Clinical and MRI evaluation of medium- to long-term results after autologous osteochondral transplantation (OCT) in the knee joint.

PURPOSE: Autologous osteochondral transplantation (OCT) is one of the surgical options currently used to treat cartilage defects. It is the only cartilage repair method that leads to a transfer of hyaline cartilage repair tissue. The purpose of this study was to evaluate the magnetic resonance observation of cartilage repair tissue (MOCART) score, the 3D MOCART score and various clinical scores in patients after OCT in knee joints. METHODS: Two women and eight men were evaluated 6-9 years (median 7.2 years) after OCT on the femoral condyle of the knee joint. All patients were evaluated by magnetic resonance imaging (MRI) measurement, using a 3.0 T Scanner with different cartilage-specific sequences. Clinical assessment included the knee injury and osteoarthritis outcome score (KOOS), the international knee documentation committee (IKDC) subjective knee form, the Noyes sport activity rating scale and the Tegner activity score. For MRI evaluation, the MOCART score and 3D MOCART score were applied. RESULTS: Clinical long-term results after OCT showed median values of 77 (range 35.7-71.4) for the IKDC; 50 (6.3-100), 66.7 (30.6-97.2), 65 (0-75), 57.1 (35.7-71.4) and 80.9 (30.9-100) for the KOOS subscales (quality of life, pain sports, symptoms and activity of daily living); 61.4 (22.3-86.2) for the Noyes scale; and 3 (0-6) for the Tegner activity score. The median MOCART score was 75 (30-90) after both 1 and 2 years and 57.5 (35-90) after 7 years, as assessed by different cartilage-specific sequences. The 3D MOCART score showed values of 70 (50-85) and 60 (50-80) in the two different isotropic sequences after 7 years. CONCLUSION: The MOCART and 3D MOCART scores are applicable tools for patient follow-up after OCT. Post-operative follow-up assessments would also benefit from the inclusion of OCT-specific parameters. Long-term results after OCT reflect an impairment in clinical scores in the first 2 years with good results during follow-up. Stable conditions were observed between 2 and 7 years after surgery. The filling of the defects and the cartilage interface appeared good at MRI evaluation after the first 2 years, but cartilage loss was observed between the medium- and long-term follow-ups. Isotropic imaging with multiplanar reconstruction is useful for daily clinical use to assess bony cylinders in cartilage repair, especially in combination with the 3D MOCART. LEVEL OF EVIDENCE: Retrospective therapeutic study, Level IV.

Gender differences following computer-navigated single- and double-bundle anterior cruciate ligament reconstruction.

PURPOSE: Female patients not only demonstrate an increased risk for injury, but also a poorer response following anterior cruciate ligament (ACL) rupture. However, no study has investigated gender-related differences between computer-navigated single-bundle (SB) and double-bundle (DB) ACL reconstruction. The aim of this study was to evaluate the effects of gender on the outcome of computer-navigated SB and DB ACL reconstruction and to present reference values. METHODS: A retrospective review of 55 consecutive patients who underwent SB (15 males, 12 females) and DB (18 males, 10 females) ACL reconstruction with autogenous hamstring tendon grafts and showed a minimum follow-up of 24 months was conducted. Intraoperatively, the anteroposterior and rotational laxity were measured and the follow-up examination included pivot-shift testing, KT-1000 arthrometer testing, International Knee Documentation Committee (IKDC) form, the Lysholm score and Tegner score. RESULTS: Pre-operatively, female patients showed a significant higher internal rotation in (p < 0.001) both the SB and DB group. Regarding the post-operative reduction in internal rotation, females in the SB group revealed a greater reduction compared to males (p < 0.001), whereas females in the DB group revealed a significantly greater post-operative reduction in anterior-posterior translation (p = 0.04). Female patients following DB ACL reconstruction presented a significant worse IKDC score, Lysholm score and Tegner score compared to male patients. All score values of the female DB group were worse than in the female SB group. In contrast, male patients showed better results of all examined clinical scores following DB procedure compared to SB technique. CONCLUSION: Female patients who underwent computer-navigated DB ACL reconstruction exhibited significantly worse outcome scores than males who underwent DB ACL reconstruction. The gender-based relationship between joint function and outcome after ACL reconstruction remains unclear and requires further investigation. LEVEL OF EVIDENCE: Retrospective case-control series, Level III.

