Knee pain after anterior cruciate ligament reconstruction: evaluation of a rehabilitation protocol.

INTRODUCTION: Anterior knee pain (AKP) is a rare and difficult complication following anterior cruciate ligament (ACL) reconstruction. This disabling pain is persistent with conventional rehabilitation protocols. The aim of this work is to validate a new rehabilitation protocol that may improve the patients and allow return to daily activities including sports. MATERIALS AND METHODS: Forty-three patients identified with functional AKP after ACL reconstruction was enrolled in the rehabilitation protocol between 2009 and 2011. The series included twenty-six patients with hamstring grafting and seventeen patients with patellar tendon transplant. This study compares the functional outcomes and pain scores before and after the isokinetic protocol until the last follow-up at an average of 25.7 months after surgery. The evaluation was performed according to the International Knee Documentation Committee (IKDC) and included a pain assessment using the visual analog scale. Statistical analysis used Student's t-test for unpaired data and the Pearson correlation test for the variables. The IKDC scores were compared by the Wilcoxon test. RESULTS: Functional outcomes and pain are significantly improved (p<0.0001). The average IKDC score improved with 28 points and the pain improved with 3.2 points on the visual analog scale (VAS). The results are correlated with the follow-up time (p=0.008) but not correlated with the delay between the surgery and the beginning of the isokinetic protocol. DISCUSSION: Isokinetic rehabilitation provides a significant improvement in the knee function as measured by the IKDC score and by the VAS, regardless of the painful period preceding the program. The function improvement continues after the end of the protocol, but the pain may not completely disappear. The isokinetic rehabilitation program may resume functional AKP related to muscular deficit and may be used as the starter of other physical therapy protocols. LEVEL OF EVIDENCE: IV.

Complications in posteromedial arthroscopic suture of the medial meniscus.

INTRODUCTION: All-inside posteromedial suture for lesions of the posterior horn of the medial meniscus in anterior cruciate ligament (ACL) repair provides effective freshening and good healing. HYPOTHESIS: The posteromedial portal provides satisfactory healing rates without increasing morbidity or complications rates. MATERIAL AND METHODS: Intra- and postoperative complications were collected for a consecutive single-center series of 132 patients undergoing posteromedial hook suture of the medial meniscus in ACL repair. Meniscal healing was assessed as the rate of recurrence of symptomatic medial meniscus lesions (Barret criteria) and on revision surgery, if any, in terms of the aspect and extent of the iterative lesion. The severity of any sensory disorder was assessed by questionnaire. RESULTS: The intraoperative complications rate was 1.5% (2 saphenous vein punctures). At a mean 31months (range, 28-35months), there was no loss to follow-up. Twelve patients (9%) showed symptomatic recurrence of the medial meniscus lesion, requiring 10 repeat surgeries. In 6 cases (4.5%), the iterative lesion involved a smaller, more central part of the meniscus anterior to the sutures, of "postage-stamp" effect, possibly implicating the suture hook and/or non-absorbable sutures. There were no cases of infection or fistula. Postoperative hematoma occurred in 7% of patients. In total, 1.8% reported dysesthesia areas equal to or greater than the size of a credit card (45cm2). DISCUSSION: Some retears, or "partial failures", may implicate a new lesion caused by the suture hook and possibly prolonged by non-resorbable sutures. Hematoma and sensory disorder rates were comparable to those reported in isolated ACL repair without posteromedial portal. CONCLUSION: The present results show that posteromedial arthroscopic hook suture in posterior medial meniscus tear provides good healing rates without increased morbidity due to the supplementary portal. LEVEL OF EVIDENCE: IV.

Prevalence of knee stiffness after arthroscopic bone suture fixation of tibial spine avulsion fractures in adults.

BACKGROUND: Tibial spine avulsion fractures (TSAFs) occur chiefly in adolescents. Few published data are available on outcomes after arthroscopic surgical treatment of TSAFs in adults. OBJECTIVES: To evaluate outcomes of consecutive patients with TSAFs managed by arthroscopic bone suture followed by a standardised non-aggressive rehabilitation programme. HYPOTHESIS: Arthroscopic bone suture followed by non-aggressive rehabilitation therapy reliably produces satisfactory outcomes in adults with TSAF. METHODS: Thirteen adults were included. Outcomes were evaluated based on the Tegner score, International Knee Documentation Committee (IKDC) score, anterior-posterior knee laxity, passive and active motion ranges, and radiological appearance. RESULTS: After a mean follow-up of 41±27months (12-94months), all 13 patients had healed fractures without secondary displacement. No patient had knee instability. Post-operative stiffness was noted in 5 patients (2 with complex regional pain syndrome and 3 with extension lag), 1 of whom required surgical release. The mean IKDC score was 91.3±11.7. The mean Tegner score was 5.46±1.37 compared to 6.38±0.70 before surgery. Mean tibial translation (measured using the Rolimeter) was 1.09±1.22mm, compared to 5.9±1.85mm before surgery. CONCLUSION: The outcomes reported here support the reliability of arthroscopic bone suture for TSAF fixation. Nevertheless, a substantial proportion of patients experienced post-operative stiffness, whose contributory factors may include stunning of the quadriceps due to the short time from injury to surgery and the use of a gentle rehabilitation programme. LEVEL OF EVIDENCE: IV, retrospective study of treatment outcomes.

