Subacromial impingement syndrome: association of multiple magnetic resonance imaging parameters with shoulder function and pain.

INTRODUCTION: Shoulder pain is one of the most common complaints in orthopaedics. This study focusses on the relationship between shoulder function in subacromial impingement syndrome and imaging criteria in magnetic resonance imaging (MRI). MATERIALS AND METHODS: This prospective clinical trial included 69 patients treated for subacromial impingement syndrome. Shoulder function (Constant Score, range of abduction, abduction force) and pain were correlated with the following MRI parameters: tendinosis of the rotator cuff, "halo-sign" around the biceps tendon, subacromial distance, critical shoulder angle, size of subacromial osteophytic spurs and maximum width of subacromial and subdeltoid bursa. Statistical analyses included Pearson's and Spearman's coefficients of correlation, multiple regression analysis and Student's t-test. RESULTS: The Constant Score was correlated positively with the critical shoulder angle (r = 0.313; p = 0.009) and inversely with a "halo-sign" around the biceps tendon (rho = -0.384; p = 0.001). There was no significant correlation between spur size and shoulder function, but the size of the subacromial and subdeltoid bursae was positively correlated with the subacromial spur's size (subacromial bursa: coronal plane: r = 0.327; p = 0.006; sagittal view: r = 0.305; p = 0.011; subdeltoid bursa coronal view: r = 0.333 p = 0.005). The width of the subdeltoid bursa in coronal plane was positively correlated with shoulder pain (r = 0.248; p = 0.004) and negatively with the range of abduction (r = -0.270; p = 0.025), as well as the mean (r = -0.332; p = 0.005) and maximum (r = -0.334; p = 0.005) abduction force. CONCLUSIONS: Shoulder function and pain in subacromial impingement are best predicted by the width of the subdeltoid bursa measured in the coronal MRI plane as an indicator of bursitis as well as the presence of a "halo-sign" around the biceps tendon indicating glenohumeral joint effusion. Presence of a subacromial spur could lead to subacromial and subdeltoid bursitis, which impairs shoulder function. Shoulder function seems not to be compromised by the presence of a subacromial spur in absence of bursitis. This study was registered at the German Clinical Trials Register on 08 February 2013 (ID: DRKS00011548).

[Influence of Patients' Profession on Therapeutical Outcome of Patients with Primary Extrinsic Shoulder Impingement]. / Einfluss der beruflichen Tätigkeit auf den Therapieerfolg von Patienten mit primär extrinsischem Impingement der Schulter.

PURPOSE: Shoulder complaints are an important reason for inability to work. There are few considerations that link the effect of kind of therapy with ability to work in connection with kind of employment. This prospective, comparative clinical follow-up study examines the influence of occupational activity with conservative and operative therapy on the outcome of therapy in terms of function, pain and ability to work. METHODS: In this study, 97 patients (women: n=22, men: n=75, mean age: 43.1±10.1 years) with a primary extrinsic shoulder impingement syndrome were included. Patients were divided into blue and white collar workers. Further on the subgroups of conservative and operative therapy were considered. Either a sole conservative therapy or an operative therapy with physiotherapeutic follow-up treatment took place. The conservative therapy was carried out as a structured re-coordination of muscles of the shoulder girdle under supervision of a physiotherapist. In the surgical cohorts an arthroscopic subacromial decompression was performed. Follow-up examinations were passed 3, 6 and 12 months after starting the intervention. Function (Constant Score), pain (NRS) and the duration of inability to work were assessed. The statistical analysis was performed using mixed-design ANOVA to calculate main effect and interactions (therapy*kind of employment*time) adjusted with age, sex and body mass index. RESULTS: There was no statistically significant difference in terms of function and pain between blue and white collar workers. Office workers showed a significantly longer inability to work 3 months after surgical treatment compared with conservative treatment (7.3±0.8 weeks vs. 0.5±7.3 weeks; p<0.001). Further the group of white collars with operative therapy was significantly longer inable to work than the group of blue collar workers after operative therapy 3 months after surgical treatment (3.0±1.1 weeks vs. 7.3±0.8 weeks; p=0.002). CONCLUSION: On the one hand, working in an office could be seen as a negative predictor for durance of inability to work. On the other hand, surgical treatment itself was a negative predictor for the durance of inability to work. Furthermore, no difference between conservative and surgical therapy could be observed in function and pain one year after starting the treatment.

