Outcomes of revision anterior cruciate ligament reconstruction secondary to reamer-irrigator-aspirator harvested bone grafting.

INTRODUCTION: Patients with widened or misplaced tunnels may require bone grafting prior to revision anterior cruciate ligament (ACL) reconstruction. Utilising reamer-irrigator-aspirator (RIA) harvested bone from the femur showed promising filling rates. Nevertheless, the procedure has neither been validated in a larger population nor been assessed with regards to radiological and clinical outcome of the subsequently conducted revision ACL reconstruction. Therefore, the aim of this study was to evaluate tunnel filling rates, positioning of the revision tunnels and outcome parameters of such two-staged revision ACL reconstructions. MATERIAL AND METHODS: A total of 15 consecutive patients were prospectively enrolled in this case series. CT scans were analysed before and after autologous RIA harvested bone grafting. Tunnel volumes and filling rates were calculated based on manual segmentation of axial CT scans. Revision ACL reconstruction was carried out after a mean interval of 6.2 months (±3.7) and positioning of the revision tunnels was assessed by plane radiographs. The mean follow-up was 19.8 months (±8.4) for objective evaluation and 37.1 months (±15.4) for patient reported outcomes. The clinical outcome was assessed by the quantification of the anterior tibial translation, the IKDC objective score, the Tegner activity scale and the Lysholm score. RESULTS: Initial CT scans revealed mean tunnel volumes of 3.8cm3 (±2.7) femoral and 6.1cm3 (±2.4) tibial. Filling rates of 76.1% (±12.4) femoral and 87.4% (±5.9) tibial were achieved. Postoperative radiographs revealed significantly improved tunnel positioning with anatomical placement in all but one case at the femur and in all cases at the tibia. At follow up, patients showed significantly improved anterior tibial translations with residual side-to-side differences of 1.7 mm (±0.8) and significantly improved IKDC objective scores. Furthermore, significantly higher values were achieved on the Tegner activity scale (5.3 ± 1.4 vs. 2.8 ± 0.5) and the Lysholm score (85.4 ± 7.9 vs. 62.5 ± 10.5) compared to the preoperative status. CONCLUSION: Autologous RIA harvested bone grafting ensures sufficient bone stock consolidation allowing for anatomical tunnel placement of the subsequently conducted revision ACL reconstruction. The two-staged procedure reliably restores stability and provides satisfying subjective and objective outcomes. Thus, RIA harvested bone grafting is an eligible alternative to autologous iliac crest or allogenic bone grafting.

Training-related improvements in musculoskeletal health and balance: a 13-week pilot study of female cancer survivors.

Cancer survivors often experience poor post-treatment musculoskeletal health. This study examined the feasibility of combined aerobic and resistant training (CART) for improving strength, skeletal health and balance. Cancer survivors (n = 24) were identified by convenience sampling in Los Angeles County with 11 survivors consenting to 13 weeks of CART. Pre- and post-intervention assessments of bone mineral density (BMD), strength, flexibility and biomarker analysis were performed. Paired t-test analysis suggested increases in lower and upper body strength. The average T-score for BMD at the femoral neck improved from -1.46 to -1.36 and whole body BMD improved from -1.65 to -1.55. From baseline to follow-up, participants also displayed decreases in sway velocity on the eyes open (7%) and eyes closed (27%) conditions. Improvement in lower body strength was associated with increases in lean body mass (LBM) (r = 0.721) and an inverse association was observed between sway velocity and LBM (r = 0.838). Age and time since last treatment were related with biomarkers of anabolic growth (IGF-1, IGFbp-3) and bone (DPD, BAP). In summary, observed physiological changes were consistent with functional improvements, suggesting that isometric and dynamic exercise prescription may reduce the risk for falls and fall-related fractures among survivors.

Targeting orphan G protein-coupled receptors for the treatment of diabetes and its complications: C-peptide and GPR146.

