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Iatrogenic perforation of a hollow organ after diagnostic or therapeutic gastrointestinal endoscopic procedures is a rare but potentially life-threatening complication. The absolute incidence of iatrogenic perforation is assumed to increase worldwide (1, 2). The reason appears to be the more frequent use of colonoscopy screening and the more widespread use of interventional endoscopic techniques, such as endoscopic mucosal resection or endoscopic submucosal dissection. Both interventions are recommended in the guidelines to treat early neoplasia (3, 4). In Germany, approximately 4.4 million screening colonoscopies were performed between 2003 and 2012 (5). The incidence of iatrogenic perforation during solely diagnostic endoscopic procedures is low; for diagnostic colonoscopy/sigmoidoscopy, it is in the range of 0.03 to 0.8% (1, 6, 7). While iatrogenic perforation occurs in approximately 1 in 3000 solely diagnostic colonoscopies, the risk of perforation grows with increasing extent of the intervention (8). An almost linear relationship between polyp size in the colon and risk of perforation after endoscopic resection has been reported (9). The Munich Polypectomy Study found polypectomy-related perforations in altogether 1.1% of cases; for sessile lesions in the right colon, the incidence increased to 11.7% (9). In more recent studies, perforation rates for colorectal adenomas >20 mm, which were removed by means of endoscopic mucosal resection (EMR), were considerably lower (0.003% to 1.3%) (10, 11). Likewise, the risk of complications increases with the complexity of the intervention. With the introduction of the endoscopic submucosal dissection (ESD) technique from Japan, the endoscopic treatment of mucosal cancer

The number of good results after triple arthrodesis due to neuromuscular foot disorders in literature varies between 24% and 94%. 46 patients with 64 triple arthrodesis due to neuromuscular foot disorders were reexamined 18 years (15 to 25 years) after the operation. In 36 cases arthrodesis was performed by k-wire and pin fixation and in 28 cases by k-wire and screw-fixation. For preoperative and follow-up grading the McGuire score was used which increased on the average due to the operation from 58 to 89 points. Good and excellent results were found in 91% of the patients. Triple arthrodesis in patients with neuromuscular foot disorders is recommended. It leads to functional good results with a small amount of complications.

QUESTION Is sonography helpful in facet joint infiltration of the lumbar spine? METHOD The sonoanatomy of the lumbar spine and the of lumbosacral junction was examined and described in a skeleton and in 10 volunteers. One representative cross section and 3 longitudinal sections were defined. According to these results (no neurological symptoms) the possibilities of ultrasound guided infiltration of the facet joints was examined in 78 patients (36 female, 42 male, average age 55 y., 38-78 y.) with chronic low back pain and increase of pain by hyperextension. 5 ml Carbostesin partially in combination with steroids were applied to each joint. In all cases the tip of the syringe could be placed on the joint. RESULTS There were no complications, especially no infection or neurological symptoms. Application of local anaesthetics into the spinal canal could be excluded in all cases. The sonoanatomy of the lumbar spine and of the lumbosacral junction can be reproduced. Sonography allows an accurate infiltration of the facet joints of the lumbar spine. Applications into the spinal canal can be avoided. CONCLUSIONS This method is a secure and economic (extra time 2-4 min.) alternative to clinically guided infiltration. Flouroscopy guided infiltration is needed only in anatomical variations or if strictly intraarticular application is necessary.

During the last 2 years 75 patients referred to our hospital for operation of a persistent tennis elbow were followed prospectively after receiving low-energetic extracorporal shock wave therapy. 3 times in weekly intervals all patients received 1000 impulses of the energy density 0.06 mJ/mm2. Follow-ups were performed at 3, 6, 12, 24 weeks. Statistical analysis showed significant improvement both of subjective and objective criteria. 41 patients became painfree. Only 7 patients decided to have an operation after the 24-weeks-follow-up. Ambulatory shock wave therapy is a considerable alternative before surgical intervention in chronic tennis elbow.

