[Laser in situ keratomileusis with microkeratome or femtosecond laser]. / Laser-in-situ-Keratomileusis mit Mikrokeratom oder Femtosekundenlaser.

OBJECTIVE AND PRINCIPLES: In LASIK, after cutting a lamellating stromal corneal incision (flap) with a microkeratome or a femtosecond laser, the underlying tissue is treated with an excimer laser for refractive correction. The objective is to achieve independency from spectacles and contact lenses due to correction of ametropia. INDICATIONS: Surgery is indicated when the patient wishes to achieve independency from spectacles and contact lenses. For LASIK, the German Commission for Refractive Surgery defined a range of applicability for myopic correction up to -8 diopters (D), astigmatic correction up to 5 D and hyperopic correction up to +3 D. Borderline applicability is defined as myopic correction up to -10 D, astigmatic correction up to 6 D and hyperopic correction up to +4 D. OPERATIVE TECHNIQUE: The surgical technique is demonstrated in detail with the help of a video of the operation, which is available online. The flap incision is created with a microkeratome or a femtosecond laser. After lifting and folding the flap, excimer ablation is performed. An eye tracking system ensures correct location of ablation by compensating for intraoperative eye movements. After repositioning the flap, the interface is irrigated and the edge of the flap is adapted with a sponge. RESULTS: The LASIK procedure is safe, predictable and efficient with a high rate of patient satisfaction. The complication rate can be minimized by using a careful and standardized surgical approach.

[Prevalence and age-related changes of corneal astigmatism in patients before cataract surgery]. / Prävalenz und Altersabhängigkeit von kornealem Astigmatismus bei Patienten vor Kataraktchirurgie.

BACKGROUND: The aim of this study was to determine the extent and the distribution of corneal astigmatism in patients awaiting cataract surgery in a mid-European tertiary clinic centre and hence to establish the demand for methods reducing corneal astigmatism. PATIENTS AND METHODS: Keratometry measurements of cataract surgery candidates assigned to a university clinic between January 2013 and October 2014 were recorded and analysed retrospectively. RESULTS: A total of 6900 eyes of 3450 patients with a mean age of 72.5 ± 12.2 were analyzed. The corneal astigmatism was more than 0.5 dioptres (D) in 5193 eyes (75.3 %), >1.0 D in 2641 eyes (38.3 %), >1.5 D in 1304 eyes (18.9 %), >2.0 D in 644 eyes (9.3 %), >2.5 D in 363 eyes (5.3 %), >3.0 D in 236 eyes (3.4 %) and >3.5 D in 149 eyes (2.2 %). With increasing age a shift from with-the-rule astigmatism towards against-the-rule astigmatism was observed. CONCLUSION: Of the patients admitted for routine cataract surgery at our clinic, 2641 eyes (38.3 %) had an astigmatism greater than 1.0 D. Our data could be helpful in establishing a protocol for using toric intraocular lenses and to determine the costs.

Predictors of outcome after single-event multilevel surgery in children with cerebral palsy: a retrospective ten-year follow-up study.

AIMS: Single event multilevel surgery (SEMLS) has been shown to improve gait in children with cerebral palsy (CP). However, there is limited evidence regarding long-term outcomes and factors influencing them. METHODS: In total 39 children (17 females and 22 males; mean age at SEMLS ten years four months, standard deviation 37 months) with bilateral CP (20 Gross Motor Function Classification System (GMFCS) level II and 19 GMFCS level III) treated with SEMLS were included. Children were evaluated using gait analysis and the Gait Deviation Index (GDI) before SEMLS and one, two to three, five and at least ten years after SEMLS. A linear mixed model was used to estimate the effect of age at the surgery, GMFCS and follow-up period on GDI. RESULTS: There was a mean improvement of 12.1 (-15.3 to 45.1) GDI points one year after SEMLS (p < 0.001) and 10.3 (-23.1 to 44.2) GDI points ten years after SEMLS compared with before SEMLS (p < 0.001). GMFCS level III children aged ten to 12 years had the most improvement. The GMFCS III group had more surgical procedures at the index SEMLS (p < 0.001) and during the follow-up period (p = 0.039). After correcting for other factors, age at surgery was the only factor predictive of long-term results. Our model was able to explain 45% of the variance of the change in GDI at the different time points. TAKE HOME MESSAGE: Children with GMFCS III level aged ten to 12 are the benchmark responders to SEMLS in the long-term.

