[Posterolateral instability of the knee joint]. / Posterolaterale Instabilität des Kniegelenks.

The posterolateral corner of the knee is composed of a multilayered complex of ligamentous, musculotendinous, and capsular structures, which interact in a synergistic stabilizing manner with the central structures, particularly the posterior cruciate ligament. Injuries of the posterolateral corner are generally accompanied by rupture of the posterior cruciate ligament. Depending on the injured structures, injuries of the posterolateral corner result in posterolateral rotational instability alone (Fanelli A) or with lateral instability (Fanelli B/C). For rotational instability alone, isolated popliteus bypass is an effective procedure; with concomitant lateral instability in flexion, additional stabilization of the lateral collateral ligament is required. Most of the various available techniques are described as open reconstruction procedures. In recent years, arthroscopic techniques for posterolateral reconstruction have also been successfully developed.

Influence of leg axis alignment on MRI T2* mapping of the knee in young professional soccer players.

BACKGROUND: Investigation of the association between leg axis alignment and biochemical MRI in young professional soccer players in order to identify a potential influence of the leg axis on cartilage regions at risk. METHODS: Sixteen professional soccer players (21 ± 3 years) underwent static and dynamic leg axis analysis via radiation free DIERS formetric 4 D as well as 3-T MRI examination of both knees. Quantitative T2* mapping of the knee cartilage was performed and T2* values were evaluated as 144 regions of interest. Subgroup analysis was performed in players with severe varus alignment (> 6°). RESULTS: Analysis of the leg axis geometry revealed a mean static alignment of 6.6° ± 2.5 varus and a mean dynamic alignment of 5.1° ± 2.6 varus. Quantitative T2* mapping showed significantly increased T2* values in the superficial cartilage layer compared to the deeper region (p < 0.001) as well as a significant increase in relaxation times in the femoral cartilage from anterior to intermediate to posterior (p < 0.001). Combination of both methods revealed a significant correlation for the degree of varus alignment and the femoral, posterior, deep region of the medial knee compartment (r = 0.4; p = 0.03). If severe varus alignment was present this region showed a significant increase in relaxation time compared to players with a less pronounced leg axis deviation (p = 0.003). CONCLUSION: This study demonstrates that varus alignment in young soccer players is associated with elevated T2* relaxation times in the deep cartilage layer of the medial, posterior, femoral compartment and might therefore be a contributing factor in the early pathogenesis of manifest cartilage lesions. Therefore, these findings should be considered in the development of preventive training programs.

Additional lateral extra-articular tenodesis in revision ACL reconstruction does not influence the outcome of patients with low-grade anterior knee laxity.

INTRODUCTION: There is limited evidence on the indications of lateral extra-articular tenodesis (LET) in revision ACLR. The aim of this study was to evaluate the influence of the LET in patients with revision ACLR with preoperative low-grade anterior knee laxity. METHODS: Between 2013 and 2018, 78 patients who underwent revision ACLR with preoperative low-grade anterior knee laxity [≤ 5 mm side-to-side difference (SSD)] were included in the retrospective cohort study. An additional modified Lemaire tenodesis was performed in 23 patients during revision ACLR and patients were clinically examined with a minimum of 2 years after revision surgery. Postoperative failure of the revision ACLR was defined as SSD in Rolimeter® testing ≥ 5 mm or pivot-shift grade 2/3. RESULTS: In total, failure of the revision ACLR occurred in 11.5% (n = 9) of the cases at a mean follow-up of 28.7 ± 8.8 (24-67) months. Patients with an additional LET and revision ACLR did not show a significantly reduced failure rate (13% vs. 11%) or an improved clinical outcome according to the postoperative functional scores or pain in regards to patients with an isolated revision ACLR (Tegner 5.7 ± 1.3 vs. 5.9 ± 1.5, n.s.; IKDC 77.5 ± 16.2 vs. 80.1 ± 14.9, n.s., Lysholm 81.9 ± 14.2 vs. 83.8 ± 14.5, n.s.; VAS 1.9 ± 2.2 vs. 1.2 ± 1.7, n.s.). CONCLUSIONS: An additional LET in patients with revision ACLR with low-grade anterior knee laxity does not influence patient-related outcomes or failure rates. Subjects with preoperative low-grade anterior knee laxity may not benefit from a LET in revision ACLR. LEVEL OF EVIDENCE: III.