Ziel: Messung des reellen Femurantetorsions (AT)- und Caput-Collum-Diaphysenwinkels (CCD-Winkels) im computer (CT)- und magnetresonanz (MR)-tomographischen Bild sowie Direktmessungen am Praparat im Vergleich. Es soll gezeigt werden, dass die mit einer Strahlenexposition verbundene computertomographische durch die rontgenstrahlenfreie MR-tomographische Messung ersetzt werden kann. Material und Methoden: Die computer- und MR-tomographischen Bilder wurden von 25 im Wasserbad gelagerten mazerierten Leichenfemora angefertigt und anschliesend an einer Workstation uber ein 3D-Programm von 4 Auswertern unabhangig voneinander ausgewertet. Des Weiteren erfolgte eine Direktmessung der Winkel am Praparat, welche als Referenzstandard diente. Ergebnisse: Es ergaben sich gute Ubereinstimmungen der 4 Auswerter bei den computer- und MR-tomographischen Messungen des AT- und CCD-Winkels, ebenso im Vergleich zur Referenzmethode. Als Mas fur die Interobserverreliabilitat der CT-Messungen ergab sich ein ICC (Intra-Class-Korrelationskoeffizient) fur die AT-Winkel von 0,97 und fur die CCD-Winkel von 0,90, bei den MRT-Messungen fur den AT-Winkel von 0,95 und fur die CCD-Winkel von 0,71. Die mittlere Abweichung aller computertomographisch bestimmten AT-Winkel von den Werten gemessen am Praparat betrug 0,8°, bei den CCD-Winkeln 0,7°. Die mittlere Abweichung aller MR-tomographisch bestimmten AT-Winkel von den Winkeln gemessen am Praparat betrug 0,3 °, bei den CCD-Winkeln - 0,4 °. Die mittlere Abweichung aller in der CT bestimmten AT-Winkel von den Winkeln gemessen in der MR-Tomographie betrug 0,5°, bei den CCD-Winkeln ebenfalls. Die durchgefuhrten Messungen zeigten keinen Anhalt fur systematische Messfehler und/oder Abhangigkeiten von der quantitativen Grose der Referenzwerte. Schlussfolgerung: Die computer- und MR-tomographischen Vergleichsmessungen des reellen AT- und CCD-Winkels an den 25 mazerierten Leichenfemora zeigten eine fur die Klinik mehr als ausreichende Genauigkeit und Reproduzierbarkeit. Die MR-tomographische Winkelmessung ergibt somit eine praktikable Untersuchungsmoglichkeit, ohne den Patienten ionisierender Strahlung aussetzen zu mussen. Purpose: To compare measurements of the real AT (femoral antetorsion) and CCD (caput-collum-diaphysis) angle by computed tomography (CT) and magnetic resonance imaging (MRI) of hip specimen using direct measurements as reference standard, and to show that measurement by MRI can replace CT measurements and may help avoiding X-ray exposition. Materials and Methods: CT and MRI measurements were obtained on 25 in water-arrested macerated human femora. Postprocessing was done by 4 independent readers on a workstation using a dedicated 3D-software. Direct measurements of the real AT and the CCD angle were used as reference standard. The analysis included Student's t test for paired values, interobserver variability using intra-class correlation coefficients (ICC), maximum and middle divergence of the angles, and Bland-Altman plots. Results: For determining AT and the CCD angle with CT and MRI, good correlation was found between the 4 readers and with measurements using the reference standard. ICCs were 0.97 and 0.90 for measuring AT and CCD angle with CT, and 0.95 and 0.71 for measurements with MRI, respectively. Mean divergence between CT measurements and those of the reference standard was 0.8° for AT and 0.7° for the CCD-angle. Mean divergence between MRI measurements and those of the reference standard was 0.3° for AT and -0.4° for the CCD-angle. Mean divergences between CT and MRI measurements of AT and CCD-angle were 0.5°. Neither systematic errors nor dependences on the qualitative size of the reference data were evident in the divergences of measurements. Conclusion: Measurements of the real AT and CCD angle by CT and MR imaging revealed a good correlation with direct measurements of the femoral specimen and consequently can be recommended for clinical use. MRI measurements can replace CT measurements, avoiding X-ray exposure especially in young patients undergoing preoperative evaluation for hip dysplasia.