[Pediatric knee injuries]. / Kindliche Kniebinnenverletzungen.

Patella dislocations are the most common knee injuries causing hemarthrosis in children. Flake fractures represent the main complication of these injuries and require fixation. First time dislocations are treated conservatively. Recurrent dislocations are managed operatively. Precise analysis of the underlying dispositional and pathological factors is important to determine the appropriate operative procedure. To protect the growth plate, special techniques are required. Tibial spine fractures are bony avulsions of the anterior cruciate ligament (ACL). Management includes closed reduction in hyperextension and immobilization in a knee cast. Tibial spine fractures which cannot be reduced require operative treatment using either arthroscopic or open reduction and stabilization without injuring the growth plate. Intraligamentous ACL injuries are increasingly observed in children and adolescents. The risk of meniscus tears or chondral damage is high in these injuries. In case of persistent ACL instability, early reconstruction is recommended. Various techniques have been described; however, there is no consensus regarding the most favorable technique. The attending physician must be familiar with different ACL reconstruction techniques and with the anatomy of the growth plate. Meniscus tears require early suturing. Healing rates are good in children.

The Baumann procedure to correct equinus gait in children with diplegic cerebral palsy: long-term results.

Although equinus gait is the most common abnormality in children with spastic cerebral palsy (CP) there is no consistency in recommendations for treatment, and evidence for best practice is lacking. The Baumann procedure allows selective fractional lengthening of the gastrocnemii and soleus muscles but the long-term outcome is not known. We followed a group of 18 children (21 limbs) with diplegic CP for ten years using three-dimensional instrumented gait analysis. The kinematic parameters of the ankle joint improved significantly following this procedure and were maintained until the end of follow-up. We observed a normalisation of the timing of the key kinematic and kinetic parameters, and an increase in the maximum generation of power of the ankle. There was a low rate of overcorrection (9.5%, n = 2), and a rate of recurrent equinus similar to that found with other techniques (23.8%, n = 5). As the procedure does not impair the muscle architecture, and allows for selective correction of the contracted gastrocnemii and soleus, it may be recommended as the preferred method for correction of a mild fixed equinus deformity.

[Diagnostic accuracy of contrast-enhanced 64-row MSCT coronary angiography in patients with severe coronary calcification in the clinical routine]. / Diagnostische Wertigkeit der kontrastverstärkten MSCT-Koronarangiografie bei Patienten mit hochgradiger Koronarverkalkung im klinischen Alltag.

PURPOSE: Our aim was to evaluate the diagnostic accuracy of contrast-enhanced 64-MSCT coronary angiography (MSCT-CA) in patients with severe coronary calcification. MATERIALS AND METHODS: 110 patients with an Agatston score > 400 were included in this retrospective analysis. Each patient underwent both conventional coronary angiography and MSCT-CA. No patient was excluded from the study because of coronary artery bypass grafting or coronary stenting. The results of MSCT-CA were compared with those of conventional coronary angiography and the diagnostic accuracy for detecting a hemodynamically significant stenosis was determined for coronary segments, vessels and patients. RESULTS: The average Agatston score for the study population was 1368 ± 1105. At least one significant stenosis was detected in 97 patients (88%) during conventional coronary angiography defining the gold standard. The sensitivity, specificity, positive and negative predictive values of MSCT-CA for detecting a significant stenosis were 54%, 83%, 52% and 85% for coronary segments (n = 1384), 80%, 70%, 74% and 77% for coronary vessels (n = 440), and 100%, 31%, 92% and 100% for patients (n = 110), respectively. No significant correlation could be observed between the degree of coronary calcification and the number of misclassified coronary segments. CONCLUSION: Artifacts caused by severe coronary calcification decrease the diagnostic accuracy of MSCT-CA. Performing MSCT-CA in patients with an Agatston score > 400 with the drawbacks of contrast media application and radiation exposure should be critically questioned and this decision should be made on an individual basis.

[Single event multilevel surgery to improve gait in diplegic cerebral palsy - a prospective controlled trial]. / Operative Mehretageneingriffe zur Gangverbesserung bei spastischer Diplegie - Eine prospektive kontrollierte Untersuchung1.

