Deficits in muscle strength are not seen following recovery from augmented primary repair of anterior cruciate ligament tears.

OBJECTIVES: Anterior cruciate ligament (ACL) repair for proximal tears, where the ligament is re-attached and augmented with suture tape, can negate the need for graft harvest, thereby maintaining native anatomy. Autograft harvest has been associated with persistent deficits in lower limb muscle strength after recovery from ACL reconstruction. The aim of this study is to compare lower limb muscle strength following ACL repair and reconstruction. METHODS: Nineteen ACL repair patients augmented with suture tape and nineteen ipsilateral semitendinosus-gracilis autograft ACL reconstruction patients (both mean 4 years postoperatively) were recruited, along with twenty healthy volunteers. Patient-reported outcome measures (PROMs) were obtained using the Knee Injury and Osteoarthritis Outcome Score (KOOS), Lysholm, and Tegner scores. Maximal isometric quadriceps and hamstring strength at 90° knee flexion were measured using a fixed Myometer after a warm-up and three maximal-effort contractions. RESULTS: Mean hamstring strength of the reconstructed legs was lower than that of healthy volunteers by 0.29 Nm/kg. The hamstring strength ratio of the operated side to the uninjured side was greater in the repair (95% â€‹± â€‹13) than in the reconstruction (81% â€‹± â€‹18) group. There were no statistically significant differences between sides for quadriceps peak torque or for hamstrings in the volunteer or repair group. PROMs scores for the reconstruction group were significantly lower than volunteers across all domains and lower than repair for KOOS activities of daily living and Lysholm scores. CONCLUSION: Hamstring weakness seen following ACL reconstruction is not evident following ACL repair with suture tape augmentation. Strength asymmetry could contribute to re-injury risk and influence functional performance, while altered loads affect knee biomechanics and may lead to osteoarthritis progression. The absence of these deficits in the repair group demonstrates a potential benefit of this technique when used in appropriate patients. LEVEL OF EVIDENCE: II.

Comparable rates of secondary surgery between anterior cruciate ligament repair with suture tape augmentation and anterior cruciate ligament reconstruction.

PURPOSE: The aim of this study was to determine the frequency of secondary surgery following anterior cruciate ligament (ACL) repair with suture tape augmentation in comparison to conventional hamstring ACL reconstruction. We hypothesised that there would be no differences between the groups. METHODS: This was a retrospective comparison study of patients undergoing ACL surgery between September 2011 and April 2018. Two hundred and 73 patients underwent ACL reconstruction using hamstring autograft. During the same timeframe, 137 patients with an acute proximal ACL rupture underwent ACL repair with suture tape augmentation. One patient was lost to follow-up in the ACL reconstruction group leaving 272 patients (99.6%) for the final analysis. In the ACL repair group, three patients were lost to follow-up leaving 134 patents (97.8%) for the final analysis. Secondary surgery was identified by contacting the patients by email/telephone and reviewing patient notes at the time of this analysis. RESULTS: Re-rupture occurred in 32 patients (11.8%) in the ACL reconstruction group compared to 22 patients (16.4%) in the ACL repair group (p = 0.194). Contralateral ACL rupture occurred in four patients (1.5%) in the ACL reconstruction group compared to three patients (2.2%) in the ACL repair group (p = 0.224). In the ACL reconstruction group, nine patients (3.3%) required secondary meniscal surgery whilst five patients (3.7%) required meniscal surgery in the ACL repair group (p = 0.830). Seven other operations were performed in the ACL reconstruction group (2.6%) compared to three other operations in the ACL repair group (2.2%) (p = 0.374). The overall number of patients undergoing secondary surgery in the ACL reconstruction group was 52 (19.1%) in comparison to 30 (22.4%) in the ACL repair group (p = 0.114). CONCLUSION: ACL repair with suture tape augmentation for acute proximal ruptures demonstrated comparable rates of secondary surgery with hamstring ACL reconstruction.

Anterior cruciate ligament repair with internal brace augmentation: A systematic review.

