C-reactive protein : albumin ratio in patients with resectable intrahepatic cholangiocarcinoma

BACKGROUND

The C-reactive protein : albumin ratio (CAR) has been reported as a novel prognostic marker in several cancers. The aim of this study was to investigate the prognostic value of CAR in patients with intrahepatic cholangiocarcinoma (ICC).

METHODS

This was a single-centre retrospective study of patients who underwent surgery for ICC in a university hospital in Japan between 1998 and 2018. CAR, Glasgow Prognostic Score (GPS) and modified GPS (mGPS) were calculated. Their correlation with recurrence-free survival (RFS) and overall survival (OS) was analysed with Cox proportional hazards models.

RESULTS

Seventy-two patients were included in the study. Patients were divided into two groups according to the optimal CAR cut-off value of 0·02. CAR above 0·02 was associated with higher carbohydrate antigen 19-9 levels (20·5 versus 66·1 units/ml for CAR of 0·02 or less; P = 0·002), larger tumour size (3·2 versus 4·4 cm respectively; P = 0·031) and a higher rate of microvascular invasion (9 of 28 versus 25 of 44; P = 0·041). RFS and OS were shorter in patients with CAR above 0·02: hazard ratio (HR) 4·31 (95 per cent c.i. 2·02 to 10·63) and HR 4·80 (1·85 to 16·40) respectively. In multivariable analysis CAR above 0·02 was an independent prognostic factor of RFS (HR 3·29 (1·33 to 8·12); P < 0·001), but not OS.

CONCLUSIONS

CAR was associated with prognosis in patients who had hepatic resection for ICC.

Right hepatic venous system variation in living donors: a three-dimensional CT analysis

BACKGROUND

The right hepatic venous system consists of the right hepatic vein (RHV) and inferior RHVs (IRHVs). When the right posterior section is used as a graft for liver transplantation, understanding variations and relationships between the RHV and IRHVs is critical for graft venous return and hepatic vein reconstruction. This study aimed to evaluate variations in the hepatic veins and the relationships between them.

METHODS

The medical records and CT images of patients who underwent hepatectomy as liver donors were assessed retrospectively. The relationship between the veins was evaluated by three-dimensional CT.

RESULTS

The configuration of the posterior section was classified into one of eight types based on the RHV and IRHVs in 307 patients. Type 1a (103 of 307), type 1b (139 of 307) and type 2a (40 of 307) accounted for 91·9 per cent of the total. The diameter of the RHV extending towards the inferior vena cava had a significant inverse correlation with that of the IRHV (r²  = -0·615, P < 0·001). Type 1a, which had no IRHVs, had the RHV with the largest diameter; conversely, type 2a, which had a large IRHV, had the RHV with the smallest diameter.

CONCLUSION

The hepatic venous system of the right posterior section was classified into eight types, with an inverse relationship between RHV and IRHV sizes. This information is useful for segment VII resection or when the right liver is used as a transplant graft.

Prognostic significance of inflammatory biomarkers in hepatocellular carcinoma following hepatic resection

Background

Cancer‐related inflammation has been correlated with cancer prognosis. This study evaluated inflammatory biomarkers, including neutrophil‐to‐lymphocyte ratio (NLR), platelet‐to‐lymphocyte ratio (PLR) and lymphocyte‐to‐monocyte ratio (LMR), programmed death ligand (PD‐L) 1 expression, and tumour microenvironment in relation to prognosis and clinicopathological features of patients with hepatocellular carcinoma (HCC) undergoing curative hepatic resection.

Methods

Patients who had liver resection for HCC in 2000–2011 were analysed. Univariable and multivariable analyses were conducted for overall (OS) and recurrence‐free (RFS) survival. Immunohistochemical analyses of PD‐L1, CD8 and CD68 expression were performed. HCC cell lines were evaluated for PD‐L1 expression. A subgroup analysis was conducted to determine patient features, survival and the tumour microenvironment. Results were validated in a cohort of patients with HCC treated surgically in 2012–2016.

Results

Some 281 patients who underwent hepatic resection for HCC were included. Multivariable analysis showed that low LMR was an independent prognostic factor of OS (hazard ratio (HR) 1·59, 95 per cent c.i. 1·00 to 2·41; P = 0·045) and RFS (HR 1·47, 1·05 to 2·04; P = 0·022) after resection. Low preoperative LMR values were correlated with higher α‐fetoprotein values (P < 0·001), larger tumour size (P < 0·001), and high rates of poor differentiation (P = 0·035) and liver cirrhosis (P = 0·008). LMR was significantly lower in PD‐L1‐positive patients than in those with PD‐L1 negativity (P < 0·001). Results were confirmed in the validation cohort. PD‐L1 expression was upregulated in HCC cell lines treated with interferon‐γ and co‐cultured with THP‐1 monocyte cells.

