Conservative treatment for rugby football players with an acute isolated posterior cruciate ligament injury.

We investigated the outcome of the conservative treatment from the point of athletic performance for rugby football players with an acute isolated PCL injury. The subjects were sixteen competitive rugby football players, with an average age of 21 years. After exercise consisting of quadriceps muscle strengthening and range of knee motion, the players were allowed to return to sports activity when swelling and pain disappeared. At one year after the injury, the period of return to pre-injury level and the self-evaluation for eleven performances during rugby football were surveyed by a questionnaire. Each performance of the athletic skills was rated as normal, nearly normal, abnormal or severely abnormal. Fourteen players (88%) returned to their pre-injury level. The time to return to pre-injury level ranged from one to seven months, with a mean of three months. High-speed running was the most affected skill (9 out of 14, 64%). These results showed that performance of athletic skills was apparently affected in rugby football players with an acute isolated PCL injury though the conservative treatment was effective

Comparison between the cross-sectional area of bone-patellar tendon-bone grafts and multistranded hamstring tendon grafts obtained from the same patients.

This study intraoperatively compared the cross-sectional area (CSA) and graft-tunnel fit of bone-patellar tendon-bone (BTB) and multistranded hamstring tendon (STG) grafts harvested from the same patient. Twenty-two patients with a mean age of 26 years were the subjects of the study. Each BTB graft was harvested from the central third of the patellar tendon. Tripled or quadrupled semitendinosus tendon with or without gracilis tendon was used as a STG graft. CSAs of both grafts in the same patients were intraoperatively measured using a custom-made area micrometer during primary ACL reconstruction and revision surgery or during combined ACL and PCL reconstruction. Graft-tunnel fit was calculated by dividing the CSA of the graft by that of the tibial bone tunnel. The average CSA of STG grafts was significantly greater than that of BTB grafts. The average value of graft-tunnel fit for the STG grafts% was also greater than that of the BTB grafts%. Thus STG grafts have a larger CSA and closer graft-tunnel fit than BTB grafts in a clinical setting.

Single- versus bi-socket anterior cruciate ligament reconstruction using autogenous multiple-stranded hamstring tendons with endoButton femoral fixation: A prospective study.

PURPOSE: This prospective study was conducted to compare the single-socket and the bi-socket anterior cruciate ligament (ACL) reconstruction techniques in terms of outcome. TYPE OF STUDY: Nonrandomized control trial. METHODS: There were 160 consecutive patients with unilateral chronic ACL insufficiency who underwent endoscopic single- or bi-socket ACL reconstruction alternately using multiple-stranded medial hamstring tendon and EndoButton (Smith & Nephew, Andover, MD) femoral fixation. All patients underwent the same postoperative rehabilitation protocol. Of them, 106 patients (57 single, 49 bi) were available for 2-year follow-up. RESULTS: According to the IKDC Knee Ligament Evaluation Form, 23 patients (40%) of the single-socket group were subjectively graded as normal, 30 (53%) as nearly normal, and 4 (7%) as abnormal. Twenty-six patients (53%) of the bi-socket group were graded as normal, 21 (43%) as nearly normal, and 2 (4%) as abnormal (P =.19). The mean side-to-side anterior laxity difference (KT-1000 manual maximum force) was 0.9 +/- 1.8 mm for the single-socket group and 0.7 +/- 1.2 mm for the bi-socket group (P =.44). Fifty-three of 57 patients (93%) in the single-socket group and all patients in the bi-socket group showed anterior laxity differences of +/-3 mm or less (P =.12). There were no differences in thigh muscle strength between the groups. CONCLUSIONS: Both single- and bi-socket ACL reconstruction using autogenous multiple-stranded hamstring tendons with EndoButton fixation provided satisfactory anterior stability, and there were no statistically significant differences in subjective results or measured restored stability between the 2 groups.

Ventricular parasystolic couplets originating in the pathway between the ventricle and the parasystolic pacemaker: mechanism of "irregular" parasystole.