Avulsion fracture and complete rupture of the thumb radial collateral ligament.

PURPOSE: Acute grade III tears of the radial collateral ligament (RCL) of the thumb as well as certain bony avulsion fractures receive early surgical repair at our institution. The aim of this study was to evaluate if patients would benefit from this treatment algorithm at long-term. METHODS: 47 patients with RCL bony avulsion fracture or grade III RCL tear were evaluated at a median follow-up of 4.5 years (range 1-17.3 years). Grade III RCL tears were treated operatively when presenting >30° angulation in stress X-ray together with palmar subluxation of ≥3 mm. Further, avulsed bony fragments with diastasis >2 mm or fragment rotation >30°-45° in conventional X-ray underwent surgery. 6 patients with grade III RCL tear as well as 9 patients with bony avulsion underwent surgical repair. RESULTS: At follow-up, metacarpophalangeal joint stability and pain free ROM did not differ significantly between the groups. Subjective satisfaction based on the Catalano grading system revealed excellent results in operatively and conservatively treated patients. CONCLUSIONS: This retrospective analysis indicates that early surgical repair in severe RCL injuries is associated with unrestricted ROM, persistent joint stability, and subjective patient satisfaction. This data suggest that surgical treatment in certain RCL injuries might be a feasible therapeutic option in order to avoid chronic instability.

Long-term results 8 years after autologous osteochondral transplantation: 7 T gagCEST and sodium magnetic resonance imaging with morphological and clinical correlation.

OBJECTIVE: To correlate long-term clinical outcome and the results of morphological as well as advanced biochemical magnetic resonance imaging (MRI) techniques [T2-mapping, glycosaminoglycan chemical exchange saturation transfer (gagCEST), sodium-23-imaging] in patients after autologous osteochondral transplantation (AOT) in knee joints. METHOD: Nine AOT patients (two female and seven male; median age, 49) had clinical [International Knee Documentation Committee (IKDC), modified Lysholm, visual analog scale (VAS)] and radiological long-term follow-up examinations at a median of 7.9 years (inter-quartile range, 7.7-8.2). Standard morphological MRI and T2-mapping of cartilage were performed on a 3 T MR unit. Biochemical imaging further included sodium-23-imaging and chemical exchange saturation transfer (CEST) imaging at 7 T. The Magnetic resonance Observation of CArtilage Repair Tissue (MOCART) score was used for quantitative assessment of morphological MRI. RESULTS: Clinical outcome was good with a median modified Lysholm score of 90. Median VAS revealed 1.0 and median MOCART score 75 points. The difference between native and repair cartilage was statistically significant for all three biochemical imaging techniques. The strongest correlation was found between the results of the advanced biochemical imaging methods sodium-23 and CEST [ρ = 0.952, 95% confidence interval (CI): (0.753; 0.992)]. Comparing the results from morphological and biochemical imaging, a correlation was found between MOCART score and CEST ratio [ρ = -0.749, 95% CI: (-0.944; -0.169)]. Comparing the results from clinical scores with MRI, a correlation between modified Lysholm and T2-mapping [ρ = -0.667, 95% CI: (-0.992; -0.005)] was observed. CONCLUSION: Long-term clinical outcome in patients 7.9 years after AOT was good, but did not correlate with morphological and biochemical imaging results except for T2-mapping.

Linear intra-bone geometry dependencies of the radius: radius length determination by maximum distal width.

PURPOSE: The aim of the study was to investigate possible linear intra-bone geometry dependencies by determining the relation between the maximum radius length and maximum distal width in two independent populations and test for possible gender or age effects. A strong correlation can help develop more representative fracture models and osteosynthetic devices as well as aid gender and height estimation in anthropologic/forensic cases. METHODS: First, maximum radius length and distal width of 100 consecutive patients, aged 20-70 years, were digitally measured on standard lower arm radiographs by two independent investigators. Second, the same measurements were performed ex vivo on a second cohort, 135 isolated, formalin fixed radii. Standard descriptive statistics as well as correlations were calculated and possible gender age influences tested for both populations separately. RESULTS: The radiographic dataset resulted in a correlation of radius length and width of r=0.753 (adj. R(2)=0.563, p<0.001) with sex having a significant (p=0.005, adj. R(2)=0.592) and side no influence on the correlation. Radius length-width correlation for the isolated radii was r=0.621 (adj. R(2)=0.381, p<0.001) with sex significantly influencing this correlation (p<0.001, adj. R(2)=0.598). CONCLUSION: A relatively strong radius length-distal width correlation was found in two different populations, indicating that linear body proportions might not only apply to body height and axial length measurements of long bones but also to proportional dependency of bone shapes in general.

