Is distal femoral torsion the same in both of a patient's legs? Morphometric CT study.

INTRODUCTION: The rotational position of the femoral component is a primary driver of success in total knee arthroplasty. However, distal femoral torsion (DFT) varies greatly between individuals. Measuring DFT preoperatively by CT in combination with computer-assisted surgery can significantly improve the rotational positioning of the femoral component. However, a preoperative CT scan is costly and exposes the patient to radiation. These are doubled when the patient is undergoing bilateral arthroplasty. The aim of this study was to determine the DFT in both knees of a patient undergoing bilateral arthroplasty. We hypothesized that DFT was symmetric between a patient's two knees and was independent of frontal alignment. MATERIAL AND METHODS: In this retrospective study of TKA cases performed between December 2008 and March 2015, 82 patients (mean age 73years) who underwent two-stage bilateral TKA (164 knees) were included. A preoperative CT scan of each knee was performed to measure the DFT using the surgical posterior condylar angle (PCA) described by Yoshioka. Two observers performed the measurements twice each, to allow calculation of the intraclass and interclass correlation coefficients. RESULTS: The mean PCA was 5.4° (±1.48) in the right knee and 5.4° (±1.45) in the left knee, with a left/right difference ranging from 0 to 2.2° (p=0.8). In the entire cohort, 84.6% of patients had a left/right difference of less than 1°. We found no significant differences in DFT in knees with large or small frontal deformity (deformity<10°, p=0.7; deformity>10°, p=0.5) or the presence of varus or valgus (p=0.9). The intraclass correlation coefficient was excellent (94%) and the interclass correlation coefficient was moderate to good (60% for left knees, 53% for right knees). DISCUSSION: Based on CT scan measurements, the DFT in both knees of an arthritic patient is comparable and this measurement is reproducible. This means that a single, unilateral preoperative CT scan is sufficient for planning purposes. LEVEL OF EVIDENCE: IV (retrospective cohort study).

Long-term assessment of meniscal extrusion after meniscal repair.

BACKGROUND: Arthroscopic meniscal repair limits the medium-term risk of radiological osteoarthritis. Magnetic resonance imaging (MRI) cannot provide an accurate assessment of meniscal healing but may show harbingers of osteoarthritis such as meniscal extrusion. The objective of this study was to assess long-term meniscal extrusion after meniscal repair. HYPOTHESIS: Arthroscopic meniscal suture is not followed by meniscal extrusion and can, therefore, provide good knee function in the long-term. METHODS: Consecutive patients who underwent arthroscopic meniscal suture on a stable or stabilised knee were included retrospectively. MRI was performed to measure absolute meniscal extrusion (AME), relative meniscal extrusion (RME), anterior sagittal extrusion (ASE), posterior sagittal extrusion (PSE), coronal cartilage coverage index (cCCI), and sagittal cartilage coverage index (sCCI). RESULTS: After a mean follow-up of 8.8±0.87 years, there was no evidence of meniscal extrusion in these patients with stable or stabilised knees: AME, 1.7±1.03 and 2.3±0.93mm, RME, 17±0.10% and 28±0.12%, ASE, 2.52±1.43 and 1.71±2.42mm, PSE, 0.29±3.49 and 0.22±2.35mm, cCCI, 23±0.08% and 20±0.09%, and sCCI, 49±0,10% and 53±0.09%. CONCLUSION: In the long-term after meniscal repair, osteoarthritis is limited and meniscal function seems preserved. LEVEL OF EVIDENCE: IV, retrospective study.

Lack of stability at more than 12 months of follow-up after anterior cruciate ligament reconstruction using all-inside quadruple-stranded semitendinosus graft with adjustable cortical button fixation in both femoral and tibial sides.

