Combined anterior cruciate ligament, posterior cruciate ligament, and posterolateral corner reconstruction with autogenous hamstring grafts in chronic instabilities.

PURPOSE: The purpose of this study was to evaluate the clinical outcome after 1-stage reconstructions of the anterior and posterior cruciate ligaments (ACL, PCL) with reconstruction of the posterolateral corner (PLC) structures using autogenous hamstring grafts in chronic knee injuries. TYPE OF STUDY: Prospective case series. METHODS: We reviewed 17 patients (13 men and 4 women) with chronic multiligamentous injuries after a minimum follow-up of 2 years (range, 24 to 66.3 months). Arthroscopically assisted combined ACL/PCL reconstructions with autogenous semitendinosus-gracilis tendon grafts were performed using the single-incision endoscopic ACL technique and the single femoral tunnel, single-bundle transtibial tunnel PCL technique. The PLC was reconstructed with a free autogenous semitendinous tendon graft. The primary outcome measures were the International Knee Documentation Committee (IKDC) score and stress radiography. As secondary outcome measure, all patients were evaluated with a subjective questionnaire, physical examination, radiologic assessment, and KT-1000 arthrometer testing. RESULTS: The mean time from injury to the reconstructive procedure was 70.2 +/- 96.7 months (range, 5.1 to 312.6 months). At final IKDC evaluation, 4 patients (29.4%) were graded level B (nearly normal), 10 patients (58.8%) level C (abnormal), and 2 patients (11.8%) level D (grossly abnormal). The mean postoperative subjective IKDC score was 71.8 +/- 19.3 points. Mean posterior tibial displacement as measured through stress radiography at 90 degrees of knee flexion was reduced from -15.06 +/- 4.68 mm preoperatively to -7.12 +/- 3.37 mm postoperatively (P < .001). Mean anterior tibial displacement was 0.94 +/- 2.75 mm preoperatively compared with -1.59 +/- 3.50 mm postoperatively (P < .01). Three patients had a fixed posterior tibial subluxation (posterior tibial displacement < or = -3 mm on anterior stress radiographs) postoperatively. Severe subjective instability was reduced significantly by the operative procedure (P < .001). The mean postoperative total anterior-posterior side-to-side difference with the KT-1000 arthrometer testing was 2.00 +/- 2.23 mm (range, -4 to 7 mm). CONCLUSIONS: Combined chronic ACL/PCL/PLC instabilities can be successfully treated with 1-stage arthroscopic cruciate ligament reconstruction combined with PLC reconstruction using autogenous hamstring grafts. Although current reconstruction techniques are not able to restore normal tibiofemoral kinematics, most patients recover a functionally stable knee and have considerably improved knee function compared with their preoperative status, based on subjective parameters and objective criteria. LEVEL OF EVIDENCE: Level IV, case series, no historical or control group.

Identification of plant-regulated genes in Ustilago maydis by enhancer-trapping mutagenesis.

To identify plant-induced genes in the maize pathogenic fungus Ustilago maydis we have developed a genetic screen that combines REMI (restriction enzyme mediated integration) mutagenesis with enhancer trapping using the gene for Green Fluorescent Protein (GFP) as vital reporter. Of 2,350 insertion mutants isolated, three were shown to express GFP only after the fungus had come into contact with the host maize plant. One of the genes tagged was mfa1, which encodes the pheromone precursor, while the second gene, pig2, codes for a product that showed similarity to protein disulfide isomerase. The third integration event had occurred in a locus which we designated the p -locus. This locus contains 11 genes in a 24-kb stretch. Of these, pig3, 4, 5, 6 and 7 show a plant-regulated expression pattern, while the other genes found at the locus (designated npi) do not. Of the plant-regulated genes only two were found to be similar to database entries: the pig4 product is related to membrane transporters of the major facilitator family, while the pig6 protein shows similarity to multidrug transporters. Detailed expression studies revealed that the five plant-regulated genes at the p -locus differ in their expression profiles. Mutants deleted for each of them showed no apparent phenotype, while the npi1 gene appeared to be essential. A viable deletion encompassing the entire p -locus could be generated when npi1 function was provided ectopically. This deletion mutant also showed no obvious alteration in virulence.

