Correlation Between Recovery of Triceps Surae Muscle Strength and Level of Activity After Open Repair of Acute Achilles Tendon Rupture.

BACKGROUND: This study aimed to determine whether physical findings reflecting triceps surae strength recovery could predict return to activities such as jogging and sports and whether patients' age and sex would influence recovery of triceps surae strength postoperatively. METHODS: Between 2009 and 2013, 96 consecutive cases of postoperative acute Achilles tendon rupture were reviewed. The postoperative triceps surae strength recovery rate was investigated in all patients by using half body weight 1-time heel rise, full body weight (FBW) 1-time heel rise, FBW 20-time heel rise, jogging, and full return to sports activities. Influence of age and sex on triceps surae strength recovery was also investigated. RESULTS: FBW 1-time heel rise and jogging were achieved at an average of 14 weeks (range, 6-24 weeks) and 15 weeks (range, 8-25 weeks) postoperatively, respectively. FBW 20-time heel rise and full return to sports activities were achieved at a mean of 21 weeks (range, 12-29 weeks) and 22 weeks (range, 13-29 weeks) postoperatively, respectively. Ability to perform FBW 1-time heel rise was directly related to resilience of jogging capability ( R2 = 0.317, P < 0.001), and ability to perform FBW 20-time heel rise was related to full return to sports activities ( R2 = 0.508, P < 0.001). Time to heel rise was not correlated with patient age or sex. CONCLUSION: Postoperative ability to perform FBW 1-time heel rise in patients postoperatively was directly related to resilience of jogging, and ability to perform FBW 20-time heel rise was directly related to full return to sports activities. LEVEL OF EVIDENCE: Level IV, case series.

Observation of intrafraction prostate displacement through the course of conventionally fractionated radiotherapy for prostate cancer.

PURPOSE: Intrafraction prostate displacement (IFPD) through the course of conventionally fractionated radiotherapy was observed by real-time tracking. MATERIALS AND METHODS: IFPD was observed by using a CyberKnife real-time tracking system over 39 serial fractions in two patients. Stereoscopic X-ray images tracking the implanted fiducial markers were obtained with mean intervals of 58 s. In preparation for treatment, urination was performed routinely 1 h before treatment and rectal gas was evacuated if necessary. Patients were immobilized by a thermoplastic body shell. RESULTS: The maximal absolute values of IFPD in all 78 fractions were 7.9, 2.1, and 11.5 mm in cranio-caudal (CC), left-right (LR), and antero-posterior (AP) direction, respectively. Only in 5 % of fractions (4/78 fractions), the maximal absolute values of IFPD were 5.0 mm or larger. In these fractions, large IFPD was temporary or persistent. IFPD of ≥3 mm was detected in only ~2-3 % of all obtained tracking images. CONCLUSIONS: Daily maximal IFPD changed day by day. Although maximal IFPD was more than 10 mm, IFPD of ≥3 mm was observed in a comparatively small proportion of treatment time. Through the course of conventionally fractionated radiotherapy, fractions with IFPD of ≥5 mm were infrequent.

Clinical features and injury patterns of medial collateral ligament tibial side avulsions: "wave sign" on magnetic resonance imaging is essential for diagnosis.

BACKGROUND: Medial collateral ligament tibial avulsion is rare. Consequently, diagnostic criteria and a treatment regimen for medial collateral ligament tibial side avulsions remain to be established. The purpose of this study is to clarify the clinical features of medial collateral ligament tibial side avulsions. METHODS: We performed a retrospective clinical and magnetic resonance imaging review of a consecutive series of 12 medial collateral ligament tibial side avulsions. All patients were treated operatively and the final diagnosis was made based on the intraoperative findings. Post-injury magnetic resonance imaging studies were reviewed to assess injury patterns with respect to the intraoperative findings. RESULTS: Eleven of 12 cases (92%) had grade III valgus laxity (unstable to valgus stress at both 0° and 30° of flexion) on an examination under anesthesia. Concomitant anterior cruciate ligament tear was noticed in all cases. Intraoperative findings were classified into 3 types depending on the location of the ruptured end of the superficial medial collateral ligament with respect to the pes anserinus tendons. Magnetic resonance imaging depicted characteristic waving ("wave sign") of the superficial layer of medial collateral ligament in all cases. CONCLUSIONS: "Wave sign" of the superficial layer of medial collateral ligament on magnetic resonance imaging is essential for diagnosing medial collateral ligament tibial side avulsions. Based on the clinical features and injury patterns, operative treatment is primarily recommended for medial collateral ligament tibial side avulsions. LEVEL OF EVIDENCE: Case series, Level IV.

Clinical outcome of anatomic double-bundle ACL reconstruction and 3D CT model-based validation of femoral socket aperture position.