BACKGROUND: Primary repair of anterior cruciate ligament (ACL) ruptures has re-emerged as a treatment option for proximal tears, with internal brace augmentation often utilised. The aim of this study is to provide an overview of the current evidence presenting outcomes of ACL repair with internal bracing to assess the safety and efficacy of this technique. METHODS: All studies reporting outcomes of arthroscopic primary repair of proximal ACL tears, augmented with internal bracing from 2014-2021 were included. Primary outcome was failure rate and secondary outcomes were subjective patient reported outcome measures (PROMs) and objective assessment of anteroposterior knee laxity. RESULTS: Nine studies were included, consisting of 347 patients, mean age 32.5 years, mean minimum follow up 2 years. There were 36 failures (10.4%, CI 7.4% - 14.1%). PROMs reporting was variable across studies. KOOS, Lysholm and IKDC scores were most frequently used with mean scores > 87%. The mean Tegner and Marx scores at follow-up were 6.1 and 7.8 respectively. The mean side to side difference measured for anteroposterior knee laxity was 1.2mm. CONCLUSIONS: This systematic review with meta-analysis shows that ACL repair with internal bracing is a safe technique for treatment of proximal ruptures, with a failure rate of 10.4%. Subjective scores and clinical laxity testing also revealed satisfactory results. This suggests that ACL repair with internal bracing should be considered as an alternative to ACL reconstruction for acute proximal tears, with the potential benefits of retained native tissue and proprioception, as well as negating the need for graft harvest.

Quantifying graft impingement in anterior cruciate ligament reconstruction.

BACKGROUND: Anterior cruciate ligament reconstructions (ACLR) fail at a rate of 10-15%, with graft impingement often a cause. In this study we investigate the prevalence and causes of impingement seen during ACLR surgery. METHODS: We reviewed consecutive primary ACLR from 2012-2018. Graft impingement was estimated intraoperatively by placing the arthroscope through the tibial tunnel and passively extending the knee, observing how much was obscured by the lateral femoral condyle from an anterior and lateral direction. Preoperative MRI scans were used to measure the intercondylar notch; Notch Width Index (NWI) and Notch Depth Index (NDI). Positioning of the tunnels was determined on postoperative radiographs. RESULTS: There were 283 ACLRs performed with 33 failures diagnosed on MRI (11.7%). 257 patients had complete imaging and follow up (91%). The mean age was 28 (±9) years and mean follow-up 5.3 (±1.8) years. The mean NWI was 0.26(±0.03), and NDI was 0.49(±0.06). The tibial tunnel aperture was located 42(±6) % of the way from anterior-posterior and 39(±6) % from medial-lateral. Impingement requiring a notchplasty was observed in 80% of cases, with lateral impingement more prominent. CONCLUSIONS: The amount of impingement did not correlate with tunnel position, which was located within the recommended area. There was a weak negative correlation between NWI and lateral impingement (rs = -0.16, p = 0.01), and NDI and anterior impingement (rs = -0.12, p = 0.04), therefore a smaller notch is associated with greater impingement. Despite optimal tunnel positioning, impingement still occurs in a significant number of cases therefore notchplasty should always be considered to keep revision rates low.

Computer-assisted measurements of coronal knee joint laxity in vitro are related to low-stress behavior rather than structural properties of the collateral ligaments.

The relationship between coronal knee laxity and the restraining properties of the collateral ligaments remains unknown. This study investigated correlations between the structural properties of the collateral ligaments and stress angles used in computer-assisted total knee arthroplasty (TKA), measured with an optically based navigation system. Ten fresh-frozen cadaveric knees (mean age: 81 ± 11 years) were dissected to leave the menisci, cruciate ligaments, posterior joint capsule and collateral ligaments. The resected femur and tibia were rigidly secured within a test system which permitted kinematic registration of the knee using a commercially available image-free navigation system. Frontal plane knee alignment and varus-valgus stress angles were acquired. The force applied during varus-valgus testing was quantified. Medial and lateral bone-collateral ligament-bone specimens were then prepared, mounted within a uni-axial materials testing machine, and extended to failure. Force and displacement data were used to calculate the principal structural properties of the ligaments. The mean varus laxity was 4 ± 1° and the mean valgus laxity was 4 ± 2°. The corresponding mean manual force applied was 10 ± 3 N and 11 ± 4 N, respectively. While measures of knee laxity were independent of the ultimate tensile strength and stiffness of the collateral ligaments, there was a significant correlation between the force applied during stress testing and the instantaneous stiffness of the medial (r = 0.91, p = 0.001) and lateral (r = 0.68, p = 0.04) collateral ligaments. These findings suggest that clinicians may perceive a rate of change of ligament stiffness as the end-point during assessment of collateral knee laxity.

