Adjacent-segment morbidity after Graf ligamentoplasty compared with posterolateral lumbar fusion.

OBJECT: Of concern to spine surgeons are accelerated degenerative changes of motion segments located above and below where spinal fusion has been performed. Graf artificial ligament stabilization has been developed to avoid the adverse effect of spinal fusion. The object of this study was to assess the adjacent-segment morbidity of Graf ligamentoplasty compared with posterolateral fusion (PF) in which instrumentation was used. METHODS: Data obtained in 45 patients who underwent L4-5 Graf ligamentoplasty (18 patients) or PF with instrumentation (27 patients) were reviewed retrospectively. The minimum follow-up period was 5 years. In the PF group a solid fusion rate of 92.6% was achieved. Radiographic evaluation included assessment of lumbar sagittal alignment, range of motion (ROM), and adjacent-disc degeneration. Adjacent-segment morbidity was clinically assessed by determining the reoperation rate. Graf ligamentoplasty maintained regional lordosis and flexibility (13 degrees in L4-5 lordosis; 4.4 degrees in L4-5 ROM). Although there was no difference in preoperative adjacent-disc condition between the two groups, radiographic evidence of adjacent-disc deterioration was observed more frequently in patients in the PF group than the Graf group (25% and 6% at L1-2; 38% and 6% at L2-3; 38% and 18% at L3-4; and 43% and 18% at L5-sacrum, respectively). One case in the Graf group (5.6%) and five cases in the PF group (18.5%) required additional surgeries for adjacent-segment lesions. CONCLUSIONS: Graf ligamentoplasty cannot completely replace spinal fusion. In a well-selected group of patients, however, it was shown to maintain lumbar mobility and sagittal alignment, and it decreased the risk of adjacent-segment deterioration compared with PF with instrumentation.

Mid-term clinical results of Graf stabilization for lumbar degenerative pathologies. a minimum 2-year follow-up.

BACKGROUND CONTEXT: Spinal fusion has some adverse effects, such as nonunion and pain at the site of grafted bone, and fusion with rigid spinal instrumentation especially may have the possibility of increasing mechanical stress on the segments adjacent to the site of fusion. The theory of the Graf system is that it will decrease adjacent disc deterioration because of maintenance of regional lordosis with flexibility and restriction of the motion of unstable segments without rigid spinal fusion. PURPOSE: To assess the clinical and radiologic results of Graf stabilization for lumbar degenerative disorders with minimal or mild instability. STUDY DESIGN: This is a retrospective study examining the mid-term results of Graf stabilization. PATIENT SAMPLE: In total, 59 patients underwent Graf ligamentoplasty and adequate decompression from April 1993 to September 1997. The subjects were 30 men and 29 women, and the mean age at the time of surgery was 60.6 years, ranging from 23 to 82 years. The average follow-up period was 3 years and 5 months, ranging from 2 years to 5 years and 10 months. OUTCOME MEASURES: We evaluated the surgical results using a scoring system, a visual analog scale, and radiological measurements. METHODS: The results were assessed according to a clinical scoring system established by the Japanese Orthopaedic Association (JOA score) and ratings based on a visual analog scale. Through analysis of x-ray images, the sagittal alignment (regional lordosis) and the range of motion (ROM) of the stabilized segments were measured in all cases, and the percentage of segments slipping and posterior disc height were determined for 29 patients with degenerative spondylolisthesis. RESULTS: Clinical scores and low back pain ratings based on a visual analog scale were significantly improved at the time of final follow-up compared with the preoperative values. Regional alignment of the operative segments was maintained in lordosis at the time of final follow-up. Preoperative ROM was significantly reduced at the time of final follow-up. There were no statistical differences in percentage of slippage or percentage of posterior disc height between the final follow-up values and the preoperative values. CONCLUSIONS: Our clinical results indicate that the Graf system is a suitable treatment option for mild and early lumbar degenerative diseases with minimum flexion instability of less than 10 degrees.

Rapid immunologic diagnosis of classic late infantile neuronal ceroid lipofuscinosis.

