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.

[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%.

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.

Anatomical placement of double femoral tunnels in anterior cruciate ligament reconstruction: anteromedial tunnel first or posterolateral tunnel first?

PURPOSE: The purpose of this study was to know which tunnel--the anteromedial (AM) bundle or the posterolateral (PL) bundle--should be prepared first to create the 2 femoral tunnels accurately in anatomic double-bundle (DB) anterior cruciate ligament (ACL) reconstruction. METHODS: Thirty-four patients were divided into 2 groups of 17 depending on the sequence of preparation of the 2 femoral tunnels. In group A, the AM tunnel was prepared first, whereas the PL tunnel was prepared first in group P. ACL reconstruction was performed using a three-dimensional (3-D) fluoroscopy-based navigation system to place the double femoral tunnels through an accessory medial portal. The double femoral socket positioning was evaluated by 3-D computed tomography (CT) scan image. RESULTS: The non-anatomical placement of the femoral sockets occurred in 5 patients (29%) in group A, whereas the 2 sockets were placed anatomically in all patients in group P (P < 0.05). Evaluation of the AM and the PL socket location on the 3-D CT images using the quadrant method showed more similar values to the laboratory data in a literature in group P than in group A. No complication occurred in group A, whereas complications such as socket communications or back wall blowout occurred in 5 patients (29%) in group P (P < 0.05). CONCLUSION: The sequence of creating 2 femoral tunnels through accessory medial portal affected the resultant location of the sockets and the rate of the complications. When femoral tunnels are prepared with a transportal technique, PL tunnel first technique seems to be superior to AM first technique regarding anatomic placement. However, PL tunnel first technique accompanies the risk of socket communication.

Intraoperative 3-dimensional imaging-based navigation-assisted anatomic double-bundle anterior cruciate ligament reconstruction.

In anatomic double-bundle anterior cruciate ligament (ACL) reconstruction, it is more technically demanding, even for experienced surgeons, to place 2 femoral tunnels within the ACL attachment than to place 2 tibial tunnels. We describe a technique using a three-dimensional (3-D) fluoroscopy-based navigation system to place 2 femoral tunnels accurately. After a reference frame is rigidly attached to the femur, an intraoperative image of the distal femur is obtained. The image is transferred to a navigation system and reconstructed into a 3-D image. During the placement of guidewires for the femoral tunnels through an accessory medial portal, a femoral guide with a tracker feeds back to the surgeons the direction of the guidewire on the 3-D femur bone surface image in real-time. The femoral guide is placed at the center of the footprint with the aid of visual guidance of the navigation and an arthroscopic view. The flexion angle of the knee is then adjusted to prevent posterior blowout on the computer screen during insertion of the guidewire. The length of the femoral tunnel can also be estimated before overdrilling the guidewire. This technology allows surgeons to place 2 femoral tunnels precisely without any complication during anatomic double-bundle ACL reconstruction.

[Susceptibilities of bacteria isolated from patients with lower respiratory infectious diseases to antibiotics (2005)].

From October 2005 to September 2006, we collected the specimen from 366 patients with lower respiratory tract infections in 12 institutions in Japan, and investigated the susceptibilities of isolated bacteria to various antibacterial agents and patients' characteristics. Of 411 strains that were isolated from specimen (mainly from sputum) and assumed to be bacteria causing in infection, 406 strains were examined. The isolated bacteria were: Staphylococcus aureus 70, Streptococcus pneumoniae 85, Haemophilus influenzae 78, Pseudomonas aeruginosa (non-mucoid) 46, P. aeruginosa (mucoid) 14, Klebsiella pneumoniae 21, and Moraxella subgenus Branhamella catarrhalis 40. Of 70 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 38 (54.3%) and 32 (45.7%) strains, respectively. Against MSSA, imipenem had the most potent antibacterial activity and inhibited the growth of 37 strains (97.4%) at 0.063 microg/ml or less. Against MRSA, arbekacin and vancomycin 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. Faropenem also had a preferable activity and inhibited the growth of all the strains at 0.25 microg/ml. In contrast, there were high-resistant strains (MIC: over 128 microg/ml) for erythromycin (38.1%) and clindamycin (22.6%). 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), arbekacin had the most potent activity and its MIC90 was 8 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. (B.) catarrhalis and the MIC90 of them were 2 microg/ml or less. The approximately half the number (53.6%) of the patients with respiratory infection were aged 70 years or older. Bacterial pneumonia and chronic bronchitis accounted for 44.3% and 29.8% of all the respiratory infection, respectively. The bacteria frequently isolated from the patients with bacterial pneumonia were S. aureus (15.4%), S. pneumoniae (23.4%), and H. influenzae (21.3%). S. aureus (25.4%) and S. pneumoniae (18.0%) also were frequently isolated from the patients with chronic bronchitis. Before the drug administration, the bacteria frequently isolated from the patients were S. pneumoniae (22.0%) and H. influenzae (21.4%). The bacteria frequently isolated from the patients treated with macrolides were S. pneumoniae and P. aeruginosa, and their isolation frequencies were each 35.3%.