Effectiveness of a physical activity intervention in preschoolers: A cluster-randomized controlled trial.

Several activity interventions in preschool settings exist, but little attention has been paid to effects on hemodynamic factors. The study aimed to assess the effectiveness of an exercise program on health-related outcomes including blood pressure (BP) and markers of vascular function in preschoolers, with focus on socioeconomic background. This study is a cluster-randomized controlled trial, with preschool as unit of randomization and children as unit of analysis. Preschools with 3- to 6-year-old children, stratified by social area, were randomly allocated to: intervention (three clusters, n = 92) including 2 d·wk-1 /45 min (6 months) exercise lessons or control (two clusters, n = 43). In total, 135 children (4.8 ± 0.8 y) had minimum one outcome measurement at baseline and follow-up. Primary outcome: peripheral BP. Secondary outcomes: central BP, pulse wave velocity (PWV), BMI, waist circumference, physical activity measures, motor skills. Maternal education was used as an indicator of socioeconomic status. Mixed models were applied to evaluate differences in mean change. Group allocation had no effect on primary or secondary outcomes. However, the intervention was effective in reducing increases in peripheral systolic BP (-3.4 mm Hg; 95% CI: -6.6; -0.2; P = 0.037), central systolic BP (-3.8 mm Hg; -6.4; -1.1; P = 0.006), and PWV (-0.1 m/s; -0.2; -0.0; P = 0.045) among children whose mothers had the lowest educational level. We found no evidence for effectiveness of a 6-months preschool-based exercise program on hemodynamics, anthropometrics, activity, or motor skills, but lack of process evaluations and poor fidelity preclude interpretation of the causal relation. However, the results indicate that children from lower social backgrounds could benefit from early exercise-promoting interventions.

Do Exercise Trials for Hypertension Adequately Report Interventions? A Reporting Quality Study.

Non-pharmacological treatment, including exercise, is an important therapy option for patients with hypertension. The study assessed the reporting quality of exercise-based interventions included in the latest meta-analysis on that topic in order to evaluate the transferability of findings into clinical practice. Reporting quality of 24 randomised controlled trials from a meta-analysis assessing blood pressure lowering effects of endurance training in 1,195 hypertensive patients was evaluated using TIDieR (Template for Intervention Description and Replication) and CERT (Consensus on Exercise Reporting Template) guidelines. Associations between reporting quality, publication year and impact factor of the publishing journals were examined. None of the studies described all intervention components completely. On average 61% (95%CI: 52-69) (TIDieR) and 57% (95%CI: 49-64) (CERT) of core items required for replication were reported. Frequent shortcomings were the reporting of adherence, intervention provider, and adverse events. Details about exercise dosage were missing in 22% (95%CI: 4-40). Publication year was related to the adherence to TIDieR (r=0.549, P=0.007) but not to CERT. No associations with journal impact factor were found. Reporting of exercise-based interventions for hypertension is not sufficient to allow for replication and limits translation of evidence into clinical practice. Researchers should apply, and review authors, journal editors and reviewers should check adherence to reporting guidelines.

[Risk Factors and Therapeutic Goals for Primary and Secondary Cardiovascular Prevention: Significance for the Glaucoma Patient]. / Risikofaktoren und Zielwerte in der kardiovaskulären Primär- und Sekundärprävention: Bedeutung für das Glaukom.

Hypertension, diabetes mellitus and dyslipidaemia are among the most important cardiovascular risk factors. In addition, there is an association with the development and progression of glaucoma. During the last years, there has been an intense discussion concerning optimal treatment goals for these risk factors. Recently, the American Heart Association has defined a blood pressure greater than 130/80 mmHg as hypertension and the European guidelines will follow this definition. These lower blood pressure limits increase the risk for a too strict blood pressure treatment with night values, which might be too low for glaucoma patients. In contrast, the treatment goals for LDL cholesterol should be as low as possible ("the lower the better"). There is a more differentiated picture concerning treatment goals for diabetes mellitus. For elderly patients, which is the main group of the glaucoma patients, a less intense blood sugar reduction is currently recommended with an HbA1c value of above 7%. The present paper summarizes the significance of cardiovascular risk factors and the respective treatment goals for the therapy of patients with glaucoma.