OBJECTIVE: To establish a new method for rapid diagnosis of late infantile neuronal ceroid lipofuscinosis (LINCL, CLN2) using specific polyclonal antibodies against the CLN2 gene product. METHODS: Cells and tissues were obtained from five patients with LINCL, two with variant type NCL, three with other lysosomal storage diseases, and eight control subjects. Two antibodies were raised against N- and C-terminal peptide fragments of the normal product of the CLN2 gene. The authors examined the possibility of diagnosis of LINCL with immunostaining and immunoblotting using specific antibodies made of the recently identified defective gene in LINCL. RESULTS: Immunoreactivity with these antibodies showed the absence or marked reduction of CLN2 immunoreactivity in the lymphocytes, lymphoblasts, and fibroblasts of all five patients with LINCL examined. CONCLUSIONS: These results indicate the usefulness of this diagnostic method based on the changes in CLN2 immunoreactivity. This relatively simple, specific, and cost-effective method is a promising diagnostic tool for this disease, although additional studies are necessary.

Pseudoaneurysm of the subclavian artery due to Xanthomonas pneumonia in a patient with acute myeloid leukemia: its rupture treated by transcatheter coil embolization.

A 52-year-old male with acute myeloid leukemia developed pseudoaneurysm of the subclavian artery. Pneumonia due to Xanthomonas maltophilia, which was multi-drug resistant, progressed to a lung abscess even under administration of antibiotics. This lung infection contiguous to the left carotid and subclavian arteries was suggested to have caused the pseudoaneurysm of the subclavian artery. The rupture of the aneurysm by penetration to the trachea amounted to about 1,000 ml of bleeding; fortunately the bleeding ceased spontaneously. Nonetheless, an emergency transcatheter coil embolization prevented re-bleeding. Endovascular treatment should be considered especially for aneurysms which develop in patients with underlying diseases.

The effect of cryotherapy on intraarticular temperature and postoperative care after anterior cruciate ligament reconstruction.

The objective of this study was to elucidate how cryotherapy after anterior cruciate ligament reconstruction affects intraarticular temperature and clinical results. A prospective and randomized study was performed on 21 knees of 21 patients. The ligament reconstruction was performed by single-incision arthroscopy using autogenous hamstring tendon. On completion of the surgery, thermosensors were implanted in the suprapatellar pouch and the intracondylar notch, and the intraarticular temperature was monitored while the joint was cooled. Cooling was performed in one group at 5 degrees C (N = 7) and in another at 10 degrees C (N = 7), for 48 hours. A control group (N = 7) did not undergo cryotherapy. The cooled groups showed three temperature phases: a low-temperature phase immediately after the ligament reconstruction, followed by a temperature-rising phase and a thermostatic phase. The control group had no low-temperature phase and immediately entered a thermostatic phase. During the low-temperature phase in the treated groups, the temperature of the suprapatellar pouch and of the intercondylar notch were significantly lower than the body temperature. The pain score and the number of times an analgesic had to be administered were both significantly lower in the 10 degrees C group than in the control group. Blood loss was significantly less in the 5 degrees C group than in the control group.

[T-cell prolymphocytic leukemia with CD4+8+25+ phenotype in a patient presenting with venous thrombosis in the lower leg].

A 58-year-old man was referred to our hospital because of painful swelling in the left lower leg and leukocytosis in January 1999. Moderate hepatosplenomegaly but no lymph node swelling was observed. Marked leukocytosis (leukocytes 44.9 x 10(4)/microliter with 95% morphologically prolymphocytes) and thrombocytopenia were detected. The surface phenotype of the leukemia cells was CD1-2+3+5+7+4+8+25+. Magnetic resonance imaging revealed dilated veins in the left lower leg. An abnormal 47XY, +22 karyotype was detected in 1/20 cells. Tests for HTLV-I antibody were negative. A diagnosis of T-cell prolymphocytic leukemia (T-PLL) was made on the basis of data including cytochemical and electron microscopic findings. Although 2 courses of chemotherapy comprising vincristine, cyclophosphamide, and prednisolone improved the venous thrombosis in the leg, the leukemia cells were refractory to chemotherapy. To prevent the recurrence of venous thrombosis due to leukostasis, the patient underwent repeated leukapheresis. The leukocyte count was maintained at around 20.0 x 10(4)/microliter after total 7 courses of leukapheresis, one course of which comprised 7l of extracorporeal circulation. In addition to the rare presentation of venous thrombosis, the CD4+8+25+ phenotype observed in this case is rare in patients with T-PLL.