AIM: To evaluate prospectively the outcome of gait-improvement surgery in children with spastic diplegia. METHOD: Three-dimensional gait analysis was performed in twenty children with spastic diplegia. Ten children underwent single event multilevel surgery for gait improvement. Indications for individual procedures followed a fixed set of selection criteria. The other ten children continued with their physiotherapy programme and served as a control group. A second gait analysis was performed in all children after 1.5 years. Time-distance parameters and kinematics of the pelvis, hip, knee and ankle joints in the sagittal plane served as main outcome measures RESULTS: The patients walked faster with an increased stride length after surgery in comparison to the conservatively treated controls. The average pelvic tilt increased slightly and the range of motion of the knee joint increased considerably after multilevel surgery. The motion at the ankle remained unchanged over the study period in both the groups. An improved knee extension during the stance phase of gait served to improve stance limb stability and facilitated an unhindered swing phase of the opposite limb. CONCLUSION: This prospective trial showed favourable changes in gait function after multilevel surgery in spastic diplegic children.

Gut-derived bone infection in the neonatal rat.

The risk of osteomyelitis is increased in the premature and critically ill neonate. Although potential sites of bacterial entry are present in many of these infants, the source of infection frequently cannot be established. This study was performed to assess the possible role of bacterial translocation from the intestine in the origin of bone infection using models of breast-fed and formula-fed rat pups. Newborn Sprague-Dawley rats suckled either ad libitum by the dam (n = 30), or were fed a rat milk-simulated formula (n = 30). After 3 d, the animals were killed, and the left femur, heart blood, mesenteric lymph nodes, liver, spleen, and terminal ileum were excised. Organs were analyzed for bacteria by standard microbiologic procedures. Bacterial translocation occurred in 23% of breast-fed rats; the bone was not infected in any of these animals. After feeding of formula diet, bacterial counts of the ileum were markedly elevated (p < 0.001), and the composition of the gut flora was disrupted. Bacterial translocation was noted in all formula-fed rats. Bone cultures were positive in 23 of 30 (77%) rats after formula-feeding (p < 0.001 versus breast-feeding). Organisms translocated to the bone included Enterococci, Proteus, Enterobacter, and Escherichia coli. Bacterial species cultured from the bone correlated with the individual colonization pattern of other extraintestinal organs and with the composition of the ileal flora. Members of the gut flora can escape the intestine and colonize the bone in formula-fed rats. The gut should be considered as a potential source for osteomyelitis in the neonate.

Conservative management of dynamic equinus in diplegic children treated by gait improvement surgery.

Multilevel surgery for gait improvement was performed on twelve ambulatory children with diplegic type of cerebral palsy and dynamic equinus deformity. Dynamic equinus deformities were defined as those who had an equinus at initial contact during preoperative gait analysis, and where the equinus deformity was correctable passively during physical examination. Ankle function was evaluated by clinical examination and gait analysis before surgery, and at least 3 years after surgery. The ankle showed an increase in dorsal flexion at initial contact, at single stance and in swing. There was an increase in dorsal flexion at the beginning of push-off, without a decrease in the range of motion of the ankle during push-off. Ankle moments demonstrated significant improvement in the maximum flexor moment in the second half of single stance. There was a change from abnormal generation of the energy in mid-stance to the normal pattern of energy absorption. Positive work during push-off was significantly increased. Conservative management of dynamic equinus deformities combined with multilevel surgery to correct other deformities of the locomotion system resulted in significant improvements in ankle function during gait.

Propulsive function during gait in diplegic children: evaluation after surgery for gait improvement.

Seventeen patients with diplegic cerebral palsy were assessed by clinical examination and three-dimensional gait analysis before and after surgery to improve gait. Selection of surgical procedures was according to a fixed set of selection criteria. The average postoperative follow-up was 3.8 years (range, 2.6-5.7 years). Clinical examination revealed an improved range of motion for the ankle and no reduction in the power grade at the hip, knee and ankle after surgery. Kinematic parameters showed improved knee extension in stance and significant changes towards a normal ankle motion pattern postoperatively. Kinetic evaluation demonstrated that most of the total power during walking was generated at the hip, with the ankle contributing a small part. After surgery, patients walked faster with an increased power generation at the hip during first double support and at the ankle during push off. Power generation at the hip in stance is pointed out to be an important mechanism for propulsion during walking.

