Hybrid Anterior Cruciate Ligament Reconstruction: Introduction of a New Technique for Anatomic Anterior Cruciate Ligament Reconstruction

Recently, anatomic or double-bundle reconstruction of the anterior cruciate ligament (ACL) has been presented in an effort to more accurately restore the native anatomy. These techniques create 2 tunnels in both the femur and tibia to reproduce the bundles of the ACL. However, the increased number of tunnels, particularly on the femoral side, has raised some concerns among authors and surgeons. We describe a technique to reconstruct the 2 distinct bundles of the ACL by using a single femoral tunnel and 2 tibial tunnels, the “hybrid” ACL reconstruction. The femoral tunnel is drilled through an anteromedial arthroscopy portal, which allows placement in a more anatomic position. Fixation in the femur is achieved with a novel device that separates a soft-tissue graft into 2 independently functioning bundles. Once fixed in the femur, the anteromedial and posterolateral bundles of the graft are passed through respective tunnels at the anatomic footprint on the tibia. These bundles are independently tensioned, which creates a reconconstruction that is similar to the native ACL. The technique presented provides surgeons with an alternative to other double-bundle techniques involving 4 tunnels.     

The Clinical Data Repository: A Challenge to Medical Student Education

The implementation of comprehensive clinical data repositories carries implications for the medical informatics curriculum for pre-MD medical students. There is the risk that electronic health records will detract from students’ acquisition of basic skills in inquiry and information management. It is possible, however, to create an application within the data repositories that will provide students with opportunities to practice their skills as they follow the evaluation and management of patients.     

Prevalence of posttraumatic stress disorder in wounded Vietnam veterans

Of 156 wounded Vietnam veterans evaluated for posttraumatic stress disorder (PTSD) by a questionnaire and a diagnostic interview in selected cases, 40% had a definite or probable lifetime diagnosis of PTSD. Of the 27 interviewed patients with lifetime PTSD, 81% currently met the PTSD criteria.     

Tularemia. A pathogen in nature and a biological weapon.

Tularemia as a potential biological weapon is of great concern because F. tularensis is a hardy organism that can be spread with a small inoculum. In addition, tularemia can be contracted through nature, predominately in rural areas. This disease can be spread by a wide variety of animals and can range from skin lesions to multi-organ involvement. The severity varies with amount of inocula, the virulence of the bacterium, and the port of entry. Exposure to aerosolized forms of F. tularensis, the major concern with bioterroism, can rapidly lead to respiratory failure and death. Untreated, other forms of tularemia can spread through the blood stream to other organs, leading to sepsis and death. Early recognition and treatment is tantamount to treatment and prevention of morbidity and mortality. Occupational health nurses are on the front line and must be assertive in identifying risk factors associated with exposure. Furthermore, education of the general population about exposure through nature can potentially decrease the incidence of tularemia. Occupational health nurses, as one of the largest health specialties in the workplace, may be the first contact for the exposed individual. Tularemia is treatable with knowledge of prevention, astute assessment, prompt identification, and treatment. Combined, they are powerful nursing tools in achieving optimal outcomes.     

Development of the rat thalamus: II. Time and site of origin and settling pattern of neurons derived from the anterior lobule of the thalamic neuroepithelium

Short-survival, sequential, and long-survival thymidine radiograms of rat embryos, fetuses, and young pups were analyzed in order to examine the time of origin, settling pattern, and neuroepithelial site of origin of the anterior thalamic nuclei--the lateral dorsal (lateral anterior), anterodorsal, anteroventral and anteromedial nuclei--and of two rostral midline structures--the anterior paraventricular and paratenial nuclei. The neurons of the lateral dorsal nucleus are generated over a 3-day period between days E14-E16 and their settling pattern displays a combined lateral-to-medial and dorsal-to-ventral neurogenetic gradient. The bulk of the neurons of the anteroventral nucleus are generated over a 3-day period between days E15-E17 and settle with an oblique lateral-to-medial and ventral-to-dorsal neurogenetic gradient. The bulk of the neurons of the anteromedial nucleus are generated over a 2-day period between days E16-E17 and show the same settling pattern as the anteroventral nucleus. The neurons of the anterodorsal nucleus are generated over a 3-day period between days E15-E17 and show a lateral-to-medial neurogenetic gradient. The bulk of the neurons of the central part and lateral part of the paraventricular nucleus are generated over a 2-day period (E16-E17 and E17-E18, respectively) and each part displays a ventral-to-dorsal neurogenetic gradient. Finally, the bulk of the neurons of the paratenial nucleus are generated over a 4-day period between days E15-E18 and settle with a lateral-to-medial neurogenetic gradient. Observations are presented that the anterior thalamic nuclei, constituting the distinct "limbic thalamus," derive from a discrete neuroepithelial source. This is the crescent-shaped germinal matrix lining the diencephalic (medial) wall of the hitherto unrecognized anterior transitional promontory, which we call the anterior thalamic neuroepithelial lobule. On day E16 three migratory streams leave the anterior neuroepithelial lobule and, on the basis of their labeling pattern in relation to the neurogenetic gradients of the anterior thalamic nuclei, they are identified, from dorsal to ventral, as the putative migratory streams of the anterodorsal, anteroventral, and lateral dorsal nuclei. On day E17 the putative migratory stream of the anteromedial nucleus appears to leave the same neuroepithelial region that on the previous days was the source of the anteroventral nucleus. Dorsally, two neuroepithelial patches persist after day E17 and these are identified as the putative cell lines of the anterior paraventricular and paratenial nuclei.