Conclusion

LMR is an independent predictor of survival after hepatic resection in patients with HCC. Modulation of the immune checkpoint pathway in the tumour microenvironment is associated with a low LMR.

Rendezvous Technique Using Double Balloon Endoscope for Removal of Multiple Intrahepatic Bile Duct Stones in Hepaticojejunostomy After Living Donor Liver Transplant: A Case Report

Cholangitis is a major complication following transplantation. We report a living donor liver transplant (LDLT) patient with cholangitis due to multiple stones in the intrahepatic bile duct during hepaticojejunostomy anastomosis, who was successfully treated with the rendezvous technique using double balloon endoscope. A 64-year-old woman underwent LDLT with right lobe graft and hepaticojejunostomy for Wilson disease. There was bile leakage with biliary peritonitis, which was treated conservatively after transplant. Two years after surgery, she developed reiterated cholangitis due to stenosis of hepaticojejunostomy anastomosis and multiple stones in the intrahepatic bile ducts. Percutaneous transhepatic biliary drainage was performed. The size of the drainage tube was increased, and the anastomotic area was dilated in a stepwise manner using a balloon catheter. The stones were crushed and lithotomy was performed using electronic hydraulic lithotripsy through cholangioscopy. Finally, lithotomy was performed for the remaining stones through endoscopic retrograde cholangiography with the rendezvous technique using the double balloon endoscope. Rendezvous approach with percutaneous transhepatic biliary drainage and double balloon endoscopic retrograde cholangiography was an effective treatment for the multiple intrahepatic stones in hepaticojejunostomy following LDLT with right lobe graft.

rs8099917 and viral genotyping as indications for living donor liver transplantation for hepatitis C: a case report

INTRODUCTION

Appropriate antiviral treatment is essential for living donor liver transplantation (LDLT) to be effective for treating hepatitis C. However, it has never been reported that pre-LDLT genetic analyses of both host and virus, with prediction of the outcome of post-LDLT antiviral treatment, indicated LDLT for a borderline case.

CASE REPORT

We have reported the case of a 68-year-old woman with liver cirrhosis caused by genotype 1b hepatitis C, a history of ruptured esophageal varices, and adequately controlled minor ascites. Her liver function was classified as Child-Pugh grade B. The donor was a 42-year-old woman with an estimated left lobe graft volume (GV) of 33.8% based on the standard liver volume of the recipient. Molecular analyses used to confirm the indication of LDLT for this combination revealed the following: The rs8099917 genotype was T/T in the donor and recipient, the HCV core protein was double wild type, there were no mutations in the interferon sensitivity-determining region, and 8 mutations were found in the interferon/ribavirin resistance-determining region. LDLT was performed because very high sensitivity to interferon treatment was predicted.

DISCUSSION

Six months after LDLT and uneventful post-LDLT courses, pegylated interferon-α2a and ribavirin were administered under immunosuppression with cyclosporine and mycophenolate mofetil. This regimen was continued for 48 weeks, resulting in a viral response at 10 weeks and a sustained viral response, as predicted.

CONCLUSIONS

We have reported the usefulness of molecular analyses of host and viral factors for indicating LDLT to treat hepatitis C in a borderline case.

Change in the cross-sectional area of a patellar tendon graft after anterior cruciate ligament reconstruction

The purpose of this study was to clarify the change in the cross-sectional area (CSA) of a patellar tendon graft after anterior cruciate ligament (ACL) reconstruction, and its relationship with postoperative knee laxity. Forty patients (25 men and 15 women) were included in this study. Intraoperative CSA measurements were performed with an instrumented areamicrometer, while a magnetic resonance imaging (MRI) evaluation was utilized for the assessment postoperatively. For intraoperative measurement, the average CSA of a 10-mm wide patellar tendon graft was 32.3 +/- 7.0 mm2, while the average CSA measured at follow-up (mean: 14.8 months) was 48.8 mm2, showing a significant mean increase ratio of 49.4%. This value corresponded to 115% of the native ACL. The average CSA measured in 30 patients at 6 months was 49.7 mm2, almost equal to the value at the final follow-up (49.8 mm2) in the same patient group. Among potentially influential factors, postoperative notch width (available space for the ACL graft) had significant correlation with the CSA of the graft at follow-up. Finally, both intra- and postoperative CSA values did not correlate with postoperative knee laxity, indicating that a bigger graft does not guarantee a better laxity.