G protein-coupled receptors (GPCRs) are the most abundant receptor family encoded by the human genome and are the targets of a high percentage of drugs currently in use or in clinical trials for the treatment of diseases such as diabetes and its associated complications. Thus, orphan GPCRs, for which the ligand is unknown, represent an important untapped source of therapeutic potential for the treatment of many diseases. We have identified the previously orphan GPCR, GPR146, as the putative receptor of proinsulin C-peptide, which may prove to be an effective treatment for diabetes-associated complications. For example, we have found a potential role of C-peptide and GPR146 in regulating the function of the retinal pigment epithelium, a monolayer of cells in the retina that serves as part of the blood-retinal barrier and is disrupted in diabetic macular oedema. However, C-peptide signalling in this cell type appears to depend at least in part on extracellular glucose concentration and its interaction with insulin. In this review, we discuss the therapeutic potential of orphan GPCRs with a special focus on C-peptide and GPR146, including past and current strategies used to 'deorphanize' this diverse family of receptors, past successes and the inherent difficulties of this process.

[Characterization of the seriously injured cyclist : An evaluation of the injury and treatment focus areas of 2817 patients]. / Charakterisierung des schwer verletzten Fahrradfahrers : Eine Auswertung der Hauptverletzungen und Behandlungsschwerpunkte von 2817 Patienten.

BACKGROUND: Transport statistics classify bicyclists in a separate road user collective. For medical reasons, this differentiation is applied as well. Much literature is published in this field. Nevertheless there is a lack of literature regarding the overall injury patterns in a defined injury severity collective. Most literature is about isolated injured regions in combination with a heterogeneous injury severity. Further parameters, such as injury patterns, epidemiological aspects, treatment focal points and characteristic outcomes, have also been studied. The aim of the present study was to evaluate and characterize injury patterns in a standardized and representative collective of severely injured bicyclists. Methods We analysed data from the Traumaregister DGU® from 2002 to 2010. In total, 2817 severely injured (ISS ≥ 9 and additional intensive/intermediate care unit) bicyclists were included. The primary endpoint was evaluation of injury patterns and injury focal points. In addition to that we analysed parameters like epidemiological aspects, circumstances of accident, treatment focal points and outcome. RESULTS: The mean age was 50.3 ± 20.9 years. Males accounted for 68.9 % (n = 1940). The mean ISS was 23.7 ± 12.6. The mean AIS regions were the head 71.9 % (n = 2025), the chest with 44.9 % (n = 1264) and the upper extremities 33.6 % (947). In 68.2 % of all cases an ISS ≥ 9 was achieved by a traumatic brain injury; 21.1 % of all cases were mono-injuries. A characteristic distribution of age and a characteristic prevalence of the accidents in relation to the weekday and the month could be shown. CONCLUSION: The present study analysed the largest ever published collective of severely injured bicyclists. Traumatic brain injury could clearly be shown as the main injury in this collective. Moreover, one of five cases achieved the state "severely injured" due to mono-injury.

[Acute posterior dislocation of the sternoclavicular joint: Reduction, fixation by endobutton system and alternative procedures]. / Akute dorsale Sternoklavikulargelenkluxation: Reposition, Fixierung mit Faden-Titanplättchen-System und alternative Techniken.

Acute posterior dislocation of the sternoclavicular (SC) joint is rare but can lead to life-threatening vascular injuries of the mediastinum; however, diagnosis is difficult and the injury can be initially overlooked so that surgical treatment is delayed. Although a variety of different treatment modalities have been published, the ideal fixation technique has not yet been identified. We report the case of a patient suffering from a locked posterior SC joint dislocation caused by a skiing accident. The injury was treated by transarticular endobutton fixation. This article describes the technique and highlights its advantages and disadvantages in comparison to previously published treatment options.

Femoral marrow cavity bone harvesting used for arthroscopic refilling of misplaced or enlarged bone tunnels in revision ACL surgery: an arthroscopically supported technique with antegrade intramedullary bone harvesting by a reamer-irrigator-aspirator (RIA) system.