Toxic endothelial cell destruction syndrome after intraocular lens repositioning with intracameral epinephrine.

A 66-year-old Chinese man developed corneal endothelial decompensation after intraocular lens (IOL) repositioning using intracameral epinephrine was performed. The presentation was compatible with toxic endothelial cell destruction syndrome, which is caused by prolonged, direct exposure of the corneal endothelium to relatively high concentrations of intracameral epinephrine. Despite its effective and immediate mydriatic effect, intracameral epinephrine is not recommended for intraoperative mydriasis in procedures such as IOL repositioning or secondary IOL implantation in which minimal irrigating solution is used.

Scanning laser polarimetry in pulmonary tuberculosis patients on chemotherapy.

INTRODUCTION: The aim of this study was to analyse the thickness of the retinal nerve fibre layer (RNFL) of pulmonary tuberculosis patients on ethambutol and isoniazid. MATERIALS AND METHODS: This was a prospective cohort study where patients with newly diagnosed pulmonary tuberculosis requiring chemotherapy, including ethambutol and isoniazid, were imaged using scanning laser polarimetry. Their mean baseline RNFL thickness and various scanning laser polarimetry parameters of both eyes were measured 2 weeks after the commencement of chemotherapy. The measurements were repeated at 3 months and 6 months after treatment. The various parameters of the baseline and the follow-up measurements were compared using paired sample t-test with Bonferroni correction. RESULTS: Twenty-four patients (16 males and 8 females; mean age, 51.0 +/- 17.6 years) were recruited. There was no statistically significant difference between the baseline and the follow-up measurements in RNFL thickness and all other scanning laser polarimetry parameters. CONCLUSION: In this cohort of subjects, there was no subclinical change in RNFL thickness detected by scanning laser polarimetry in pulmonary tuberculosis patients on chemotherapy, including ethambutol and isoniazid, after 6 months of treatment.

Scanning laser polarimetry in pulmonary tuberculosis patients on chemotherapy

<p><b>INTRODUCTION</b>The aim of this study was to analyse the thickness of the retinal nerve fibre layer (RNFL) of pulmonary tuberculosis patients on ethambutol and isoniazid.</p><p><b>MATERIALS AND METHODS</b>This was a prospective cohort study where patients with newly diagnosed pulmonary tuberculosis requiring chemotherapy, including ethambutol and isoniazid, were imaged using scanning laser polarimetry. Their mean baseline RNFL thickness and various scanning laser polarimetry parameters of both eyes were measured 2 weeks after the commencement of chemotherapy. The measurements were repeated at 3 months and 6 months after treatment. The various parameters of the baseline and the follow-up measurements were compared using paired sample t-test with Bonferroni correction.</p><p><b>RESULTS</b>Twenty-four patients (16 males and 8 females; mean age, 51.0 +/- 17.6 years) were recruited. There was no statistically significant difference between the baseline and the follow-up measurements in RNFL thickness and all other scanning laser polarimetry parameters.</p><p><b>CONCLUSION</b>In this cohort of subjects, there was no subclinical change in RNFL thickness detected by scanning laser polarimetry in pulmonary tuberculosis patients on chemotherapy, including ethambutol and isoniazid, after 6 months of treatment.</p>

Scanning laser polarimetry in patients with acute attack of primary angle closure.