A prospective comparison of clamping the drain or post-operative salvage of blood in reducing blood loss after total knee arthroplasty

We undertook a prospective, randomised study in order to evaluate the efficacy of clamping the drains after intra-articular injection of saline with 1:500 000 adrenaline compared with post-operative blood salvage in reducing blood loss in 212 total knee arthroplasties. The mean post-operative drained blood volume after drain clamping was 352.1 ml compared to 662.3 ml after blood salvage (p < 0.0001). Allogenic blood transfusion was needed in one patient in the drain group and for three in the blood salvage group. Drain clamping with intra-articular injection of saline with adrenaline is more effective than post-operative autologous blood transfusion in reducing blood loss during total knee arthroplasty.

Anchorage on fibronectin via VLA-5 (alpha5beta1 integrin) protects rheumatoid synovial cells from Fas-induced apoptosis

BACKGROUND

Rheumatoid synovial cells are resistant to apoptosis induction in vivo, whereas, fibroblast-like synovial cells in rheumatoid arthritis (RA-FLS) are vulnerable to Fas-induced apoptosis in vitro.

OBJECTIVE

To clarify this discrepancy by studying the contribution of the interaction between cellular integrin and matrix fibronectin (Fn), which is significantly increased in the rheumatoid joints, to the induction of apoptosis in RA-FLS.

METHODS

Integrin and Fas mRNAs were measured by reverse transcription-polymerase chain reaction in RA-FLS. Integrins expressed in rheumatoid synovial tissues were analysed by immunohistochemistry. RA-FLS plated either on Fn or on control poly-L-lysine were incubated with agonistic anti-Fas monoclonal antibodies (mAbs). Apoptosis induction was evaluated using terminal deoxynucleotidyl transferase mediated UTP nick end labelling (TUNEL) and immunoblotting for caspase-3 and poly (ADP-ribose) polymerase in the presence or absence of anti-VLA-5 mAb.

RESULTS

VLA-5 (alpha5beta1 integrin), a major integrin expressed on RA-FLS, was required for the adhesion of RA-FLS on Fn. RA-FLS plated on Fn were more resistant to Fas-induced apoptosis than those plated on control poly-L-lysine. This protection by Fn was reversed by anti-VLA-5 mAb.

CONCLUSION

Anchorage of RA-FLS on matrix Fn via VLA-5 protects RA-FLS from Fas-induced apoptosis, and Fn abundantly present in rheumatoid synovium appears to afford RA-FLS resistance against apoptosis induction in vivo.

TRAUMATIC SPONDYLOLISTHESIS OF THE LUMBOSACRAL SPINE WITH MULTIPLE FRACTURES OF THE POSTERIOR ELEMENTS

We describe a patient with a traumatic spondylolisthesis of L5 and multiple, bilateral pedicle fractures from L2 to L5. Conservative treatment was chosen, with eventual neurological recovery and bony union. We are not aware of previous reports of this pattern of injury.

Traumatic spondylolisthesis of the lumbosacral spine with multiple fractures of the posterior elements

We describe a patient with a traumatic spondylolisthesis of L5 and multiple, bilateral pedicle fractures from L2 to L5. Conservative treatment was chosen, with eventual neurological recovery and bony union. We are not aware of previous reports of this pattern of injury.

Production of adrenomedullin from synovial cells in rheumatoid arthritis patients

It was recently reported that plasma levels of adrenomedullin (AM), identified as a vasorelaxant peptide, are significantly higher in rheumatoid arthritis (RA) patients than in osteoarthritis (OA) patients. The objective of the present study was to elucidate AM production in synovial cells from patients with RA. Adrenomedullin mRNA was detected in cultured synovial cells from RA patients by reverse transcription polymerase chain reaction (RT-PCR). Immunohistochemical analysis demonstrated the presence of AM in synovial cells from RA patients. In addition, we investigated AM levels in knee joint fluids from RA and OA patients. Those from RA patients were elevated approximately threefold over those of OA patients. In this study, we demonstrated for the first time AM expression in synovial cells from RA patients and high levels of AM production in RA joint fluid.