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.

[Susceptibilities of bacteria isolated from patients with lower respiratory infectious diseases to antibiotics (2004)].

From October 2004 to September 2005, we collected the specimen from 319 patients with lower respiratory tract infections in 12 institutions in Japan, and investigated the susceptibilities of isolated bacteria to various antibacterial agents and patients' characteristics. Of 383 strains that were isolated from specimen (mainly from sputum) and assumed to be bacteria causing in inflammation, 381 strains were examined. The breakdown of the isolated bacteria were: Staphylococcus aureus 87, Streptococcus pneumoniae 80, Haemophilus influenzae 78, Pseudomonas aeruginosa (non-mucoid) 35, P. aeruginosa (mucoid) 9, Klebsiella pneumoniae 15, Moraxella subgenus Branhamella catarrhalis 30, etc. Of 87 S. aureus strains, those with 2 microg/mL or less of MIC of oxacillin (methicillin-sensitive S. aureus: MSSA) and those with 4 microg/mL or more of MIC of oxacillin (methicillin-resistant S. aureus: MRSA) were 40 (46.0%) and 47 (54.0%) strains, respectively. Against MSSA, imipenem had the most potent antibacterial activity and inhibited the growth of all the strains at 0.063 microg/mL. Against MRSA, vancomycin showed the most potent activity and inhibited the growth of all the strains at 1 microg/mL. Arbekacin (ABK) also showed the potent activity and its MIC90 was 2 microg/mL. Carbapenems showed the most potent activities against S. pneumoniae and inhibited the growth of all the strains at 0.25-0.5 microg/mL. Cefozopran (CZOP) also had a preferable activity (MIC90: 1 microg/mL) and inhibited the growth of all the strains at 2 microg/mL. In contrast, there were high-resistant strains (MIC: 128 microg/mL or more) for ABK (2.5%), erythromycin (37.5%), and clindamycin (38.8%). Against H. influenzae, levofloxacin showed the most potent activity and inhibited the growth of all the strains at 0.125 microg/mL. Meropenem showed the most potent activity against P. aeruginosa (mucoid) and inhibited the growth of all the strains at 2 microg/mL. Against P. aeruginosa (non-mucoid), amikacin (AMK) had the most potent activity and its MIC90 was 4 microg/mL. The activity of CZOP against the non-mucoid type also was preferable and its MIC90 was 8 microg/mL. Against K. pneumoniae, CZOP, cefmenoxime, cefpirome, flomoxef were the most potent activity and inhibited the growth of all the strains at 0.063 microg/mL. Also, all the agents generally showed a potent activity against M. (B.) catarrhalis and the MIC90 of them were 4 microg/mL or less. The approximately half the number (57.0%) of the patients with respiratory infection were aged 70 years or older. Bacterial pneumonia and chronic bronchitis accounted for 50.8% and 23.8% of all the respiratory infection, respectively. The bacteria frequently isolated from the patients with bacterial pneumonia were S. aureus (21.6%), S. pneumoniae (24.7%) and H. influenzae (20.1%). S. aureus (20.9%), S. pneumoniae (16.1%), and H. influenzae (16.1%) also were relatively frequently isolated from the patients with chronic bronchitis. Before the drug administration, the bacteria frequently isolated from the patients were S. pneumoniae (22.3%) and H. influenzae (25.1%). The bacteria relatively frequently isolated from the patients treated with macrolides were P. aeruginosa and the isolation frequency was 43.5%.