Application of the Templates TIDieR and CERT Reveal Incomplete Reporting and Poor Replicability of Exercise Interventions for Type 2 Diabetes Mellitus.

BACKGROUND: Exercise is strongly recommended for the management of type 2 diabetes mellitus (T2DM). However, incomplete intervention reporting in clinical trials limits the replication of exercise protocols. As previously demonstrated by us for exercise and hypertension, the reporting quality might also be insufficient in studies with respect to T2DM and exercise. OBJECTIVE: The aim of the study was to assess the completeness of exercise intervention reporting in randomized controlled trials (RCTs) for T2DM. METHODS: Two independent reviewers applied the Consensus on Exercise Reporting Template (CERT) and the template for intervention description and replication (TIDieR) to 23 exercise trials obtained from the most recent and frequently cited meta-analysis in current guidelines. The completeness of reporting was evaluated, focusing on the F.I.T.T. components (frequency, intensity, time, type). Interrater agreement and associations with publication year and journal impact factor were examined. RESULTS: Mean CERT score was 11/19 (range 5-17), and 8/12 (range 4-12) for TIDieR. F.I.T.T. components were almost completely described, whereas overall completeness of exercise reporting was 60% and 68% (CERT and TIDieR). Replication of each exercise of the respective program was not possible in 52% of interventions. The majority of items had shown excellent agreement. No associations with publication year or impact factor were found. CONCLUSION: Exercise interventions were not found to be sufficiently reported in RCTs that currently guide clinical practice in T2DM. Replication in further studies or clinical practice is limited due to poor exercise description. We suggest the use of more specific CERT for reporting results of exercise interventions. Further refinement for internal diseases is needed to better describe exercise interventions.

Comparison of the influence of supportive and sensorimotor insoles in the muscle activity of tibialis anterior and peroneus longus in combat boots.

INTRODUCTION: Flatfoot is a very common static deformity. It occurs frequently in soldiers and causes problems in the lower extremities. There is a lack of data regarding therapy with insoles, especially with sensorimotor insoles. The objective of this study was to investigate the influence in muscle activity of supporting/correcting and sensorimotor insoles in combat boots in the muscles of the lower limb and thus to draw conclusions according to the benefits of insole therapy in military footwear. METHODS: 73 patients (12 female, 61 males; average age: 30.8 ± 7.9 years) with pes planovalgus deformity were included in this prospective randomized placebo-controlled study. For intervention supporting (N = 23), sensorimotor (N = 28) and placebo insoles (N = 22) were used. During gait analysis muscle activity was measured by means of surface electromyography (EMG) of the tibialis anterior and peroneus longus muscle in combat boots with and without insoles. Statistical evaluation was performed using two-factor ANOVA with repeated measures. RESULTS: EMG measures (amplitude, integral, maximum, mean) showed mainly activating effects in the peroneus longus muscle in the case of sensorimotor and activity reductions in supporting insoles. Comparing effects of different kinds of insoles to the peroneus longus muscle, significant differences could be shown. No significant differences in muscular activation were observed for the tibialis anterior muscle. CONCLUSION: Even in combat boots effects of sensorimotor insoles on the peroneus longus muscle can be detected. The expected effects, attributed to the different kinds of insole, could be observed, too. While sensorimotor insoles had an activating kind of effect, supportive insoles reduced muscular activity of the peroneus longus. In contrast for the tibialis anterior muscle no clear conclusion could be drawn. Its muscular activity seems not to be influenced by insoles in combat boots. However, it remains unclear whether clinical long term effects, e.g. pain and function, can be improved.

[Sport and exercise in prevention and therapy of cardiovascular diseases]. / Sport und Bewegung in Prävention und Therapie kardiovaskulärer Erkrankungen.

Sport and exercise improve physical performance, quality of life and prognosis in virtually all cardiovascular risk factors and diseases. Not only moderate endurance exercise but also specific strength training programs are recommended. However, research and practice are also focusing on more intense, interval exercise and targeted interventions to improve performance. In the primary and secondary prevention of cardiovascular diseases, adapted strength training without press breathing is also suitable.In addition to moderate endurance training, higher-intensity, interval-type exercise is now recommended for individual patients. An individually adapted load control is important after exhaustion in the load ECG. Rules of thumb should not be applied. With the exception of nicotine cessation, an improvement in physical performance is the most effective measure in terms of prognosis. Increased daily activity measured by a daily step count of more than 7500, optimally more than 10 000, also has a positive effect.

