Management of acute knee dislocations: anatomic repair and ligament bracing as a new treatment option-results of a multicentre study.

PURPOSE: The literature shows no consensus regarding the best method and timing for the treatment of acute knee dislocations. Studies indicate that a one-stage procedure performed in the early stages of injury can lead to superior results. The aim of this study was to evaluate the results after performing early surgical repair with additional suture augmentation (ligament bracing) of all torn ligaments in acute knee dislocations. METHODS: In this prospective multicentre study, 73 patients with an acute type III or IV knee dislocation were treated with one-stage ligament bracing within 10 days. Twenty-six patients sustained a type III medial dislocation, thirty-nine patients sustained a type III lateral dislocation, and eight patients presented a type IV dislocation. Four patients were lost to follow-up. Within the follow-up evaluation, various scores were collected (International Knee Documentation Committee IKDC Score, Tegner Score and Lysholm Score). Additional stress radiography was performed (Telos™) postoperatively. RESULTS: Sixty-nine knee dislocations (Schenck III and IV) with a follow-up at a mean of 14 ± 1.6 months were evaluated. The average IKDC score was 75.5 ± 14.5, the average Lysholm score was 81.0 ± 15.5, and the median loss of activity in the Tegner score was 1 (range 0-3) point. Stress radiographs showed side-to-side differences at a mean of 3.2 ± 1.3 mm for the anterior cruciate ligament (ACL) and of 2.9 ± 2.1 mm for the posterior cruciate ligament (PCL). The operative revision rate (early and late) was 17.4%. In the early stage, one wound infection and one case of transient common peroneal nerve (CPN) paresis were successfully revised. In the later stage, four patients with knee stiffness and six cases with symptomatic knee instability needed reoperation. Patients without ultra-low velocity (ULV) dislocations or CPN showed good or excellent results in 87.5% according to the Lysholm score. CONCLUSION: In cases of acute knee dislocation, primary ACL and PCL transosseous sutures with additional suture augmentation predominantly lead to good and excellent clinical results. Obese patients sustaining ultra-low velocity (ULV) dislocations and patients following injury to the CPN show inferior outcomes. In patients without ULV and CPN intraoperative and postoperative complications occurred in 10.1%. The obtained results and revision rates show that early primary suture repair is a promising option. LEVEL OF EVIDENCE: Prospective multicentre study, II.

[Ligamentous knee injuries in children and adolescents]. / Ligamentäre Kniegelenkverletzungen im Wachstumsalter.

Due to an increase in sporting activities, the number of injuries of the immature knee is continuously increasing. These injuries necessitate a special approach regarding the particular anatomical situation with open growth plates. Three of the most commonly occurring injuries are rupture of the anterior cruciate ligament, patella dislocation and meniscus injuries. The clinical results for conservative treatment of ruptures of the anterior cruciate ligament in the growth phase are inferior to operative treatment. Transepiphyseal reconstruction has been shown to be a safe treatment method and provides good clinical results. Therapy of patella instability in children has shown poor results and new surgical techniques have been introduced to perform an anatomical reconstruction of the medial patellofemoral ligament as well as to improve distal alignment. Isolated injuries to the meniscus are rare and discoid meniscus is a special phenomenon occurring in infancy. Meniscus injuries should be treated with primary sutures rather than resection. A discoid meniscus should be resected with extreme caution and anatomically reconstructed.

[Ligament bracing--augmented cruciate ligament sutures: biomechanical studies of a new treatment concept]. / "Ligament bracing"--die augmentierte Kreuzbandnaht: Biomechanische Grundlagen für ein neues Behandlungskonzept.