PURPOSE: To compare the retinal nerve fiber layer measurements of attacked eyes with their fellow eyes after a single unilateral attack of acute primary angle closure (APAC). METHODS: Patients with a single episode of APAC in 1 eye, successfully treated with laser peripheral iridotomy, were recruited. Eyes with persistently raised intraocular pressure (IOP) after resolution of the acute attack were excluded. Scanning laser polarimetry was carried out at 6 months after remission of the acute attack. The various parameters between the attacked and the fellow eyes were compared using the Student t-test. RESULTS: Twenty-six patients (24 female and 2 male, mean age 66.9+/-8.1 years) were recruited. The duration of the APAC ranged from 5 to 98 hours (mean, 36.3 hours). The mean presenting IOP during the acute attack was 62.0+/-9.4 mm Hg. Only the mean inferior ratio and the ellipse modulation showed a statistically significant difference between the attacked and the fellow eyes among the 12 standard scanning laser polarimetry measurement parameters. CONCLUSION: No severe retinal nerve fiber layer damage was documented in eyes that suffered a single episode of APAC with duration of attack up to 48 hours. With duration of attack longer than 48 hours, retinal nerve fiber layer damage was detected.

A comparison of the bioeffects of four different modes of stone therapy on renal function and morphology.

A variety of therapeutic options exists for removal of symptomatic renal calculi, including extracorporeal shock wave lithotripsy, percutaneous nephrostolithotomy and open pyelolithotomy or nephrolithotomy. Although lithotripsy offers the advantage of reduced patient morbidity, the relative alterations in renal function and morphology for each of the respective treatment modalities have not been completely assessed. We evaluated 17 pigs (40 to 50 lb.) for evidence of histologic and functional renal changes after a pyelotomy (N = 3) or nephrotomy (N = 4), piezoelectric lithotripsy (N = 5), or placement of a percutaneous nephrostomy tube with balloon dilation (N = 5). Pathologic evaluation one month after treatment revealed no renal scarring in the animals that underwent a pyelotomy and minimal parenchymal fibrosis in the nephrotomy and lithotripsy groups (0.014 +/- 0.001% and 0.015 +/- 0.002%, respectively). In contrast, the percutaneous nephrostomy group demonstrated 1.53 +/- 0.4% of the treated kidney to be involved by scarring (p < 0.001). Despite the statistically significant increase in renal scarring after percutaneous nephrostomy, neither creatinine and PAH clearances nor renal plasma flows changed significantly among the four treatment groups. Moreover, no change in renal function after treatment was observed when compared with baseline evaluations. All four therapeutic options for renal stone removal appear to result in small amounts of renal parenchymal damage but are not associated with significant alterations in renal function.

Management of low velocity gunshot wounds to the anterior urethra: the role of primary repair versus urinary diversion alone.

The management of partial transection of the anterior urethra following penetrating penile injuries is controversial. Optional therapeutic techniques range from a primary sutured reapproximation to urinary diversion alone. We recently managed 17 low velocity gunshot wounds to the external genitalia in which the missile traversed the penile corpus cavernosum, and was associated with less than 40% transection of the corpus spongiosum and anterior urethra. Nine patients were managed with suprapubic diversion, skin débridement and corporeal closure along with placement of a urethral catheter. Eight patients were managed by suprapubic diversion, débridement, closure of the corporeal bodies and a primary sutured reapproximation of the anterior urethra. Urethral strictures developed in 7 patients (78%) managed by a suprapubic tube and urethral stenting during an average followup of 20 months (range 18 to 24). In contrast, 1 patient (12%) managed by a sutured urethral approximation had a urethral stricture during an average followup of 20 months (range 18 to 30, p < 0.01). Our data support a significantly better prognosis for partial transection of the anterior urethra secondary to low velocity gunshot wounds if managed by aggressive wound débridement, corporeal repair, placement of a suprapubic catheter and primary repair of the urethra.

Treatment philosophy and retreatment rates following piezoelectric lithotripsy.