Sulcus deepening trochleoplasty for patellofemoral instability: A series of 34 cases after 15 years postoperative follow-up.

INTRODUCTION: Trochlear dysplasia is one of the main elements of patellofemoral instability. Although correction by trochleoplasty seems logical, the long-term outcome of this procedure is unknown and the progression to osteoarthritis has not been clarified. Thus, we performed a retrospective study of a series of sulcus deepening trochleoplasties with a 15-year follow-up whose goal was to (1) evaluate the long-term clinical outcome and radiological rate of osteoarthritis, and (2) define the results in relation to the type of instability and the grade of dysplasia. HYPOTHESIS: Sulcus deepening trochleoplasty is an effective procedure to stabilize the patellofemoral joint that does not increase the risk of osteoarthritis. PATIENTS AND METHODS: This retrospective study analyzed 34 sulcus deepening trochleoplasties based on clinical scores (IKS, Lille, Kujala and Oxford scores) and radiological results (stage of osteoarthritis according to the Iwano score) after a mean follow-up of 15 years (12-19 years). An Insall procedure was systematically associated with an anterior tibial tubercle transfer in 17 cases (7 prior tibial transfers). RESULTS: No recurrent objective instability was observed. Seven knees had additional surgery after a mean follow-up of 7 years (2-16): 7 underwent conversion to total knee arthroplasty because of progression of osteoarthritis and one knee had tibial tubercle transfer for pain and episodes of the knee giving way. The mean Lille, Kujala and IKS scores increased from 53.3 (30-92), 55 (13-75) and 127 (54-184) to 61.5 (25-93), 76 (51-94) and 152.4 (66-200) respectively between preoperative and follow-up assessment (P<0.05) (revisions included). Functional outcome was significantly better for dysplasia with supratrochlear spurs (IKS score 168 [127-200] versus 153 [98-198] and Kujula score 81.5 [51-98] versus 76 [51-94] [P<0.05]). Patients were satisfied in 65% of the cases and the total mean Oxford score was 24.1/60 (12-45 points). Occasional pain was present in 53% of the cases. The trochlear prominence decreased from 4.9 mm (3-9 mm) to -1.2mm (-7-4mm). Ten cases of preoperative patellofemoral osteoarthritis were identified, but none with>Iwano 2, while osteoarthritis was present in 33/34 cases at the final follow-up with 20 cases>Iwano 2 (65%). DISCUSSION: Sulcus deepening trochleoplasty corrects patellofemoral stability even in patients with severe dysplasia and the long-term functional outcome is better in this group. It does not prevent patellofemoral osteoarthritis. It should be limited to severe dysplasia with supratrochlear spurs and associated with procedures to realign the extensor apparatus.

Normal rat uterine stromal cells in continuous culture: characterization and progestin regulation of growth.

Stromal cells were isolated from rat uterus by sequential enzymatic digestion and density fractionation on Percoll gradient and subcultured by trypsinization. Two stable subcultures, named UII and UIII, were obtained. UII cells exhibited a spindle-shaped, elongated, fibroblast-like morphology, while UIII cells were rounded and polygonal. Both cell types expressed the intermediate filament vimentin but not cytokeratin, nor desmin, suggesting that both were of stromal origin. In UIII cells, the presence of progesterone and prolactin (PRL) receptors was demonstrated by immunocytochemical and binding studies. Cross-linking and Western blotting showed that PRL receptor in UIII cells corresponded to 3 molecular forms of 54, 42 and 32 kDa. The growth properties of these cells were studied under different conditions of culture. In fetal calf serum (FCS) supplemented medium, proliferation of UIII cells was dependent on serum concentration and was not affected by estradiol and progesterone. In 10% FCS supplemented medium, the doubling time was 41.5 +/- 0.8 h. When cultured in 10% dextran-charcoal-treated FCS, cells were maintained in a viable but quiescent state. Under these conditions, progesterone was able to induce growth of these cells in a dose-dependent manner. A 3-fold increase in DNA content was measurable in 10(-7) M progesterone-treated versus control cultures after 5 days. Reduction of serum concentration from 10% to 2% abolished the effect of progesterone suggesting that this effect requires the presence of serum factor(s). In conclusion, this study showed that uterine stromal cells, in continuous culture, retained progesterone and prolactin receptors and progesterone regulation of growth.