Time course of spontaneous bacterial translocation from gastrointestinal tract and its relationship to intestinal microflora in conventionally reared infant rats.

Whereas the developed gut mucosal barrier prevents luminal bacteria from invading the host, bacterial translocation appears to be facilitated in the neonate. The aim of this study was to determine the extent to which bacteria spontaneously translocate from the gut to extraintestinal organs during the neonatal period and to relate translocation to the evolving intestinal flora in the rat. Newborn Sprague-Dawley rats suckled ad libitum and ate regular chow after weaning. A total of 167 rats were killed either immediately or at 1, 9, 14, 21, 26, or 42 days after delivery. Mesenteric lymph nodes (MLN), liver, heart blood, and the terminal ileal loop were harvested under sterile conditions and analyzed for aerobic and facultatively anaerobic bacteria by standard microbiologic procedures. Bacterial translocation to the MLN and liver began soon after birth and peaked during the second week. On day 14, translocation to any organ was present in 85% of rats. All cultures from the liver were sterile after day 26. By contrast, the fall in translocation to the MLN was incomplete, as 50% of pups still had positive MLN on day 42. Blood cultures were positive in three of the 167 rats. The intensity of translocation as determined by the number of organs infected significantly increased with the number of gram-negative enterics and gram-positive cocci in the gut and was negatively correlated with the percentage of lactobacilli from the total measured intestinal flora (P < 0.0001). In conclusion, bacterial translocation from the gut is a physiological and age-dependent phenomenon in the neonatal rat. Translocation appears to be facilitated when intestinal concentrations of gram-negative enterics and gram-positive cocci are high and when the concentration of lactobacilli is low.

Hip locomotion mechanisms in cerebral palsy crouch gait.

The purpose of this study was to evaluate three defined locomotion patterns in cerebral palsy gait using computerised gait analysis. Ambulant diplegic children who had no previous surgery were included in the study and were divided into two groups: one group consisted of children having a crouch gait, and the other group did not have the crouch pattern of gait. An age-matched group of normal children served as the control group. Locomotion patterns studied were the hip hike, propulsive function of the hip extensors, and pseudo-adduction. A statistical analysis was performed between the groups, using defined parameters. The mechanism of hip hike was not utilised by any of the groups. Both groups of diplegic children showed power generation at the hip beginning in the first double support phase of the gait cycle and continuing in the first half of single limb support, while in the normals this was only in the first half of single limb support. Both the groups of diplegic children showed significantly more internal rotation in the first half of stance as compared to the group of normal children; the degree of hip adduction was the same in all the groups. Thus diplegic children had pseudo-adduction.

Fixed and dynamic equinus in cerebral palsy: evaluation of ankle function after multilevel surgery.

Multilevel surgery for gait improvement was performed on 29 ambulatory children with diplegic cerebral palsy. Patients were divided into two groups based on the presence of dynamic equinus (12 cases) and fixed equinus deformity (17 cases). Dynamic equinus deformities were not corrected surgically, and fixed deformities were corrected by intramuscular gastrosoleus lengthening. Ankle function was evaluated by clinical examination and gait analysis before surgery and a minimum of 3 years after surgery. Positive changes in ankle function were observed in both the groups. Conservative management of dynamic equinus deformities resulted in significant improvements in ankle function. Intramuscular lengthening of fixed equinus deformities does not cause a weakening of the muscle and improves static and dynamic function of the ankle.

Complex foot deformities associated with soft-tissue scarring in children.

Two cases of deformities in scarred feet are presented. One case had an old, well healed forefoot amputation with severe equinovarus deformity, and the other had an equinus deformity following a burn injury 10 months prior. Both the cases were managed by primary release of the contracted joint capsules. The correction of the soft-tissue contractures was achieved by gradual distraction using the Ilizarov apparatus. The clinical presentation and surgical treatment of complex foot deformities, complicated by the presence of scar tissue, are presented. These cases illustrate the benefits of combining soft-tissue release with the Ilizarov technique of distraction histogenesis in the treatment of complicated foot deformities associated with scarring in pediatric patients.

Assessment of hip rotation after gait improvement surgery in cerebral palsy.