Second generation lithotriptors offer the advantage of anesthesia-free fragmentation of renal and ureteral calculi but they frequently require multiple treatments to attain a stone-free status. However, excessive single lithotripsy sessions or multiple treatments may be associated with significant damage to the kidney. For some clinicians a common treatment philosophy involves evaluation of serial plain abdominal films every 24 hours after lithotripsy and immediate retreatment of all patients with incomplete fragmentation. To avoid unnecessary retreatments and, thus, minimize potential renal damage, we prospectively evaluated 100 patients undergoing lithotripsy on a Wolf Piezolith 2300 device. Patients were routinely treated with 4,000 shocks at 1,100 bar. Serial plain abdominal films were obtained at 1 day and 2 weeks after lithotripsy. The need for retreatment was determined by the plain abdominal film results. Additional therapy was considered necessary if there was no stone fragmentation or if residual fragments measured greater than 4 mm. Of the patients whose plain abdominal film at 24 hours indicated the need for a repeat treatment 43% were stone-free on the 2-week film. Thus, these patients were spared an unnecessary treatment by allowing adequate time for the stone fragments to pass spontaneously. Our data suggest that repeat treatments on second generation lithotriptors should not be performed within 24 hours. Rather, the patient should be reevaluated at least 1 to 2 weeks later to avoid unnecessary retreatment with the attendant potential for renal injury. In addition, when comparing the retreatment rates of various lithotriptors, one should also consider the treatment philosophy used at the particular institution and the timing of the radiographic studies used to determine the stone-free status.

Postpubertal genitourinary function following posterior urethral disruptions in children.

A total of 24 boys sustaining a simultaneous pelvic fracture and posterior urethral disruption was observed from the time of injury through puberty. Average length of followup was 6 years. In contrast to the adult, in whom the urethra is invariably injured at the prostatomembranous junction, the posterior urethral disruptions in the prepubertal patient were at 3 distinct locations: 1) supraprostatic in 4 patients, 2) transprostatic in 4 and 3) prostatomembranous in 16. Prolonged followup through puberty in these children revealed that the frequency of complications was significantly higher for urethral injuries proximal to the prostatomembranous region compared to those at this latter site: impotence 75% versus 31%, intractable strictures following repairs 75% versus 12% and urinary incontinence 25% versus 0%. In summary, the prognosis of children who sustain a posterior urethral disruption should be based on the location of the injury and must remain guarded until the individual attains a postpubertal status.

Testicular tumors in men with human immunodeficiency virus.

During a 2-year period 5 men positive for the human immunodeficiency virus (HIV) presented with 6 testis tumors among a total of 3,015 men seen at our hospital acquired immunodeficiency syndrome (AIDS) clinic. This testis tumor incidence of 0.2% is 57 times that of the United States average of 3.5 cases per 100,000 men. Two patients were only HIV positive and 3 others already had AIDS-related complex for 2 to 15 months at the time of tumor diagnosis. Tumor histology was mixed germ cell tumor in 4 patients, pure seminoma in 1 and Burkitt's lymphoma in 1. Patients underwent routine staging evaluations. Three patients had low stage mixed germ cell tumor (clinical stage 1 or 2A) and underwent retroperitoneal lymphadenectomy, which revealed pathological stage 1 or 2A disease in 1 and 2, respectively. These patients did not receive adjuvant chemotherapy. Two patients had advanced mixed germ cell tumor (clinical stage 2C) or Burkitt's lymphoma (clinical stage 4) and received combination chemotherapy from the onset. Outcome was evaluated with regard to progression of HIV disease and tumor status. The 2 patients who were only HIV positive remained so for 9 and 48 months. The 3 patients with AIDS-related complex had progression to AIDS within 1 to 9 months and 2 of these patients died 1 1/2 and 7 months after tumor diagnosis. All 3 patients with resected low stage disease had tumor recurrence within 1 to 9 months and were begun on platinum-based combination chemotherapy. The risk of false low clinical staging and early tumor progression may be higher in HIV positive men than in other testis tumor patients. Patient ability to tolerate chemotherapy and to obtain a satisfactory tumor response appeared to be primarily related to lack of progression of HIV disease to frank AIDS.

A comparison of renal damage induced by varying modes of shock wave generation.