Effects of prophylactic ankle supports on pronation during gait

We performed a gait analysis of 12 healthy subjects in order to analyse the rear foot pronation-supination angle and the shift of centre of pressure (COP) during walking. We used a video system and a force plate and examined the effects of semi-rigid Air-Stirrup brace, lace-up cloth RocketSoc brace, ankle taping and no bracing. Both the lace-up cloth brace and taping increased the maximum pronation angle during the stance phase. The lace-up cloth brace alone was associated with a larger maximum pronation velocity. With the lace-up cloth brace and taping, the COP was more laterally placed, allowing greater leverage about the subtalar axis and thus increasing the tendency toward pronation. The two braces and the tape did not similarly affect ankle joint biomechanics during gait. The ability to reduce excessive amounts of pronation is an important design consideration for prophylactic ankle supports.

Repeat tears of repaired menisci after arthroscopic confirmation of healing

We undertook 114 arthroscopic meniscal repairs in 111 patients and subsequently carried out second-look arthroscopy to confirm meniscal healing at a mean of 13 months after repair. Stable healing at the repaired site was seen in 90. Of these, however, 13 had another arthroscopy later for a further tear. The mean period between the repair and the observation of a repeat tear was 48 months. Of the 13 patients, 11 had returned to high activity levels (International Knee Documentation Committee level I or II) after the repair.

An attempt should be made to preserve meniscal function by repairing tears, but even after arthroscopic confirmation of stable healing repaired menisci may tear again. The long-term rate of healing may not be as high as is currently reported. Second-look arthroscopy cannot predict late meniscal failure and may not be justified as a method of assessment for meniscal healing. Young patients engaged in arduous sporting activities should be reviewed regularly even after arthroscopic confirmation of healing.

Intraosseous lipoma of the humeral head: MR appearance

Intraosseous lipoma is the rarest benign primary bone tumor. We report a case of juxtaarticular intraosseous lipoma in the humeral head of a 50-year-old man. Roentgenographic, computed tomographic (CT), magnetic resonance (MR), scintigraphic, and histologic findings of this case are presented.

Ossified intramuscular hemangioma: multimodality imaging findings

Whereas calcification of hemangiomas is common, ossification is unusual. Multimodality imaging findings of a rare case of an ossified intramuscular hemangioma in the calf of a 24-year-old woman are presented. Radiographic, computed tomographic, magnetic resonance (MR), scintigraphic, and histologic features of this case are reported. The radiologic differential diagnosis of an ossified mass in soft tissue is also discussed.

Influence of macrophage infiltration of herniated disc tissue on the production of matrix metalloproteinases leading to disc resorption

STUDY DESIGN

Herniated lumbar disc specimens were cocultured with peripheral blood mononuclear cells, and cells isolated from extruded disc were cultured to study the production of matrix metalloproteinases.

OBJECTIVE

To investigate the role of peripheral blood mononuclear cells infiltrating extruded discs and disc-derived cells in the production of matrix metalloproteinases.

SUMMARY OF BACKGROUND DATA

Magnetic resonance imaging analysis of herniated disc patients revealed a progressive decrease in the size of herniated discs. Spontaneous regression of herniated disc is associated with infiltrating macrophages, and matrix metalloproteinases have been implicated in this phenomenon. However, the correlation between infiltrating macrophages and the production of matrix metalloproteinases has received little research attention.

METHODS

Each disc specimen was incubated with homologous peripheral blood mononuclear cells. The numbers of peripheral blood mononuclear cells attached to the surfaces of herniated discs were counted and the culture media was assayed for MMP-3. The cells isolated from herniated discs were incubated with cytokines and the production of matrix metalloproteinases was measured. Total RNA was extracted from herniated discs and RT-PCR was carried out.

RESULTS

Significantly larger numbers of peripheral blood mononuclear cells were attached to the surfaces of extruded discs, and higher amounts of MMP-3 were detected than those of control discs. The culture medium of extruded discs showed higher MMP-1 and MMP-3 production than those from controls. Significant enhancement of MMP-1 and MMP-3 mRNA expression was observed in the disc-derived cells stimulated with cytokines.

CONCLUSION

These results suggest that peripheral blood mononuclear cells infiltrating extruded discs may secrete a variety of biologic materials capable of further recruiting monocytes into herniated discs in an autocrine fashion. Disc cells stimulated with cytokines showed enhanced production of matrix metalloproteinases, which might play an important role in spontaneous regression of disc materials.

Contained rupture of the aneurysm of common iliac artery associated with pyogenic vertebral spondylitis

STUDY DESIGN

A case report.