Sixteen children with diplegic type of cerebral palsy and spastic internal rotation gait were evaluated using gait analysis before and an average of 3 years after multiple soft tissue surgery. Significant correction of the internal rotation gait was observed after multi-level soft tissue surgery which included medial hamstring lengthening in all cases. Our results suggest that for children with spastic internal rotation gait, multi-level soft tissue surgery effectively corrects the dynamic internal rotation gait in the absence of fixed bony rotational deformities.

The Baumann procedure for fixed contracture of the gastrosoleus in cerebral palsy. Evaluation of function of the ankle after multilevel surgery.

We treated 22 children (28 limbs) with diplegic cerebral palsy who were able to walk by the Baumann procedure for correction of fixed contracture of the gastrosoleus as part of multilevel single-stage surgery to improve gait. The function of the ankle was assessed by clinical examination and gait analysis before and at two years (2.1 to 4.0) after operation. At follow-up the ankle showed an increase in dorsiflexion at initial contact, in single stance and in the swing phase. There was an increase in dorsiflexion at initial push-off without a decrease in the range of movement of the ankle, and a significant improvement in the maximum flexor moment in the ankle in the second half of single stance. There was also a change from abnormal generation of energy in mid-stance to the normal pattern of energy absorption. Positive work during push-off was significantly increased. Lengthening of the gastrocnemius fascia by the Baumann procedure improved the function of the ankle significantly, and did not result in weakening of the triceps surae. We discuss the anatomical and mechanical merits of the procedure.

Intrasubject repeatability of gait analysis data in normal and spastic children.

OBJECTIVE: To evaluate intrasubject repeatability of data obtained from computer-aided motion analysis in normal and spastic children. DESIGN: Prospective controlled study. BACKGROUND: Information from gait analysis is used in selecting therapeutic interventions for gait improvement in cerebral palsy. While there are several studies regarding repeatability of normal gait, there are no studies evaluating the repeatability of spastic gait. METHODS: Forty children (20 normal, 20 with diplegic type of cerebral palsy) were subjected to gait analysis. Kinematic, kinetic and time distance parameters obtained from gait analysis were studied for intrasubject variability within-day and between-day using statistical measures. RESULTS: Normal children had lower variability in time distance parameters than spastic children both within and between days. The repeatability of kinetics was better than those of kinematics, and values for normal children were better than those for spastic children. Within-day repeatability of kinematics and kinetics was better in normal children. Between-day repeatability of kinematics was better in normal children, while spastic children showed better repeatability for kinetics. CONCLUSIONS: We found lower repeatability of gait analysis data in spastic children compared to normal children. Restricted joint range of motion due to spasticity in the group of cerebral palsy patients may be responsible for the lower repeatability of data. Some errors due to marker placement are inadvertent and contribute to the lower between-day repeatability. RELEVANCE: The results of this study should be of interest to clinicians who make therapeutic decisions in patients with cerebral palsy using gait analysis data, and for scientists studying normal and pathological gait.

Implantation of a soft-tissue expander before operation for club foot in children.

Primary skin closure after surgery for club foot in children can be difficult especially in revision operations. Between 1990 and 1996 a soft-tissue expander was implanted in 13 feet before such procedures. Two were primary operations and 11 were revisions. A standard technique was used for implantation of the expander. Skin augmentation was successful in 11 cases. There was failure of one expander and one case of wound infection. Sufficient stable skin could be gained at an average of five weeks. Primary skin closure after surgery was achieved in 12 cases. We conclude that soft-tissue expansion can be used successfully before extensive surgery for club foot. The method should be reserved for revision procedures and for older children. The technique is not very demanding, but requires experience to achieve successful results.

The effect of vitamin C and vitamin E supplementation on bacterial translocation in chronic portal hypertensive and common-bile-duct-ligated rats.

In rats with chronic portal hypertension (PH) and common bile duct ligation (CBDL), significant ileal bacterial overgrowth, translocation of indigenous intestinal bacteria, a decrease in hepatic and ileal reduced glutathione (GSH) and an increase in ileal mucosal lipid peroxidation occur. alpha-Tocopherol (vitamin E) and ascorbic acid (vitamin C) treatment attenuated the incidence of bacterial translocation, improved hepatic and ileal GSH levels and decreased ileal mucosal lipid peroxidation. These results suggest that in chronic PH and CBDL oxidative processes in the liver and intestine play an important role for bacterial translocation.