BACKGROUND: In the context of acute knee dislocations, suture repair of ruptured cruciate ligaments leads to good clinical results in 80% of cases. Disadvantages are low primary stability and subsequently secondary elongation of the sutured ligaments. In the present study, we compared primary stability of suture repair, reinforced by different suture augments, to cruciate ligament reconstruction. OBJECTIVE: The concept of ligament bracing with transosseous suture repair of the cruciate ligaments and additional suture augmentation is biomechanically superior to cruciate ligament reconstruction. MATERIAL AND METHODS: A total of 42 porcine knee joints divided into seven groups were examined. The stability of four different suture/augmentation combinations were compared to cruciate ligament reconstruction with human hamstring tendons. The investigational setup consisted of testing 1000 cycles with 20 N to 154 N load in a.-p. translation and 60° flexion. Elongation and load to failure were measured. RESULTS: Neither reconstruction (3.13 ± 1.65 mm; 362 ± 51 N) nor augmented suture repair (1.89-2.5 mm; 464-624 N) achieved the primary stability of the intact cruciate ligament (0.63 ± 0.34 mm, 1012 ± 91 N). In comparison to ligament reconstruction, all four augmented suture repairs showed minor elongation in the cyclic test and a higher load to failure. The isolated suture repair showed poor results (6.79 ± 4.86 mm, 177 ± 73 N). CONCLUSION: Augmented suture repair provides significantly higher stability compared with isolated suture repair and reconstruction with hamstring tendons. The concept of ligament bracing could be a promising future treatment option in acute knee dislocations. Clinical results remain to be seen.

[Acute medial collateral ligament injuries of the knee: diagnostics and therapy]. / Akute mediale Seitenbandverletzung am Kniegelenk: Diagnostik und Therapie.

The medial collateral ligament complex (MCL) is the most commonly damaged ligamentous stabilizer of the human knee. The diagnostic algorithm comprises patient history, clinical examination and magnetic resonance imaging (MRI). It is important to distinguish between incomplete and complete ruptures of the MCL. For adequate treatment the classification and exact knowledge about concomitant injuries are important. A nonoperative treatment of incomplete ruptures (grades I and II) is widely accepted and usually results in a good clinical outcome but the treatment of complete ruptures (grade III) is a subject of controversy. Complete intraligamentous ruptures with a correct approximation of the stumps and intact dorsomedial joint capsule can also be treated nonoperatively with good and excellent results. In contrast, ruptures close to the abutment and bony avulsions tend to heal better through operative treatment. Dehiscence or dislocation of the ligament stumps in MRI is an indication for operative treatment. In the context of a multiligamentous injury or complex instability, the majority of authors suggest an operative stabilization. As the treatment of chronic instability can be challenging, the initial and adequate treatment of acute ruptures is of great importance.

[Osteochondritis dissecans of the talus. Diagnosis and treatment]. / Osteochondrosis dissecans tali. Diagnostik und Therapie.

Osteochondritis dissecans of the talus (ODT) describes a special entity of osteochondral lesions of the talus (OLT) which has to be distinguished from acute traumatic lesions. Its exact etiology still remains uncertain with multiple predispositioning factors being discussed. Following the knee and elbow, the ankle joint with 4% is the third most affected joint. Early stages can often be treated conservatively. In case of an advanced stage or failure of conservative treatment, a variety of operative techniques are available, which can be used based on the patient and the stage.

Biallelic loss of function of the promyelocytic leukaemia zinc finger (PLZF) gene causes severe skeletal defects and genital hypoplasia.

BACKGROUND: Deletions of 11q23 are associated with mental retardation, craniofacial dysmorphism, microcephaly and short stature. We present a patient with similar clinical findings, in addition to absence of the thumbs, hypoplasia of the radii and ulnae, additional vertebrae and ribs, retarded bone age and genital hypoplasia. METHODS: Genomic DNA from the patient was screened for chromosomal imbalances by array-based comparative genomic hybridisation. DNA sequence analyses and reporter gene assays were performed in order to identify candidate gene mutations. RESULTS: The patient has an approximately 8 Mbp de novo deletion on the paternal chromosome 11, which includes the promyelocytic leukaemia zinc-finger gene (PLZF, ZBTB16; OMIM 176797). The maternal PLZF allele harbours a recessive missense mutation (c.1849A-->G), which leads to the substitution of a highly conserved methionine by valine (p.Met617Val) within a zinc-finger motif. Taking into account specific alpha-helical propensities of Val and Met, this mutation is likely to destabilise the alpha helix of the zinc finger that forms the contact with the DNA duplex, thus affecting the biological function as shown by reporter-gene assays. DISCUSSION: The PLZF gene is one of five partners fused to the retinoic acid receptor alpha in acute promyelocytic leukaemia. We describe the first patient, to our knowledge, with a germline mutation of PLZF. Our findings as well as observations in Plzf-deficient mice indicate that PLZF is a key regulator of skeletal and male germline development. Furthermore, this case highlights the importance of searching for a recessive mutation on the non-deleted chromosome in patients with a microdeletion and atypical clinical findings.