Effects of tamoxifen, tamoxifen metabolites, and nafoxidine on adenosine 3',5'-monophosphate phosphodiesterase: correlations with growth inhibitory activities but not estrogen receptor affinities.

Triphenylethylenes [Tamoxifen (TAM), TAM metabolites, and nafoxidine] were found to inhibit Ca2+-calmodulin (CaM)-dependent cAMP phosphodiesterase (PDE) activity of the quail oviduct, whereas 17 beta-estradiol was inactive. The Ca2+-CaM-independent PDE activity was not affected by triphenylethylenes, suggesting that they do not interact directly with the active site of the enzyme. Kinetic analysis indicated that these drugs competitively inhibited the activation of PDE by CaM with the following potencies: N-desmethyltamoxifen, Ki = 3 microM; metabolite Z, trans-4-hydroxytamoxifen, and TAM Ki = 5 microM; nafoxidine, Ki = 8.5 microM; and metabolite Y and cis-4-hydroxytamoxifen, Ki = 50 microM. Injected alone into immature quails, none of these drugs significantly affected oviduct weight. When administrated together with estradiol benzoate, these drugs reduced the trophic effect of estradiol in a dose-dependent relationship, with ID50 values ranging from 0.07 mg/kg for N-desmethyltamoxifen to 2.02 mg/kg for cis-4-hydroxytamoxifen. The order of growth inhibitory potency was not correlated with estrogen receptor affinities, but was the same as that reported for PDE inhibition. This correlation suggests that interaction of antiestrogen with Ca2+-CaM dependent PDE may be one of the mechanisms responsible for the estrogen antagonist activity of these drugs.

Control of cell proliferation via transduction of sPLA(2)-I activity and possible PPAR activation at the nuclear level.

Pancreatic phospholipase A2 (PLA(2)-I) stimulates U(III) cells proliferation, a rat uterine cell line, after binding to membrane receptors, internalization and translocation. Here, we demonstrate that during these steps of internalization, PLA(2)-I retains its hydrolytic activity and thus could exert its proliferative effect via nuclear phospholipids hydrolysis. Since fatty acids and eicosanoids released by such activity are known to be ligands of PPAR, we study the expression of these nuclear receptors and demonstrate that, in the experimental conditions where PLA(2)-I stimulates U(III) cells proliferation, PLA(2)-I also regulates PPAR expression indicating a possible mechanism of its proliferative effect.

Protein kinase C inhibitors stimulate arachidonic and docosahexaenoic acids release from uterine stromal cells through a Ca2+-independent pathway.

The mechanisms underlying arachidonic acid (AA) release by uterine stromal (U(III)) cells were studied. Stimulation of AA release by calcium ionophore and PMA are inhibited by various PKC inhibitors and by calcium deprivation. These results suggest the involvement of an AA-specific cPLA2 as the release of docosahexaenoic acid (DHA) from prelabelled cells is much lower than the release of AA. The results also show a more original stimulation of AA and DHA release induced by PKC inhibitors, which is insensitive to calcium deprivation. This stimulation is not due to acyltransferase inhibition, suggesting the participation of a Ca2+-independent PLA2 (iPLA2). However, iPLA2 activity measured in U(III) cells is inhibited by the specific iPLA2 inhibitor, BEL, and is not stimulated by PKC inhibitors, in contrast with the AA and DHA release. It seems therefore that this iPLA2 cannot be involved in this mechanism. The participation of another iPLA2, BEL-insensitive, is discussed.

The level of pancreatic PLA2 receptor is closely associated with the proliferative state of rat uterine stromal cells.

Rat uterine stromal cells (U(III)) express pancreatic type PLA2 (PLA2-I) receptor and internalize the enzyme bound to receptors. Here, we investigate the proliferating effect and alterations in binding of PLA2-I. There is a dramatic decline in PLA2-I binding in U(III) cells as they progress from a non-confluent proliferating state (40,000 sites/cell) to a confluent state (1300 sites/cell). Intracellular concentration of PLA2-I changed with the alteration in binding, suggesting that regulation in the PLA2 binding capacity may have important implications in growth control mechanisms.