PURPOSE: In anterior cruciate ligament (ACL) revision surgery, refilling of misplaced or enlarged tunnels frequently requires bone harvesting from the iliac crest. Unfortunately, donor-site pain displays a relevant complication. In order to optimize patients' comfort, we developed a procedure combining minimally invasive intramedullary bone harvesting from the femur with arthroscopic tunnel refilling. METHODS: Patients with ACL reconstruction failure that were not eligible for one-step revision surgery but required tunnel refilling prior to the next ACL reconstruction were enrolled prospectively. Cancellous bone was harvested intramedullarily from the ipsilateral femur using the reamer-irrigator-aspirator system in a minimally invasive manner. Afterwards, the femoral and tibial tunnels were arthroscopically refilled using cones and push rods. Computer tomography (CT) analyses were carried out before and after the filling procedure. Pain levels were assessed during the entire follow-up. Patients undergoing iliac crest bone harvesting for other reasons served as a control group. Finally, the quality of the newly formed bone stock was evaluated in the subsequent ACL reconstruction procedure. RESULTS: Five patients were included during a 6-month period. Prior to refilling, tunnel analysis revealed a mean tunnel volume of 7.9 cm(3) at the femur [SD ± 5.3 cm(3)] and of 6.7 cm(3) [SD ± 5.1 cm(3)] at the tibia. The CT analyses further revealed that graft failure was predominantly caused by tunnel misplacement. Post-operatively, pain levels due to intramedullary bone harvesting were significantly lower compared to iliac crest bone harvesting at every analysed time point. Three to five months after tunnel filling, CT analyses showed sufficiently incorporated bone stocks with filling rates of 75 % femoral and 94 % tibial. ACL revision surgery was performed 4-5 months after tunnel filling without any complication. CONCLUSION: Intramedullary bone harvesting from the ipsilateral femur combined with arthroscopic refilling of the bone tunnels ensures a high-quality bone stock for further ACL reconstruction. The clinical relevance is shown by the feasibility of this technique and the significantly reduced pain levels during post-operative recovery.

[Tuberculous encephalitis, Landouzy sepsis and Pott's disease: complications after surgery for spinal stenosis]. / Tuberkulöse Enzephalitis, Landouzy-Sepsis und Pott-Krankheit : Komplikationen nach operativer Versorgung einer Spinalkanalstenose.

Tuberculosis is an infectious disease with a decreasing incidence in Germany. In particular, the occurrence of reinfections and possible complications associated with this disease, such as tuberculous meningitis/encephalitis and Landouzy sepsis are rare in industrial countries. In this article the intensive care treatment of a patient who initially underwent surgery for spinal stenosis is reported. Due to recurrent appearance of neurological symptoms with increasing severity and abscess formation in the spine, further surgery was performed. Additionally, the patient developed sepsis and meningitis. At this time an infection with Mycobacterium tuberculosis could be detected in both cerebrospinal fluid and abscess material of the spine suggesting a Landouzy sepsis, tuberculous meningitis/encephalitis and the suspicion of an underlying Pott's disease.

[Prevention of infection in the current treatment of open fractures: an evidence-based systematic analysis]. / Prävention von Infektionen bei offenen Frakturen heute: Ein evidenzbasierter systematischer Review.