PURPOSE: The purpose of this study was to evaluate the clinical results of anatomic double-bundle (DB) anterior cruciate ligament (ACL) reconstruction in which anatomic position of femoral socket apertures was validated using three-dimensional (3D) computed tomography (CT) modelling. METHODS: Anatomic DB ACL reconstructions with hamstring autografts were performed in 34 patients. Two femoral sockets were created through a far anteromedial (AM) portal behind the lateral intercondylar ridge with the assistance of intraoperative 3D fluoroscopic navigation. Femoral tunnel aperture positioning was investigated postoperatively using 3D CT images in all patients. Clinical results were also evaluated subjectively and objectively at least up to 2 years. RESULTS: Measurement of the AM and the posterolateral (PL) femoral socket locations on the 3D CT images using the quadrant method showed that the centre of the AM socket aperture was located at a depth of 21.0 ± 4.1% and a height of 30.5 ± 9.3% and that of the PL socket aperture was located at a depth of 31.3 ± 5.8% and a height of 57.2 ± 7.7%. The femoral socket locations were considered as anatomic in accordance with previous cadaveric studies examining the positions of ACL femoral insertion site. Subjectively, the mean Lysholm score was 96.9 ± 4.0 points. According to IKDC final objective scores, 26 knees (76%) were objectively graded as normal, 8 (24%) as nearly normal, and 0 (0%) as abnormal or severely abnormal. Postoperative side-to-side anterior translation measured with a KT-2000 arthrometer averaged 0.7 ± 1.2 mm. CONCLUSIONS: DB ACL reconstructions in which femoral socket apertures were validated anatomically using 3D CT provided satisfactory short-term results. LEVEL OF EVIDENCE: Case series, Level IV.

Influence of navigation system updates on total knee arthroplasty.

BACKGROUND: The purpose of this study was to evaluate the influence of image-free computer-assisted navigation system update on outcome in total knee arthroplasty. METHODS: Thirty-three knees were replaced using the Stryker 3.1 image-free navigation system and 49 knees were replaced using the Stryker 4.0 system. One surgeon took part in all procedures as chief surgeon or first assistant. All patients received the Stryker Scopio NRG CR total knee prosthesis. We compared the accuracy of component positioning measured using radiographs and CT scans, operating time and clinical outcome 1 year after surgery. RESULTS: The mean hip-knee-ankle, frontal femoral and tibial component angle were 179.8° (ideally implanted 85%), 89.8° (88%), 90.4° (88%) respectively for the 3.1 group and 179.5° (96%), 90.6° (92%), 90.2° (94%) for the 4.0 group. The mean sagittal tibial component angle was 85.5° (82%) for the 3.1 group and 85.6° (92%) for the 4.0 group. The mean rotational femoral and tibial component angle were -0.5° (81%), -0.7° (73%) for the 3.1 group and 0.0° (84%), 0.4° (72%) for the 4.0 group. There were no statistically significant findings with regard to component positioning. Operating time was significantly longer in the 3.1 group (3.1 group: 137 min, 4.1group: 125 min, P < 0.01). No significant difference was detected in postoperative clinical outcome. CONCLUSION: The navigation system update from Stryker 3.1 to Stryker 4.0 reduced operating time by 12 min. However, there were no statistically significant findings with regard to component positioning and clinical outcome.

[Susceptibilities of bacteria isolated from patients with lower respiratory infectious diseases to antibiotics (2006)].

From October 2006 to September 2007, we collected the specimen from 356 patients with lower respiratory tract infections in 14 institutions in Japan, and investigated the susceptibilities of isolated bacteria to various antibacterial agents and patients' characteristics. Of 414 strains that were isolated from specimen (mainly from sputum) and assumed to be bacteria causing in infection, 407 strains were examined. The isolated bacteria were: Staphylococcus aureus 64, Streptococcus pneumoniae 96, Haemophilus influenzae 87, Pseudomonas aeruginosa (non-mucoid) 52, P. aeruginosa (mucoid) 11, Klebsiella pneumoniae 20, and Moraxella catarrhalis 44. Of 64 S. aureus strains, those with 2 microg/ml or less of MIC of oxacillin (methicillin-susceptible S. aureus: MSSA) and those with 4 microg/ml or more of MIC of oxacillin (methicillin-resistant S. aureus: MRSA) were 27 (42.2%) and 37 (57.8%) strains, respectively. Against MSSA, imipenem had the most potent antibacterial activity and inhibited the growth of all strains at 0.063 microg/ml or less. Against MRSA, vancomycin and linezolid showed the most potent activity and inhibited the growth of all the strains at 1 microg/ml. Carbapenems showed the most potent activities against S. pneumoniae and in particular, panipenem inhibited the growth of all the strains at 0.063 microg/ml or less. Imipenem and faropenem also had a preferable activity and inhibited the growth of all the strains at 0.125 and 0.5 microg/ml, respectively. In contrast, there were high-resistant strains (MIC: over 128 microg/ml) for erythromycin (45.8%) and clindamycin (20.8%). Against H. influenzae, levofloxacin showed the most potent activity and its MIC90 was 0.063 microg/ml or less. Meropenem showed the most potent activity against P. aeruginosa (mucoid) and its MIC90 was 0.5 microg/ml. Against P. aeruginosa (non-mucoid), tobramycin had the most potent activity and its MIC90 was 2 microg/ml. Against K. pneumoniae, cefozopran was the most potent activity and inhibited the growth of all the strains at 0.063 microg/ml or less. Also, all the antibacterial agents except ampicillin generally showed a potent activity against M. catarrhalis and the MIC90 of them were 2 microg/ml or less. The approximately half the number (50.6%) of the patients with respiratory infection were aged 70 years or older. Bacterial pneumonia and chronic bronchitis accounted for 49.2% and 28.1% of all the respiratory infections, respectively. The bacteria frequently isolated from the patients with bacterial pneumonia were S. pneumoniae (29.2%), S. aureus (20.8%), and H. influenzae (12.9%). H. influenzae (25.0%) and P. aeruginosa (21.7%) also were frequently isolated from the patients with chronic bronchitis. Before the antibacterial agent administration, the bacteria frequently isolated from the patients were S. pneumoniae (27.5%) and H. influenzae (22.5%). The bacteria frequently isolated from the patients treated with macrolides was P. aeruginosa, and its isolation frequently was 39.4%.