Changes in muscle strength properties caused by harvesting of autogenous semitendinosus tendon for reconstruction of contralateral anterior cruciate ligament.

A prospective study was conducted of how the muscle strength of the donor knee is affected by harvesting of the autogenous semitendinosus tendon (St) for use as a substitute graft material in cruciate ligament reconstruction. There were 25 patients from whom only the St was harvested from the contralateral (i.e., healthy/donor) knee. Using a Biodex System II (Biodex, New York, NY), the strength of the donor knee was measured during both extension and flexion, both before and 12 months after the tendon harvesting procedure. A comparative study was made of the preharvest and postharvest values for the peak torque and peak torque angle in the isokinetic contraction. There were no statistically significant differences between the preharvest and postharvest peak torque values of the donor knee. However, the peak torque angle decreased significantly after the tendon harvest; the range of the mean decrease was from 11.7 degrees to 15.0 degrees. This indicates that there was a change to a small flexion angle (P < .05). After the tendon harvest, regardless of the applied angular velocity, more than 80% of the cases showed a change of torque curve shape in which there was no peak in the latter half, and the position of the peak was shifted to the left. In conclusion, the results of this study indicate that harvesting of the autogenous St does not affect the peak torque, but the peak torque angle during flexion of the donor knee is reduced.

Arthroscopic studies of variants of the anterior horn of the medical meniscus.

The objective of this study was to arthroscopically analyse the morphology and dynamics of variants of the anterior horn of the medial meniscus of the knee (VAMM) and to then consider the pathological significance of these variants. VAMM was defined as knees in which the anterior horn of the medial meniscus is not attached to the tibia. Between April 1992 and March 1995, arthroscopy was performed on 953 knees of 903 patients. At the time of this examination, observation and probing were performed to determine the condition of the synovium, the synovial plica, the cartilage in all compartments, the meniscus, the cruciate ligaments, and the popliteal tendon. In particular, detailed examination was made of the anterior horn of the medial meniscus with regard to the point of insertion to the tibia and the degree of movement in knee flexion/ extension. Cases of VAMM diagnosed on the basis of the arthroscopic findings were classified into the following four categories: the ACL (anterior cruciate ligament) type, where the anterior horn of the medial meniscus was attached to the ACL; the transverse ligament type, where the anterior horn of the medial meniscus was attached to the transverse ligament; the coronary ligament type, where the anterior horn of the medial meniscus was attached to the coronary ligament; and the infrapatellar fold type, where the anterior horn of the medial meniscus was attached to the infrapatellar synovial fold. These patients were then analyzed with regard to the arthroscopic findings and the intra-articular lesions other than VAMM. In 98 (10.9%) of the total patients, 103 knees were classified as VAMM. Classification of those 103 knees using the above criteria showed 39 ACL type knees, 51 transverse ligament type knees, 11 coronary ligament type knees, and 2 infrapatellar fold type knees. The arthroscopic findings indicated that the anterior horn of the medial meniscus was not attached directly to the tibia in any of these knees. Probing and flexion/extension of the knee revealed hypermobility at the anterior horn of the medial meniscus. In this study, anterior knee pain syndrome was diagnosed in 12 (11.7%) of the 103 VAMM knees. In addition, there was no clear history of trauma in 20 of 23 knees found to have an isolated medial meniscus tear. In these cases, even detailed arthroscopic observation proved the causes of the symptoms or injury. On the basis of these findings, we surmised that the anterior portion shows hypermobility at the time of flexion/extension of the knee, regardless of the type of VAMM. In this study, we discussed the possibility that the existence of VAMM may become the cause of pain or injury to the meniscus.

