Day case arthroscopic anterior cruciate ligament reconstruction

Renal abscess, a very uncommon renal disease in the pediatric patient is often complicated by irrelevant antibiotics treated urinary tract infection or due to other unknown reasons. In this paper, two cases of renal abscess were reported though they had been treated with antibiotics. The diagnosis had been made soon by sonography and computed tomography (CT). In addition, during the period of treatment, a series of sonography were performed to monitor resolution of abscess. In one, the lesion was resolved by antibiotics alone for 2 months duration, the other nearly disappeared 3 weeks later after antibiotics treatment combined with tube-drainage. These imaging techniques permit a prompt diagnosis as well as percutaneous drainage performed if antibiotic treatment dose not lead to resolution of the abscess.     

Comparison of arthroscopic and open reconstruction of the anterior cruciate ligament. Early results

The purpose of this study was to determine in a prospective, randomized, blinded design whether arthroscopically assisted anterior cruciate ligament reconstruction offered any significant immediate or short-term advantages over traditional open reconstruction through a limited arthrotomy. Patients with a diagnosis of deficiency of the anterior cruciate ligament were randomly assigned to one of two treatment groups: the open group (limited open reconstruction) or the arthroscopic group (fully arthroscopic reconstruction). Postoperatively, both groups were treated identically. Intra- and postoperative observations included length of surgery, duration of hospitalization, and amount of pain medication. Follow-up evaluations were performed at 1, 6, 12, 16, 20, and 24 weeks to record crepitus, swelling, range of motion, ligament laxity, and thigh atrophy. Lysholm scores were obtained at the 16 and 24 week follow-ups. At 24 weeks, 86% of the open group and 89% of the arthroscopic group had good-to-excellent results. Intraoperative, postoperative, and follow-up findings indicated no statistically significant differences or relationships between the two groups in any of the variables measured, except that operative time was 13 minutes longer in the arthroscopic group (P < 0.001). The results do not substantiate a clinical advantage for either technique.     

The impact of surgical timing on postoperative motion and stability following anterior cruciate ligament reconstruction

A prospective study was designed to determine the impact of surgical timing on postoperative motion and stability following anterior cruciate ligament (ACL) reconstructive surgery. The study population was limited to acute ACL ruptures from downhill skiing undergoing arthroscopic ACL surgery without arthrotomy or surgical intervention for other ligamentous structures; 185 patients were entered into four separate groups based on the time interval from injury to surgery. Motion and stability were tested at multiple time points from the index surgery and adverse events were recorded. We found no statistical difference in restoration of extension or flexion in any group at any time point. KT-1000 data at 12 months showed a side-to-side difference of < or = 3 mm in 94%, with 6% showing a side-to-side difference of > 3 and < or = 5 mm. We conclude that, in this population, by using modern arthroscopic surgical techniques and an aggressive postoperative physical therapy protocol, motion and stability can be restored in a high percentage of patients and that surgical success is independent of the timing of surgery.     

Periarticular heterotopic ossification: a complication of arthroscopic anterior cruciate ligament reconstruction using a two-incision technique

Extra-articular heterotopic bone formation was recognized as a postoperative complication of arthroscopic anterior cruciate ligament reconstructions in four knees around the femoral drill hole. Although laxity of the reconstructed anterior cruciate ligament was not observed in these patients, local pain, swelling, and deformity at the site of heterotopic ossification required surgical intervention. The ectopic bone can be successfully excised with restoration of function. The incidence rate of this complication is less than 1%.     

Revision of failed prosthetic anterior cruciate ligament reconstruction

Revision of failed prosthetic anterior cruciate ligament reconstructions will continue to be necessary as previously placed prosthetic devices fail with time. These patients often present with recurrent instability, pain, swelling, or effusions. Graft rupture and the generation of particulate debris are common causes of these symptoms. To effectively treat these patients requires careful preoperative evaluation and planning. Operative treatment includes removing the prosthesis and metal fixation devices, evaluating femoral and tibial bone stock, and determining adequacy of previous tunnel position. Staging of the operation may be a necessity if significant bone loss or poor tunnel position on either the femoral or tibial side requires bone grafting. The use of an autogenous bone-patellar tendon-bone graft is suggested and has proven to be effective in restoring knee stability in these revision cases. The ultimate outcome following revision of failed prosthetic ligaments may be limited by associated intraarticular pathology often seen in this patient population.     

