Epidemiology of posterior cruciate ligament injuries.

BACKGROUND: The epidemiology of posterior cruciate ligament (PCL) injuries has not been well clarified. Isolated and combined PCL injuries are a frequently missed diagnosis. A better understanding of typical injury mechanisms may help in more accurate diagnosis of these injuries. METHODS: In this study the epidemiology of PCL insufficiency in 494 patients was retrospectively analysed. Stress-radiography was used to quantify posterior tibial displacement. RESULTS: The mean age at the time of injury was 27.5+/-9.9 years. Traffic accidents (45%) and athletic injuries (40%) were the most common injury causes. Motorcycle accidents (28%) and soccer-related injuries (25%) accounted for the main specific injury causes. The most common injury mechanisms were dashboard injuries (35%) and falls on the flexed knee with the foot in plantar flexion (24%). The mean side-to-side difference of posterior tibial displacement on posterior stress-radiographs in 90 degrees of flexion was 13.4+/-4.7 mm. According to the posterior displacement values, 232 (47%) patients had isolated PCL ruptures, while 262 (53%) patients with a posterior displacement of >12 mm were classified as having a combined posterior instability. There were significantly more combined PCL lesions due to vehicular trauma as compared with athletic trauma ( p<0.0001). CONCLUSIONS: In many PCL lesions, initiation of an adequate treatment regimen is delayed despite typical injury mechanisms and symptoms. In the future, a better understanding of the epidemiology of PCL injuries should enable us to diagnose the injury more reliably through a detailed history and a thorough physical and radiographic examination in the acute setting.

[Arthroscopic therapy in limited mobility of the elbow joint]. / Die arthroskopische Therapie bei Bewegungseinschränkungen des Ellenbogengelenks.

Limitation of elbow mobility constitutes a grave problem for therapy. Arthroscopy offers a therapeutic option, but in cases of loss of motion poses a considerable challenge to the operative technique. Placement of the portals already carries an increased risk of neurovascular lesions due to the altered anatomy and reduced distension capacity of the joint. Thus, particular significance attaches to the standardized arthroscopic procedure for localization and placement of the cannulas, intra-articular assessment, differentiated evaluation of the dorsal joint regions, and operative tactics for transsection of cicatrization, removal of loose bodies, and excision of osteophytes. If extra-articular factors are involved in the genesis of the limited motion, arthroscopic treatment often does not achieve the desired result. It is therefore considered propitious to differentiate the causes of the loss of motion during clinical examination with imaging diagnostics, in particular to determine those caused by extra-articular elements. If, however, individually localized intra-articular adhesive bands or loose bodies are responsible, the prognosis for arthroscopic management is clearly more favorable. Patients with minor loss of motion (> 15 degrees) profit more from the arthroscopic operation than those with a extension or flexion deficit of more than 30 degrees.

[Diagnosis and therapy of fresh and chronic posterior cruciate ligament lesions]. / Diagnostik und Therapie der frischen und chronischen hinteren Kreuzbandläsion.

Injuries to the posterior cruciate ligament are among the major injuries to the knee joint. Today we are often confronted with an inappropriate and delayed diagnosis of this injury and its concomitant lesions. Additionally, the outcome of operative treatment has not yet reached an acceptable rate of satisfactory results. Therefore, the goal of this current concept review is to give a comprehensive insight into anatomy and biomechanics, injury mechanisms and pathobiomechanics, based on our experiences and data from the international literature. A further goal is to clarify diagnostic problems with respect to clinical examination and imaging techniques. We also present a differential concept for the perioperative and conservative management of posterior cruciate ligament deficient knees in order to also adequately address concomitant injuries such as posterolateral rotatory instability and combined anterior cruciate ligament injuries with the aim of further improving results.

[Primary tumor volume and prognosis in bronchial carcinoma]. / Primärtumorvolumen und Prognose beim Bronchialkarzinom.

UNLABELLED: Lymph node involvement and histologic type are well known and accepted as prognostic factors for bronchial carcinoma. The role of the primary tumor volume has been but rarely examined. However, it is accepted that there is a clear correlation between primary tumor mass and the level of tumor cell dissemination. Therefore primary tumor volume can be a useful prognostic indicator especially for those tumors of which no evidence of metastases can be proved even with CT or MR. In case of 1022 patients, having been received a tumor dose more than 5600 cGys (on the 80% isodose curve), if metastatic including the primary lymph nodes, we examined the correlation between histologic type, lymph node involvement, primary tumor volume and overall survival, response on chest X-ray films, and tumor destruction in autopsy materials, respectively. We found: 1. There was a strong correlation, especially in N0-cases, between primary tumor volume and overall survival, in all histologic types. 2. Small regional metastatic tumors (N1, N2) had a better prognosis than that of great tumors with no metastases (N0), in all histologic types. 3. Small adenocarcinomas and large-cell tumors without lymph node involvement had a better prognosis than that of squamous cell tumors of the same stage. 4. In 222 cases of T2N0-tumors five-year overall survival was 15.3%, in 43 cases of large-cell tumors and adenocarcinomas 29%, respectively. CONCLUSION: Primary tumor volume is an important prognostic factor and can be easily and objectively evaluated.