The effect of a scalable online training module for shared decision making based on flawed video examples - a randomized controlled trial.

OBJECTIVE: Shared Decision Making (SDM) is considered the gold standard of medical decision making as it provides a method to systematically integrate the patient's preferences, evidence-based medicine and the experience of health care professionals. Therefore, evidence-based training methods for a broad implementation into healthcare are needed. A new online training was designed, based on the concept of flawed/flawless video examples and additional educational concepts. METHODS: In a single-blind randomized-controlled trial, medical students were randomly assigned to intervention group receiving the online training (n = 82) or waiting control group (n = 105). SDM-related knowledge and the ability to judge distinct levels of SDM were compared between both groups. Additionally, feedback regarding the intervention was collected. RESULTS: SDM-related knowledge and judging ability increased significantly in the intervention group compared to controls (SDM knowledge: mean difference: 12 %; 95 % CI: 7.3-18.5; p < 0.001; SDM judging ability (inter-rater concordance displayed by weighted t): mean difference: 0.07; 95 %CI: 0.03-0.11; p = 0.001). Feedback was positive. CONCLUSION: The online training with its distinctive methodology prove effective. As it shares the theoretical and didactical background with an already existing face-to-face training, both approaches may also be used complementarily. PRACTICE IMPLICATIONS: SDM can be trained effectively and efficiently with this easily scalable online training.

Discrepancies in meta-analyses answering the same clinical question were hard to explain: a meta-epidemiological study.

OBJECTIVES: To systematically explore the methodological factors underpinning discrepancies in the pooled effect estimates from Cochrane reviews (CRs) and non-Cochrane reviews (NCRs) systematic reviews, answering the same clinical question. STUDY DESIGN AND SETTING: Quantitative and qualitative analysis of concordance in effect estimates between meta-analyses from CR and NCR matched on population, intervention, condition, and outcome. RESULTS: We identified 24 matched meta-analyses from 24 CR to 20 NCR reviews (545 randomized controlled trials [RCTs]). Compared to their CR matched-pair, pooled effects from NCR were the same in only one pair, were on average 0.12 log units (13%) higher (P = 0.012), and had a greater than twofold larger effect size in four matched-pairs. Two-thirds of CR (15/24, 70.8%) and 0/20 (0%) NCR were rated to have moderate to high confidence in their results (AMSTAR 2). Differences in pre-defined methods, including search strategy, eligibility criteria, and performance of dual screening, could explain mismatches in included studies. Disagreements in the interpretation of eligibility criteria were identified as reasons underpinning discrepant findings in 14 pairs. 23/24 meta-analyses included at least one study of its match. Only two pairs agreed on the numerical data presented for the same studies. An assessment of 50% of discrepant studies (n = 45) showed that reasons for differences in extracted data could be identified in 15 studies. CONCLUSION: On average, meta-analyses from NCR reported higher effect estimates compared with meta-analyses from CR answering the same clinical question. Methodological and author judgments and performance are key aspects underpinning poor overlap of included studies and discrepancies in reported effect estimates. The potential impacts on health care policy and clinical practice are far-reaching but still remain unknown. Reinforcing awareness and scrutiny of application of reporting guidelines and improvements in protocol registration are needed.

Single Pill Regimen Leads to Better Adherence and Clinical Outcome in Daily Practice in Patients Suffering from Hypertension and/or Dyslipidemia: Results of a Meta-Analysis.