BACKGROUND: Treatment of open fractures remains an interdisciplinary challenge. Even success and evidence of infection prevention especially of new treatment options is not clear. METHOD: A systematic search in available electronic databases over the years 1974 until 2011 was conducted. Only clinical analyses with more than 5 adult patients in the German, English or French languages were included. All studies were rated according to Centre for Evidence-Based Medicine (CEBM) criteria. RESULTS: Over 855 articles were found due to the search and after applying the exclusion and inclusion criteria 49 studies were finally assessed to contribute to the evidence-based recommendations. Grade A recommendation: early application of antibiotics against gram-positive organisms for all open fracture types, additional coverage of gram-negative organisms for type III open fractures. Early surgical debridement should be performed. Grade B recommendation: type III open fractures should be treated with antibiotics for a minimum of 72 h but not longer than 24 h after wound closure. Vacuum treatment is justified and beneficial if wound closure is not achieved. Grade C recommendation: additional local antibiotic treatment in combination with systematic antibiotics may be of benefit. Definitive wound closure should be achieved within 1 week. DISCUSSION: This evidence-based analysis shows that there is good evidence for the treatment of open fractures with antibiotics and surgical debridement. Vacuum treatment can be recommended if wound closure is not possible.

[Treatment results after cemented hemiprosthesis for care of unstable pertrochanteric femoral fractures in the elderly]. / Behandlungsergebnisse nach zementierter Hemiprothese zur Versorgung instabiler pertrochantärer Femurfrakturen alter Patienten.

BACKGROUND: The optimal treatment strategy for unstable trochanteric fractures in the elderly is still controversial because of the frequent failure of osteosynthesis. METHODS: A cohort of patients with unstable trochanteric fractures who were treated with cemented hemiarthroplasty and presented in our department during the period 2003-2009 was analyzed. Complications, reoperations, walking ability and full weight bearing were documented. RESULTS: A total of 91 patients were included (mean age 87.7±6.8 years) and predominantly 31A2 fractures (89%) were treated. There were 3.3% reoperations in the cohort and the 30 day mortality was 5.5%. At least 1 general complication occurred in over 50% of the patients. However, 30% of the patients had lower urinary tract infections, disturbances of electrolyte balance or transitory psychotic symptoms. On average full weight bearing could be performed at 3.5 (±3) days after the operation. CONCLUSION: Cemented hemiarthroplasty is a safe treatment strategy for unstable trochanteric fractures in the elderly, which allows early full weight bearing. Because of frequent general complications, more interdisciplinary units and centres of excellence are needed to handle this challenging cohort.

[Removal of a bent intramedullary tibia nail. Case report and review of literature]. / Verbogener intramedullärer Tibiamarknagel nach erneutem Trauma. Fallbeschreibung und Literaturübersicht.

Breakage or deformity of intramedullary nails of the lower extremities is the result of subsequent high energy trauma, falling or noncompliance of the patient in partial weight bearing. We describe the removal of a bent tibia nail in a young patient who sustained another high energy trauma on the same limb. Different surgical options are discussed on the basis of the current literature. Possible removal strategies could be: drilling half diameter of the nail and then straighten it backwards, cutting the nail with a burr or removing the nail without any manipulation of the nail itself. The most customized procedure depends on the available capabilities and the individual case because of the rare occurrence of bent nails. Soft tissue damage, degree of bending and re-osteosynthesis must be considered in individual treatment strategies.

[Value of the clinical examination in suspected meniscal injuries. A meta-analysis]. / Der verletzte Meniskus: Wie sicher ist die klinische Untersuchung? Eine Metaanalyse.