Arthroscopic popliteus bypass graft for posterolateral instabilities of the knee : A new surgical technique.

OBJECTIVE: An arthroscopic technique for the reconstruction of the posterolateral corner combined with posterior cruciate ligament (PCL) reconstruction was developed. INDICATIONS: Posterolateral rotational instabilities of the knee. Combined lesions of the PCL, the popliteus complex (PLT) and the posterolateral corner. Isolated PLT lesions lacking static stabilizing function. CONTRAINDICATIONS: Neuromuscular disorders; knee deformities or fractures; severe posterolateral soft tissue damage. SURGICAL TECHNIQUE: Six arthroscopic portals are necessary. Using the posteromedial portal, resect dorsal septum with a shaver. Visualize the PCL, the lateral femoral condyle and the posterolateral recessus with the PLT. Dissect the popliteomeniscal fibers; retract PLT until sulcus popliteus is visualized. Drill a 6-mm tunnel anteriorly into the distal third of the sulcus popliteus. Visualize femoral footprint of the PLT and place an anatomical drill tunnel. Pull the popliteus bypass graft into the knee and fix with bioscrews. Fix the reconstructed PCL. In cases of additional LCL injury, reconstruct LCL with autologous graft. POSTOPERATIVE MANAGEMENT: Partial weight-bearing for 6 weeks, range of motion exercises, quadriceps-strengthening exercises on postoperative day 1. Full extension allowed immediately with flexion limited to 20° for 2 weeks, to 45° for up to week 4, and to 60° up to week 6. Use a PCL brace for 3 months, running and squatting exercises allowed after 3 months. RESULTS: In the 35 patients treated, no technique-related complications. After 1 year, 12 patients had a mean Lysholm Score of 88.6 (± 8.7) points and a side-to-side difference in the posterior drawer test of 2.9 (± 2.2) mm (preoperative 13.3 [± 1.9] mm). CONCLUSION: Low complication risk and good and excellent clinical results after arthroscopic posterolateral corner reconstruction.

[Renal function during treatment with angiotensin converting enzyme inhibitors]. / Nyrefunktionen under behandling med angiotensinkonverterende enzymhaemmere.

The use of ACE-inhibitors has increased greatly during the last years. They were first used in treating hypertension, but nowadays cardiac diseases, mainly cardiac failure, are common indications. This means that the drugs are used in the treatment of more elderly patients who often have generalised atherosclerosis. This means that the patients must be controlled more often after initiation of treatment, especially concerning kidney function, since treatment with ACE-inhibitors can cause pronounced changes in renal haemodynamics and kidney function. This review focuses on the effects of ACE-inhibitors on renal haemodynamics and kidney function, which may be positive, with preservation of kidney function in diabetic and other chronic nephropathy, or negative, for example in cases with atherosclerotic stenosis of large or small renal arteries. It is concluded, that in cases of diabetic nephropathy an ACE-inhibitor is the "drug of choice" for treatment of hypertension. Furthermore the ACE-inhibitors seem to reduce the rate of deterioration of renal function and proteinuria in other kidney diseases. It is emphasized, that during treatment with ACE-inhibitors kidney function must be controlled before and following one to two weeks of treatment, if the dose is changed and in all cases following two to three months of treatment. Special attention should be given to patients with atherosclerotic manifestations e.g. angina.

[Renal function during treatment of chronic renal failure with angiotensin converting enzyme inhibitors]. / Nyrefunktionen under behandling af kronisk hjerteinsufficiens med angiotensinkonverterende enzymhaemmere.