[Pilot studies on systemic radiotherapy of organ tumors (sequential upper and lower body irradiation)]. / Pilotversuche zur systemischen Strahlentherapie bei Organtumoren (sequentielle obere und untere Halbkörperbestrahlung).

UNLABELLED: A survey of literature shows that systemic radiotherapy, given as low dose total body irradiation, offers the same healing results in malignant systemic diseases as tumor chemotherapy. Single high dose half body doses are even effective against less sensitive organ cancers. The problem involved is the tolerance of the lung (fatal radiopneumonitis). The considerations made about the mode of action of ionizing radiation and cytostatic combinations result in clinical assays aiming at the establishment of a systemic radiotherapy based on sequential half body irradiation as an alternative to palliative or adjuvant cytostatic therapy. The advantage of this treatment would lie in the negligible subjective side effects, the great saving of time, and the moderate expense. The most important target of these pilot studies was in increase the pulmonary tolerance. 78 patients with small cell bronchial carcinomas, divided into four groups, are treated by different half body irradiation modalities: interruption of the single dose for 5 hours, small superfractionated additional doses conserving the principle of the high single dose. RESULTS: the possibility to increase the tolerance dose of the lung by 33% and, at the same time, to spare the bone marrow is demonstrated. No (negative) influence of the different irradiation modalities on the different irradiation modalities on the primary tumor is found (by histological examination). The median survival times of the irradiation series are 56 to 64 weeks (for "LD" patients) which lies within the scope of modern chemotherapy results. These pilot studies confirm the efficacy of sequential half body irradiations in systemic tumor therapy. The author give some recommendations how to extend this method.

Ultrastructural retinal changes after irradiation with fast neutrons.

Morphological changes occurring in the rabbit retina after fast neutron irradiation levels of 250,500 and 1,000 cGy are discussed. The threshold dose that may cause damage to retinal structures is 250 cGy.

Results of neutron therapy of soft-tissue sarcomas.

82 radioresistant mesenchymal sarcomas localized mainly at the trunk and the extremities have been irradiated with fast neutrons. In all three tumor dose ranges applied (6 to 9.6, 10 to 12.6, and 13 to 19 Gy) alike with 90% of the tumors either complete (congruent to 50%) or partial (congruent to 40%) regressions were observed; only 10% were unresponsive. Further 53 soft tissue sarcomas, showing a spontaneous recurrence rate following local extirpation up to 50%, underwent postoperative prophylactic irradiation with tumor doses of about 10 Gy. In 45 cases surveyed for at least two years, there developed seven (15%) recurrences in the irradiation field. The high regression rate and the good prophylactic effect against recurrences with doses well tolerable, render neutron radiation especially suitable for the treatment of soft tissue sarcomas.

[Lymphocyte depletion after irradiation of the chest region dependent on irradiation technics]. / Lymphozytendepression bei Bestrahlung im Thoraxbereich in Abhängigkeit von der Bestrahlungstechnik.

In a prospective alternating study, the mediastinum of patients with bronchial carcinomas was preoperatively irradiated with 2000 cGy in ten fractions for an isodose of 80% by Co-60 stationary field or pendulum therapy. The leucocyte and lymphocyte blood count was determined every day. It was found out that the lymphocyte depression was significantly higher after pendulum therapy than after stationary field therapy. This is explained by the fact that the lymphocyte depression is caused rather by the irradiation of lymphocytes in the blood stream than by the irradiation of bone marrow.

[Treatment of inoperable small-cell bronchial carcinoma with local radiotherapy and supplementary high-dosage one-time upper and lower half-body irradiation]. / Zur Behandlung inoperabler kleinzelliger Bronchialkarzinome mit lokaler Strahlentherapie und zusätzlicher hochdosierter einzeitiger oberer und unterer Halbkörperbestrahlung.