INTRODUCTION: The physical examination of the knee in cases of suspected meniscal tears serves to increase the probability of a correct diagnosis. Although there is a large variety of functional tests, the quality of each diagnostic test is controversially discussed. MATERIALS AND METHODS: Through a systematic literature search in Medline and the Cochrane Database two reviewers independently screened publications, evaluated each study for methodological quality and categorized them into levels of evidence (CEBM). Sensitivity, specificity, positive and negative predicted value, as well as positive and negative likelihood ratio (LR+/LR-) values were calculated in order to render the quality threshold of the physical examination in meniscus impairment. RESULTS: The Thessaly test (sensitivity: 91%, specificity: 97%, PPV: 97%, NPV: 91% LR+: 31.1, LR-: 0.1) revealed the highest test quality. Limited quality was shown for the Mc Murray test (sensitivity: 51%, specificity: 78%, PPV: 70%, NPV: 61%, LR+: 2.3, LR-: 0.6), "joint line tenderness" (sensitivity: 64%, specificity: 61%, PPV: 62%, NPV: 63%, LR+: 1.6, LR-: 0.6), the Apley-Grinding test (sensitivity: 38%, specificity: 84%, PPV: 71%, NPV: 58%, LR+: 2.4, LR-: 0.7) and the Ege test (sensitivity: 66%, specificity: 86%, PPV: 83%, NPV: 72%, LR+: 4.7, LR-: 0.4). Evidence for Steinman's test, Bragard's test and the meniscal signs of Böhler or Payr could not be tested. CONCLUSION: Meniscal injury can be detected by several functional tests. Using the Thessaly test can improve the physical examination by means of probability of the correct diagnosis, but the results are based on a single study. In patients with ambiguous findings in the physical examination or with suspected combined injury, further diagnostic procedures such as magnetic resonance imaging are necessary to confirm the diagnosis. In clinically certain cases the use of additional diagnostic imaging procedures should be avoided as other authors have shown that with few exceptions this has no influence on the therapy.

Insights into the molecular basis of polyglutamine neurodegeneration from studies of a spinocerebellar ataxia type 7 mouse model.

Spinocerebellar ataxia type 7 (SCA7) is one member of a growing list of neurodegenerative disorders that are all caused by CAG repeat expansions that produce disease by encoding elongated polyglutamine tracts in a variety of apparently unrelated proteins. In this review, we provide an overview of our efforts to determine the molecular basis of polyglutamine neurotoxicity in SCA7 by modeling this polyglutamine repeat disorder in mice. We discuss how our SCA7 mouse model develops a phenotype that is reminiscent of the retinal and cerebellar disease pathology seen in human patients. All of these findings are considered in the context of numerous other models of polyglutamine disease pathology in mice and other organisms, together with various other in vitro and biochemical studies. We present the competing hypotheses of polyglutamine disease pathogenesis, and explain how our studies of SCA7 brainstem and retinal degeneration using this mouse model have yielded insights into possible mechanisms and pathways of polyglutamine disease pathology. In addition to illustrating how our SCA7 mouse model has allowed us to develop and advance notions of disease pathogenesis, we propose a model of polyglutamine molecular pathology that attempts to integrate the key observations in the field. We close by describing why our SCA7 mouse model should be useful for the next phase of polyglutamine disease research--the development of therapies, and predict that this stage of experimentation will continue to rely heavily on the mouse.

Zinc elevates neuropeptide Y levels in rat pheochromocytoma cells by a mechanism independent of L-channel mediated inhibition of release.

Both zinc and neuropeptide Y (NPY) have been implicated as playing a role in seizures and feeding behavior. We investigated the hypothesis that zinc could regulate levels of NPY, and found that chronic exposure to 50-100 microM zinc increased levels of cellular NPY in cultured PC12 cells grown in the presence of nerve growth factor. Zinc's effect on NPY was specific, time- and concentration-dependent, and independent of inhibition of NPY release secondary to blockade of dihydropyridine-sensitive calcium channels. These results are consistent with a role for zinc in regulating hippocampal NPY following high-frequency neuronal activity.

Activated protein C (APC)-resistance: automated detection of the point mutation at position 1691 in the factor V gene.

Proteolytic cleavage of factor Va, caused by activated protein C, is an important mechanism in limiting clot formation in normal haemostasis. A single point mutation in the factor V gene has been demonstrated to cause resistance of factor Va to proteolytic cleavage by activated protein C. With an 8-fold increased risk of thrombosis and a 2 to 13% prevalence in the Caucasian population for the heterozygous state of this mutation, knowledge of the patient's genetic disposition is of great importance in conditions such as pregnancy, surgery, use of oral contraceptives and immobilization. Therefore we have developed an automated test for the detection of the factor V mutation. This PCR based test makes use of the disappearance of an Mnl 1 restriction site if the mutation is present. The assay has been developed for the widely used ES-systems of Boehringer Mannheim. The test discriminates between the heterozygous and the homozygous state. Because of its low costs and easy handling the assay can be used as a screening test and can be performed in routine clinical laboratories.