Prolactin up-regulates prostaglandin E2 production through increased expression of pancreatic-type phospholipase A2 (type I) and prostaglandin G/H synthase 2 in uterine cells.

Uterine stromal cells produce and release PGE2, both processes being regulated by hormonal factors. In this study, we examined the effect of PRL on the PGE2 production and release measured by radioimmunoassay. For this purpose, we used a rat uterine stromal cell line, UIII cells, which produce PGE2 and contain PRL receptors. The expression of sPLA2I and PGHS (PGHS1 and PGHS2), enzymes required for PGE2 production, was also estimated by immunocytochemistry and 'Western blotting' in response to PRL. PRL (10 to 60 ng/ml) significantly increased the PGE2 release (up to 6-fold) and production, in a dose-dependent manner. Results show that PGHS1 and PGHS2 are both expressed constitutively in the uterine UIII cells, although PGHS2 is expressed at a low level. PRL did not increase PGHS1 expression, but stimulated the expression of sPLA2I and PGHS2 by 3.5- and 2.5-fold, respectively. These data show for the first time a regulation of sPLA2I and PGHS2 expression by PRL and may indicate that, in uterine cells, PRL enhances the PGE2 release and production by increasing the expression of both sPLA2I and PGHS2.

Regulation of quail oviduct phospholipase A2 activity by estradiol.

The phospholipase A2 (PLA2) activity was measured in the oviduct of immature and estradiol benzoate (EB)-treated quails. The pH profiles demonstrate the presence of two PLA2 isoforms in the avian oviduct: a neutral isoform, optimally active at pH 7-7.5 and calcium independent, responsible for most of the hydrolytic activity in the immature oviduct and poorly stimulated by estradiol; and an alkaline isoform, optimally active at pH 8-9.5 and calcium dependent, with little activity in the immature tissue but markedly stimulated by EB. After EB injection, PLA2 activation occurs at first during the prereplicative period of oviduct cells (+172% at 6 h), it is dose dependent from 0.01 to 1 mg/kg EB and can be prevented by cycloheximide together with ornithine decarboxylase activation. Moreover, estradiol was inactive on cell-free extracts of immature oviducts. These results suggest that EB increases PLA2 activity through gene activation and de novo protein synthesis. The correlation between the early stimulation of PLA2 activity and the proliferation of oviduct cells is discussed.

Opposite regulation of cAMP concentration in the quail oviduct and the mouse uterus by tamoxifen. Correlation with estrogen-antagonist and estrogen-agonist activity.

The ability of estradiol and tamoxifen to regulate cAMP levels and cAMP phosphodiesterase activities has been determined in the quail oviduct and in the mouse uterus. In the quail, tamoxifen (1 mg/kg daily for 3 days) had no effect on oviducal growth but significantly increased cAMP concentration (+49%). Injected concurrently with estradiol, tamoxifen completely inhibited oviduct growth as well as the increase of cAMP phosphodiesterase activity induced by the hormone alone and increased cAMP concentration (+229% over estradiol treated group). In the mouse, estradiol and tamoxifen displayed uterotrophic activity and increased cAMP phosphodiesterase activity. In both groups, cAMP concentration was greatly reduced (-76% in estradiol treated group; -86% in tamoxifen treated group). The opposite regulation of cAMP levels in the quail oviduct and the mouse uterus by tamoxifen reflected large differences in the contribution of calmodulin-dependent and -independent forms of phosphodiesterase to the hydrolysis of cAMP in the two models and the fact that tamoxifen stimulated the activity of the calmodulin-independent isoenzyme, while it competitively inhibited the activation of the calmodulin-dependent isoenzyme by calmodulin. Several lines of evidence strongly suggest that the regulation of cAMP levels is involved in growth-inhibiting or growth-promoting activity of tamoxifen.

Phospholipase A2 inhibitors regulate the proliferation of normal uterine cells.

The effects of inhibitors of phospholipase A2, cyclooxygenase, lipoxygenase and cytochrome P450 activity on the proliferation of normal rat uterine stromal cells (UIII) were studied. At non-cytotoxic doses, inhibitors of cyclooxygenase, lipoxygenase and cytochrome P450 activity had no effect; UIII cells did not lose their ability to synthesize and secrete arachidonic acid metabolites, mainly prostaglandin I2 and prostaglandin E2, after successive passages. Inhibition of prostaglandin production did not affect their proliferation. In contrast, phospholipase A2 inhibitors significantly reduced UIII cell proliferation in a reversible and dose-dependent manner. Aristolochic acid was the most potent inhibitor with an IC50 of 0.3 mumol/l on day 7 of culture. Moreover, low doses of arachidonic acid stimulated UIII cell proliferation. Thus the proliferation of normal uterine stromal cells appears to be independent of arachidonic acid oxygenated metabolites, contrary to what is observed in tumor cells, but requires an intact phospholipase A2 pathway.