[Non-tuberculous mycobacterial infections of the hand and wrist: a retrospective review of five cases from a single centre]. / Nicht-tuberkulöse mykobakterielle Infektionen an Hand und Handgelenk: Eine retrospektive Analyse von fünf Fällen.

PURPOSE: A suggestion for a graduated diagnostic and therapeutic approach for patients with a suspected infection with non-tuberculous mycobacteria (NTM) of the hand and wrist is made. PATIENTS AND METHODS: Between March 2003 and February 2007, 2 women and 3 men with an average age of 64 years were treated for an NTM infection of the hand and wrist. 4 patients had a tenosynovitis of the wrist. In 1 patient both wrists were involved. 1 patient had a granuloma of the index finger. The patients' charts, the operation reports, histological and bacteriological findings and the antibiogram were evaluated. RESULTS: An inoculating trauma was identified in four patients. Intraoperatively rice bodies were present in the 4 patients with a tenosynovitis of the wrist. Histological findings showed acid-fast bacilli in 2 patients and chronic inflammatory reaction with/without granuloma (3/2) in 5 patients. Species identification was based on PCR and microbiological culture and revealed in three patients slow growing species (M. malmoense, M. nonchromogenicum, M. szulgai) and in two patients M. marinum (intermediate growth rate). Therapy consisted of immediate postoperative empirical combined drug treatment followed by antibiogram-based therapy. All patients showed healing of the infection at the final follow-up at an average of 25.2 months (range: 15-44 months) postoperatively. CONCLUSION: Consideration of non-tuberculous mycobacteria in the differential diagnosis in cases of localised tenosynovitis is paramount for diagnosis. Treatment based on graduated diagnostic steps, surgery and drugs (empirical followed by directed drugs) can achieve favourable clinical outcomes.

Decreased elastic fibers and desmosine content in incompetent cervix.

Incompetence of the uterine cervix is a syndrome of painless, progressive dilatation and effacement occurring between the sixteenth and twenty-fourth weeks of gestation that represents abnormal functioning. It may serve as a model to elucidate normal function. Because the incompetent cervix results in painless opening of this organ without uterine contraction before term gestation, it is considered one of the causes of midtrimester spontaneous abortion, habitual spontaneous abortion, and early preterm labor. Untreated, it leads to rapid expulsion and often death of the fetus. We used light microscopy to compare decreased elastic fibers in incompetent cervices with those of normal nonpregnant and pregnant cervices. Morphologic analysis of this difference was extended to biochemical quantification of elastin content in one patient with cervical incompetence. The decrease in elastin suggests that one function of cervical elastin may be to maintain a closed and undilated cervix throughout gestation. There may be a relationship between changes in cross-linked elastin and the incompetent cervix; further studies are therefore indicated.

Increased synthesis of elastin in amiodarone-induced pulmonary fibrosis.

Both synthesis and total content of lung elastin were measured after induction of interstitial pulmonary fibrosis in hamsters by a single intratracheal insufflation of amiodarone. Elastin synthesis, as measured by 14C-lysine incorporation into desmosine and isodesmosine, was significantly elevated (P less than 0.05) above control values for a 3-week interval after induction of lung injury. Total lung elastin content in the amiodarone-treated animals was 32% greater than in controls (P less than 0.05) 2 weeks after insufflation of the agent. Furthermore, the time course of elastin synthesis in this experimental model was similar to that observed in bleomycin-induced pulmonary fibrosis in hamsters. Increases in elastin may therefore be a common feature of interstitial pulmonary fibrosis and may contribute to the altered lung mechanics seen in this disease.

Orientation of elastic fibers in the human cervix.

We have determined the microanatomy of the cervix in relation to elastic fibers by serial dissection of human cervix in three tissue planes: cross, sagittal, and frontal sections. Analysis suggests that elastin is localized to specific regions of the uterine cervix and not dispersed throughout the connective tissue stroma. By Musto stain the majority of elastic fibers are noted to be oriented from the external os to the periphery and from there in a band upward toward the internal os where they become sparse in the area of the cervix with the greatest amount of smooth muscle just below the internal os. Elastic fibers were noted to be sparsely distributed in the cervical stroma.

