Anatomical reconstruction of posterolateral corner and combined injuries of the knee.

PURPOSE: The goal of this study was to present a 2- to 5-year prospective follow-up of an anatomical posterolateral corner reconstruction in a series of 16 patients with symptomatic instability and pain complaints of the knee. METHODS: All 16 patients underwent a posterolateral corner reconstruction as described by LaPrade et al. If cruciate ligament ruptures were present and had not been addressed earlier, these were reconstructed as well. Preoperatively and 2-5 years after surgery, multiple subjective knee outcome scores (VAS satisfaction score, Tegner, Lysholm, Noyes score and IKDC subjective knee form) were obtained, and the laxity of the joint was evaluated objectively by using bilateral varus stress radiographs to compare the injured with the uninjured knee. RESULTS: Eleven patients had concomitant ACL or PCL surgery or already had undergone surgery on this cruciate ligament. Mean varus laxity of the injured knee on varus stress radiographs improved significantly from 9.6° (6.6-17.1) to 6.3° (0.3-13.4), p = 0.0011. Post-operative varus laxity did not return to the level of the uninjured knee: 4.4° (1.5-7.7), p = 0.036. VAS satisfaction score, the Tegner, Lysholm, Noyes scores and the IKDC subjective knee form all improved significantly. CONCLUSION: The anatomical reconstruction of the posterolateral corner does provide restoration of the external rotation stability in the majority of patients. However, the varus laxity could not be restored in all patients. Functional knee scores improved significantly, and most reconstructed knees had a laxity of <3° compared with the uninjured knee, but the reconstructed knee did not become as stable as the uninjured knee. The results of this study can assist surgeons and patients to have realistic expectations of this operation. LEVEL OF EVIDENCE: Case series with no comparative group, Level IV.

The natural course of chronic exertional compartment syndrome of the lower leg.

PURPOSE: The aim of this study was to investigate the natural course of chronic exertional compartment syndrome (CECS) in the lower leg. METHODS: Twelve military men [mean age 30 (SD 4)] diagnosed with CECS after intracompartmental pressure (ICP) measurements immediately post-exercise in 21 legs, who did not undergo a fasciotomy, were reviewed and participated in a repeat pressure measurement after a mean time of 50 months (SD 15). RESULTS: Sixteen of 21 legs still showed an ICP of 35 mm Hg or more (the cut-off point) at the second visit. All twelve patients still had typical complaints. Mean ICP at index measurement was 58 (SD 15) mm Hg. At the second visit, it was 51 (SD 15) mm Hg. Six patients chose to undergo a subcutaneous fasciotomy, and these six patients all benefited in the short term. CONCLUSION: The natural course of CECS seems to be persistent symptoms over time. LEVEL OF EVIDENCE: Case series with no comparative group, Level IV.

Virtual reality training for endoscopic surgery: voluntary or obligatory?

INTRODUCTION: Virtual reality (VR) simulators have been developed to train basic endoscopic surgical skills outside of the operating room. An important issue is how to create optimal conditions for integration of these types of simulators into the surgical training curriculum. The willingness of surgical residents to train these skills on a voluntary basis was surveyed. METHODS: Twenty-one surgical residents were given unrestricted access to a VR simulator for a period of four months. After this period, a competitive element was introduced to enhance individual training time spent on the simulator. The overall end-scores for individual residents were announced periodically to the full surgical department, and the winner was awarded a prize. RESULTS: In the first four months of study, only two of the 21 residents (10%) trained on the simulator, for a total time span of 163 minutes. After introducing the competitive element the number of trainees increased to seven residents (33%). The amount of training time spent on the simulator increased to 738 minutes. CONCLUSIONS: Free unlimited access to a VR simulator for training basic endoscopic skills, without any form of obligation or assessment, did not motivate surgical residents to use the simulator. Introducing a competitive element for enhancing training time had only a marginal effect. The acquisition of expensive devices to train basic psychomotor skills for endoscopic surgery is probably only effective when it is an integrated and mandatory part of the surgical curriculum.