Numerous formal, positional and angular foot skeleton deviations have been described in radiographic evaluation of congenital clubfoot. To clear up the correlation between clinical and radiological findings, a retrospective study involving 62 cases of congenital clubfoot in 38 patients was carried out, including follow-up observation for 7 years after soft-tissue surgery. Only clubfeet with grade II Harrold and Walker classifications according to the initial findings were included. Clinical follow-up examinations followed the Functional Rating System (FRS) of Laaveg and Ponseti. The postoperative talocalcaneal (TC) angle, measured on a lateral image, averaged 23 degrees as opposed to 32 degrees in healthy feet, i.e. much smaller, although this very significant angle dimension showed only minimum differences between the evaluation groups "very good" to "poor". The TC angle anteroposterior (AP), talonavicular angle (AP and lateral) as well as the calcaneometatarsal V angle revealed considerable deviations, although a correlation of clinical severity grading with the measured angular dimensions was not possible due to measurement imprecision and the range of values occurring within the different severity groups.

We aimed to determine whether extracorporeal shock waves of varying intensity would damage the intact tendo Achillis and paratenon in a rabbit model. We used 42 female New Zealand white rabbits randomly divided into four groups as follows: group a received 1000 shock-wave impulses of an energy flux density of 0.08 mJ/mm2, group b 1000 impulses of 0.28 mJ/mm2, group c 1000 impulses of 0.60 mJ/mm2, and group d was a control group. Sonographic and histological evaluation showed no changes in group a, and transient swelling of the tendon with a minor inflammatory reaction in group b. Group c had formation of paratendinous fluid with a significant increase in the anteroposterior diameter of the tendon. In this group there were marked histological changes with increased eosin staining, fibrinoid necrosis, fibrosis in the paratenon and infiltration of inflammatory cells. We conclude that there are dose-dependent changes in the tendon and paratenon after extracorporeal shock-wave therapy and that energy flux densities of over 0.28 mJ/mm2 should not be used clinically in the treatment of tendon disorders.

This study compares sonographical, histopathological, magnetic resonance imaging (MRI), and electromyographical (EMG) findings following acute muscle denervation. We performed an experimental denervation of the supraspinatus and infraspinatus muscles on 35 New Zealand white rabbits by segment resection of the suprascapular nerve. The sonographical appearance of the supraspinatus muscle was followed and documented at short time intervals within a 2-month follow-up period. The sonographical, histopathological, and MRI changes due to denervation suggest a regular pattern. Apart from the reduction of the muscle diameter, there were considerable sonographical signs of denervation with an increase of echointensity and inhomogenicity of echotexture that appeared on day 14 after injury, and progressed continuously with time. MRI revealed a remarkable increase in signal intensity 3 weeks after denervation and reproducible T2 times. Pathological spontaneous activity on EMG could also be detected from day 14 after injury. Conventional histopathological staining methods (H & E, NADH, ATPase, basic and acid phosphatase) confirmed denervation and absence of reinnervation. The first nonspecific histopathological changes were seen 11 days after denervation in the form of moderately atrophic fibers. Typical histopathological signs of denervation appeared 3 weeks after nerve dissection. In summary, EMG, ultrasound, MRI, and histopathology each showed first abnormalities after about 2 weeks. In addition to EMG, sonography and MRI can document the course of muscle atrophy and mesenchymal abnormalities in neurogenic muscle lesions.

Since the late 1980s, experiments have been performed to influence physiologic and disturbed healing of bone. However, the mainly negative results of animal studies, cannot be applied to the human nonunion situation as long as there is no adequate animal pseudarthrosis model. Prospective clinical studies in various centres have resulted in success rates of more than 50 %, although the majority of patients had been treated repeatedly and ineffectively with the gold standard of re-osteosynthesis and grafting. Since the mechanisms are not yet understood, only such desperate conditions are an indication for the application of high-energy extracorporal shock waves.

After sonographical examination with a 7.5-MHz linear array scanner, we created an experimental muscle injury of known sitze and location on 28 New Zealand white rabbits by stabbing them with a scalpel in the supraspinatus muscle. The changes in the healing process were followed and documented by sonography and magnetic resonance imaging (MRI) before and 2, 5, 11, 14, 36 and 64 days after injury. The changes in sonography and MRI followed a regular course. Ultrasound revealed an echo-poor area after injury with ever increasing echogenicity from the 14th day. Strong reflexes were found after 2 months. MRI showed few changes, only a slight increase of signal intensity, but a characteristic curve of calculated T2-times (a program of the MRI software). The interpretation of the sonographical picture in histopathological terms remained limited. The development of a hematoma and of fibrous scars can be followed up by sonography, but it is not possible to determine the point of time after injury very accurately. Nevertheless, sonography is a method of great value in the diagnosis of muscle injuries and, given certain limits, in the follow-up of the healing process, too. The significance of MRI can be increased by calculations with the implemented software, as in our study calculated T2-times produced a characteristic curve reflecting the shift of fluids after muscle injury.