The effect on kidney function fo treatment of cardiac failure with ACE-inhibitors was examined retrospectively in a material of 87 consecutive patients. Furthermore, it was evaluated whether concomitant treatment with diuretics or existing generalised atherosclerosis as indicated by ongoing treatment with nitrates could be a risk factor concerning reduction of kidney function. In 11.9% of the patients an increase in S-creatinine of > 30% was observed during the first weeks of treatment. It was only necessary to stop treatment in two of these patients. In the remainder S-creatinine decreased again during ongoing treatment. In another 10.7% of patients an increase of 20-30% in S-creatinine was observed. Seventy-two point six percent of the patients had unchanged kidney function during treatment with an ACE-inhibitor. Ongoing treatment with diuretics did not seem to be a risk factor for developing reduced kidney function, whereas significantly more patients on treatment with nitrates, indicating generalised atherosclerosis, developed reduced kidney function during treatment with ACE-inhibitors. It is recommended to control kidney function before, one to two weeks and two to three months following initiation of treatment with ACE-inhibitors and to pay special attention to patients with generalised atherosclerosis.

Knee injuries in children and adolescents.

As more children and adolescents are involved in sporting activities, the number of injuries to immature knees rises. We will focus on three entities: ruptures of the anterior cruciate ligament, patellar dislocation, and meniscal injuries. There is a trend in recent literature toward early reconstruction of the anterior cruciate ligament in children and adolescents. In this article, we will try to highlight the anatomic specialities and the diagnostic steps toward the correct diagnosis, review technical considerations and risks of the different surgical techniques, and present outcomes and offer a treatment recommendation. The treatment of patellar dislocation has changed considerably since we gained a better understanding of the unique anatomy of the patellofemoral joint. We will show diagnostic steps and risk factors for recurrent patellar dislocation, discuss conservative and different operative therapy options, and present a modified technique to achieve a dynamic reconstruction of the medial patellofemoral ligament without damage to the growth plates. Meniscal tears and discoid menisci are rare in comparison to the other injuries. We will herein explain what specialities in the anatomy should be considered in children and adolescents concerning the menisci, and present the diagnostic steps and treatment options available.

[Ligament bracing--augmented primary suture repair in multiligamentous knee injuries]. / Ligament bracing--Augmentierte Primärnaht bei multiligamentären Verletzungen des Kniegelenks.

OBJECTIVE: Reconstruction of knee stability by primary ligament sutures and additional augmentation after knee dislocation. INDICATIONS: Acute knee dislocation Schenck type III and IV. Operative treatment should be performed within 7 days after injury. CONTRAINDICATIONS: Chronic instability after knee dislocation, refixable bony avulsions, critical soft tissue, infection, lack of compliance. SURGICAL TECHNIQUE: Supine position with electric leg holder. Short arthroscopic assessment of concomitant injuries. Schenck type III medial injuries and Schenck IV injuries: anteromedial parapatellar arthrotomy. Injuries type Schenck III lateral: anteromedian arthrotomy. Armoring of ligament stumps for transosseus sutures. Placement of anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) drill tunnels. Extracortical diversion of the suture armorings and insertion of augmentation systems. Fixation of the PCL augmentation in 70-90° flexion. Fixation of the ACL augmentation in 20-30° flexion. Knotting of the transosseus ligament sutures. If necessary (postero-)lateral and/or medial stabilization. POSTOPERATIVE MANAGEMENT: Limited weight bearing with 20 kg for 6 weeks. Stabilizing brace (e.g., Hypex-Lite®, Albrecht) generally for 12 weeks. Mobilization under tension of the quadriceps muscle for 6 weeks. RESULTS: In total, 20 patients have been treated using the principle of "ligament bracing". So far 8 patients (aged 18-60 years, median 33 years) have been assessed with a follow-up of 10-15 months (median 12 months) postoperatively. In all, 6 patients showed stable knees with good results. Recurrent instability of the ACL was observed in 2 patients; the collateral ligaments and PCL were stable. For the evaluation the following scores were used: IKDC score, Tegner score, and Lysholm score. To objectify the data, stress radiography and physical examination were performed. Using the operative technique mentioned above, no complications occurred. During follow-up 2 patients reported a deficiency of flexion.