Graft site morbidity with autogenous semitendinosus and gracilis tendons.

To distinguish between morbidity caused by harvesting semitendinosus and gracilis tendons and morbidity associated with anterior cruciate ligament reconstruction surgery, we performed a prospective randomized study using 65 patients who underwent anterior cruciate ligament reconstruction using these tendons. The patients underwent either contralateral (N = 34) or ipsilateral (N = 31) graft harvest. For the nonoperated knees in the ipsilateral harvest group, isometric and isokinetic strength of the quadriceps and hamstring muscles increased to approximately 120% of the preoperative value at 12 months after surgery. Compared with these knees, the tendon harvest did not affect quadriceps muscle strength at all. However, harvest did decrease hamstring muscles strength for 9 months after surgery. The graft harvest in the knees with anterior cruciate ligament reconstruction also did not significantly affect quadriceps muscle strength, but it did significantly decrease hamstring muscles strength only at 1 month. Activity-related soreness at the donor site was rarely restricting and resolved by 3 months. This study demonstrated that the semitendinosus and gracilis tendon graft is a reasonable choice to minimize the donor site morbidity in ligament reconstruction using autografts.

[Primary myelofibrosis in an infant--a case report and review of the literature].

Primary myelofibrosis (PMF) is regarded as a chronic myeloproliferative disorder. It is characterized by marrow fibrosis, leukoerythroblastosis, tear drop erythrocytes and extramedullary hematopoiesis. Most patients are in their late 50s when first diagnosed. Pediatric PMF is said to be quite rare. Here describe a female infant with PMF. The patient was born on Aug. 7, 1991. The pregnancy and delivery were uneventful. Hepatomegaly was noted soon after birth. Combined blood counts showed polycythemia and leukocytosis. It was thought to be extramedullary hematopoiesis due to intrauterine infection. She was followed up in another hospital, but since her condition was unchanged she was admitted to our hospital for further medical examinations at age 7 months. On the peripheral blood smear, there were tear drop erythrocytes, normoblasts and early myeloid elements. Repeated bone marrow aspirations were dry taps. This case presented the classical findings of fibrosis of the bone marrow on bone marrow biopsy. She is in good health without any therapy until now. A review of 7 cases of PMF, including our case, in Japanese children was made and discussed in comparison to adult cases.

Quantitative evaluation of knee instability and muscle strength after anterior cruciate ligament reconstruction using patellar and quadriceps tendon.

Anterior cruciate ligament reconstruction using an autologous graft harvested from the central one-third of the patellar and quadriceps tendon was performed in 65 knees of 65 patients who were followed from 3 to 7 years. Mean anterior laxity of both knees was measured before and after surgery in each patient using the Styker Knee Laxity Tester. At 30 degrees of knee flexion, 58 patients (89%) had differences of less than 2.5 mm between the operated and unoperated knees. Quadriceps strength was measured with the Cybex II and was less than 50% of the uninjured knee at 3 months after surgery. In men, quadriceps strength returned to 78% of normal at 1 year and 85% at final followup. These values were equal to the preoperative level. In women, the quadriceps strength at final followup was 70%, significantly lower than preoperative strength. Hamstring strength recovered to equal the normal strength. Although anterior cruciate ligament reconstruction using one-third of the patellar and quadriceps tendon achieves stability, postoperative quadriceps weakness is a disadvantage. This weakness may be caused by impairment of the knee extensor mechanism resulting from harvesting the graft. We do not currently recommend this technique for anterior cruciate ligament reconstruction.

Biomechanical analysis of rehabilitation in the standing position.

Biomechanical analysis of the two-dimensional models composed from roentgenographic pictures and electromyographic analysis of the shear force exerted on the tibia during standing on both legs were conducted in 21 young adult males. The simultaneous contraction of the quadriceps and hamstrings was observed in all electromyograms. Amplitude observed on electromyograms of the hamstrings increased as the trunk flexion angle increased. The calculated average values of shear force were negative at every knee flexion angle (negative value means posteriorly directed force). As the trunk flexion angle increased, posterior drawer force increased at knee flexion angles of 30 degrees and 60 degrees. The simultaneous contraction of the quadriceps and the hamstrings was considered to be the main factor that influenced these results. Standing on both legs with knee and trunk flexion was considered to be applicable in the early stages after anterior cruciate ligament reconstruction.