[Combined PCL ligament bracing and ACL reconstruction in acute knee dislocation (Schenck IV) - The Hamburg Approach : Video article]. / Hamburger Konzept der operativen Versorgungsstrategie einer akuten Kniegelenkluxation (Schenck IV) : Videobeitrag.

OBJECTIVE: Stepwise reconstruction of knee stability and physiological kinematics in acute knee dislocation. INDICATIONS: The operative technique is demonstrated in a case of multiligamentous injury of the knee with involvement of both cruciate ligaments and additional medial and lateral peripheral injuries (type IV according to Schenck classification). CONTRAINDICATIONS: Critical soft tissue conditions, infections, old age, obesity, lack of compliance. SURGICAL TECHNIQUE: Time-limited arthroscopy in order to primarily identify and treat posterior horn/root injuries of the meniscus and concomitant intra-articular injuries. Anatomical placement of anterior cruciate ligament (ACL) drill wires for later ACL tunnel drilling is arthroscopically guided. Subsequent conversion to an anteromedial arthrotomy and ligament bracing of the posterior cruciate ligament. The ACL is reconstructed using the ipsilateral semitendinosus tendon. Medial and lateral peripheral injures are anatomically reconstructed followed by a posterolateral augmentation in a technique described by Arciero. FOLLOW-UP: Limited weight bearing for 6 weeks and stepwise increase of flexion using a standard knee brace and close clinical monitoring. EVIDENCE: Ligament bracing of both cruciate ligaments is an established treatment technique in acute knee dislocations and has been proven to achieve good to excellent clinical results. In an ongoing clinical study primary ACL reconstruction as a modified treatment approach indicated superior stability in a 12-month follow-up in patients with acute knee dislocations.

Conservative versus tailored surgical treatment in patients with first time lateral patella dislocation: a randomized-controlled trial.

BACKGROUND: Patellar instability has a high incidence and occurs particularly in young and female patients. If the patella dislocates for the first time, treatment is usually conservative. However, this cautious approach carries the risk of recurrence and of secondary pathologies such as osteochondral fractures. Moreover, there is also risk of continuous symptoms apparent, as recurrent patella dislocation is related to patellofemoral osteoarthritis as well. An initial surgical treatment could possibly avoid these consequences of recurrent patella dislocation. METHODS: A prospective, randomized-controlled trial design is applied. Patients with unilateral first-time patella dislocation will be considered for participation. Study participants will be randomized to either conservative treatment or to a tailored patella stabilizing treatment. In the conservative group, patients will use a knee brace and will be prescribed outpatient physical therapy. The surgical treatment will be performed in a tailored manner, addressing the pathologic anatomy that predisposes to patella dislocation. The Banff Patellofemoral Instability-Instrument 2.0, recurrence rate, apprehension test, joint degeneration, and the Patella Instability Severity Score will serve as outcome parameters. The main analysis will focus on the difference in change of the scores between the two groups within a 2-year follow-up. Statistical analysis will use linear mixed models. Power analysis was done for the comparison of the two study arms at 2-year follow-up with regard to the BPII Score. A sample size of N = 64 per study arm (128 overall) provides 80% power (alpha = 0.05, two-tailed) to detect a difference of 0.5 standard deviations in a t-test for independent samples. DISCUSSION: Although several studies have already dealt with this issue, there is still no consensus on the ideal treatment concept for primary patellar dislocation. Moreover, most of these studies show a unified surgical group, which means that all patients were treated with the same surgical procedure. This is regarded as a major limitation as surgical treatment of patella dislocation should depend on the patient's anatomic pathologies leading to patellar instability. To our knowledge, this is the first study investigating whether patients with primary patella dislocation are better treated conservatively or operatively with tailored surgery to stabilize the patella. TRIAL REGISTRATION: The study will be prospectively registered in the publicly accessible database www.ClinicalTrials.gov .