OBJECTIVES

To report and discuss a case of contained rupture of the aneurysm of common iliac artery associated with pyogenic vertebral spondylitis, so that investigators and practitioners may avoid the diagnostic and therapeutic pitfalls associated with pyogenic vertebral spondylitis and aortic disease.

SUMMARY OF BACKGROUND DATA

Pyogenic vertebral spondylitis is a rare disorder that may have serious consequences, including death, if it is not diagnosed promptly and treated effectively. The association of pyogenic vertebral spondylitis with infection of the aorta is a rare but potentially fatal condition that requires prompt diagnosis and aggressive surgical and medical therapy. To our knowledge, this is the first report of a contained rupture of the aneurysm of common iliac artery case associated with pyogenic vertebral spondylitis resulting from an infection with Bacteroides fragilis,although Salmonellae infections are commonly associated with vertebral osteomyelitis and lesions of the contiguous aorta.

METHODS

A 60-year-old man with chronic lower back pain began to experience a severe pain and had increased difficulty in walking. An MRI scan showed an increased signal in the L4-L5 disc space and an abscess extending into the spinal canal. The presumptive diagnosis was infective spondylitis. While performing a CT-guided needle biopsy, an unexpected contained rupture of the aneurysm of common iliac artery was discovered.

RESULTS

A wide resection of all infected tissue, including the right common iliac artery and bony lesions, was performed in combination with antimicrobial therapy. A cryopreserved aortic allograft was used to reconstruct the artery, and an iliac strut graft was used to fill the debrided vertebral cavity. The patient's postoperative recovery was uneventful.

CONCLUSION

The coexistence of pyogenic vertebral spondylitis and lesions of the aorta is rare, but may be lethal if not diagnosed promptly and treated effectively. Even if a patient's condition is stable and the hematocrit is normal, it is important to consider the possibility of a contained rupture of a mycotic abdominal aneurysm in all patients with vertebral osteomyelitis who have acute episodes of unusual severe back pain. CT is sometimes more beneficial than MRI in the identification and characterization of contained rupture of aneurysms.

Radiographic and computed tomographic analysis of the position of the tibial tubercle in recurrent dislocation and subluxation of the patella

Among the factors that influence the patellofemoral alignment and stability, the position of the tibial tubercle was evaluated using plain radiographs and computed tomography (CT). Radiographs of the Q-angle with the knee in full extension and quadriceps muscle relaxed showed that mean Q-angles in the dislocation or subluxation group and control group were 13.8 degrees and 14.3 degrees, respectively. The major reason for this deceptive measurement was a patella positioned laterally in the dislocation or subluxation group. Better estimation was made with the modified Q-angle measurement by using the most concave point of the intercondylar notch as a reference point instead of the center of the patella. By overshadowing CT images of the levels of the patellofemoral joint and the tibial tubercle, it was possible to evaluate the location of the tibial tubercle in relation to the femoral trochlea. Both the angular measurement (lateral deviation angle [LDA]) and the distance measurement (lateral deviation index [LDI]) showed that the tibial tubercle in the dislocation or subluxation group was rotated externally and shifted laterally (LDA, 36.3+/-7.0 degrees and LDI, 30.1+/-5.6) compared with the control group (LDA, 20.2+/-7.1 degrees and LDI, 15.1+/-5.6). Further study is warranted to elucidate the exact mechanism of recurrent patellar dislocation and subluxation.

Expression of a bioactive bovine interleukin-12 using baculovirus

Recombinant baculoviruses that express recombinant bovine interleukin-12 (rboIL-12) subunits, p35 and p40 subunits were constructed. A recombinant virus containing the p40 subunit gene expressed the p40 subunit as a 40kDa monomer and an 80kDa disulfide-linked homodimer in the infected insect cells and in the culture supernatant. The p35 subunit was expressed in a 30kDa monomer in the infected cells but not in the supernatant. Superinfection of both recombinant viruses into the cells in a spinner flask resulted in the formation of a 70kDa disulfide-bonded heterodimer detected in the supernatant by immunoblotting using anti-p40 and anti-p35 subunits antibodies. The superinfected culture supernatant showed induction of IFNgamma mRNA synthesis and IFNgamma production in bovine peripheral blood mononuclear cells. Thus, the bioactive rboIL-12 was produced in large scale using a baculovirus expression system.

A new fibular osteotomy in association with high tibial osteotomy (a comparative study with conventional mid-third fibular osteotomy)

A new technique for dividing the fibula when performing a high tibial osteotomy is described. The head of the fibula is enucleated and morselized. The technique is simple and safe with a low complication rate.