Muscle weakness after anterior cruciate ligament reconstruction using patellar and quadriceps tendons.

Eighty-five knees of 85 patients who underwent anterior cruciate ligament reconstruction with autologous patellar and quadriceps tendon grafts were followed for 3-7 years. Hamstrings strength improved to normal. Quadriceps strength in men returned to the preoperative level, but not to normal strength. Quadriceps strength in women, at the final follow-up, was significantly less than it had been preoperatively. This weakness may be a consequence of impairment of the knee extensor mechanism resulting from harvesting the graft. Although favorable postoperative stability of the knee was obtained, we do not recommend this technique for ACL reconstruction because of the quadriceps weakness.

[Analysis of the shear force exerted on the tibia during standing on bilateral legs with knee flexion].

Biomechanical analysis of the two-dimensional models composed of roentgenographic pictures and electromyographic analysis about the shear force (Fs) exerted on tibia during standing on bilateral legs was conducted in 21 young adult males. The simultaneous contraction of the quadriceps and hamstrings was observed in all electromyograms (EMGs). Amplitude observed on EMGs of the hamstrings increased as the trunk flexion angle increased. The calculated average values of Fs were negative at every knee flexion angle; Negative value means posteriorly directed force. As the trunk flexion angle increased, posterior drawer force increased at knee flexion angles of 30 degrees and 60 degrees. The simultaneous contraction of the quadriceps and the hamstrings was considered to represent the main factor that influenced these results. The standing on bilateral legs with knee and trunk flexion was considered to be applicable in the early stages after anterior cruciate ligament reconstruction.

Arthroscopic observations of autogeneic quadriceps and patellar tendon grafts after anterior cruciate ligament reconstruction of the knee.

Fifty-six arthroscopic observations on 53 knees at various periods after anterior cruciate ligament (ACL) reconstruction using the autogeneic quadriceps and patellar tendon were analyzed to clarify the morphologic maturation process of such grafts in human patients. Arthroscopic observations of the grafts were divided into four types, excluding one rerupture case. Type I was observed in three knees less than six months after ACL reconstruction and in one knee six to 12 months after; Type II, in seven knees six to 12 months after; Type III, in six knees six to 12 months after, in 13 knees 12-18 months after, and in five knees more than 18 months after; and Type IV, in eight knees 12-18 months after and in 12 knees more than 18 months after. The types and the intervals after reconstruction were correlated with four phases of healing, including the maturation process of the implanted autogeneic grafts: (1) synovial envelopment, (2) fibrous tissue ingrowth, (3) transformation into ligamentlike tissue, and (4) hypertrophy or maturation of striated ligamentlike structure.

Maturation of autogenous tendon grafts in anterior cruciate ligament reconstruction of the human knee--an arthroscopic study.

Fifty-six arthroscopic observations on 53 knees at various intervals after anterior cruciate ligament (ACL) reconstruction using the autogenous quadriceps and patellar tendon were analyzed to clarify the morphological maturation process of the grafts in human patients. Arthroscopic observations of the grafts were divided into four types, except for one rerupture case. In type I, thick synovial tissue with abundant capillary blood vessels filled the intercondylar fossa. In type II, synovial tissue mass was decreased and ligamentous tissue showed through the thin synovial tissue. In type III, relatively thick synovial tissue with many folds and abundant capillary blood vessels enveloped thick ligamentous tissue. In type IV, thin synovial tissue with relatively few blood vessels enveloped thick ligamentous tissue. Correlation between these graded types and intervals after reconstruction was significant (chi-square test, p less than 0.001). These four types of arthroscopic findings are thought to represent four phases of the maturation process of autogenous grafts after ACL reconstruction in human patients.