The relationship between anterior cruciate ligament reconstruction tibial tunnel location and the anterior aspect of the posterior cruciate ligament insertion

OBJECTIVE: To assess the outcome of 31 patients treated in a day and semi-residential psychotherapy setting. METHOD: Patients had moderate to severe personality difficulties and were referred when current therapy was insufficient or because of the severity of their problems. Eighty-one percent had a Cluster C and 19% a Cluster B (Borderline) Personality Disorder diagnosis (DSM-III-R). Therapy was psychodynamically and feministin-formed and included a sociopolitical dimension. Rating scales used were the Symptom Checklist 90, Goal Attainment Scale, Global Assessment Scale and measures of health resource usage, which were completed pre-treatment, post-treatment and at 4-, 12- and 24-month follow-up. RESULTS: Mean duration of therapy was 4 months (68 therapy days). All clinical rating scales demonstrated marked improvements following treatment (p < 0.0001) which were sustained at 2-year follow-up. There were also improvements of health resource usage. CONCLUSIONS: The results document the clinical efficacy of psychotherapy in this setting, provide support for the philosophy of practice, and suggest that psychotherapy outcome can be evaluated at reasonable financial cost in many settings.     

Gait adaptations before and after anterior cruciate ligament reconstruction surgery

Gait analyses of rehabilitated individuals with anterior cruciate ligament (ACL) deficiency and reconstruction have identified the final adaptations of increased hip extensor torque and hamstring electromyography (EMG) and decreased knee extensor torque and quadriceps EMG during stance. The initial adaptations to injury and surgery are, however, unknown as are the factors that influence the development of the adaptations. Identification of the initial response to injury would provide a basis for determining whether the final adaptations are learned automatically or if they are the result of a lengthy training period in which various factors may affect their development. The purpose of the study was to evaluate the initial effects of ACL injury and reconstruction surgery on joint kinematics, kinetics, and energetics, during walking. Injured limbs from nine subjects with ACL injury were tested 2 wk after injury, and 3 and 5 wk after surgery. Ten healthy subjects were tested. Kinematic and ground reaction data were collected and combined with inverse dynamics to calculate the joint torques and powers. A knee extensor torque throughout most of stance was observed in the injured limbs at all test sessions. This result was in conflict with previous observations of reduced extensor torque or a flexor torque in rehabilitated patients with ACL reconstruction and patients with ACL deficiency. This result also differed from the typical midstance extensor then flexor torque in healthy control subjects. Trend analysis showed a significant (P < 0.001) change in average position at the hip and knee, extensor angular impulse at the hip, and positive work done at the hip 3 wk after surgery followed by a partial rehabilitation at 5 wk after surgery. Power and work produced at the knee were reduced fivefold (P < 0.001) after 5 wk of rehabilitation and did not recover to pre-surgical levels. The existence of a long-lasting knee extensor torque 2 wk after injury indicated that the adaptation process to ACL deficiency is lengthy, requiring many gait cycles, and that numerous factors could be involved in learning the adaptations.     

Analysis of the drill hole orientation in anterior cruciate ligament reconstruction

In the reconstructive procedure of the anterior cruciate ligament (ACL), the relationship was investigated between the orientation of the drill holes from the isometric points and the deformity in the ligament graft. We first investigated, by numerical analysis, the optimal orientation of the drill holes for minimal deformation. Secondly, we experimentally by using eight fresh cadaveric knees, measured the relationship between the orientation of the drill holes and the bending angle in the grafts. The optimal orientation of the drill hole in the femur was found to be tilted 20 degrees laterally in the coronal plane and 23 degrees anteriorly in the sagittal plane. In the tibia, the drill hole should be directed 24 degrees medially and 50 degrees anteriorly from the isometric point. The numerically analysed bending angle corresponded well to the results from the experimental study. The deformation in the graft on the femoral side was larger than that on the tibial side. Therefore, the orientation of the femoral drill hole was concluded to be more important than the orientation of the tibial drill hole.     