Graft healing in the bone tunnel in anterior cruciate ligament reconstruction

The histologic sequence in the bone tunnel after anterior cruciate ligament reconstruction using the bone-patellar tendon-bone graft was investigated in this study. Eighteen adult mongrel dogs were used. After excision of the anterior cruciate ligament, the graft was routed through the bone tunnels and fixed with interference fit screws. After the dogs were sacrificed at intervals, the bone blocks containing the bone tunnels were isolated and processed for histologic examination. At the bone-bone interface, incorporation of the bone plug at each end of the graft was completed at 12 weeks. The structure of the tendon insertion of the grafted patellar tendon, consisting of four distinct zones, was observed without apparent necrotic and degenerative change for as long as 12 weeks. Between the tendon and the bone tunnel, a layer of hypercellular fibrous tissue gradually became mature with time. Thus, it appeared the morphologic characteristics and location of the reestablished attachment of the bone-patellar tendon-bone graft were more similar to those of the native anterior cruciate ligament compared with the graft to bone healing in the hamstring tendon graft.

Localization of growth factors in the reconstructed anterior cruciate ligament: immunohistological study in dogs

This study was designed to examine localization of the growth factors in the autogenous patellar tendon graft used to reconstruct the anterior cruciate ligament (ACL) in the canine model. Among the various growth factors, basic fibroblast growth factor, transforming growth factor-beta1, and platelet-derived growth factor were selected for analysis as potential factors that regulate graft remodeling processes. In the control patellar tendon and the ACL only basic fibroblast growth factor was positively stained. In the reconstructed graft increased levels of staining for all the three factors were observed in the early postoperative period, reaching the greatest expression 3 weeks after implantation. Thereafter immunoreactivity of these growth factors decreased and returned to the preoperative levels, which were similar to that of the control ACL 12 weeks postoperatively. This rapid reduction in the level of their localization indicates that once the extrinsic cells are infiltrated to the graft and revascularization completed, these growth factors may have less significance for subsequent remodeling.

Efficacy of the axially loaded pivot shift test for the diagnosis of a meniscal tear

Although magnetic resonance imaging (MRI) has improved the diagnostic accuracy of meniscal pathology, the authors believe that physical examination remains essential to the evaluation of knee pathology. In this study, the diagnostic accuracy of five clinical tests for meniscal pathology was prospectively evaluated in 160 patients, who thereafter underwent arthroscopy. 69% (109 knees) of the knees tested had associated ACL deficiency. There were 144 meniscal lesions in 130 of the 160 knees which were examined. The sensitivity of the tests was lower than the specificity. Conventional tests such as McMurray and Apley tests showed a low accuracy rate of 45% and 28% respectively. The diagnostic value of the axially loaded pivot shift test was significantly higher, indicating that this remains a useful diagnostic aid.

Evaluation of functional deficits determined by four different hop tests in patients with anterior cruciate ligament deficiency

The purpose of this study was to analyze the validity of the newly designed functional ability test (FAT) for the normal population and patients with deficiency of the anterior cruciate ligament (ACL). The FAT consists of four tests: the figure-of-eight hop, the up-down hop, the side hop, and the single hop. Sixty control subjects and 50 patients with unilateral ACL deficiency were tested. In the control group, the values measured were significantly different between males and females in all of the tests. On the other hand, when left/right difference values were compared, no significant difference was found between males and females in any of the tests. More than 95% of control group exhibited symmetrical function in each part of the FAT, whereas in the ACL-deficient group, the percentage of patients who showed abnormal symmetry was 68% in the figure-of-eight hop, 58% in the up-down hop, 44% in the side hop, and 42% in the single hop. The percentage of ACL-deficient patients with functional asymmetry in at least one of the four tests was 82%. The FAT was found to be useful in evaluating lower limb function in ACL-deficient patients.

Effect of basic fibroblast growth factor on the healing of defects in the canine anterior cruciate ligament

The effect of basic fibroblast growth factor (bFGF) on the healing of partial anterior cruciate ligament (ACL) lacerations was investigated in 17 adult mongrel canines. The defect was created in the midsubstance of both ACLs using a biopsy punch. In the bFGF group, a bFGF-impregnated pellet was sutured to the infrapatellar fat pad close to the defect. In the control group, the same pellet without bFGF was used. The healing process was evaluated macroscopically and histologically at 1, 3, 6, and 24 weeks postoperatively. In the bFGF group, a pannus-like tissue which contained abundant blood vessels extended into the defect from the adjacent synovial tissue in the early postoperative phase. Histological examination of the tissue which filled the defect revealed initial remodeling processes with a decreased number of cells and better orientation of the collagen fibers at 6-24 weeks. On the other hand, in the control group, poor healing processes were observed at each examination period. This study demonstrated that the application of a bFGF-impregnated pellet may enhance the healing potential of a partially injured ACL. Enhanced neovascularization and the formation of granulation tissue induced by bFGF early in the healing process accounted for the increased healing response.