To evaluate for the possible differences in the extent of pathologic injury occurring following treatment with various lithotripsy modalities, we subjected rabbits to treatment on either an electrohydraulic, electromechanical, or piezoelectric lithotripter. Functional evaluations by enzymuria failed to reveal any difference in the extent of damage between the lithotripters. Pathologic evaluation of the kidneys revealed that both electrohydraulic and electromechanical lithotripsy resulted in an increased instance of acute subcapsular hematoma and fibrosis when compared to piezoelectric treated kidneys (p less than 0.001). Despite the definitive differences noted in the acute animals, there was no significant variation in the area of permanent renal damage that occurred between the various lithotripters.

Temporal effects of shock wave lithotripsy.

Previous studies have demonstrated that renal parenchymal injury following extracorporeal shock wave lithotripsy is dependent upon shock wave power as well as the total number of shock waves administered. In order to determine the deleterious effects of temporal versus cumulative doses of shock wave administration, adult female rabbits were divided into five groups receiving either: 1000 shock waves in one session; 2000 shock waves in one session; 2000 shock waves in two sessions, one week apart; unilateral nephrectomy without lithotripsy; or anesthesia only as control population. One month following lithotripsy, renal functional studies for gamma glutamyl transferase and N-acetyl-beta-glucosaminidase revealed persistent enzymuria in the animals treated with 2000 shocks in one session. Pathologic studies in these animals confirmed an increased area of periglomerular and intratubular fibrosis when compared to animals managed by either 1000 shocks or 2000 shocks in divided doses (p less than 0.01). These findings suggest the importance of avoiding single treatments with large doses of shock waves and favor the administration of multiple small-doses of shock waves to minimize renal damage during the treatment of patients with hard or large calculi.

Prostatomembranous urethral disruptions: management by suprapubic cystostomy and delayed urethroplasty.

Management of prostatomembranous urethral disruptions associated with pelvic fractures remains a major controversy in urology. A group of 64 patients who suffered a prostatomembranous urethral disruption in association with a pelvic fracture and who were managed initially by suprapubic cystostomy with delayed urethroplasty was compared to 17 patients managed initially by primary realignment. No statistically significant difference in the incidence of impotence or urinary incontinence was found between the 2 groups (p greater than 0.5) Secondary reconstructions for impassable strictures developed in 95% of the patients treated by a suprapubic tube alone compared to 53% of those treated by primary realignment. Indeed, only 1 patient in the latter group achieved urethral continuity that did not require further intervention. We conclude that while primary realignment is associated with no increase in the instance of impotence and urinary incontinence, it subjects the patient to a major operation at a critical time and provides little in the way of long-term positive gains for the effort expended. In the final analysis the outcome is more dependent upon the nature of the injury and the quality of the repair than upon the order in which the repair is effected.

Extracorporeal shock wave lithotripsy. An update.

Extracorporeal shock wave lithotripsy has revolutionized the treatment of urinary calculi. It should be considered the treatment of choice for renal stones smaller than 2 cm and for the majority of ureteral calculi, under which circumstances success rates approaching 80 to 90 per cent may be anticipated. Larger renal calculi or impacted ureteral stones probably should be managed by endoscopic techniques with or without adjunctive intracorporeal (ultrasonic or electrohydraulic) lithotripsy or laser fragmentation. Recent modifications in lithotripter design have been focused on the development of pain-free lithotripsy. Concomitant with a decrease in power, however, is an attendant decrease in the efficiency with which stones can be fragmented, resulting in an increase in the number of lithotripsy treatments required for adequate stone fragmentation. Additionally, sonography is assuming an increasing role in stone localization, and its use will require sonographic training on the part of the urologist. Biliary lithotripsy has been promising in preliminary European studies, with success rates approaching 90 per cent. It must be noted, however, that the U.S. experience has not been as impressive. Moreover, only 20 to 30 per cent of patients referred for biliary lithotripsy appear to be optimal candidates for this new technique. Adjunctive dissolution of gallstones with chronic oral medical therapy may be required after biliary lithotripsy, and long-term follow-up studies still need to be performed. Finally, the potential deleterious effects of extracorporeal shock wave lithotripsy must always be kept in mind. Although the majority of clinical and animal investigations have documented no significant long-term alterations in renal function, care must still be exercised when performing lithotripsy with the knowledge of the potential for long-term injurious effects on the functioning renal parenchyma.