Graft fixation strength with arthroscopic anterior cruciate ligament reconstruction. Two-incision rear entry technique compared with one-incision technique

OBJECTIVES: This study examined how patient acceptability influences the effectiveness of directly observed therapy for tuberculosis. METHODS: Decision and sensitivity analyses were used in assessing influences. RESULTS: If mandatory directly observed therapy discourages 6% of initial tuberculosis patients (range: 4% to 10%) from seeking care, then such therapy will be less effective than self-administered therapy. Directly observed therapy is more effective than repeated self-administered therapy for patients failing to complete initial treatment unless 32% (range: 27% to 38%) of patients avoid seeking care. CONCLUSIONS: Patient acceptability must be taken into consideration before selecting public health strategies.     

The effect of immediate weightbearing after anterior cruciate ligament reconstruction

Immediate weightbearing has been advocated after anterior cruciate ligament reconstruction and is thought to enhance the return of quadriceps muscle activity and knee extension range of motion without jeopardizing graft integrity. This study examined the effect of immediate weightbearing after anterior cruciate ligament reconstruction on the return of vastus medialis oblique electromyography activity, knee extension range of motion, knee stability, physical examination, Lysholm score, and anterior knee pain. Forty-nine patients (24 men and 25 women) undergoing endoscopic central third patella tendon autograft reconstruction were randomized prospectively into two groups. Group 1 patients underwent immediate weightbearing as tolerated. Group 2 patients were kept nonweightbearing for 2 weeks. All measurements were taken before surgery, 2 weeks after surgery, and between 6 and 14 months (average, 7.3 months) followup. There was no effect of weightbearing on knee extension range of motion or vastus medialis oblique function at followup. In addition, knee stability was not compromised after surgery. Seven of 20 (35%) nonweightbearing patients and only two of 25 (8%) immediate weightbearing patients reported anterior knee pain at followup. Overall, immediate weightbearing did not compromise knee joint stability and resulted in a better outcome with a decreased incidence of anterior knee pain.     

Bone graft procurement for patellar defect grafting in anterior cruciate ligament reconstruction

OBJECTIVE: To report a possible case of leukocytoclastic vasculitis associated with clarithromycin therapy. CASE SUMMARY: An 83-year-old white woman was prescribed clarithromycin for pneumonia. Six days after her initial presentation, she developed lesions on her palms. Clarithromycin was discontinued at that time. The following day she developed purpuric eccymotic nonblanching lesions that primarily appeared on the lower extremities, buttocks, and abdomen. Colonoscopy revealed generalized erythema and edema of the bowel mucosa. Gastroscopy revealed duodenitis and gastritis, but no bleeding or ulceration. Skin biopsy of the lesions was compatible with leukocytoclastic vasculitis. Renal function was not affected, although hematuria was noted. All symptoms resolved after drug withdrawal and a short course of corticosteroids. DATA SOURCES: Searches were performed on MEDLINE, Embase, International Pharmaceutical Abstracts, and major adverse drug reaction databases to identify reports and articles discussing clarithromycin- and macrolide-induced leukocytoclastic vasculitis. DISCUSSION: Leukocytoclastic vasculitis is one category of drug hypersensitivity reactions characterized by distinctive patterns of perivascular inflammation. The case described here is consistent with the diagnosis of leukocytoclastic vasculitis, and is similar to the other single published case report associated with clarithromycin. CONCLUSIONS: Leukocytoclastic vasculitis induced by clarithromycin is a rare but serious potential adverse effect.     

The search for the Holy Grail: a century of anterior cruciate ligament reconstruction

A perspective on the history of the development of anterior cruciate ligament reconstruction is presented. The lack of critical analyses establishing the relative effectiveness of many previously described procedures is documented.     