Survivin mRNA in peripheral blood is frequently detected and significantly decreased following resection of gastrointestinal cancers.

BACKGROUND AND OBJECTIVES: We evaluated if mRNA expression of survivin, an inhibitor of apoptosis, can be used to detect circulating tumor cells in peripheral blood of patients with various gastrointestinal cancers and if they decrease following complete surgical resection. METHODS: Blood samples from 40 gastrointestinal cancer patients were analyzed prior and following surgical resection by direct quantitative real-time reverse transcriptase-PCR (RT-PCR) assays. RESULTS: Survivin mRNA expression was pre-operatively detected in 35 of 40 cancer patients (88%). Post-operative survivin levels were significantly lower than pre-operative levels in 59% of resected patients and were non-detectable in 38% (Wilcoxon rank test: P < 0.04). CONCLUSIONS: This is the first report showing that direct quantitative real-time RT-PCR analysis of survivin mRNA expression in peripheral blood of patients with gastrointestinal cancers is technically feasible. Survivin mRNA levels fall significantly following complete resection and might become a molecular marker for the completeness of surgical resection.

Analysis of prevalence of presumed inherited eye diseases in Entlebucher Mountain Dogs.

We analyzed the prevalence of the presumed inherited eye diseases (PIED) noncongenital cataract and progressive retinal atrophy in the Entlebucher Mountain Dog for systematic environmental influences and the additive genetic variation. Multivariate linear animal models using residual maximum likelihood methods and multivariate threshold animal models using Gibbs sampling in Bayesian analyses were used to estimate variance and covariance components. Data were obtained from the kennel club for Swiss Mountain Dog breeds in Germany. PIED were recorded using the standardized protocols of the Dortmunder Kreis, the German panel of the European Eye Scheme for Diagnosis of Inherited Eye Diseases in Animals (DOK). The material included 515 Entlebucher Mountain Dogs from 344 litters at 77 different kennels. Veterinary diagnoses for PIED were from the years 1981-2001. Pedigree information was available for up to nine generations. The multivariate animal model regarded the fixed effects of sex, birth year, experience of the veterinary ophthalmologist, litter size, percentage of examined dogs per litter, inbreeding coefficient and age at examination. The common environment of the litter and the additive genetic effect of the animal were taken into account as randomly distributed effects. The heritability estimates for PIED in the Entlebucher Mountain Dog were h2=0.15+/-0.06 (noncongenital cataract), and h2=0.34+/-0.08 (progressive retinal atrophy) in the linear model and h2=0.32+/-0.05 (noncongenital cataract) and h2=0.59+/-0.03 (progessive retinal atrophy) in the threshold model. The additive genetic correlation between noncongenital cataract and progressive retinal atrophy was moderately positive (r(g)=0.54+/-0.08) in the threshold model. The number of examinations performed by the veterinary ophthalmologists was associated with slightly higher heritabilities for noncongenital cataract and considerably higher heritabilities for progressive retinal atrophy. The investigated PIED in the Entlebucher Mountain Dog are genetically influenced and the size of the genetic parameters estimated may be sensitive to the accuracy of the diagnosis and how the data were collected.

[Lymphadenopathy and a lower T-helper/suppressor cell (Th/Ts) ratio in homosexual men in West Germany. Studies of 147 patients to evaluate the individual risk of acquiring AIDS]. / Lymphadenopathie und erniedrigte T-Helfer-/Suppressorzell (Th/Ts)-Relation bei homosexuellen Männern in der Bundesrepublik Deutschland. Untersuchungen an 147 gefährdeten Personen zur Erfassung des individuellen AIDS-Risikos.