[Patellar dislocation : Causes and treatment]. / Patellaluxation : Ursachen und Therapie.

The causes of patellofemoral instability (PFI) are complex. In accordance with the current literature a classification was developed which clearly weights all entities and derives diagnostic and therapeutic consequences. It considers patellar instability and patellar maltracking or the complete loss of patellar tracking and differentiates into 5 types. Type 1: patellar dislocation without maltracking or instability with a low risk of redislocation. Type 2: high risk of redislocation, no maltracking. Type 3: instability and maltracking; reasons for maltracking are a) soft tissue contracture, b) patella alta, c) pathological tibial tuberosity trochlear groove (TTTG) distance, c) valgus deformities and e) torsional deformities. Type 4: massively unstable floating patella, which is based on a high-grade trochlear dysplasia. Type 5: maltracking without instability.

[Posttraumatic deformities of the knee joint : Intra-articular osteotomy after malreduction of tibial head fractures]. / Posttraumatische Deformitäten am Kniegelenk : Intraartikuläre Korrekturosteotomien nach fehlverheilter Tibiakopffraktur.

Malreduction of tibial head fractures often leads to malalignment of the lower extremity, pain, limited range of motion and instability. The extent of the complaints and the degree of deformity requires an exact analysis and a standardized approach. True ligamentous instability should be distinguished from pseudoinstability of the joint. Also extra- and intra-articular deformities have to be differentiated. In intra-articular deformities the extent of articular surface displacement, defects and clefts must be accurately evaluated. A specific surgical approach is necessary, which allows adequate visualization, correct osteotomy and refixation of the fractured area of the tibial head. In the long-term course good clinical results are described for intra-articular osteotomies. If the joint is damaged to such an extent that it cannot be reconstructed or in cases of advanced posttraumatic osteoarthritis, total knee arthroplasty may be necessary; however, whenever possible and reasonable, anatomical reconstruction and preservation of the joint should be attempted.

Model based classification of cardiovascular response patterns.

A comprehensive analysis of cardiovascular control (CVC) patterns with multiple subjects is presented. It became feasible by recent methodological advances. Simple computer models were generated automatically, reproducing only factors of the true model that are relevant to the focus if investigation. These models--named aspect-models--could in turn be used in model individualization, thus reducing the necessary computational amount. The achieved speedup by a factor of more than three thousand and the high numerical stability of the resulting method allows the unsupervised identification of a large body of experimental data. The analysis of tilt table experiments of 18 subjects revealed a remarkable variety of reaction patterns. Closer examination yielded different classes of subjects. Two main groups corresponding to basic types of CVC were observed. Three outliers could be assigned to the specific situation of some subjects.

Model based characterization of microgravity induced alterations of CVS-regulation.

A concept called model individualization is presented. It is used to modify computer based models to reproduce observed individual behavior. During D2-, MIR97- and Neurolab-missions tilt-table and LBNP-experiments were carried out. Physiological data describing the cardiovascular reactions of the astronauts were recorded. The appropriateness of the rheoretical principles is demonstrated with MIR97 tilt-table experiments. Finally the resulting individualized model is investigated to propose hypotheses on probable alterations in the cardiovascular system induced by microgravity.

Fermentative degradation of triethanolamine by a homoacetogenic bacterium.

With triethanolamine as sole source of energy and organic carbon, a strictly anaerobic, gram-positive, rod-shaped bacterium, strain LuTria 3, was isolated from sewage sludge and was assigned to the genus Acetobacterium on the basis of morphological and physiological properties. The G+C content of the DNA was 34.9 +/- 1.0 mol %. The new isolate fermented triethanolamine to acetate and ammonia. In cell-free extracts, a triethanolamine-degrading enzyme activity was detected that formed acetaldehyde as reaction product. Triethanolamine cleavage was stimulated 30-fold by added adenosylcobalamin (co-enzyme B12) and inhibited by cyanocobalamin or hydroxocobalamin. Ethanolamine ammonia lyase, acetaldehyde:acceptor oxidoreductase, phosphate acetyltransferase, acetate kinase, and carbon monoxide dehydrogenase were measured in cell-free extracts of this strain. Our results establish that triethanolamine is degraded by a corrinoid-dependent shifting of the terminal hydroxyl group to the subterminal carbon atom, analogous to a diol dehydratase reaction, to form an unstable intermediate that releases acetaldehyde. No anaerobic degradation of triethylamine was observed in similar enrichment assays.