37 patients with histologically verified inoperable small-cell bronchial carcinomas were treated with local tumor irradiation (40 Gy), combined with upper and lower half-body irradiation. Continuous analysis of the treatment results led to modification of therapy, from which two groups of patients resulted. In group I the whole-body treatment consisted of an irradiation of the upper, and six weeks later, of the lower half of the body with a dose of 8.8 Gy. In group 2 the half-body dose of 8.8 Gy was applied in 2 fractions on the same day (6.0 Gy, break of 5 hours, 2.0 Gy). The critical organ was the lung: the pneumonitis rate and the effect on tumor and metastases and survival times are reported.

[Autopsy and clinical findings of metastases in bronchial carcinoma. A study of 649 intensively irradiated cases]. / Autoptische und klinische Befunde der Metastasierung des Bronchialkarzinoms. Eine Untersuchung an 649 intensiv bestrahlten Fällen.

Between the years of 1958 to 1980, 1636 patients suffering from histologically demonstrated bronchial carcinomas were submitted to an intensive radiotherapy at the Robert-Rössle Hospital in Berlin-Buch. The tumors received a minimum dose of 5000 Gy. The autopsy reports of 649 cases could be evaluated. The tumor destruction rate determined by autopsy and the distribution of metastases in dependence on the histologic tumor type are described and compared to the frequency of metastases determined by clinical or X-ray examination. With respect to clinical practice, the conclusion is drawn that a prophylactic radiotherapy to the brain, the upper abdominal lymph nodes and the adrenal glands possibly could improve the therapeutic results because of the high rate of metastases of microcellular and non-differentiated bronchial carcinomas found in these regions.

Preliminary report on "one-time" and high dose irradiation of the upper and lower half-body in patients with small cell lung cancer.

Forty-two patients with histologically confirmed inoperable small (oat) cell lung cancer were treated with local tumor irradiation (approximately 4,000 cGy) combined with "one-time" irradiation of the upper and lower half of the body. Twenty-five patients (Group I) received the irradiation in lateral position first to the upper half-body, and six weeks later to the lower half-body, the midplane dose averaging 880 cGy (not corrected for lung tissue). In 17 patients, lethal pneumonitis occurred. The mean time of survival was 8.2 months for 22 patients having the disease limited to one thorax-side and 4.0 months for three patients having distant metastases, stated by conventional clinical and X ray investigations. Seventeen patients (Group II) received the two half-body irradiation treatments through anterior-posterior fields. The average dose had been reduced to 800 cGy (uncorrected) and was given on one day in two fractions (600 and 200 cGy, separated by an interval of 5 hours). Furthermore, the forearms and the lower legs had been left outside the fields. Only one patient showed pneumonitis. The mean time of survival was 14.3 months for 12 patients having the disease limited to one thorax-side and 6.6 months for five patients having distant metastases. In both groups, serious reactions of the bone marrow were not observed. In Group II, leucocytes and lymphocytes had reached their original values three months after the end of irradiation. For all 42 patients, X ray films showed complete regression of the primary tumor. In 12 out of 35 autopsy specimens, the primary tumor could not be detected histologically, but only five of these were free of metastases. Presently, additional irradiation of the two halves of the body with lower and fractionated doses are being tested in order to achieve the further reduction of tumor cell numbers.

Results of a pilot study on neutron therapy with 600 patients.

Combined neutron-photon-irradiation was applied to tumors of medium radiosensitivity. Compared with pure 60CO radiation the tumor destroying effect increased considerably. This was proved by comparative histological investigations of autopsy specimens taken from prospectively selected groups of patients suffering from carcinoma of bronchus, stomach or esophagus. Pure neutron irradiation was used for tumors of high radioresistance. Even when these tumors were irradiated with comparatively low doses (600-1800 cGy), complete or almost complete regression was fairly sure to occur. This was proved for 64 patients having mesenchymal sarcomata and 11 patients having parotid tumors or bronchial cylindromata. Postoperative prophylactic neutron irradiation after the local extirpation is sure to prevent recurrences of radioresistant tumors exhibiting a strong tendency towards recurrence. This was demonstrated for 33 patients (irradiated with doses of approximately 1200 cGy) who were observed for 12-24 months. Regarding normal tissues there is an increased late reaction of the vascular connective tissue of the skin, which serves here as a model for the general regenerative tissue (RBE greater than 4). Sufficient tumor irradiation, however, can be achieved without exceeding the tolerance dose (necrosis at approximately 2000 cGy). A substantial increase in late reaction was also found for the spinal cord after neutron irradiation in comparison with photon irradiation (RBE approximately 4.5), radiomyelonecrosis occurring at 1000 cGy and more. Some of the other normal tissues (stomach, liver, bones) do not manifest a substantial increase in medium-term reactions. Hence, neutron therapy will make possible an essential advance in the treatment of tumors.