Comparison of anatomic ACL reconstruction between selective bundle reconstruction and double-bundle reconstruction

Purpose

The objective of this study was to compare the clinical and radiologic results of preserved ligament remnants in the selective bundle anterior cruciate ligament (ACL) reconstruction and totally sacrificed ligament remnant in the double-bundle ACL reconstruction in order to confirm the evidence of selective bundle reconstruction.

Methods

This retrospective comparative study was conducted for comparison between preserved ligament remnants in the selective bundle ACL reconstruction and totally sacrificed ligament remnant in the double-bundle ACL reconstruction. From 2008 to 2010, 16 patients (group I) underwent selective bundle ACL reconstruction and 30 patients (group II) underwent double-bundle ACL reconstruction. Clinical, stability and radiologic results (tunnel locations of femoral tunnels using 3-D computed tomography and graft signal intensity using magnetic resonance imaging) were compared.

Results

In comparison with functional results, no statistical differences in the Lysholm, Tegner and International Knee Documentation Committee scores were observed between the two groups (n.s.). In comparison with stability results between the two groups, no statistical differences were observed in the Lachman, pivot shift and anterior drawer stress tests using a Telos^® device at 30° and 90° flexed positions (n.s.). In evaluation of the femoral tunnel location, no statistical significant differences in the tunnel position were observed between the groups (n.s.). No statistically significant differences in signal intensity were observed between the two groups (n.s.).

Conclusions

Compared to the double-bundle ACL reconstruction, selective bundle ACL reconstruction produced comparable clinical and radiologic results. Selective bundle ACL reconstruction could be performed instead of double-bundle ACL reconstruction if some intact bundle exists.

Level of evidence

Comparative study, Level III.     

Two-stage total knee arthroplasty for non-salvageable septic arthritis in diabetes mellitus patients

Pyogenic knee arthritis in a patient with advanced osteoarthritis is a serious medical problem. We have performed arthroscopic debridement in 136 patients with pyogenic knee arthritis from January 1999 to December 2001. Five of these patients were diabetic, they did not respond to the standard treatment protocol and they continued to have infection. For these patients, we performed open arthrotomy, with implantation of antibiotic cement as a spacer, and staged total knee arthroplasty. The clinical results were evaluated using the Hospital for Special Surgery (HSS) scoring system. At an average follow-up of 38 months (range: 29 to 46), the average pain score was 83 and the functional score was 73 with no patient having recurrence of the infection. This study shows that just as a 2-stage revision is now done for infected total knee arthroplasty, primary uncontrolled infected knees may be treated by a 2-stage arthroplasty as well.     

Alveolar soft part sarcoma: MR and angiographic findings

Objective. To present the MR and angiographic findings of alveolar soft part sarcoma (ASPS). Design and patients. MR examinations (12 tumors of 10 patients) of ASPS performed at multiple hospitals were retrospectively reviewed. The tumors were found in the thigh (n=4), lower leg (n=4), femur (n=2, local metastasis), scalp (n=1) and arm (n=1). The MR signal characteristics including signal intensity, homogeneity and signal void of lesions and bony invasion including direct invasion or local metastasis were evaluated. Angiographic findings (n=4) and post-embolotherapy follow-up MR imaging (n=2) findings were also assessed. Results. Local bony metastasis was found in two cases. Seven tumors showed heterogeneous high signal intensity on T1- and T2-weighted images with good enhancement. One tumor had a very high signal on T1-weighted images. Eight tumors (67%) showed numerous signal voids in or near the tumors. All four angiographic studies showed numerous enlarged vessels, arteriovenous shunts and delayed washout. Two cases mimicked arteriovenous malformations on angiographic studies but MR images demonstrated solid soft tissue components as well as tortuous vessels. Conclusions. High signal on T1-weighted image and numerous signal voids are highly suggestive of ASPS, although they are not universal as has been suggested and arteriovenous malformation should be included in the differential diagnosis. Local bony metastases in ASPS were seen in two cases and should be carefully investigated. Received: 12 April 2000 Revision requested: 27 June 2000, 8 August 2000 Revision received: 2 August 2000, 21 August 2000 Accepted: 22 August 2000     