Fermentation of phenoxyethanol to phenol and acetate by a homoacetogenic bacterium.

A strictly anaerobic gram-positive, rod-shaped bacterium, strain LuPhet1, was isolated from sewage sludge with phenoxyethanol as sole carbon and energy source, and was assigned to the genus Acetobacterium. The new isolate fermented the alkylaryl ether compound phenoxyethanol stoichiometrically to phenol and acetate, whereas phenoxyacetic acid was not degraded. In cell-free extracts of strain LuPhet1, cleavage of the ether linkage was shown, and acetaldehyde was detected as reaction product. Coenzyme A-dependent acetaldehyde: acceptor oxidoreductase, phosphate acetyltransferase, acetate kinase, and carbon monoxide dehydrogenase were measured in cell-free extracts of this strain. Our results indicate that the ether linkage of phenoxyethanol is cleaved by a shift of the hydroxyl group to the subterminal carbon atom, analogous to a corrinoid-dependent diol dehydratase reaction, to form an unstable hemiacetal that releases phenol and acetaldehyde. Obviously, phenoxyethanol is degraded by the same strategy as in anaerobic degradation of the alkyl ether polyethylene glycol.

Microbial degradation of natural and of new synthetic polymers.

In landfills, deposited waste material is usually faced with strictly anoxic conditions. This means that the design of new biodegradable polymers must take into consideration that degradation should be possible especially in the absence of molecular oxygen. Poly-beta-hydroxybutyrate is depolymerized by the anaerobic fermenting bacterium Ilyobacter delafieldii through an extracellular hydrolase. Monomers are degraded inside the cells through classical beta-oxidation. Polyalkanoates containing odd-numbered or branched-chain acid monomers should he degraded in an analogous manner; in most cases the final mineralization of these residues requires special pathways. A comparison of the chemistry of natural polymer biodegradation leads to the conclusion that synthetic biodegradable polymers should be designed in the future to contain linkages which can be cleaved by extracellular hydrolytic enzymes. Recent findings on aerobic and anaerobic bacterial degradation of synthetic polyethers suggest that natural evolution of new depolymerizing enzymes, perhaps from existing hydrolases, could be possible in a reasonable amount of time, provided that the monomers are likely energy sources for a broad variety of microbes.

Enzymes Involved in Anaerobic Polyethylene Glycol Degradation by Pelobacter venetianus and Bacteroides Strain PG1.

In extracts of polyethylene glycol (PEG)-grown cells of the strictly anaerobically fermenting bacterium Pelobacter venetianus, two different enzyme activities were detected, a diol dehydratase and a PEG-degrading enzyme which was characterized as a PEG acetaldehyde lyase. Both enzymes were oxygen sensitive and depended on a reductant, such as titanium citrate or sulfhydryl compounds, for optimal activity. The diol dehydratase was inhibited by various corrinoids (adenosylcobalamin, cyanocobalamin, hydroxocobalamin, and methylcobalamin) by up to 37% at a concentration of 100 muM. Changes in ionic strength and the K ion concentration had only limited effects on this enzyme activity; glycerol inhibited the enzyme by 95%. The PEG-degrading enzyme activity was stimulated by the same corrinoids by up to 80%, exhibited optimal activity in 0.75 M potassium phosphate buffer or in the presence of 4 M KCI, and was only slightly affected by glycerol. Both enzymes were located in the cytoplasmic space. Also, another PEG-degrading bacterium, Bacteroides strain PG1, contained a PEG acetaldehyde lyase activity analogous to the corresponding enzyme of P. venetianus but no diol dehydratase. Our results confirm that corrinoid-influenced PEG degradation analogous to a diol dehydratase reaction is a common strategy among several different strictly anaerobic PEG-degrading bacteria.