The incidence of deep venous thrombosis in anterior cruciate ligament reconstruction

Elcatonin, used for treatment of hypercalcaemia, Paget's disease and osteoporosis, causes flushing of the face and hands. To determine whether this was because of increased levels of vasoactive intestinal peptide, which is known to induce vasodilation, the effect of elcatonin on the plasma levels of vasoactive intestinal peptide was studied in five healthy volunteers. After a single intramuscular administration of elcatonin (20 int units), peak plasma elcatonin levels (approx. 30 pg mL-1) were achieved 30 min after injection. Plasma vasoactive intestinal peptide concentrations rose similarly with peak levels of about 17 pg mL-1 after 30 min. Side-effects such as cutaneous flushing (most obvious in the face and hands) occurred to an extent dependent on the amount of elcatonin administered, and declined over 45 min in parallel with the fate of plasma vasoactive intestinal peptide. The side-effects of elcatonin, especially cutaneous flushing, seem to be closely connected with vasoactive intestinal peptide.     

The use of cold therapy after anterior cruciate ligament reconstruction. A prospective, randomized study and literature review

We performed a randomized, prospective study to assess the effectiveness of postoperative cold therapy in patients who had anterior cruciate ligament reconstructions. Drain output, length of hospital stay, range of motion, and use of pain medication were all assessed. Patients were randomized into one of four groups after surgery. Group 1 patients had a cooling pad applied to the knee postoperatively and set at a temperature of 40 degrees to 50 degrees F, Group 2 had the cooling pad set at 70 degrees to 80 degrees F, Group 3 received ice packs, and Group 4 received no cold therapy of any kind. The skin temperatures in Groups 1 and 3 were significantly lower than the skin temperatures in Groups 2 and 4 (P < 0.001). The length of hospital stay, range of motion at discharge, use of oral and intramuscular pain medicine, and drain output were not significantly different between groups. No complications related to the type of cold therapy were seen in any group. Thus, both ice packs and cooling pads significantly decreased knee temperature, but we found no objective benefits in the early postoperative course due to this decrease in temperature.     

The effects of knee reconstruction on combined anterior cruciate ligament and anterolateral capsular deficiencies

We tested the effect of intraarticular reconstructions of the anterior cruciate ligament alone and in combination with extraarticular reconstructions in 10 cadaveric knees. These knees had anterior cruciate ligament deficiency alone or in combination with anterolateral capsuloligamentous deficiencies. In the knees with combined injury, intraarticular reconstruction returned anterior stability to levels not significantly different from levels found for the knees deficient in the anterior cruciate ligament alone and treated with this procedure. After intraarticular reconstruction, rotational stability of the knee with combined injuries failed to return to the levels seen in the knee with isolated anterior cruciate ligament deficiencies that underwent the same treatment. When a tenodesis with either 0 N or 22 N of tension was added to the intraarticular reconstruction in the knee with combined injuries, we found that excessive internal rotation significantly decreased at all angles of flexion, except at full extension with 0 N of tension. In addition, the extraarticular reconstruction with 22 N of tension in the tenodesis overconstrained the knee in internal rotation between 30 degrees and 90 degrees of knee flexion. The tenodesis with 0 N of tension overconstrained the knee at only 60 degrees and 90 degrees of flexion. These results suggest extraarticular reconstruction as an adjunct to the intraarticular operation for the knee with anterior cruciate ligament and anterolateral structural injuries. The results also suggest that the surgeon can affect anterior and rotational laxity by adjusting the tension in the tenodesis.     