A method for the scrutiny of live mammalian cells in culture and for the measurement of their proliferative ability after x-irradiation.

A method is described for the observation of live mammalian cells in culture with an incubated phase-contrast microscope. A sample of plated cells may be watched and their respective capacities to form a colony measured by daily cell counts. The method has first been used to make direct estimations of the plating efficiency of the diploid line of Syrian hamster fibroblasts, BHK 21 C13, and then to observe the response of synchronous samples of these cells to 220 kV X-rays. A dose of 1.4 Gy given in Gl has no immediate detectable effect on cell or unclear morphology, and cell capacity to reach post-irradiation mitosis in unimpaired apart from delay. In contrast, after this mitosis is completed, descendant cells from some mitoses retain a normal form and clonogenic capacity, whereas the cells from other mitoses show varying degrees of abnormality and produce either slow-growth or stop-growth (micro-) colonies.

Observations of radiation-induced chromosome fragment loss in live mammalian cells in culture, and its effect on colony-forming ability.

Our preceding paper (Crote, Joshi, Revell and Shaw 1981) described a method for the direct scrutiny of live cultured mammalian cells with a microscope, and reported that all diploid Syrian hamster cells (BHK 21 C13) of a sample given 1.4 Gy of 220 kV X-rays in Gl reached post-radiation mitosis without discernible abnormality, but then diverged in observed behaviour: descendent cells from some first mitoses continued to proliferate normally while cells from other first mitoses behaved abnormally and produced either slow-growth or stop-growth colonies. This paper completes our study of the same irradiated cell sample, and shows that these post-mitotic differences in clonogenic ability were related to acentric chromosome fragment losses at post-radiation mitosis, which were detected in live daughter-cell pairs as micronuclei. The proportion of live daughter-cell pairs scored as deficient was at least 80 per cent of the proportion of comparable fixed-and-stained mitoses with detected acentric fragments.

[Effect of the lead-petrol-law on the contents of lead and benzo(a)pyren in urban environmental dust (author's transl)]. / Die Auswirkungen des Benzin-Blei-Gesetzes auf den Gehalt and Blei und 3,4-Benzpyren im städtischen Umwelstaub.

For the purpose of evaluating the stress on citydwellers by pollutants emanating from traffic sources the contents of lead and 3,4-benzpyrene in sedimentable city dust were determined in samples collected at 46 sites with different traffic densities in a city of medium size but considerable overall traffic volume (Erlangen, Bavaria). To estimate the effect of the gasoline-lead-law of Aug 5, 1971, determinations were carried out both in 1971, i.e. before this law came into effect, and in 1977 when the lead content in gasoline was finally limited to 0.15 g/1. The following results were obtained: - In city areas with dense traffic, the medium lead content dropped from 4.2 to 2.2 mg/g of dust, and the medium 3,4-benzpyrene concentration dropped from 1.3 to 0.5 microgram/g of dust. This amounts to a reduction of both the lead and 3,4-benzpyrene contents in city dust by about one half. - In the city periphery with lesser traffic density, the lead and benzpyrene contents, resp., were originally lower by about one half. In the case of lead, the concentration dropped from 1.9 mg to 1.2 mg/g dust, while 3,4-benzpyrene dropped from 0.6 to 0.4 microgram/g dust. Thus, the beneficial effect of the gasoline-lead-law was less obvious in these low-traffic parts of the city area. - The decrease in 3,4-benzpyrene with decreasing lead content is remarkable (striking, a striking pheromeron) and may be explained by lesser emission of this pollutant when burning gasoline low in lead.