Effect of fibrin glue and endothelial cell growth factor on the early healing response of the transplanted allogenic meniscus: a pilot study

Twentyfour meniscal allotransplantations were conducted in 12 adult mongrel dogs. The medial meniscus was replaced using a deep-frozen meniscal allograft. The junction between the meniscus and capsule was treated in one of the three ways. In the control group, the meniscus was sutured only to the adjacent capsular tissue (group C). In the second group, fibrin glue was injected at the junction (group F), and in the third group, fibrin glue and endothelial cell growth factor (ECGF) were injected at the juncture between the transplanted meniscus and the adjacent capsule before the meniscus was sutured (group FE). Histological observation was performed to investigate the effect of fibrin glue and ECGF on the healing process of transplants at various intervals of 1, 4, 8 and 12 weeks. No immunological response was noted in any of the knees. The healing of the transplanted meniscus was first observed at the peripheral attachment. Also, the pannus-like tissue extended from the synovium to the surface of the meniscus. The healing rate in each group at 1 week and 12 weeks was 22% and 77% in group C, 52% and 80% in group F, and 64% and 80% in group FE, respectively. At 4 and 8 weeks, early cellular repopulation was found in group FE and the area which contained new cells was larger than the acellular central core at 8 weeks. However, there was no difference among the three groups at 12 weeks.(ABSTRACT TRUNCATED AT 250 WORDS)

Light and electron microscopic study of remodeling and maturation process in autogenous graft for anterior cruciate ligament reconstruction

We evaluated the remodeling process of autogenous patellar tendon graft for anterior cruciate ligament (ACL) reconstruction by means of light microscopic (LM) and electron microscopic (EM) examinations from the biopsy specimens obtained at the time of second-look arthroscopy. Twenty-one patients were examined at various times postoperatively (from 6 weeks to 15 months, mean 9.5 months), and the results were correlated with the morphology of normal patellar tendon and normal ACL. Our study showed that the graft was revascularized in the early postoperative period, fibroblastic remodeling took place, and the graft obtained gross similarity to the original ACL on their arthroscopic and LM appearances at approximately 1 year postoperatively. However, EM study showed that at both approximately 6 months and 1 year postoperatively the grafts consisted equally of active fibroblasts with a higher cytoplasm-to-nucleus ratio compared with normal ACL. Collagen fibrils of these grafts were of uniformly small diameter compared with normal patellar tendon and ACL. Our results with ultrastructural study suggest that the grafts were still immature even at 1 year postoperatively.

Meniscal repair using fibrin sealant and endothelial cell growth factor. An experimental study in dogs

The effect of fibrin sealant and endothelial cell growth factor on the healing of defects of the avascular portion of canine menisci was investigated in 30 menisci of 15 adult mongrel dogs. The defects were treated in one of three ways: Group 1, the defect was left empty; Group 2, the defect was filled with fibrin sealant; and Group 3, the defect was filled with fibrin sealant and endothelial cell growth factor. The healing process was evaluated macroscopically and histologically at intervals of 1, 2, 6, 12, and 24 weeks. The average percentage of each defect that was filled with connective tissue was 5% in Group 1, 76.6% in Group 2, and 89.4% in Group 3. In the early phase of this repair, the extrinsic pannus-like tissue that contained many capillary vessels extended from the meniscosynovial junction into the defect. Subsequently, organized fibrous connective tissue was formed, which had changed to cartilaginous tissue at 12 to 24 weeks. The combination of fibrin sealant and endothelial cell growth factor enhanced the neovascularization and formation of granulation tissue, which accounted for the increased healing level in the avascular portion of the meniscus.

Longitudinal ruptures of the peroneal tendons. A report of a rugby player

Rupture of one or both peroneal tendons is rare. We present a case of longitudinal ruptures in both peroneus longus and brevis tendons. We obtained a very satisfactory clinical result with surgical debridement of the abnormal granulation tissue and proliferated synovial sheath.