INTRODUCTION: The use of the semitendinosus tendon alone for anterior cruciate ligament reconstruction keeps the gracilis muscle intact and decreases anterior pain in comparison with the use of the patellar tendon. Recently, Lubowitz described a new all-inside technique with an ST4 tendon fixed with a cortical button in both femoral and tibial sides. We hypothesized that this type of graft with cortical button fixation provides well-controlled residual anterior tibial translation (<3mm). The aim of this study was to assess the results obtained with this technique in terms of laxity and IKDC score at more than 1 year of follow-up. MATERIAL AND METHODS: We performed a prospective single-center study to evaluate the results with this procedure with at least 1 year of follow-up. The primary endpoint was the objective IKDC score and side-to-side anterior tibial translation difference. The secondary endpoint was the subjective assessment using the subjective IKDC and Lysholm scores. Tunnel positioning was assessed using the Aglietti criteria. RESULTS: Thirty-five patients were included and reviewed with a mean follow-up of 19.7 months. Sixty-three percent of the patients were male and the mean age at the procedure was 28 years. The IKDC score was A or B in 43% of the patients and C or D in 57%; 54% of the patients had a residual side-to-side anterior tibial translation difference less than 3mm and 29% presented significant pivot shift (grade C or D). Five patients underwent revision surgery, including one for rupture of the ACL reconstruction. The meniscal status did not influence postoperative laxity and the IKDC grade. DISCUSSION: Our hypothesis was not verified and the postoperative stability of the knee was insufficient. Postoperative side-to-side anterior tibial translation difference remained greater than 3mm for 16 patients and the analysis seems to indicate that the distal cortical fixation of the graft with an adjusted loop is insufficient. LEVEL OF EVIDENCE: Prospective study - Level IV.

Muscle recovery after ACL reconstruction with 4-strand semitendinosus graft harvested through either a posterior or anterior incision: a preliminary study.

INTRODUCTION: Harvesting of a 4-strand semitendinosis (ST4) graft during anterior cruciate ligament (ACL) reconstruction can be performed through either a posterior or anterior approach. The objective of this study was to evaluate the recovery of the quadriceps and hamstring muscles as a function of the graft harvesting method. We hypothesized that posterior harvesting (PH) would lead to better recovery in hamstring strength than anterior harvesting (AH). METHODS: In this prospective study, the semitendinosus was harvested through an anterior incision in the first group of patients and through a posterior one in the second group of patients. The patients were enrolled consecutively, without randomization. Isokinetic muscle testing was performed three and six months postoperative to determine the strength deficit in the quadriceps and hamstring muscles of the operated leg relative to the uninjured contralateral leg. RESULTS: Thirty-nine patients were included: 20 in the AH group and 19 in the PH group. The mean quadriceps strength deficit after three and six months was 42% and 26% for AH and 29% and 19% for the PH, respectively (P=0.01 after three months and P=0.16 after six months). The mean hamstring strength deficit after three and six months was 31% and 17% for AH and 23% and 15% for the PH, respectively (P=0.09 after three months and P=0.45 after six months). After three months, the PH group had recovered 12% more quadriceps muscle strength than the AH group (P=0.03). CONCLUSION: Our hypothesis was not confirmed. Harvesting of a ST4 graft for ACL reconstruction using a posterior approach led to better muscle strength recovery in the quadriceps only after three months. CASE CONTROL STUDY: Level 3.

Recombinant human LH supplementation during GnRH antagonist administration in IVF/ICSI cycles: a prospective randomized study.

BACKGROUND: When administered in the late follicular phase to prevent an LH surge, GnRH antagonists induce a sharp decrease in serum LH levels that may be detrimental for assisted reproductive technology cycle outcome. Therefore, a prospective study was designed to assess the effects of recombinant human (r)LH supplementation during GnRH antagonist (cetrorelix) administration. METHODS: The protocol consisted of cycle programming with oral contraceptive pill, ovarian stimulation with rFSH and flexible administration of a single dose of cetrorelix (3 mg). A total of 218 patients from three IVF centres were randomized (by sealed envelopes or according to woman's birth date) to receive (n = 114) or not (n = 104) a daily injection of rLH 75 IU from GnRH antagonist initiation to hCG injection. RESULTS: The only significant difference was a higher serum peak E2 level in patients treated with rLH (1476 +/- 787 versus 1012 +/- 659 pg/ml, P < 0.001) whereas the numbers of oocytes and embryos as well as the delivery rate (25.2 versus 24%) and the implantation rate per embryo (19.1 versus 17.4%) were similar in both groups. CONCLUSIONS: These results show that in an unselected group of patients, there is no evident benefit to supplement GnRH antagonist-treated cycles with rLH.

Cdc42, dynein, and dynactin regulate MTOC reorientation independent of Rho-regulated microtubule stabilization.