Investigations on 147 homosexual men in Berlin-West (17-57 years old, kappa = 32 years) revealed the presence of lymphadenopathy in 90 cases (61.2%). In addition, the Th/Ts-ratio was significantly reduced in the entire homosexual group compared to a control group of heterosexual men (n = 13) of comparable age [2P(z) = 0.0001; Mann-Whitney-U-test]. In homosexual men with marked lymphadenopathy (n = 43) the ThlTs-ratio was found to be lower than in those without lymphadenopathy (n = 57); the difference was significant (P less than 0.01). The reduction of the Th/Ts-ratio in the entire group was mainly due to a significant increase of the number of Ts-lymphocytes (P less than 0.005); Th-lymphocytes showed a trend to decrease which only became significant values in the group of homosexual men with marked lymphadenopathy (P less than 0.05). Similarly, no statistical correlation was found between reduction of Th/Ts-ratio and the age of homosexual men in the entire group (n = 147) as compared to controls; whereas, in the group of homosexuals with marked lymphadenopathy (n = 43) the decrease of Th/Ts became significant with increasing age. No statistical correlation was found between lymphadenopathy, reduction of Th/Ts-ratio and promiscuity (lifetime number of partners, number of partners during the last 6 months). The high prevalence of lymphadenopathy and reduction of Th/Ts-ratio, regarded as parameters of the individual AIDS-risk, indicate that a considerable number of homosexual men in Germany may develop that syndrome.

[The lymphadenopathy syndrome. Immunologic studies of young homosexual men with and without lymphadenopathy]. / Das Lymphadenopathie-Syndrom (LAS). Immunologische Untersuchungen bei jungen Homosexuellen Männern mit und ohne Lymphadenopathie.

Investigations on 147 young homosexual men living in Berlin (West) revealed lymphadenopathy in 61.2% (90 pat.). This finding was prominent in 43.4% of all cases. Evaluation of total T-, T-helper und T-suppressor lymphocytes by means of immunofluorescence with monoclonal antibodies showed an unchanged total number of T-lymphocytes; in contrast, the T-helper subpopulation was decreased and the T-suppressor subpopulation was increased in the peripheral blood, in comparison to a control group of heterosexual men. Therefore, a significantly reduced Th/Ts-ratio was supposed. These changes were more pronounced in the group with marked lymphadenopathy. Our investigations prove a high prevalence of lymphadenopathy and immune dysfunction among young homosexual men in Germany. Both are correlates of one syndrome characterized by persisting unexplained lymphadenopathy, immune dysfunction, and general clinical symptoms (including loss of weight, fever, diarrhoea, etc.). This so called lymphadenopathy syndrome (LAS) with the above mentioned clinical symptoms and reduction of the Th/Ts-ratio may represent a prodrome of AIDS. A long-term and careful follow-up of these patients is therefore necessary.

Renal and cardiac function during alpha1-beta-blockade in congestive heart failure.

UNLABELLED: The kidney and the neurohormonal systems are essential in the pathogenesis of congestive heart failure (CHF) and the physiologic response. Routine treatment of moderate to severe CHF consists of diuretics, angiotensin-converting enzyme (ACE) inhibition and beta-blockade. The need for control of renal function during initiation of ACE-inhibition in patients with CHF is well known. The aim of this study was to investigate whether supplementation by a combined alpha1-beta-blockade to diuretics and ACE-inhibition might improve cardiac function without reducing renal function. METHODS: Fourteen patients treated for moderate to severe CHF with diuretics and ACE inhibitors were investigated at baseline, after 4 months of maximum carvedilol treatment and after withdrawal of carvedilol. RESULTS: Carvedilol lowered blood pressure and heart rate but increased left and right ventricular ejection fractions without changing cardiac output or pulmonary blood volume. At the same time, a minor fall was seen in glomerular filtration rate (GFR). but renal blood flow was unchanged and effective renal plasma flow slightly increased. Carvedilol also lowered the plasma levels of angiotensin II and aldosterone. All changes were reversed after withdrawal of carvedilol. CONCLUSIONS: Carvedilol augments ACE-inhibitor-induced vasodilation by lowering blood pressure, and angiotensin II beside reducing heart rate. The heart adapts to the haemodynamic alterations without changes in cardiac output and pulmonary blood volume. GFR is slightly lowered despite no changes in renal blood flow and a slight increase in effective renal plasma flow. The study emphasizes the need for control of renal function during treatment with carvedilol in patients with CHF.