The fibronectin content of canine lungs is increased in bleomycin-induced fibrosis.

Fibronectin (Fn), a high molecular weight glycoprotein, was found to constitute 0.43% of the normal adult beagle dog lung. The tissue Fn (TFn) was solubilized by sequential chemical extractions and quantified by ELISA (enzyme-linked immunoabsorbent assay). Subsequent plasmin digestion did not appear to solubilize significantly more Fn. Since 70% of the lung tissue was solubilized by the extractions and plasmin digestions, the TFn quantified represented the bulk of lung Fn. The TFn was identical to plasma fibronectin in the ELISA and one can infer that the Fn molecule is not significantly altered as it is incorporated into the lung connective tissue matrix. Lungs from beagles in which fibrosis had been induced with bleomycin contained 0.99% Fn, more than a twofold increase over normal. In the ELISA TFn from fibrotic lungs gave an inhibition curve of the same shape as did TFn from normal lungs. Thus, Fn from fibrotic lungs is not different qualitatively from Fn from normal lungs in any way detectable with this antiserum. The TFn content of plasmin digests of intact lung was less than that of extracts, which was the converse of results obtained on placenta (B. A. Bray (1985) Biochem. J. 226, 811-815). This difference between lung TFn and placental TFn may be due to differences in degree of glycosylation, which determines susceptibility to proteases.

Synthesis of crosslinked elastin by a mesothelial cell culture.

Synthesis of crosslinked elastin was measured in cultures of pleural mesothelial cells. Results indicate that mesothelial cells are a rich source of crosslinked elastin and may therefore be useful for in vitro studies of this connective tissue component.

Cigarette smoke impairs elastin resynthesis in lungs of hamsters with elastase-induced emphysema.

The severity of pulmonary emphysema can be affected by exposure to cigarette smoke in several ways. Inactivation of alpha-1-antitrypsin and recruitment of leukocytes to lung airways shifts the protease-antiprotease balance towards increased elastolytic activity. The present study demonstrates an additional effect of cigarette smoke inhalation and retardation of the repair process and of the neosynthesis of cross-linked elastin. Hamsters with elastase-induced emphysema, exposed to cigarette smoke for 1 wk immediately after elastase administration, showed a 40% reduction of 14C-lysine incorporation into the elastin-specific cross-links, desmosine, and isodesmosine. Concomitantly, there was a decrease in the level of lung lysyl oxidase to that observed in uninjured control animals, in sharp contrast to the sevenfold increase in lysyl oxidase activity in hamsters with elastase-induced emphysema recovering under atmospheric conditions. These findings suggest that impairment of the production of lysyl oxidase and the resynthesis of cross-linked elastin by smoke inhalation exacerbates alveolar destruction.

Impairment of elastin resynthesis in the lungs of hamsters with experimental emphysema induced by sequential administration of elastase and trypsin.

The nonelastolytic proteases trypsin and chymotrypsin were administered to hamsters 24 hours after intratracheal injection of elastase. Severity of the disease, extent of degradation and resynthesis, new cross-link formation, and the levels of the enzyme lysyl oxidase, which mediates the cross-link formation, were compared with the same parameters measured in hamsters with experimental emphysema induced by elastase alone. Increases in mean linear intercept indicated that a more severe form of the disease was produced. Although elastin degradation after 1 week was similar in both groups, resynthesis of the elastin destroyed by the elastolytic insult was significantly impaired in the animals injected sequentially with elastase and trypsin or chymotrypsin. Formation of new elastin as monitored by 14C-lysine incorporation into the elastin specific cross-links desmosine and isodesmosine was reduced approximately 40%, although there was no significant difference in the levels of lysyl oxidase activity. It is suggested that the most likely mechanism compatible with the recorded observations involves destruction of the microfibrillar component of the elastic fiber by trypsin or chymotrypsin, resulting in the absence of the requisite template for resynthesis of the pulmonary elastin.

Stimulation of lung lysyl oxidase activity in hamsters with elastase-induced emphysema.