In migrating adherent cells such as fibroblasts and endothelial cells, the microtubule-organizing center (MTOC) reorients toward the leading edge [1-3]. MTOC reorientation repositions the Golgi toward the front of the cell [1] and contributes to directional migration [4]. The mechanism of MTOC reorientation and its relation to the formation of stabilized microtubules (MTs) in the leading edge, which occurs concomitantly with MTOC reorientation [3], is unknown. We show that serum and the serum lipid, lysophosphatidic acid (LPA), increased Cdc42 GTP levels and triggered MTOC reorientation in serum-starved wounded monolayers of 3T3 fibroblasts. Cdc42, but not Rho or Rac, was both sufficient and necessary for LPA-stimulated MTOC reorientation. MTOC reorientation was independent of Cdc42-induced changes in actin and was not blocked by cytochalasin D. Inhibition of dynein or dynactin blocked LPA- and Cdc42-stimulated MTOC reorientation. LPA also stimulates a Rho/mDia pathway that selectively stabilizes MTs in the leading edge [5, 6]; however, activators and inhibitors of MTOC reorientation and MT stabilization showed that each response was regulated independently. These results establish an LPA/Cdc42 signaling pathway that regulates MTOC reorientation in a dynein-dependent manner. MTOC reorientation and MT stabilization both act to polarize the MT array in migrating cells, yet these processes act independently and are regulated by separate Rho family GTPase-signaling pathways.

A role for the lissencephaly gene LIS1 in mitosis and cytoplasmic dynein function.

Mutations in the LIS1 gene cause gross histological disorganization of the developing human brain, resulting in a brain surface that is almost smooth. Here we show that LIS1 protein co-immunoprecipitates with cytoplasmic dynein and dynactin, and localizes to the cell cortex and to mitotic kinetochores, which are known sites for binding of cytoplasmic dynein. Overexpression of LIS1 in cultured mammalian cells interferes with mitotic progression and leads to spindle misorientation. Injection of anti-LIS1 antibody interferes with attachment of chromosomes to the metaphase plate, and leads to chromosome loss. We conclude that LIS1 participates in a subset of dynein functions, and may regulate the division of neuronal progenitor cells in the developing brain.

Kinetochore fibers are not involved in the formation of the first meiotic spindle in mouse oocytes, but control the exit from the first meiotic M phase.

During meiosis, two successive divisions occur without any intermediate S phase to produce haploid gametes. The first meiotic division is unique in that homologous chromosomes are segregated while the cohesion between sister chromatids is maintained, resulting in a reductional division. Moreover, the duration of the first meiotic M phase is usually prolonged when compared with mitotic M phases lasting 8 h in mouse oocytes.We investigated the spindle assembly pathway and its role in the progression of the first meiotic M phase in mouse oocytes. During the first 4 h, a bipolar spindle forms and the chromosomes congress near the equatorial plane of the spindle without stable kinetochore- microtubule end interactions. This late prometaphase spindle is then maintained for 4 h with chromosomes oscillating in the central region of the spindle. The kinetochore-microtubule end interactions are set up at the end of the first meiotic M phase (8 h after entry into M phase). This event allows the final alignment of the chromosomes and exit from metaphase. The continuous presence of the prometaphase spindle is not required for progression of the first meiotic M phase. Finally, the ability of kinetochores to interact with microtubules is acquired at the end of the first meiotic M phase and determines the timing of polar body extrusion.

Can an oxygenator design potentially contribute to air embolism in cardiopulmonary bypass? A novel method for the determination of the air removal capabilities of neonatal membrane oxygenators.

At present, air handling of a membrane oxygenator is generally studied by using an ultrasonic sound bubble counter. However, this is not a quantitative method and it does not give any information on where air was entrapped in the oxygenator and if it eventually was removed through the membrane for gas exchange. The study presented here gives a novel technique for the determination of the air-handling characteristics of a membrane oxygenator. The study aimed at defining not only the amount of air released by the oxygenator, but also the amount of air trapped within the oxygenator and/or removed through the gas exchange membrane. Two neonatal membrane oxygenators without the use of an arterial filter were investigated: the Polystan Microsafe and the Dideco Lilliput. Although the air trap function of both oxygenators when challenged with a bolus of air was similar, the Microsafe obtained this effect mainly by capturing the air in the heat exchanger compartment while the Lilliput did remove a large amount of air through the membrane. In conclusion, the difference in trap function was most striking during continuous infusion of air. Immediate contact with a microporous membrane, avoidance of high velocities within the oxygenator, pressure drop, transit time and construction of the fibre mat all contribute to the air-handling characteristics of a membrane oxygenator.

Evidence for a role of CLIP-170 in the establishment of metaphase chromosome alignment.