[Spondylodiscitis as cause of unexplained fever]. / Spondylodiscitis als oorzaak van onbegrepen koorts.

An 83-year-old woman was admitted to hospital with complaints of fever, abdominal pain and other complaints suggesting urosepsis. Additional analyses did not reveal the cause of her complaints. After cessation of antibiotic therapy, there was a spontaneous decrease in the infection parameters and she was subsequently discharged. Two and a half months later she was presented in our hospital with low back pain with radiating to the legs. MRI showed signs ofa spondylodiscitis at the level of LIII-LIV existing for some time. Finally, a gram-positive streptococcus infection was found and she was treated with antibiotics for 13 weeks. 6 months later she was free of symptoms. A 57-year-old man was admitted to the intensive care with a double-sided olecranon bursitis and sepsis. An endocarditis caused by Staphylococcus aureus was thought to be the cause of the sepsis and the patient was treated with surgical intervention and antibiotics. Because of persistent sepsis, different CT-scans were performed, and after one and a half months an extensive spondylodiscitis with abscess formation was diagnosed and subsequently treated surgically. A delay in diagnosing spondylodiscitis is the rule rather the exception. The diagnosis should be considered in any patient with localised back pain, especially when accompanied by fever, high ESR, and the presence of risk factors such as high age, diabetes mellitus, immunosuppression, and/or rheumatoid arthritis.

Attenuation of acute lung injury by ozone inhalation--the effect of low level pre-exposure.

The attenuating influence of a pre-exposure of rats to a low concentration of ozone (O3) for 7 days on a subsequent O3 challenge was investigated. Effects of O3 were quantified by measuring indicators of lung permeability and inflammation in bronchoalveolar lavage fluid. The results suggest that pre-exposure to relatively low levels of O3 produces a diminished permeability response in lower airways of rats upon a following challenge with a higher level of O3. Extrapolated to human exposure situations, these data suggest that health effect evaluation of repeated exposure periods of enhanced O3 levels is rather complex and needs further investigation.

Exercise-induced muscle damage in the rat: the effect of vitamin E deficiency.

Rats, fed a vitamin-E-deficient diet for 6 weeks, performed treadmill exercise for 2 h. Muscle damage was assessed by measuring the creatine kinase (CK) activity in plasma before and after exercise, and by studying semi-thin longitudinal sections of the soleus muscle 48 h after running. Vitamin-E-deficient male and female rats showed an increased post-exercise CK activity when compared to matched controls, but male rats showed a larger CK response than females. This rise in plasma CK activity was caused mainly by an increased activity of the muscle-specific CK-isoenzyme, CK-MM (males + 1238%; females + 540%, P less than 0.05). In a parallel histological study we observed in vitamin-E-deficient male rats a dramatic and significant disturbance of the normal cyto-architecture of the muscle fibres after exercise (focal necrosis, phagocytosis and cellular infiltrates), whereas in females only minor, non-significant, changes were seen. We conclude that vitamin E deficiency enhances the susceptibility to exercise-induced muscle damage in male rats more than in female rats. This difference between the sexes is attributed to the protective effect of oestradiol that remains operative in female rats when the vitamin E status is disturbed: male rats lack such hormonal protection.

Dietary vitamin E deficiency and zinc metabolism.

In adult rats, the influence of vitamin E deficiency on zinc metabolism in general and specifically in 15 tissues was studied. After 50 days, we found evidence of vitamin E deficiency and at this time point we injected a tracer amount of 65Zn. During the next 18 days the zinc status was unaffected. The zinc metabolism, however, was altered: the apparent retention increased and the biological half life was prolonged. On day 68, the changes in various tissues varied. Some tissues were affected in zinc concentration (higher in plasma and spleen; lower in cerebrum, fur and tail), others in specific activity (higher in pancreas; lower in cerebellum). The different effects may reflect differences in tissue response on impairement, caused by vitamin E deficiency.