INTRODUCTION: Cardiovascular diseases (CVD) represent the first cause of mortality in western countries. Hypertension and dyslipidemia are strong risk factors for CVD, and are prevalent either alone or in combination. Although effective substances for the treatment of both factors are available, there is space for optimization of treatment regimens due to poor patient's adherence to medication, which is usually a combination of several substances. Adherence decreases with the number of pills a patient needs to take. A combination of substances in one single-pill (single pill combination, SPC), might increase adherence, and lead to a better clinical outcome. AIM: We conducted a meta-analysis to compare the effect of SPC with that of free-combination treatment (FCT) in patients with either hypertension, dyslipidemia or the combination of both diseases under conditions of daily practice. METHODS: Studies were identified by searching in PubMed from November 2014 until February 2015. Search criteria focused on trials in identical hypertension and/or dyslipidemia treatment as FCT therapy or as SPC. Adherence and persistence outcome included proportion-of-days-covered (PDC), medication possession ratio (MPR), time-to treatment gap of 30 and 60 days and no treatment gap of 30 days (y/n). Clinical outcomes were all cause hospitalisation, hypertension-related hospitalisation, all cause emergency room visits, hypertension-related emergency room visits, outpatient visits, hypertension-related outpatient visits, and number of patients reaching blood pressure goal. Randomized clinical studies were excluded because they usually do not reflect daily practice. RESULTS: 11 out of 1.465 studies met the predefined inclusion criteria. PDC ≥ 80% showed an odds ratio (OR) of 1.78 (95% CI: 1.30-2.45; p = 0.004) after 6 months and an OR of 1.85 (95% CI: 1.71; 2.37; p < 0.001) after ≥ 12 months in favour to the SPC. MPR ≥ 80% after 12 months also was in favour to SPC (OR 2.13; 95% CI: 1.30; 3.47; p = 0.003). Persistence was positively affected by SPC after 6, 12, and 18 months. Time to treatment gap of 60 days resulted in a hazard ratio (HR) of 2.03 (95% CI: 1.77; 2.33, p < 0.001). The use of SPC was associated with a significant improvement in systolic blood pressure reduction, leading to a higher number of patients reaching individual blood pressure goals (FCT vs SPC results in OR = 0.77; 95% CI: 0.69; 0.85, p < 0.001). Outpatient visits, emergency room visits and hospitalisations, both overall and hypertension-related were reduced by SPC: all-cause hospitalisation (SPC vs FCT: 15.0% vs 18.2%, OR 0.79, 95% CI 0.67; 0.94, p = 0.009), all-cause emergency room visits (SPC vs FCT: 25.7% vs 31.4%, OR 0.75, 95% CI 0.65; 0.87, p = 0.001) and hypertension related emergency room visits (SPC vs FCT: 9.7% vs 14.1%, OR 0.65, 95% CI 0.54; 0.80, p < 0.001). CONCLUSIONS: SPC improved medication adherence and clinical outcome parameter in patients suffering from hypertension and/or dyslipidemia and led to a better clinical outcome compared to FCT under conditions of daily practice.

Outcome of catheter ablation of non-reentrant ventricular arrhythmias in patients with and without structural heart disease.

BACKGROUND: Catheter ablation of non-reentrant, commonly termed "idiopathic" ventricular arrhythmias (VA) is highly effective in patients without structural heart disease (SHD). Meanwhile, the outcome of catheter ablation of these arrhythmias in patients with SHD remains unclear. This study sought to characterize the outcome of patients with and without SHD undergoing catheter ablation of non-reentrant VA. METHODS: In this single-centre study the acute and long-term outcome of 266 consecutive patients undergoing catheter ablation of non-reentrant VA was investigated. In 41.0% of patients a SHD was present (n = 109, 80.7% male, age 59.1 ± 14.7 years), 59.0% had no SHD (n = 157; 44.0% male, age 49.9 ± 16.5 years). RESULTS: Acute procedural success (absence of spontaneous or provoked VA at the end of procedure and within 48 h after the procedure) was achieved in 89.9% of patients with SHD vs. 94.3% without SHD (p = 0.238). During a mean follow-up of 34.7 ± 15.1 months a repeat catheter ablation was performed in 19.6% of patients with SHD vs. 13.0% without SHD (p = 0.179). Patients with dilated cardiomyopathy (DCM) were the most likely to require a repeat ablation procedure (32.0% of patients with DCM vs. 13.0% without SHD; p = 0.022). Periprocedural complications occurred in 5.5% of patients with SHD vs. 5.7% without SHD (p > 0.999). All complications were managed without sequelae. CONCLUSIONS: The outcome of catheter ablation of non-reentrant VA in patients with SHD appears good and is comparable to patients without SHD. A slightly higher rate of repeat ablations was observed in patients with DCM.

Kramer and Chevron Osteotomy for Hallux Valgus Deformity - Retrospective Comparison of Functional and Radiological Results. / Kramer- und Chevron-Osteotomie bei Hallux valgus ­ retrospektive vergleichende Untersuchung des funktionellen und radiologischen Ergebnisses.