This article explains the mechanism of "irregular" parasystole. Two theories have been suggested: "electrotonic modulation" and "type I second degree entrance block." This study attempts to clarify the mechanism of irregular parasystole in cases of true ventricular parasystole associated with ventricular parasystolic couplets. Cases associated with ventricular parasystolic couplets were selected from 37 clinical cases of true ventricular parasystole in which one or more pure parasystolic cycles with no intervening nonectopic QRS complexes were found. Of the 37 cases of true ventricular parasystole, ventricular parasystolic couplets were found in 4 cases. In none of the other 33 cases, ventricular parasystolic couplets were found. In all the cases coexisting with ventricular parasystolic couplets, the latter ectopic QRS complex of the couplet failed to reset the parasystolic rhythm. The above findings suggest that the latter ectopic QRS complex of the parasystolic couplet originated not in the parasystolic pacemaker but in the pathway between the ventricle and the parasystolic pacemaker. It seems that when a sinus impulse fell late in the parasystolic cycle, it passed through the site of second degree entrance block and that the parasystolic couplets originated from the reentrant pathway between the ventricle and the pacemaker. This strengthens our previous suggestion that the mechanism of irregular parasystole is governed by "type I second degree entrance block" and not by "electrotonic modulation."

Twenty-seven-year follow-up of arrhythmogenic right ventricular dysplasia.

This case report describes clinical features, especially of surface ECG changes, observed for 27 years in a patient with arrhythmogenic right ventricular dysplasia (ARVD). The course of this patient was characterized by progressive deterioration of right ventricular function and progression of delayed potentials (so-called epsilon waves) following QRS complexes. However, the relation between ventricular arrhythmias and ECG changes or the degree of right ventricular abnormality was difficult to discern.

Inhibitory effect of apple pectin and culture condensate of Bifidobacterium longum on colorectal tumors induced by 1,2-dimethylhydrazine in transgenic mice harboring human prototype c-Ha-ras genes.

The number and tumor score of colorectal tumors induced by 1,2-dymethylhydrazine in transgenic (Tg) mice carrying human c-Ha-ras genes were significantly reduced by ingestion of apple pectin (AP) or a culture condensate of Bifidobacterium longum (MB) when compared with a control diet. There was no statistical difference in the incidence of colorectal tumors in Tg mice between the AP or MB diet and the control diet. This study demonstrated that Tg mice are a useful tool for screening inhibition of colorectal tumors by functional foods.

Nonunited avulsion fractures of the intercondylar eminence of the tibia.

We report 3 cases of nonunited avulsion fracture of the intercondylar eminence of the tibia. Characteristics of the clinical symptoms were limitation of knee extension, pain at knee extension, and a small amount of anterior instability. For the patient with a normal anterior cruciate ligament (ACL), the fragment was fixed by sutures with a button after curettage of the fibrous tissue. Two patients underwent endoscopic ACL reconstruction using quadrupled semitendinosus tendon because their ACLs had degenerated. Since the technique of ACL reconstruction under arthroscopic control has been well refined, endoscopic ACL reconstruction is considered to be 1 of the surgical options for nonunited avulsion fracture with symptomatic anterior instability if the ACL is degenerated.

The gravity sag view: a simple radiographic technique to show posterior laxity of the knee.

We introduce a simple radiographic technique of taking a "gravity sag view" to show sagittal laxity secondary to posterior cruciate ligament injury. Side-to-side differences of the tibia-femur step-off measured with these radiographs have proved to be useful parameters for evaluating posterior laxity. This radiographic technique is recommended instead of routine lateral radiographs taken with the knee kept recumbent.

Preoperative anterior knee laxity did not influence postoperative stability restored by anterior cruciate ligament reconstruction.