Roofplasty requirements in vitro for different tibial hole placements in anterior cruciate ligament reconstruction

In this study we sought both to quantify the forces that result in anterior cruciate ligament graft impingement and the amount of roofplasty necessary to prevent it. The perpendicular force of the intercondylar roof against an anterior cruciate ligament graft was measured in seven fresh-frozen cadaveric knees. Two tibial hole placements were evaluated: an anterior/eccentric hole (26.6% +/- 3.1% of the sagittal depth) and a customized hole aligned 4 to 5 mm posterior and parallel to the slope of the intercondylar roof in the extended knee (42.0% +/- 2.6% of the sagittal depth). A transducer that measured the contact force with the graft was implanted in the roof. An extensive roofplasty was performed so that the sensor would bear all of the roof force. Graft tension was also measured. Extension moments were applied to 20 N-m with a six degree of freedom load application system. Load cycles were repeated with the roof force sensor backed out in 0.8 mm increments. The sensor backout represented a corresponding amount of bone removal in a roofplasty. The flexion angle at roof-graft contact was consistently greater using the anterior tibial hole than the customized one. This held true for all increments of sensor backout. With the anterior hole, the roof sensor (no backout) contacted the graft at 12.8 degrees +/- 6.7 degrees of flexion, whereas the customized hole resulted in contact at 4.1 degrees +/- 4.2 degrees (P = 0.020).(ABSTRACT TRUNCATED AT 250 WORDS)     

Gait biomechanics are not normal after anterior cruciate ligament reconstruction and accelerated rehabilitation

PURPOSE: Accelerated rehabilitation for anterior cruciate ligament (ACL) injury and reconstruction surgery is designed to return injured people to athletic activities in approximately 6 months. The small amount of empirical data on this population suggests, however, that the torque at the knee joint may not return until 22 months after surgery during walking and even longer during running. Although the rehabilitation has ended and individuals have returned to preinjury activities, gait mechanics appear to be abnormal at the end of accelerated programs. The purpose of this study was to compare lower extremity joint kinematics, kinetics, and energetics between individuals having undergone ACL reconstruction and accelerated rehabilitation and healthy individuals. METHODS: Eight ACL-injured and 22 healthy subjects were tested. Injured subjects were tested 3 wk and 6 months (the end of rehabilitation) after surgery. Ground reaction force and kinematic data were combined with inverse dynamics to predict sagittal plane joint torques and powers from which angular impulse and work were derived. RESULTS: The difference in all kinematic variables between the two tests for the ACL group averaged 38% (all P < 0.05). The kinematics were not different between the ACL group after rehabilitation and healthy subjects. Angular impulses and work averaged 100% difference for all joints (all P < 0.05) between tests for the ACL group. After rehabilitation, the differences between injured and healthy groups in angular impulse and work at both the hip and knee remained large and averaged 52% (all P < 0.05). CONCLUSIONS: Results indicated that after reconstruction surgery and accelerated rehabilitation for ACL injury, humans walk with normal kinematic patterns but continue to use altered joint torque and power patterns.     

Integration of hamstring tendon graft with bone in reconstruction of the anterior cruciate ligament

Anterior cruciate ligament (ACL) reconstruction using four-strand hamstring graft with round-headed, cannulated, interference (RCI) screw fixation requires osteointegration of the tendon graft. This report describes the histology at the bone-tendon junction of two specimens retrieved from patients undergoing revision surgery after traumatic mid-substance ACL graft rupture at 6 and 10 weeks after initial reconstruction. Revision was performed at 12 and 15 weeks. Integration of the graft was evident by observation of collagen fiber continuity between bone and tendon. This histology plus the low incidence of early graft failure suggest that free tendon autograft attached to bone by RCI screw allows adequate osteointegration between 6 and 15 weeks after surgery.     

Value of posterior cruciate ligament index in the diagnosis of anterior cruciate ligament injuries

Several EF-hand recoverin mutants were obtained and their abilities to bind to photoreceptor membranes and to inhibit rhodopsin kinase were determined. The mutants with the 'spoiled' 2nd, 3rd or (2nd+3rd) EF-hand structures did not act upon the kinase activity in the microM range of Ca2+ concentrations. Mutations of the 4th EF hand, which 'repaired' its Ca2+-binding activity, resulted in recoverin with three 'working' Ca2+-binding sites. The latter mutant inhibited rhodopsin kinase even more effectively than the wild-type recoverin, containing two working Ca2+-binding structures.