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 evaluation of articular cartilage lesions in posterior-cruciate-ligament-deficient knees.

PURPOSE: The goal of this study was to gain more information on the likelihood of developing cartilage lesions in posterior cruciate ligament (PCL)-deficient knees. TYPE OF STUDY: Retrospective clinical study. METHODS: Standardized arthroscopy records of 181 patients with a nonsurgically treated acute or chronic PCL injury were analyzed with respect to cartilage degeneration. Subgroups with different duration of PCL insufficiency, the influence of isolated PCL or combined PCL/posterolateral instability, and the grade of posterior laxity was analyzed. RESULTS: PCL insufficiency significantly increased the risk of developing medial femoral condyle and patellar cartilage degeneration over time. Of patients whose PCL deficiency was present for more than 5 years, 77.8% showed degenerative cartilage lesions of the medial femoral condyle and 46.7% showed cartilage degeneration of the patella. After 1 year of PCL insufficiency, the number of medial femoral cartilage lesions increased threefold (13.6% v 39.1%). With the presence of combined PCL/posterolateral insufficiency the amount of medial femoral degeneration was significantly increased (36.6% v 60.6%). CONCLUSIONS: We found that PCL insufficiency is not a benign injury with respect to the development of degenerative articular cartilage lesions. The early and continuous increase in cartilage degeneration at the medial femoral condyle and the patella should be considered when discussing operative versus conservative treatment for a PCL-deficient knee. The rapid development of medial arthritis should also be considered during decision making, particularly in patients with combined PCL/posterolateral instability or those who underwent previous partial medial menisectomy.

Fixed posterior subluxation in posterior cruciate ligament-deficient knees: diagnosis and treatment of a new clinical sign.

Among 248 patients seen for posterior cruciate ligament insufficiency, 109 (44%) had fixed posterior subluxation of the tibia, defined as a condition in which posterior sag could not be reduced to a neutral position, as evidenced by posterior tibial displacement of 3 mm or more on anterior stress radiographs at 200 N. The mean fixed posterior displacement was 6.23 mm (range, 3 to 20). The fixed posterior subluxation was divided into three grades: I, 3 to 5 mm (57.8%); II, 6 to 10 mm (33.9%); and III, more than 10 mm (8.3%). Comparison of the 109 study patients with the 139 control patients revealed a history of a failed posterior cruciate ligament operation or of a patellar tendon harvest, male sex, and a long history of posterior cruciate ligament insufficiency as significant risk factors for the development of a fixed posterior subluxation. After patients were treated with a posterior tibial support brace, the fixed posterior subluxation could be reduced to a mean of 2.58 +/- 5.22 mm within an average treatment period of 180 days. Fixed posterior subluxation can be detected in patients with posterior cruciate ligament deficiency by anterior and posterior stress radiographs and should be addressed before posterior cruciate ligament reconstruction to prevent early overloading of the graft.

[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.

A controlled aquatic ecological life support system (CAELSS) for combined production of fish and higher plant biomass suitable for integration into a lunar or planetary base.

Based on the construction principle of the already operative Closed Equilibrated Biological Aquatic System (C.E.B.A.S.) the concept of an aquaculture system for combined production of animal and plant biomass was developed. It consists of a tank for intensive fish culture which is equipped with a feeding lock representing also a trap for biomass removal followed by a water recycling system. This is an optimized version of the original C.E.B.A.S. filters adapted to higher water pollutions. It operates in a fully biological mode and is able to convert the high ammonia ion concentrations excreted by the fish gills into nitrite ions. The second biomass production site is a higher plant cultivator with an internal fiber optics light distributor which may utilize of solar energy. The selected water plant is a tropical rootless duckweed of the genus Wolffia which possesses a high capacity in nitrate elimination and is terrestrially cultured as a vegetable for human nutrition in Southeast Asia. It is produced in an improved suspension culture which allows the removal of excess biomass by tangential centrifugation. The plant cultivator is able to supply the whole system with oxygen for respiration and eliminates vice versa the carbon dioxide exhaled by the fish via photosynthesis. A gas exchanger may be used for emergency purposes or to deliver excess oxygen into the environment and may be implemented into the air regeneration system of a closed environment of higher order. The plant biomass is fed into a biomass processor which delivers condensed fresh and dried biomass as pellets. The recovered water is fed back into the aquaculture loop. The fresh plants can be used for human nutrition immediately or can be stored after sterilization in an adequate packing. The dried Wolffia pellets are collected and brought into the fish tank by an automated feeder. In parallel the water from the plant cultivator is driven back to the animal tank by a pump. The special feature of the system described is, however, the used fish species. It is the herbivorous teleost Ctenopharyngodon idellus (Chinese Grass Carp) which can be raised solely with plant biomass. In this case, moreover, it can be useful for the bioregeneration of plant biomass inedible for humans which can be used easily as additional food for the fishes thus resulting in an intensivation of animal protein production. The resupply of removed fish biomass has to be guaranteed by a separate hatchery.