Eighty-six chronic anterior cruciate ligament (ACL)-injured patients were quantitatively measured for anterior knee stability preoperatively and at 2 years or later (mean, 30 months) postoperatively to examine the influence of preoperative knee laxity on the postoperative knee stability restored by the ACL reconstruction using multiplied hamstring tendon graft. The patients were divided into 3 groups according to the preoperative injured minus normal anterior laxity difference (AL-D) (group I [n = 27] <5 mm, group II [n = 48] 5 to 9 mm, group III [n = 11] >10 mm). The 3 groups were comparable in gender, age, meniscal status, graft excursion measured during operation, time from injury to operation, and activity level. The postoperative AL-D in group I was 0.8 +/- 1. 7 mm, that in group II was 1.1 +/- 1.6 mm, and in group III was 1.5 +/- 1.4 mm. There were no significant statistical differences among these 3 groups. With our surgical technique including postoperative rehabilitation, patients with severe instability could be treated successfully without needing any additional procedures such as extra-articular augmentation or specially designed postoperative rehabilitation programs.

[An autopsy case of catastrophic antiphospholipid syndrome presenting with recurrent multiple cerebral infarction associated with lung cancer].

We reported an autopsy case of cerebral infarction with primary lung cancer. The patient was a 50-year-old man. Despite having been treated with warfarin potassium and ticlopidine hydrochloride, he relapsed cerebral infarction. His laboratory data on admission showed that lupus anticoagulant was positive, together with a high value of beta-thromboglobulin, thrombin-antithrombin III complex, markers of platelet and coagulation activation, CEA and CA 19-9. The autopsy finding revealed a primary papillary adenocarcinoma in the right lower lung, multiple cerebral infarction, renal infarction, pulmonary infarction and splenic infarction. The atherosclerotic changes were mild in the whole tissues and findings of vasculitis were not observed. Recurrence of cerebral infarction was effectively suppressed with the addition of steroid therapy to antithrombotic therapy. This case was considered as catastrophic antiphospholipid syndrome. It is necessary to differentiate antiphospholipid syndrome in case of the abnormal coagulation and fibrinolytic factors with recurrent cerebral infarction. Moreover, systemic examinations are important, because malignant tumor may exist on the background of the case.

Concealed conduction in the reentrant pathway as a mechanism of stable ventricular quadrigeminy.

This is the first report on the stable occurrence of ventricular quadrigeminy as a manifestation of concealed bigeminy in a case of fixed and late coupled ventricular extrasystoles. A 46-year-old man is reported in whom the period of ventricular bigeminy alternated with the period of ventricular quadrigeminy. Coupling intervals of the extrasystoles were fixed and much longer than sinus QT intervals. When the heart rate is decreased, the period of bigeminy changed to the period of quadrigeminy without gradual decrease in coupling of the preceding extrasystoles. Once such a change occurred, stable quadrigeminy is maintained for a period. These findings suggest the possibility that concealed electrotonic conduction of blocked impulses and interference of conducted impulses may occur in the reentrant extrasystolic pathway as a mechanism of stable ventricular quadrigeminy.

Chondral injury associated with acute isolated posterior cruciate ligament injury.

SUMMARY: To evaluate associated cartilaginous damage with acute isolated posterior cruciate ligament (PCL) injury without other concomitant ligamentous injury, arthroscopic evaluations were performed on 61 consecutive patients. Meniscal tear was found in 17 cases (28%). Of these, 3 had medial meniscal tear, 11 had lateral meniscal tear, and 3 had both medial and lateral meniscal tears. Longitudinal tears of anterior segment in lateral menisci were the most common (10 cases). Thirty-two patients (52%) had articular cartilage injury. Of these, 7 had damage greater than one half of the thickness of the articular cartilage, and 3 had erosion that extended to the subchondral bone. The most frequently injured location was the medial femoral condyle (19 cases, 31%). Significant cartilaginous injury could be combined in acute isolated PCL injury. Therefore, it is unreasonable to manage every acute isolated PCL-injured knee using a single treatment modality. Concomitant meniscal and articular cartilaginous lesions should be evaluated when treatment for acute PCL injury is planned.