BACKGROUND: Hallux valgus is the most common forefoot deformity, with a prevalence of up to 23%. Surgical treatment is necessary in symptomatic patients. Prospective studies comparing different procedures are rare. Chevron osteotomy is the preferred procedure for distal osteotomy. The relevance of Kramer osteotomy is not clearly defined. The objective of this study was to compare the two procedures in terms of functional and radiological outcome. MATERIAL AND METHODS: 174 patients (42 male, 132 female, 44.0 ± 16.8 years), treated with Chevron (n = 71) or Kramer osteotomy (n = 103) between 2008 and 2015, were enrolled in this retrospective study. Time for surgery was analysed. Pre- and postoperative X-rays were evaluated to detect hallux valgus angle, intermetatarsal angle and position of sesamoids (mean ± SD). Function and quality of life were assessed using the Foot and Ankle Outcome Score (FAOS) and EuroQol5D questionnaire. Pain was rated by using the numeric rating scale (NRS). Statistical analyses were performed with mixed model ANOVA and the t test for independent samples. RESULTS: Both procedures reduce the hallux valgus angle (Kramer: 30° to 9°; Chevron 26° to 16°; p < 0.001). A significant difference was found between the two procedures (10° ± 2°; 95% CI: - 12.93; - 6.49; p < 0.001). A minimally reduced intermetatarsal angle was found in both groups (14° ± 3° to 12° ± 3°; p < 0.001). However, there was no significant difference between the two procedures (p = 0.116). The position of sesamoids was more improved by Kramer osteotomy (2/2 to 0/1; p < 0.001) according to Appel than with the Chevron osteotomy (2/2 to 2/1; p = 0.052). Time for surgery was significantly shorter when Kramer osteotomy was performed (31 ± 14 min vs. 44 ± 12 min; p < 0.001). No relevant differences in pain and function were observed (NRS postoperative Chevron: 1.3; Kramer: 1.7; p = 0.413; FAOS: no significant differences in all categories). CONCLUSION: The results of the two procedures were equal in functional outcome. Time of surgery and radiological results were significantly better in the group with Kramer osteotomy. Therefore, Kramer osteotomy is an alternative option to Chevron osteotomy. Further prospective studies are necessary to confirm these results.

Arch index and running biomechanics in children aged 10-14 years.

BACKGROUND: While altered foot arch characteristics (high or low) are frequently assumed to influence lower limb biomechanics and are suspected to be a contributing factor for injuries, the association between arch characteristics and lower limb running biomechanics in children is unclear. RESEARCH QUESTION: Therefore, the aim of this study was to investigate the relationship between a dynamically measured arch index and running biomechanics in healthy children. METHODS: One hundred and one children aged 10-14 years were included in this study and underwent a biomechanical investigation. Plantar distribution (Novel, Emed) was used to determine the dynamic arch index and 3D motion capture (Vicon) to measure running biomechanics. Linear mixed models were established to determine the association between dynamic arch index and foot strike patterns, running kinematics, kinetics and temporal-spatial outcomes. RESULTS: No association was found between dynamic arch index and rate of rearfoot strikes (p = 0.072). Of all secondary outcomes, only the foot progression angle was associated with the dynamic arch index (p = 0.032) with greater external rotation in lower arched children. SIGNIFICANCE: Overall, we found only few associations between arch characteristics and running biomechanics in children. However, altered foot arch characteristics are of clinical interest. Future studies should focus on detailed foot biomechanics and include clinically diagnosed high and low arched children.

[Time in the OR, Outcome and Surgeons' Experience - The Use of Patient Matched Instruments in Arthroplasty of the Knee]. / OP-Zeit, Ergebnis und Ausbildungsstand des Chirurgen ­ der Einsatz patientenindividueller Instrumente bei der Implantation von Kniegelenkendoprothesen.