Lysyl oxidase activity was measured in lung extracts of hamsters with elastase-induced emphysema 8 days after administration of the enzyme and again after 2, 3, and 4 wk. Levels of activity rose rapidly to 7 times the base values determined in the lungs of saline-injected control animals. In parallel with the increase in lysyl oxidase activity, the rate of 14C-lysine incorporation into desmosine and isodesmosine was at its maximum 1 wk after elastase administration, reflecting the lysyl-oxidase-mediated cross-link formation, which is the final step in the resynthesis of the pulmonary elastin destroyed by the elastolytic insult.

Emphysema induced by intravenously administered endotoxin in an alpha 1-antitrypsin-deficient rat model.

The effect of repeated intravenous injections of Escherichia coli endotoxin on lung structure and lung parenchymal elastin proportions was studied in rats rendered deficient in alpha 1-antitrypsin by administration of galactosamine. Within 24 h after endotoxin administration, polymorphonuclear leukocyte sequestration was demonstrable by microscopy and differential cell counts of pulmonary lavage fluid. Measurement of the proportions of elastin in lung parenchyma at 24 h revealed values in the normal range; 10 wk after repeated galactosamine and endotoxin administration, there was a reduction in the proportions of lung parenchymal elastin. At 10 wk, these animals showed a significant increase in the mean linear intercept and pulmonary compliance. Animals treated with endotoxin alone developed some but not all of the changes seen in the animals deficient in alpha 1-antitrypsin.

Changes in hepatic glycosaminoglycans following endotoxin administration.

Incorporation of [35]S-sulfate into hepatic glycosaminoglycans (GAGs) is affected by intravenous administration of endotoxin. There are significant increases in total labeled glycosaminoglycans and in the percentage of labeled dermatan sulfate 72 h post-endotoxin.

Measurement of cross-linked elastin synthesis in bleomycin-induced pulmonary fibrosis using a highly sensitive assay for desmosine and isodesmosine.

Cross-linked elastin synthesis was measured in the intratracheal bleomycin model of interstitial pulmonary fibrosis by incorporation of 14C-lysine into the elastin-specific crosslinks, desmosine and isodesmosine. Detection of the labeled crosslinks was facilitated by development of a highly sensitive assay utilizing thin-layer electrophoresis. The results indicate that crosslinked elastin synthesis is significantly elevated from controls (p less than 0.05) at 1 to 3 weeks after exposure to bleomycin and returns to normal by 5 weeks. The increases in labeled elastin synthesis are not directly related to changes in either total lung protein synthesis or the pool size of the 14C-lysine. In comparison with collagen and glycosaminoglycan synthesis in this model of lung injury, maximal increases in cross-linked elastin formation occur later, but overlap with the elevated synthesis of these other connective tissue components. The marked increase from normal in cross-linked elastin synthesis in this model suggests that this tissue component is an important part of the fibrotic response of the pulmonary parenchyma and may play a role in the observed alterations in lung structure and function.

Amiodarone-induced pulmonary fibrosis in hamsters.

Amiodarone, a cardiac antiarrhythmic agent, has been associated with the development of interstitial pulmonary fibrosis in patients receiving prolonged therapy with the drug. To further assess the toxic effects of amiodarone on lung tissue, Syrian hamsters were given a single intratracheal insufflation of the agent and evaluated for histologic evidence of lung injury. Control animals received intratracheal insufflations of the vehicle in which amiodarone was dissolved. After an initial, transient alveolitis in both experimental and control animals, the amiodarone-treated lungs developed increased interstitial thickening due to fibrinous exudates, alveolar epithelial hyperplasia, inflammatory cell infiltrates, and marked deposition of collagen manifested on trichrome staining. Controls, in contrast, showed nearly complete resolution of the initial alveolitis. An unusual feature of the amiodarone-induced lung injury was reemergence of the alveolitis between 5 and 14 days, which included a marked influx of eosinophils into the lung. Although the precise mechanism of the lung injury is not known, the persistence of the acute inflammatory cells as well as the presence of eosinophils suggests a hypersensitivity-type reaction. Furthermore, the progression of lung injury to fibrosis after a single insult with the drug suggests that mere discontinuation of amiodarone therapy in humans may not reverse the disease process, but that corticosteroid therapy may also be required. Amiodarone appears to be a useful agent to induce diffuse fibrotic reactions in the lung that morphologically resemble idiopathic pulmonary fibrosis in humans.