From 87 patients who underwent anterior cruciate ligament (ACL) surgery with an alloplastic ligament (Trevira hochfest) the radiographs of 77 patients were examined by 2 physicians, who were not involved in the operation. They evaluated the increase of degenerative osteoarthritis according to the classification by Holz [12] finding a significant increase of degenerative osteoarthritis after surgery with a mean follow-up of 41.2 months. The ligament reconstruction was performed in 50 fresh ACL tears by reinsertion plus synthetic ligament protection and in 27 chronic instabilities with several failed previous operations by using the alloplastic ligament as an ACL prosthesis by means of a salvage procedure. Both investigators found a significant increase of degenerative osteoarthritis in both groups, but the chronically instable knees had a higher initial value. Patients with concomitant meniscus and/or posterior cruciate ligament (PCL) ruptures showed the highest increase of osteoarthritic changes; isolated ACL tears were found with very low degeneration. Considering the special profile of our collective, the factors that were found to as a risk of osteoarthritis and the comparison with the literature we could not find any indication for a relevantly increased risk of osteoarthritic progression using the Trevira hochfest ligament.

We report a controlled, prospective study to investigate the effect of treatment by low-energy extracorporeal shock waves on pain in tennis elbow. We assigned at random 100 patients who had had symptoms for more than 12 months to two groups to receive low-energy shock-wave therapy. Group I received a total of 3000 impulses of 0.08 mJ/mm2 and group II, the control group, 30 impulses. The patients were reviewed after 3, 6 and 24 weeks. There was significant alleviation of pain and improvement of function after treatment in group I in which there was a good or excellent outcome in 48% and an acceptable result in 42% at the final review, compared with 6% and 24%, respectively, in group II.

Summary Over a period of 4 years we performed a prospective randomized trial on 100 patients in order to compare the effects of low-energy extracorporal shock-wave therapy (ESWT) in the treatment of painful heel (chronic plantar fasciitis). Patients in group I were treated three times at weekly intervals with 1000 impulses of 0.08 mJ/mm 2 given around the heel spur. Group II received treatment three times with 10 impulses of the same energy density at weekly intervals. Follow-up examinations were done at 12 and 52 weeks, respectively. The main outcomes assessed were reduction in severity of pressure pain, period of pain-free walking, and patient satisfaction. At 12 weeks, 16 of 50 patients in group I were almost or completely pain free, compared to one in group II. The period of pain-free walking increased by 141% in group I, compared to 33% in group II. The subjective assessment showed 10 excellent and 18 good results in group I compared to no excellent and eight good or fair results in group II. Twenty-six patients in group I were satisfied with the treatment compared to six in group II. Several patients had additional treatment after the 12-week assessment. At one year, 20% of group I patients had received combined conservative therapy, and 4% had had an operation, whereas 58% of group II had had combined therapy and 32% had had surgery. At the one-year follow-up there was still a difference in outcome in favour of group I, with 29 patients satisfied in group I versus 18 in group II. We conclude that three treatments with 1000 impulses of low-energy shock waves at 12 and 52 weeks provides an effective therapy for chronic plantar fasciitis.

For the purpose of follow-up of the disease as well as the availability of magnetic resonance imaging (MRI) as a method for diagnosing soft tissue changes 20 patients with imminent and manifest compartment syndrome were examined for their fluid content of the lower limb. Considering the normal side as well as 10 healthy volunteers a significant reduction of fluid content was diagnosed in the manifest compartment syndrome after fasciotomy in the late phase of disease (r = 0.49, p > 0.005, n = 29). This was interpreted as a sign of fibrosis. The patients with imminent compartment syndrome and fasciotomy (r = 0.83, p > 0.001, n = 19) demonstrated no significant changes compared to the normal volunteers (r = 0.91, p > 0.001, n = 40) as well as the normal compartments of the diseased lower extremities (r = 0.85, p > 0.001, n = 32). MRI is a useful method in the examination of soft tissue changes and underlines the importance of an early fasciotomy in case of imminent compartment syndrome.