Large-Scale Proteomics and Phosphoproteomics of Urinary Exosomes

Normal human urine contains large numbers of exosomes, which are 40- to 100-nm vesicles that originate as the internal vesicles in multivesicular bodies from every renal epithelial cell type facing the urinary space. Here, we used LC-MS/MS to profile the proteome of human urinary exosomes. Overall, the analysis identified 1132 proteins unambiguously, including 177 that are represented on the Online Mendelian Inheritance in Man database of disease-related genes, suggesting that exosome analysis is a potential approach to discover urinary biomarkers. We extended the proteomic analysis to phosphoproteomic profiling using neutral loss scanning, and this yielded multiple novel phosphorylation sites, including serine-811 in the thiazide-sensitive Na-Cl co-transporter, NCC. To demonstrate the potential use of exosome analysis to identify a genetic renal disease, we carried out immunoblotting of exosomes from urine samples of patients with a clinical diagnosis of Bartter syndrome type I, showing an absence of the sodium-potassium-chloride co-transporter 2, NKCC2. The proteomic data are publicly accessible at http://dir.nhlbi.nih.gov/papers/lkem/exosome/.Urinary exosomes are small extracellular vesicles (<100 nm in diameter) that originate from the internal vesicles of multivesicular bodies (MVB) in renal epithelial cells, including glomerular podocytes, renal tubule cells, and the cells lining the urinary drainage system.¹ Exosomes are released into the urine when the outer membrane of the MVB fuses with the apical plasma membrane of the epithelial cell.Exosomes can be recovered from the urine by differential centrifugation as a low-density membrane fraction. Exosome isolation can result in marked enrichment of low-abundance urinary proteins that have potential pathophysiologic significance. As a consequence, we and others have been working to define optimal conditions for their isolation and purification as a prelude to their use in biomarker discovery studies.^1–3In this study, we thoroughly expanded the known proteome of human urinary exosomes by using a highly sensitive LC-MS/MS system, improved software for identification of peptide ions and a more elaborate data analysis strategy than in our previous study. In addition, we used a neutral loss scanning approach⁴ to investigate the phosphoproteome of human urinary exosomes. The study identified 1412 proteins including 14 phosphoproteins in human urinary exosomes. Overall, there are 177 proteins that are associated with diseases as judged by their presence on the Online Mendelian Inheritance in Man (OMIM) database, 34 of which are known to be associated with renal diseases. The potential clinical usefulness of urinary exosomes was demonstrated using the well-defined renal tubulopathy, Bartter syndrome type I, as an example. The rich information from the proteomic analysis also provides further insight into the biogenesis of urinary exosomes.     

US screening for detection of nonpalpable locoregional recurrence after mastectomy

Purpose

To assess the value of screening ultrasonography (US) in the detection of nonpalpable locoregional recurrence following mastectomy for breast cancer and to describe the US appearances of occult recurrent cancers.

Materials and methods

During a 36-month period, 1180 consecutive US screenings were performed for mastectomy sites and ipsilateral axillary fossae in 468 asymptomatic women who had undergone mastectomy for breast cancer. All US results were divided into three groups: negative findings, probably benign nodules, and suspicious for malignant nodules. The final diagnoses were based on pathology results and clinical or sonographic follow-up for more than 12 months. The diagnostic performance of US for detecting nonpalpable locoregional recurrence was assessed. The US appearances of occult recurrent cancers were retrospectively reviewed.

Results

Of the 468 patients assessed, 19 (4.1%) showed “suspicious for malignant nodules”; of these lesions, 10 were malignant. One false-negative case was identified. The sensitivity and specificity were 90.9% and 98.0%, respectively. A biopsy positive predictive value of 52.6% was observed. Cancer detection rates were 2.1% with US screenings of mastectomy sites and ipsilateral axillary fossae. The common US features of occult recurrences at the mastectomy sites were irregular shaped, not-circumscribed marginated, and hypoechoic masses with intratumoral vascularities. The most common location was within the deep muscle layer.

Conclusion

Although locoregional recurrence infrequently occurs after mastectomy for breast cancer, screening US enables detection of nonpalpable cancer before it can be detected by clinical examination. Routine follow-up US can be advocated for early detection of nonpalpable locoregional recurrent cancer.     

The flavonoid quercetin induces apoptosis and inhibits migration through a MAPK-dependent mechanism in osteoblasts

The present study was undertaken to evaluate effects of quercetin, a major dietary flavonoid occurring in foods of plant origin, on cell viability and migration of osteoblastic cells. Quercetin inhibited cell viability, which was largely attributed to apoptosis, in a dose-and time-dependent manner in osteoblastic cells. Similar cytotoxicity of quercetin was observed in adipose tissue-derived stromal cells. Quercetin exerted a protective effect against H₂O₂-induced cell death, whereas it increased TNF-α-induced cell death. Western blot analysis showed that quercetin induced activation of ERK and p38, but not JNK. Quercetin-induced cell death was prevented by the ERK inhibitor PD98059, but not by inhibitors of p38 and JNK. Quercetin increased Bax expression and caused depolarization of mitochondrial membrane potential, which were inhibited by PD98059. Quercetin induced caspase-3 activation, and the quercetininduced cell death was prevented by caspase inhibitors. Quercetin inhibited cell migration, and its effect was prevented by inhibitors of ERK and p38. Taken together, these findings suggest that quercetin induces apoptosis through a mitochondria-dependent mechanism involving ERK activation and inhibits migration through activation of ERK and p38 pathways. Quercetin may exert both protective and deleterious effects in bone repair.     

