be the most important cause, followed by malignant illnesses. Human immunodeficiency virus (HIV) serology tests were only available in the article concerning Ethiopia. Relatively more men were involved in traumatic SCIs and the average age was higher in the non-traumatic than in the traumatic group. CONCLUSION: Although literature on the subject is scarce, prevention should focus on road-safety, tuberculosis and HIV. Standardized registration of SCI is needed for prevention and further research. The use of the current International SCI core data set should be encouraged worldwide as a uniform classification method.

Open versus closed kinetic chain exercises for patellofemoral pain. A prospective, randomized study.

The goal of this prospective study was to evaluate the efficacy of open versus closed kinetic chain exercises in the nonoperative management of patellofemoral pain. Sixty patients were randomized into a 5-week program that consisted of only closed kinetic chain exercises or only open kinetic chain exercises. Muscle characteristics, subjective symptoms, and functional performance were evaluated in this study at the time of the initial physical examination, at the end of the treatment period, and 3 months later. Both groups experienced a statistically significant decrease in pain and an increase in functional performance. This study shows that both open and closed kinetic chain exercise programs lead to an improved subjective and clinical outcome in patients with anterior knee pain. The few significantly better functional results for some of the tested parameters in the closed kinetic chain group suggest that this type of treatment is a little more effective than the open kinetic chain program in the treatment of these patients.

Gelatin sponge plug to seal fetoscopy port sites: technique in ovine and primate models.

Amniotic fluid leakage and rupture of membranes are common complications of fetoscopy. We describe a plug technique for leakproof removal of endoscopic cannulas. Thirty gelatin sponge plugs were introduced in 5 pregnant ewes and 5 pregnant rhesus monkeys. In the primate model no evidence of amniorrhexis was noted on postoperative ultrasonography. Myometrium and membranes at the port sites were intact at term. A gelatin sponge plug technique may facilitate leakproof port removal after fetoscopy.

Natural protective mechanisms against endoscopic white-light injury in the fetal lamb eye.

OBJECTIVE: To evaluate light transmission, possible light trauma, and techniques for protection of the fetal eyes during intrauterine videoendoscopic surgery in a sheep model. METHODS: In vitro studies were done at various gestational ages, including spectrometry of light output by a halogen light source and telescope and light transmission by spectrophotometry in the range of 180-3000 nm through amniotic fluid (AF) and fetal eyelids. In vivo electron-microscopic, morphologic analysis of the retinas of 65-, 95-, 108-, and 112-day-old fetal lambs with (n = 8) and without (n = 8) 30 minutes' light exposure to the open eye was also done. RESULTS: The light spectrum at the tip of the telescope was 400-750 nm, with a maximum irradiance of 3x10(-3) W/cm2 at 580 nm. In the ultraviolet spectrum (less than 300 nm), irradiance was less than 0.5x10(-3) W/cm2. Light transmission through ovine AF ranged from 30% at 300 nm to 89% at 700 nm at 84 days' gestation, decreasing to less than 0.01% (300 nm) and 70% (700 nm) at 112 days. Fetal eyelids did not transmit more than 1% of light (any wavelength). After direct in vivo light exposure, no retinal damage was found. Photoreceptors were present from 108 days onward, but chromophores were scant or absent at all ages studied. CONCLUSION: The light spectrum of a standard endoscope is limited to 400-750 nm; ultraviolet light is filtered out. The AF transmits harmful blue light poorly. Fetal eyelids seem to protect the eye by extremely low transmission and light dispersion. Even with the eye open, no morphologic retinal damage was found. The strong light sources used with fetal endoscopy did not appear to pose a threat to the fetal retina.

Experience with fetoscopic cord ligation.

OBJECTIVE: In the case of a monochorionic multiple pregnancy with one non-viable fetus who compromises its co-twin, fetoscopic cord ligation may be performed. We describe our fetoscopic cord ligation technique and discuss the efficacy of cord ligation for salvaging the co-twin, based on available data. STUDY DESIGN: Descriptive case series of four cases and review of the cases published up to 1996. RESULTS: We performed four successful ligations. Of the 23 reported cases, which include the present series, two ligations failed. Four fetuses died in utero, and 17 were born alive at a mean of 8 weeks following the procedure. Two babies died in the perinatal period, a third after 60 days. Preterm uterine contractions do not seem to be a clinical problem. Preterm prelabour rupture of the membranes (PPROM) complicates about 40% of cases, the majority occurring prior to 32 weeks. CONCLUSION: Fetoscopic cord ligation is a feasible procedure with a 71% survival rate and a high risk for PPROM.

Access techniques in endoscopic fetal surgery.

Endoscopic surgery may in the future become an attractive alternative to open fetal surgery. Herein, we present our evolving experience with minimal access techniques in sheep and nonhuman primate models. Fifty-two pregnant sheep (term = 145 d) were used. All underwent laparotomy. Cannulas were 5 mm diameter with balloon fixation device. In group I (95-105 d, n = 22, and 70-74 d, n = 19), a total of 119 cannulas were placed by open hysterotomy and pursestring suture through myometrium and membranes. In group II (n = 11), access was obtained by Seldinger guidewire technique. Eight cannulas were introduced over a dilator and 7 were radially expanding endoscopic cannulas. Fifteen cannulas were also placed in 5 pregnant Rhesus monkeys using Seldinger and radially expanding techniques. Cannula removal was followed by insertion of a collagen sponge plug and oversewing of the myometrium. Mini-hysterotomies with purse-stringing provided excellent access to the amniotic cavity, without dissection of the membranes. Classic Seldinger technique with forward dilatation was equally effective, but caused stretching of membranes. In sheep and in primates, Seldinger technique with radial dilatation allowed safe access without membrane separation. Leak-proof removal of the cannulas was achieved in all primates. Open hysterotomy with purse-string and balloon-tipped cannula provides efficient and safe access to the gravid sheep uterus. Seldinger technique allows equally secure access, and alleviates the need for hysterotomies. Radial dilatation of the porthole eliminates forward dissection of the membranes, both in sheep and primate models. This method, and collagen plug insertion upon completion of the endoscopic procedure, may provide a truly minimally invasive approach to in-utero surgery.