An 18 Kaninchen wurde eine Stichinzision von definierter Grose am Musculus supraspinatus vorgenommen und das kernspintomographische Signalverhalten dieses Muskels bis zum 64. Tag nach Lasion bestimmt. Wahrend bei der Betrachtung der MRT-Bilder keine Auffalligkeiten zu erkennen waren, konnte eine charakteristische Verlaufskurve der kalkulierten T2-Zeiten (ein rechnerisches Verfahren der MRT-Software) beobachtet werden. Die kernspintomographischen Ergebnisse sind mit den histopathologischen Vorgangen nach Muskelverletzung vereinbar. Die kernspintomographische Untersuchung ermoglicht durch den Nachweis von Flussigkeitsverschiebungen mittels kalkulierter T2-Zeiten die Beurteilung von Schaden der Muskulatur auch nach Minimalverletzungen.

An 28 Neuseelandkaninchen wurde eine experimentelle partielle Durchtrennung der Achillessehne durchgefuhrt. Die Veranderungen im Verlauf der Heilung wurden nach einem festen Untersuchungsschema in kurzen Intervallen uber zwei Monate sonographisch dokumentiert. Die sonographisch feststellbaren Veranderungen unterliegen regelhaften Ablaufen. Die Veranderungen des Ultraschallbildes sind unter Berucksichtigung theoretischer Ultraschallphysik durch die feingeweblichen Veranderungen erklarbar. Hamatomentwicklung und fibrose Vernarbung konnen sonographisch verfolgt werden. Die Sonographie ist sowohl eine wertvolle Methode in der Diagnostik der partiellen und totalen Sehnenruptur als auch unter Vorbehalten in der Verlaufskontrolle der Heilungsvorgange. Der Aussagekraft der Sonographie bei der Beurteilung von Sehnenverletzungen sind jedoch Grenzen gesetzt.

The value of neurophysiological tests of the autonomic nerve system is limited. One of the clinically most commonly applied test is the skin sudomotor response, frequently referred to as 'sympathetic skin response' (SSR). However, the SSR is a more qualitative than quantitative evaluation technique. Continuous wave (cw) Doppler sonography of the radial artery may be an alternative quantitative approach. We studied 41 age matched volunteers (23 female, 18 male; 16-82 years (mean age 53 years)). The stimulus was a loud and unexpected acoustic signal, alternatively a cough. SSR evaluation included the latency of onset, the duration and the amplitude of the response. Doppler evaluation also included flow velocity and resistance index (RI) changes with adequate stimulation. SSRs were observed in 36 volunteers (88%), Doppler responses in 35 (85%). The latency between stimulus and response onset was 1.35 s with SSR and 1.52 s with ultrasound (n.s.). The mean SSR amplitude was 1.3 mV, systolic velocities decreased by 20% and diastolic velocities by 124% (flow reversal). RI increased from 0.85 to 1.25 with no correlation between SSR amplitude and flow velocity changes. SSR and cw Doppler are complementary methods. Doppler sonography offers an additional approach of autonomic nerve evaluation.

Fifty patients who suffered from persistent tennis elbow for more than 12 months, and were referred for surgical treatment, were assigned at random to 2 groups of low-energy extracorporal shock wave therapy. Group I received a total of 3000 impulses of 0.08 mJ/mm2; group II (controls) 30 impulses of 0.08 mJ/mm2. Follow up was after 3 and 12 weeks. We found no significant differences between the 2 groups before treatment, there was but significant relief of pain and improvement of function in group I with good or excellent outcome in 56% at the last evaluation.

The knee radiographys of 77 patients were examined by two physicians not involved in the operation a mean of 41.2 months after implantation of a synthetic ligament (Trevira hochfest). They evaluated the increase of degenerative osteoarthritis on a five-grade scale (0–4) by Jonasch and Mohing as modified by Holz, and using the IKDC score. Fifty patients with acute rupture had the synthetic ligament implanted for protection of anterior cruciate repair. Twenty-seven patients had a salvage procedure with the alloplastic ligament functioning as a prosthesis. Both examiners found a statistically significant increase of degenerative arthritis. Patients with acute anterior cruciate tears had a lower degree of osteoarthritis on the day of surgery compared to the patients with chronic insufficiency, but the postoperative increase was identical in both groups. Statistical analysis revealed correlations between osteoarthric changes and several factors such as concomitant meniscus or posterior cruciate injury and demonstrated no correlation to the grade of postoperative stability or injuries to the medial or lateral collateral ligaments or capsule.