[An aged case of bilateral ballistic movement which was thought to be exacerbated by respiratory insufficiency].

We report a 75-year-old man who had shown bilateral ballistic movements. He had suffered from pulmonary emphysema for about 35 years and was treated with oxygen therapy 3 years before. When he was 70 years old, involuntary movements appeared in bilateral limbs. His involuntary movements were ballistic, and become gradually worse. T2-weighted MRI after admission demonstrated high signal intensities in the bilateral pallidum, indicating multiple brain infarcts in the subcortical white matter. Ultrasonography showed 2 plaques in the left common carotid artery. Laboratory studies revealed blood coagulation abnormalities and hypoxia. Medication with clonazepam and tiapride together with oxygen therapy normalized blood gas levels and improved his involuntary movements. But after discharge, he stopped oxygen therapy and involuntary movement became worse again, associated with hypoxia demonstrated by his blood gas analysis. These findings suggest that not only cerebrovascular disease but hypoxia might play an important role in the appearance and exacerbation of involuntary movements.

[An elderly case of chronic inflammatory demyelinating polyneuropathy with acute onset in the course of diabetes mellitus].

A 77-year-old man was admitted because of muscle weakness in both upper and lower extremities. Diabetes mellitus was diagnosed in 1988 and he had been treated by oral hypoglycemic agents. He had a common cold at the end of January, 1997. Muscle weakness appeared in the upper extremities, followed by the lower extremities at the end of February. No sensory disturbance or dysuria was recognized. Nerve conduction study revealed distally dominant demyelinating polyneuropathy. Guillain-Barré's syndrome was diagnosed and he recovered completely following immunological absorption therapy (IAT). However, he had quadriplegia again at the end of April. He was treated by IAT combined with corticosteroid and has shown no relapse. In June, 1997, gastric cancer was detected by upper gastrointestinal fiberscopy and subtotal gastrectomy was performed. Judging from this clinical course, this case seems to be chronic inflammatory demyelinating polyneuropathy (CIDP) with acute onset. Many kinds of causes often contribute to the pathogenesis of neuropathy in the elderly. So in cases of progression or worsening, we should consider such possibilities and it is necessary not to exclude treatable causes of neuropathy.

Effect of bifidobacteria feeding on fecal flora and production of immunoglobulins in lactating mouse.

To elucidate the effects of probiotics on the stimulation of immunoglobulin production during lactation, feeding trials of bifidobacteria in lactating mice were conducted. Bifidobacteria appeared in feces at 9.67+/-0.17 log 10 number per gram levels. All bifidobacteria found in the feces were the administered strain. Mice fed bifidobacteria for 12 days showed significantly high levels of fecal total IgA compared to that of the control group (P < 0.05). The levels of anti-beta-lactoglobulin IgA in milk as well as in fecal extracts were significantly higher in the bifidobacteria-fed group than that of the control group (P < 0.05). These results suggest that the intake of bifidobacteria can enhance local production of IgA in milk and the intestine, which may help to protect both pups and dams from exposure to food antigens.

Osteochondritis dissecans of the lateral femoral condyle of the knee joint.

Differences in the features of osteochondritis dissecans (OCD) affecting the lateral and medial femoral condyles were investigated in 13 patients (14 knees) treated from 1991 to 1994. OCD affected the lateral femoral condyle in 6 knees (lateral group) and the medial condyle in 8 knees (medial group). The lateral group was younger (mean age, 14 v. 20 years). The radiological stage (Brückl) of the lateral group was stage 2 in 3 knees and stage 3 in 3. The lateral menisci were all discoid and the condylar articular surface of the lesions was normal in two knees, softened in 3 and detached in 1. The medial group comprised 1 knee in stage 2, 1 in stage 3, 1 in stage 4, and 5 in stage 5. The OCD lesion showed softening in 2 knees and detachment in 6. Repetitive abnormal stress on weaker osteochondral structures in the growing period produced by a discoid meniscus during growth may cause OCD of the lateral femoral condyle.