Prevalence of osteoporosis and reference data for lumbar spine and hip bone mineral density in a Korean population

The aims of this study were to establish reference data for bone mineral density (BMD) at central skeletal sites using Lunar dual-energy X-ray absorptiometry (DXA), and to estimate the age-and sex-specific prevalence of osteoporosis in a Korean population. We performed a population-based, cross-sectional study. The subjects were 4148 (1810 men and 2338 women) Korean adults, aged 20–79 years. The BMD for central sites (lumbar spine, femoral neck, trochanter, and Ward’s triangle) were measured by DXA. The standardized prevalence of osteoporosis among individual aged 50–79 years in lumbar spine, femoral neck, Ward’s triangle, and trochanter was 40.1%, 12.4%, 28.4%, and 4.4% in women and 6.5%, 5.9%, 3.7%, and 1.6% in men, respectively. In women, peak BMD occurred in the age range 40–49 years for the femoral neck and trochanter, 30–39 years for the lumbar spine, and 20–29 years for Ward’s triangle. In men, peak BMD values were observed at 20–29 years for all measured sites. This study establishes a normative database for BMD at central skeletal sites using dualenergy X-ray absorptiometry and provides more reliable information on the prevalence of osteoporosis in Korea.     

Factors Influencing Pathologic Results after Total Mesorectal Excision for Rectal Cancer: Analysis of Consecutive 100 Cases

Background The aim of this study was to analyze clinical and anatomical factors affecting the pathologic quality of the resected specimen after total mesorectal excision (TME) for rectal cancer. Methods A total of 100 patients who underwent TME for mid or low rectal cancer were evaluated prospectively. MRI pelvimetry data (transverse diameter, obstetric conjugate, interspinous distance, sacrum length, and sacrum depth) were analyzed as anatomically affecting factors to postoperative specimen quality. Sex, body mass index (BMI), type of surgery, tumor size, and tumor distance from the anal verge were analyzed as clinically affecting factors. The gross judgment of resected specimen, circumferential resection margin and the number of harvested lymph nodes were used to access postoperative specimen quality. Results The univariate and multivariate analysis showed that narrow obstetric conjugate and shorter interspinous distance were related to the inadequate quality of the mesorectum in the specimen (P = 0.022, P = 0.030). Interspinous distance was a predicting factor of a positive circumferential resection margin (P = 0.007). There were no clinical factors affecting the inadequate quality of the mesorectum or positive circumferential resection margin. Moreover, there were no clinico-anatomical factors affecting the number of harvested lymph nodes after TME. Conclusion Narrow obstetric conjugate and shorter interspinous distance were factors leading to poor postoperative specimen quality. Rectal cancer patients with narrow obstetric conjugate or shorter interspinous distance should be considered as high-risk patients with regard to specimen quality, which is in turn related to oncological outcome.     

Anterior shoulder instability with humeral avulsion of the glenohumeral ligament lesion

Humeral avulsion of the glenohumeral ligament (HAGL) is a rare lesion. The purpose of this study was to analyze the clinical manifestations of HAGL lesions in patients who underwent operative treatment for anterior shoulder instability. Six patients with HAGL lesions were studied. Four patients had an HAGL lesion associated with a Bankart lesion, and two had an isolated HAGL lesion. The range of motion at final follow-up showed a loss of 1 degree in forward flexion and of 15 degrees in external rotation. During an operation to treat anterior shoulder instability, a thorough examination for not only Bankart lesions but also other associated lesions, including an HAGL lesion, should be considered to lower the risk of redislocation. In repairing an HAGL lesion, the surgeon should keep in mind the possibility of a postoperative loss of external rotation and follow an active rehabilitation protocol to obtain successful results.     

Epidural naloxone reduces postoperative nausea and vomiting in patients receiving epidural sufentanil for postoperative analgesia

Background: Epidural opioids have excellent analgesic properties, but theirside-effects limit their use in patient-controlled epiduralanalgesia. This study was designed to evaluate the effect ofepidural naloxone on the side-effects of sufentanil, focusingon postoperative nausea and vomiting (PONV) in patients undergoingtotal knee replacement (TKR). Methods: After obtaining Institutional Review Board approval and informedconsent, 50 patients undergoing unilateral TKR were randomlyassigned to receive either sufentanil in ropivacaine alone (GroupC, n = 25) or the same solution with naloxone (Group N, n =25) for their postoperative epidural analgesia. Episodes ofPONV and five-point-scaled nausea scores were evaluated at 6,12, and 24 h after epidural analgesia was started. Visual analoguescale (VAS) score for pain and the incidence of sedation, pruritus,hypotension, and respiratory depression were also evaluatedat each of three time points. Results: The nausea score in Group N was significantly lower than thatin Group C. The VAS pain score at rest and on movement weresignificantly lower in Group N than in Group C at 24 h. Otheropioid-induced side-effects were not significantly different. Conclusions: Epidural naloxone was effective in reducing PONV induced byepidural sufentanil and additionally enhanced the analgesiceffect. Therefore, concomitant infusion of a small dose of epiduralnaloxone should be considered to reduce PONV, especially inpatients at greater risk for PONV.