Amnioinfusion with Hartmann's solution: a safe distention medium for endoscopic fetal surgery in the ovine model.

In this study, we have investigated the maternal effects of distending the uterine cavity with Hartmann's solution in 2nd trimester equivalent pregnant sheep. In 7 pregnant ewes, double endoscopic cannulation of the amniotic cavity was performed under general anesthesia, and 1 liter of Hartmann's solution at 38 degrees C, radiolabeled with 99mTc-red blood cells, was infused. Maternal central venous pressure, hematocrit, serum and amniotic fluid osmolarity, and amniotic fluid volume were measured at nine time points within a 2-hour period. Over this time interval, no significant fluid shift to the maternal compartment was observed. We detected no adsorption of radioactivity to the fetus or membranes, and no diffusion of radioactivity to maternal or fetal tissues was noticed. We conclude from these experiments that following double cannulation and intra-amniotic infusion of Hartmann's solution into the 2nd-trimester pregnant ovine uterus, no significant shift of fluid to the maternal compartment was observed over a 2-hour time period.

The effect of open and endoscopic fetal surgery on uteroplacental oxygen delivery in the sheep.

Open fetal surgery predictably results in postoperative uterine contractions and often in premature labor, but its intraoperative effects on the uterus are not known. In 10 pregnant ewes (108 to 115 days' gestation), uterine artery flow, uterine venous oxygen saturation, arterial saturation, and uterine electromyography were recorded simultaneously (control). Six ewes underwent a stapled hysterotomy, and four underwent placement of three endoscopic surgery cannulas and amnioinfusion. Uterine contractions were present 52% of the time (range, 34% to 72%), and there was no significant difference between control, hysterotomy, and endoscopic access. Uterine artery blood flow and uteroplacental oxygen delivery at rest decreased (to 73% of control) after hysterotomy (P < .05), but not after endoscopy. Fetal + uteroplacental oxygen consumption did not differ significantly between the groups. In conclusion, (1) uteroplacental oxygen delivery after hysterotomy alone decreased to levels critical for adequate fetal oxygenation; (2) endoscopy did not alter uteroplacental oxygen delivery; and (3) during open fetal surgery, further oxygen demand/delivery mismatch is likely, by traction on uterine and umbilical vessels and fetal stress.

Gasless laparoscopy in infants: the rabbit model.

Laparoscopic operations can be performed in neonates and infants, but carbon dioxide pneumoperitoneum may be more dangerous than in adults. Therefore the concept of gasless laparoscopy is especially attractive for small children. The authors have developed an animal training model of gasless infant laparoscopy using the rabbit. Eleven New Zealand white rabbits (mean weight, 2.2 kg) were premedicated with fentanyl (10 micrograms intramuscularly) and maintained under inhalation anesthesia by mask, with halothane (1.0 to 2.5%) in oxygen and nitrous oxide (1:1). The animals were neither intubated nor mechanically ventilated. Heart rate and oxygen saturation were monitored by pulse oximetry. A supraumbilical incision was made through the peritoneum, and an abdominal wall elevator was inserted. A 4-mm-diameter 30 degrees endoscope was introduced at the same site, allowing excellent visualization of the abdominal cavity. Three additional 5-mm cannulas were placed, and a standard Nissen fundoplication was performed in all 11 animals. In seven of these, a left nephrectomy was also performed. Five-millimeter pediatric instruments and 1.7- and 2.7-mm laryngoscopic instruments were used. The rabbit can serve as a training model for laparoscopy in the infant. Gasless laparoscopy, using abdominal wall elevation, may be particularly useful in very small patients.

Intrauterine endoscopic creation of urinary tract obstruction in the fetal lamb: a model for fetal surgery.

OBJECTIVE: Our purpose was to evaluate the feasibility of intrauterine endoscopic fetal surgery in a fetal lamb model by creating a urinary tract obstruction. STUDY DESIGN: Lower urinary tract obstruction was created by ligation of the urethra and urachus in 21 fetal lambs, eight at 95 to 105 days' gestation (term 145 days) and 13 at 70 to 75 days. The endoscopic approach consisted of a 0-degree 5 mm telescope, three 5 mm cannulas, uterine distention by amnioinfusion, and adapted instrumentation. Intrauterine fetal monitoring included temperature and pulse oximetry registration. RESULTS: In 20 cases the urachus could be identified and ligated inside the umbilical cord. The urethra was ligated in the anterior abdominal wall (n = 7) or obstructed at the level of the penis (n = 13). Mean fetal heart rate was 147 +/- 35 beats/min, and fetal temperature at the end of intervention was 38.14 degrees +/- 2.1 degrees C. The overall postoperative survival rate was 76%. CONCLUSION: Urinary tract obstruction can be created endoscopically in the fetal lamb. This operation can serve as a model for endoscopic fetal surgery.