Cross-sectional area measurement of the semitendinosus tendon for anterior cruciate ligament reconstruction.

We measured the cross-sectional area (CSA) of the semitendinosus tendon (SMT) in 79 anterior cruciate ligament (ACL)-injured patients using magnetic resonance imaging (MRI) to scrutinize their appropriateness for ACL grafts. Measurements of the CSAs of the SMT with MRI were closely correlated with intraoperative direct measurement (y = 0.697). The mean CSAs of the SMT measured with MRI ranged from 6.3 to 15.0 mm2 with a mean of 10.1+/-2.1 mm2. The CSA of the SMT measured with MRI proved to be a useful indicator to determine preoperatively whether the SMT graft would be of adequate dimensions (7 mm or more in diameter, 60 mm or more in length) for ACL reconstruction. If the CSA of the SMT was more than 11 mm2, a sufficiently thick and long graft could be prepared with a tripled or quadrupled SMT in 89% of cases. We conclude that tissue CSA measurements using MRI could potentially be implemented as a useful tool for determining the most appropriate donor autograft tissue preoperatively, thus minimizing harvest-site morbidity.

Osteochondritis dissecans of the medial femoral condyle associated with congenital hypoplasia of the lateral meniscus and anterior cruciate ligament.

We report a patient with osteochondritis dissecans of the medial femoral condyle associated with congenital hypoplasia of the lateral meniscus and anterior cruciate ligament. This is the first report of such a case.

Effect of a probiotic formula on intestinal immunoglobulin A production in healthy children.

The anti-infectious effect of probiotics has recently been reported and one mechanism may be the non-specific stimulation of immunity. This study was performed to elucidate the influence of a probiotic formula on intestinal microflora and local immunity in healthy children. A follow-up formula containing viable bifidobacteria was given to seven healthy Japanese children (15 to 31 months old) for 21 days. During intake of the formula, the administered strain was detected in feces from five subjects (71%) and total fecal bifidobacteria slightly increased. Fecal levels of total IgA and anti-poliovirus IgA during intake of the formula were significantly higher than those before intake (P < 0.05). The increase in local IgA levels resulting from ingestion of the probiotic formula may contribute to enhancement of the mucosal resistance against gastrointestinal infections.

Effect of mouse intestinal bacteria on incidence of colorectal tumors induced by 1,2-dimethylhydrazine injection in gnotobiotic transgenic mice harboring human prototype c-Ha-ras genes.

We produced transgenic (Tg) gnotobiotic (GB) mice carrying human prototype c-Ha-ras genes and compared the incidence of colorectal tumors induced by 1,2-dimethylhydrazine (DMH) injection. At 7 to 11 weeks of age, germfree (GF) CB6F1-Tg Hras2 mice were inoculated with various mouse fecal suspensions or mixtures of bacteria isolated from mouse feces. Three weeks after bacterial inoculation, DMH was administered by subcutaneous injection at 20 mg per kg body weight for 20 weeks. Mice were euthanized 5 weeks after the last injection to investigate the number of colorectal tumors. The incidence of colorectal tumors was high in both Tg- and non-Tg-GF mice (100%). In Tg-specific pathogen-free (SPF) mice and Tg-GB-4 mice associated with basic mouse flora consisting of Escherichia coli, lactobacilli, Bacteroides and clostridia, the incidence of colorectal tumors was as high as that in GF mice. In Tg-SPF mice, the tumor score was higher than in Tg-GF mice (p < 0.01), but no colorectal tumors were detected in non-Tg groups of SPF, and the tumor incidence was remarkably low in non-Tg-GB-4 mice. The tumor incidence and score in Tg- and non-Tg-GB mice varied depending on the bacterial combination in their intestine. These results indicate that the presence of human c-Ha-ras genes and intestinal bacteria substantially modify colorectal tumorigenesis induced by DMH.