Three-dimensional fluoroscopic navigation guidance for femoral tunnel creation in revision anterior cruciate ligament reconstruction.

Revision anterior cruciate ligament (ACL) reconstruction is accompanied by several technical challenges that must be addressed, such as a primary malpositioned bone tunnel, pre-existing hardware, or bone defects due to tunnel expansion. We describe a surgical technique used to create an anatomic femoral socket using a 3-dimensional (3D) fluoroscopy-based navigation system in technically demanding revision cases. After a reference frame is rigidly attached to the femur, an intraoperative image of the distal femur is obtained, which is transferred to a navigation system and reconstructed into a 3D image. A navigation computer helps the surgeon to visualize the whole image of the lateral wall of the femoral notch, even if the natural morphology of the intercondylar notch has been destroyed by the primary procedure. In addition, the surgeon can also confirm the position of the previous bone tunnel aperture, the previous exit of the femoral tunnel, and the presence of any pre-existing hardware on the navigation monitor. When a new femoral guidewire for the revision procedure is placed, the virtual femoral tunnel is overlaid on the reconstructed 3D image in real time. At our institution, 12 patients underwent 1-stage revision ACL procedures with the assistance of this computer navigation system, and the grafts were securely fixed in anatomically created tunnels in all cases. This technology can assist surgeons in creating anatomic femoral tunnels in technically challenging revision ACL reconstructions.

Immunohistological analysis of extracted anterior cruciate ligament graft impinged against posterior cruciate ligament.

A young female athlete suffered from the residual instability of the knee after anterior cruciate ligament (ACL) reconstruction with hamstring autograft. The 3-dimensional (3-D) CT scan showed the "high noon" positioning of the primary femoral bone tunnel. The revision surgery with anatomic double-bundle technique was performed two years after the primary surgery and the femoral tunnels were created with the assistance of the 3-D fluoroscopy-based navigation. An arthroscopic examination confirmed the ACL graft impingement against posterior cruciate ligament (PCL) when the knee was deeply flexed. The histological analysis of the resected primary ACL graft showed local inflammatory infiltration, enhanced synovial coverage and vascularization at the impinged site. The enhanced expression of vascular endothelial growth factor (VEGF) at the impinged area when compared with non-impinged area was observed on immunohistochemical analysis. Abnormal mechanical stress by the impingement against PCL might have induced chronic inflammation and VEGF overexpression.

Prevention and management of knee osteoarthritis and knee cartilage injury in sports.

Articular cartilage defects in the knee of young or active individuals remain a problem in orthopaedic practice. These defects have limited ability to heal and may progress to osteoarthritis. The prevalence of knee osteoarthritis among athletes is higher than in the non-athletic population. The clinical symptoms of osteoarthritis are joint pain, limitation of range of motion and joint stiffness. The diagnosis of osteoarthritis is confirmed by the symptoms and the radiological findings (narrowing joint space, osteophyte formation and subchondral sclerosis). There is no strong correlation between symptoms and radiographic findings. The aetiology of knee osteoarthritis is multifactorial. Excessive musculoskeletal loading (at work or in sports), high body mass index, previous knee injury, female gender and muscle weakness are well-known risk factors. The high-level athlete with a major knee injury has a high incidence of knee osteoarthritis. Cartilage injuries are frequently observed in young and middle-aged active athletes. Often this injury precedes osteoarthritis. Reducing risk factors can decrease the prevalence of knee osteoarthritis. The prevention of knee injury, especially anterior cruciate ligament and meniscus injury in sports, is important to avoid progression of knee osteoarthritis.