Background Arthrosis of the knee is a common problem in Germany that is often treated with arthroplasty. To support the orthopaedic surgeon, person-matched instruments (PMI) are available from several providers. In this study we investigated the clinical and radiological outcome of the use of the PMI Visionaire™ (Smith&Nephew). Furthermore, we investigated the influence of operative experience of the orthopaedic surgeon on the clinical and radiological results. Time in the operating room (OR) was identified as a parameter for cost effectiveness even during training to become an orthopaedic surgeon. Material und Methods 173 of 436 cases (56.6% women, 68.7 ± 0.7 years) were included in this retrospective observation. Time in the OR, Oxford Knee Score (OKS), range of motion (ROM) as well as the position of the used implant under radiological control were the parameters used to describe the results. Hereby, we compared the use and the non-use of the PMI as well as the experience of the orthopaedic surgeon (years of training and experience). Results The use of PMI led to significant decrease of time in the OR (7 minutes in mean; p = 0.004). Surgeons with more than 6 years of experience were faster than surgeons with less than 6 years of experience with and without the use of PMI (21 respectively 17 minutes). In both groups, the use of PMI led to reduced time in the OR (more experience: 6 minutes [p = 0.211]; less experience: 10 minutes [p = 0.005]). There were no relevant differences in clinical and radiological findings in the comparison of use or non-use of PMI or surgeons with more or less than 6 years of experience. Conclusion The use of PMI for knee arthroplasty is a helpful tool for reducing time in the OR. Because there were no relevant differences in the clinical and radiological results, there were no higher risks for patients. The only relevant advantage was the reduction of time in the OR. If this affects the incidence of periprosthetic infections or leads to cost effectiveness for the hospitals especially during the period of training of young surgeons are questions that should be investigated in further studies.

Reference Values for Exercise Systolic Blood Pressure in 12- to 17-Year-Old Adolescents.

OBJECTIVE: In adults, blood pressure (BP) during exercise has prognostic advantages compared to resting BP, whereas its relevance for children has not been revealed as clearly. Because exercise BP among young subjects might be of clinical importance, we sought to determine reference values in adolescents. METHODS: BP recordings at rest and during a cycle ergometer test (1.5W/kg) were assessed in 492 teenagers (12-17 years) in the Kiel EX.PRESS. Study (EXercise and PRESSure). The resting systolic BP (SBP) values at the 90th and 95th percentile of the German reference population were applied on our resting SBP distribution. The resulting resting SBP percentiles were then used to propose exercise SBP limits. RESULTS: Of our group, 12.4% exhibited a resting SBP ≥ 90th reference percentile, with 7.9% ≥ 95th percentile. The corresponding age group- and sex-specific percentiles were assigned to the exercise SBP distribution resulting in reference values for high normal and elevated SBP (upper limit, girls/boys, mm Hg): 172/172 for 12-13 years, 174.7/177.3 for 14-15 years, 178.5/201.3 for 16-17 years). Using these limits, exercise SBP values were elevated in 8.1%, 5.5% were within the high normal range. Normal resting SBP but at least high normal exercise SBP was found in 7.7%. In contrast, 7.4% were high normal or hypertensive at rest but normotensive during exercise. CONCLUSIONS: Exercise BP is expected to be of additional use for the evaluation of BP in younger age groups. As long as prognostic data for exercise BP in adolescents are not available, the limits proposed might be considered in clinical practice.

Effects of parental smoking on exercise systolic blood pressure in adolescents.

BACKGROUND: In adults, exercise blood pressure seems to be more closely related to cardiovascular risk than resting blood pressure; however, few data are available on the effects of familial risk factors, including smoking habits, on exercise blood pressure in adolescents. METHODS AND RESULTS: Blood pressure at rest and during exercise, parental smoking, and other familial risk factors were investigated in 532 adolescents aged 12 to 17 years (14.6±1.5 years) in the Kiel EX.PRESS. (EXercise PRESSure) Study. Exercise blood pressure was determined at 1.5 W/kg body weight using a standardized submaximal cycle ergometer test. Mean resting blood pressure was 113.1±12.8/57.2±7.1 mm Hg, and exercise blood pressure was 149.9±19.8/54.2±8.6 mm Hg. Parental smoking increased exercise systolic blood pressure (+4.0 mm Hg, 3.1 to 4.9; P=0.03) but not resting blood pressure of the subjects (adjusted for age, sex, height, body mass index percentile, fitness). Parental overweight and familial hypertension were related to both higher resting and exercise systolic blood pressure values, whereas associations with an inactive lifestyle and a low educational level of the parents were found only with adolescents' blood pressure during exercise. The cumulative effect of familial risk factors on exercise systolic blood pressure was more pronounced than on blood pressure at rest. CONCLUSIONS: Parental smoking might be a novel risk factor for higher blood pressure, especially during exercise. In addition, systolic blood pressure during a submaximal exercise test was more closely associated with familial risk factors than was resting blood pressure, even in adolescents.