Cerebral metabolite patterns in dialysis patients: evaluation with H-1 MR spectroscopy.

PURPOSE: To analyze metabolic changes in the brain of patients undergoing dialysis. MATERIALS AND METHODS: Sixteen patients undergoing hemodialysis, 10 patients undergoing continuous ambulatory peritoneal dialysis (CAPD), and 42 healthy volunteers underwent magnetic resonance (MR) spectroscopy and MR imaging. Spectra were obtained from one occipital gray matter voxel and one parietal white matter voxel. Changes in N-acetylaspartate (NAA), choline (Cho), myo-inositol and glycine (Myo), and creatine (Cr) were analyzed and the results presented as ratios, with Cr as the reference. RESULTS: Three abnormalities were observed in the spectra of the hemodialysis patients: (a) significant elevation of the Cho/Cr ratio in gray matter, (b) significant elevation of the Myo/Cr ratio in gray matter, and (c) significant reduction of the NAA/Cr ratio in gray and white matter. The strongest metabolic alterations were found in cortical gray matter. In CAPD patients, only gray matter Cho/Cr ratio was significantly elevated. An increased frequency of focal white matter lesions was observed on MR images in the dialysis patients. CONCLUSION: Proton MR spectroscopy is useful for in vivo monitoring of metabolic alterations in the brain due to chronic dialysis.

[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.

[Comments on electroconvulsive treatment from the viewpoint of the psychotherapy-oriented psychiatrist]. / Gedanken zur Elektrokrampfbehandlung aus der Sicht des psychotherapeutischen Psychiaters.

The use of electroconvulsive treatment is discussed from the viewpoint of the psychotherapist. It is explained that such treatment is incompatible with genuine psychotherapy.

[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.

[Development of the specialty fields of psychiatry and psychotherapy in East Germany]. / Die Entwicklung der Fachgebiete Psychiatrie und Psychotherapie in der DDR.

The development of psychiatry and/with psychotherapy ever since the beginning of the German Democratic Republic after WW2 is described and analysed. The author's main focus is on the confrontation, addition, and cooperation of both the classical medicine of matters and medicine of mind with conflicting, and at least varying paradigmatic reference. The pro and cons on shock therapy are discussed as a crucial point, here. The author holds that shock therapy interferes with the basics of a therapy where the patient is an integral and responsible part of the work as the mode of such treatment annihilates the Leitmotiv of psychotherapy within the framework of social psychiatry.

[Some aspects of psychotherapy research exemplified by a comparison of open and closed therapy groups]. / Einige Aspekte der Psychotherapie- forschung am Beispiel des Vergleiches offener und geschlossener Therapiegruppen.

The paper reports on a randomised clinical study of group psychotherapy in open and closed groups. Results of the therapy, pre and post measurement, and follow-up are discussed.

[Ward assessment questionnaire--a further possibility for objectively evaluating therapeutically significant milieu conditions]. / Der Stationsbeurteilungsbogen--eine weitere Möglichkeit zur Objektivierung therapeutisch bedeutsamer Milieubedingungen.

Ways of evaluating the therapeutic environment in psychiatry and psychotherapy are discussed, and an account of work with Engels Ward Assessment Form is given.