In vivo inhibition of basal and estrogen-induced phospholipase A2 activities by the triphenylethylene antiestrogen, tamoxifen, in immature quail oviduct.

The effects of tamoxifen on oviductal phospholipase A2 activity were studied in immature quails. Injected alone, from 0.1 to 10 mg/kg tamoxifen significantly reduced basal phospholipase A2 activity 6 h after the injection, independently of the dose used. At 24 h, maximal inhibition (-50%) was observed with 0.1 mg/kg tamoxifen, while higher doses were less effective. Combined with estradiol benzoate, tamoxifen reduced even below the control value (1 mg/kg for 24 h) the increase in phospholipase A2 activity induced by estrogen.

[Unruptured aneurysms of Valsalva sinus of septal origin]. / Anévrysmes du sinus de Valsalva non rompus à développement septal

Aneurysms of Valvsalva sinus unruptured into a cavity, but developing into the membranous and even muscular interventricular septum are exceptional. Two cases illustrating this fact are reported. In one of them, a massive mitral incompetence by elongated chordae tendinae related to the presence of a voluminous intra-septal pouch. Atrio-ventricular and intraventricular conduction disturbances were present in both patients. The interest of supra-valvar angiography which makes it possible to advise operation before the eventual rupture is underlined.

[Long-term fate of mitral valve prostheses]. / Evolution à long terme des prothèses valvulaires mitrales

The long term fate of mitral valve replacements (over 2 years) has been studied by the collection of information from many French cardiology centres. The Starr valve with a plastic ball-valve is by far the most commonly used prosthesis. The late complications are dominated by thrombo-embolic sequelae. The functional result seems to be proportionally better the earlier the stage at which the operation is carried out.

Proximal hamstring avulsion in a professional soccer player.

Acute hamstring strains are a common athletic injury, which may be treated non-operatively with a satisfactory outcome. A complete proximal hamstring avulsion is a rare and potentially career ending injury to an elite athlete. For these high demand patients, surgical reattachment should be immediately undertaken to shorten return to sport and to improve functional outcome. This report describes the occurrence of a complete avulsion of the proximal hamstrings in a professional footballer during an international match. We highlight the clinical presentation, the appropriate diagnostic investigations, the surgical technique and the rehabilitation protocol for this injury. The successful surgical reattachment of the common hamstring tendon was confirmed by magnetic resonance imaging done 5 months after repair and allowed the player a full return to competition at 6 months after surgery. Hamstrings isokinetic peak torque was 80% at 6 months and 106% at 11 months after repair comparing with the uninjured side.

High lateral portal for sparing the infrapatellar fat-pad during ACL reconstruction.

During arthroscopic ACL reconstruction, intra-articular visualization can be compromised by the interposition of the infrapatellar fat pad (IPFP) between the scope and the notch. In this technical note, we describe our technique of using lateral higher arthroscopic portal, starting arthroscopy with the resection of the ligamentum mucosum and performing the tibial tunnel in 40° of knee flexion to optimise the intra-articular view without IPFP debridement. This technique was performed in 112 consecutive arthroscopic ACL reconstructions and compared to that in the previous 112 cases in which a conventional method was used. The use of this technique was associated with a shorter operative time and no increase in the difficulty in performing associated meniscal procedures.

The influence of the tibial slope and the size of the intercondylar notch on rupture of the anterior cruciate ligament.

It has been suggested that an increased posterior tibial slope (PTS) and a narrow notch width index (NWI) increase the risk of anterior cruciate ligament (ACL) injury. The aim of this study was to establish why there are conflicting reports on their significance. A total of fifty patients with a ruptured ACL and 50 patients with an intact ACL were included in the study. The group with ACL rupture had a statistically significantly increased PTS (p < 0.001) and a smaller NWI (p < 0.001) than the control group. When a high PTS and/or a narrow NWI were defined as risk factors for an ACL rupture, 80% of patients had at least one risk factor present; only 24% had both factors present. In both groups the PTS was negatively correlated to the NWI (correlation coefficient = -0.28, p = 0.0052). Using a univariate model, PTS and NWI appear to be correlated to rupture of the ACL. Using a logistic regression model, the PTS (p = 0.006) and the NWI (p < 0.0001) remain significant risk factors. From these results, either a steep PTS or a narrow NWI predisposes an individual to ACL injury. Future studies should consider these factors in combination rather than in isolation.