Knee arthroscopy using local anesthetic

The purpose of this study was to examine the effectiveness and safety of local anesthetics (a mixture of lidocaine and bupivacaine) in knee arthroscopy. Local anesthetic agents were shown to be effective and safe, based on chart review and measurement of blood levels of the anesthetic drugs.

Graft tension in anterior cruciate ligament reconstruction. An in vivo study in dogs

The purpose of this study was to examine the effect of initial tensioning on the outcome of reconstruction of the ACL. The ACLs of 15 adult mongrel dogs were excised and reconstructed. In the first five dogs, the ACLs of both knees were reconstructed using the medial one-third of the patellar tendon. The graft was fixed under a tension of 1 N (0.22 pounds) in one knee and 39 N (8.8 pounds) in the opposite knee. In the remainder of the dogs, the reconstructions were augmented with Dacron prostheses. Tensioning of both graft components in the augmented reconstructions was either with 1 N in one knee and 39 N in the contralateral knee or disproportionate tensions of 1 N and 39 N applied to the autogenous material and to the prosthesis. Sacrifice was 3 months postsurgery and results were examined with microangiography/history and mechanical testing. In the reconstructions with the patellar tendon alone, the biologic study showed poor vascularity and focal myxoid degeneration within the graft pretensioned with a load of 39 N. In the augmented reconstructions, the knees in which both graft materials were fixed with 1 N tension showed the strongest and stiffest reconstruction at 3 months. The study suggests that minimal tension should be applied to the graft materials during surgical reconstruction of the ACL.

A biomechanical comparison of different surgical techniques of graft fixation in anterior cruciate ligament reconstruction

Different surgical methods of graft fixation in ACL reconstruction were examined to determine the effects on mechanical properties of the reconstructed ACL. Ten human cadavers were used in this study. Six different types of grafts were studied. The tendon grafts were removed from each cadaver and fixed to femurs and tibias as ACL substitutes with different surgical fixation methods, leaving femur-reconstructed graft-tibia preparations. The surgical techniques used were staple fixation, tying sutures over buttons, and screw fixation. In the latter, the screws were introduced through femoral and tibial drill holes from the outside in order to achieve interference fit as described by Lambert. Tensile testing demonstrated that the original ACL is significantly stronger than the graft used for reconstruction in linear load, stiffness, and maximum tensile strength. All of the failures of the reconstructed ACL grafts occurred at the fixation site, indicating that the mechanically weak link of the reconstructed graft is located at the fixation site. Among the different methods of fixation, one-third of the patellar tendon secured with a cancellous screw, especially with a custom designed large diameter screw, showed significantly higher values. Although many other factors affect the success of ACL reconstruction, our study indicates that the method of surgical fixation is the major factor influencing the graft's mechanical properties in the immediate postoperative period.

Augmentation of anterior cruciate ligament reconstruction in dogs with prostheses of different stiffnesses

The purpose of this study was to investigate the biological and biomechanical properties of anterior cruciate ligament (ACL) reconstruction augmented with Dacron prostheses of three different stiffnesses. The ACLs of 36 adult mongrel dogs were removed and the ligament was reconstructed. In 18 dogs, one knee was reconstructed with patellar tendon alone, and the contralateral knee with Dacron augmented patellar tendon. In the remaining 18 dogs, reconstruction was with Dacron augmented patellar tendon with Dacron alone being used for the contralateral control knee. Death was 3 months after surgery, and the reconstructions were examined biologically and biomechanically. The mechanical data were compared with immediate postoperative data obtained from 45 reconstructed fresh cadaveric knees. Tensile testing demonstrated that an increase in failure load was found when the implanted patellar tendon graft was compared with the cadaveric reconstruction. The strength of the Dacron augmented reconstruction showed little change while the Dacron alone graft decreased in strength during the period of implantation. No clear difference was found between the performance of augmentation devices of different stiffnesses. Microangiography showed that grafts were totally revascularized in patellar tendon alone, but not well revascularized in Dacron augmented patellar tendon and Dacron alone reconstruction. The presence of the Dacron appeared to have an adverse effect on revascularization.

Histologic and histochemical investigation of Gaucher cells

Electron microscopic investigations suggest that morphologically, Gaucher cells and histiocytes are very similar. The fact that there are tubular elements in the lysosomes strongly suggests the possibility of lysosomes as the precursors of Gaucher bodies. By means of the lectin staining methods, the localization of glucocerebroside is clearly demonstrable in Gaucher cells. Lectin staining is the significant diagnostic feature of both Gaucher's and Krabbe's diseases.