CLIPs (cytoplasmic linker proteins) are a class of proteins believed to mediate the initial, static interaction of organelles with microtubules. CLIP-170, the CLIP best characterized to date, is required for in vitro binding of endocytic transport vesicles to microtubules. We report here that CLIP-170 transiently associates with prometaphase chromosome kinetochores and codistributes with dynein and dynactin at kinetochores, but not polar regions, during mitosis. Like dynein and dynactin, a fraction of the total CLIP-170 pool can be detected on kinetochores of unattached chromosomes but not on those that have become aligned at the metaphase plate. The COOH-terminal domain of CLIP-170, when transiently overexpressed, localizes to kinetochores and causes endogenous full-length CLIP-170 to be lost from the kinetochores, resulting in a delay in prometaphase. Overexpression of the dynactin subunit, dynamitin, strongly reduces the amount of CLIP-170 at kinetochores suggesting that CLIP-170 targeting may involve the dynein/dynactin complex. Thus, CLIP-170 may be a linker for cargo in mitosis as well as interphase. However, dynein and dynactin staining at kinetochores are unaffected by this treatment and further overexpression studies indicate that neither CLIP-170 nor dynein and dynactin are required for the formation of kinetochore fibers. Nevertheless, these results strongly suggest that CLIP-170 contributes in some way to kinetochore function in vivo.

Dynein and dynactin are localized to astral microtubules and at cortical sites in mitotic epithelial cells.

The mitotic spindle is often positioned in a characteristic location during development, for example to enable the proper segregation of developmental determinants [1,2]. When epithelial cells divide, the mitotic spindle is often positioned parallel to the plane of the epithelium, so that both daughter cells contribute to the epithelium [3]. The mechanisms by which mitotic spindles are positioned have not been characterized in great detail, but evidence is accumulating that in some systems the dynein-dynactin microtubule motor complex plays a role [4-6]. Dynein has yet not been localized to cortical sites where it could bind to microtubules and exert a force that might orient the mitotic spindle, however [7,8]. Here, we report that in mitotic polarized epithelial cells, the dynein-dynactin complex accumulates, from prometaphase onwards, along astral microtubules and at cortical spots, into which many of the astral microtubules dock. The spots are assembled at the lateral plasma membrane, in the region below the tight junctions. Their formation is inhibited by cytochalasin D, and under these conditions the spindles do not orient properly. This novel localization of the dynein-dynactin complex is consistent with a role for the complex in the positioning of the mitotic spindle. We also show that, during prophase, the motor complex colocalizes with the nuclear envelope, consistent with it having a role in separating the centrosomes that are associated with the nuclear envelope.

Impact of oxygenator design on hemolysis, shear stress, and white blood cell and platelet counts.

OBJECTIVE: To determine whether relative pressure drop, shear stress, hemolysis, and white blood cell and platelet counts are influenced by different oxygenator designs. To compare the oxygenator results with the average shear stress over an arterial cannula. DESIGN: Prospective; patients enrolled consecutively. SETTING: University hospital. PARTICIPANTS: Three groups of 12 adults patients, scheduled for routine cardiac surgery. INTERVENTIONS: Each group was submitted to a different oxygenator design: group 1 to a high-pressure hollow-fiber membrane oxygenator (Sarns Turbo); group 2 to a medium-pressure hollow-fiber membrane oxygenator (Cobe optima); and group 3 to a flat-sheet membrane oxygenator (Cobe Duo). MEASUREMENTS AND MAIN RESULTS: Although the investigated oxygenators have important differences in pressure drop and shear stress, no statistical differences were found in hemolysis generation or blood handling among the different groups. Actually, the study shows much higher shear stress levels over an average arterial cannula than over any of the evaluated oxygenators. CONCLUSIONS: The pressure drop over an oxygenator does not correlate well with shear stress and hemolysis because the dimensions of the system (radius and length) must be included in the calculation of shear stress from pressure drop.

Low extracorporeal priming volumes for infants: a benefit?

An extracorporeal circuit consisting of an oxygenator especially designed for neonatal use and appropriately sized tubing, with an average total priming volume of 205 ml, was used on 80 infants undergoing cardiac surgery for congenital heart-disease. The priming volume and foreign surface area of the circuit were determined. The influence of low priming volumes on the use of blood products and the management of cardiopulmonary bypass was studied. No whole blood or platelets were used in this study. The mean volume of packed red blood cells used over the hospital stay was 202 +/- 67 ml. The mean volume of fresh frozen plasma (FFP) used until the second postoperative day was 62 +/- 72 ml. The mean total blood loss until the second postoperative day was 15.8 +/- 9.2 ml/kg. The priming volume of the extracorporeal circuit was 62% lower than values commonly reported in the literature. The low priming volume had a strong influence on the use of platelets and FFP and to a lesser extent on the use of packed red blood cells.