[Susceptibilities of bacteria isolated from patients with lower respiratory infectious diseases to antibiotics (2003)].

From October 2003 to September 2004, we collected the specimen from 399 patients with lower respiratory tract infections in 12 institutions in Japan, and investigated the susceptibilities of isolated bacteria to various antibacterial agents and patients' characteristics. Of 474 strains that were isolated from specimen (mainly from sputum) and assumed to be bacteria causing in inflammation, 469 strains were examined. The breakdown of the isolated bacteria were: Staphylococcus aureus 76, Streptococcus pneumoniae 81, Haemophilus influenzae 84, Pseudomonas aeruginosa (non-mucoid) 56, P. aeruginosa (mucoid) 11, Klebsiella pneumoniae 36, Moraxella subgenus Branhamella catarrhalis 24, etc. Of 76 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 both 38 strains (50.0%). Against MSSA, imipenem had the most potent antibacterial activity and inhibited the growth of all the strains at 0.063 microg/mL. Against MRSA, vancomycin showed the most potent activity and inhibited the growth of all the strains at 2 microg/mL. Arbekacin also showed the potent activity and inhibited the growth of all the strains at 4 microg/mL. Carbapenems showed the most potent activities against S. pneumoniae and inhibited the growth of all the strains at 0.125-0.5 microg/mL. Cefozopran (CZOP) also had a preferable activity (MIC90:2 microg/ mL) and inhibited the growth of all the strains at 4 microg/mL. In contrast, there were high-resistant strains (MIC: 128 microg/mL or more) for cefaclor (11.1%), erythromycin (43.2%), and clindamycin (40.7%). Against H. influenzae, levofloxacin showed the most potent activity and inhibited the growth of 83 of all the strains (98.8%) at 0.063 microg/mL. Tobramycin showed the most potent activity against P. aeruginosa (both mucoid and non-mucoid) and its MIC90 was 2 microg/mL. The activity of CZOP also was preferable and its MIC90 was 4 microg/mL for the mucoid-type and 8 microg/mL for the non-mucoid type. CZOP was the most potent activities against K. pneumoniae and inhibited the growth of all the strains at 0.125 microg/mL. Also, all the agents generally showed potent activities against M. (B.) catarrhalis and the MIC90 of them were 4 microg/mL or less. The approximately half the number (54.1%) of the patients with respiratory infection were aged 70 years or older. Bacterial pneumonia and chronic bronchitis accounted for 46.1% and 30.6% of all the respiratory infection, respectively. The bacteria frequently isolated from the patients with bacterial pneumonia were S. aureus (18.6%) and H. influenzae (18.1%). In contrast, S. aureus (16.9%) and S. pneumoniae (14.9%) were frequently isolated from the patients with chronic bronchitis. Before the drug administration, the bacteria frequently isolated from the patients were S. pneumoniae (20.6%) and H. influenzae (21.5%). The bacteria relatively frequently isolated from the patients treated with cephems or macrolides were P. aeruginosa, and S. aureus was relatively frequently isolated from the patients treated with quinolones.

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.

[A case of Nocardia farcinica pneumonia treated with sulfamethoxazole-trimethoprim monitoring its serum concentration].

A 75-year-old male suffered from interstitial pneumonia in December 2000 and treated with predonisolone. The treatment was effective, and the dosage of predonisolone had been gradually tapered. In January 2001, when the dosage was 30 mg/day, he complained of cough and yellowish sputum. The chest X-ray and CT revealed bilateral infiltrations with cavities. He was treated with cefozopram and fluconazole. However, there were no improvements. The sputa of the 2nd, 3rd, 6th and 8th hospital days showed the presence of gram-positive branched rods, which were identified as Nocardia farcinica. Therefore, the treatment was changed to sulfamethoxazole-trimethoprim. During the treatment, serum concentration of sulfamethoxazole was repeatedly measured, and kept over 60 microgram/ml. He was swiftly recovered after the start of sulfamethoxazole-trimethoprim. This case was supposed to be the seventh one of N. farcinica pneumonia in Japan, and the measurement of the concentration of sulfamethoxazole was useful to determine its dosage.

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.

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.

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.

A case of catastrophic antiphospholipid syndrome presenting with acute respiratory distress syndrome as the initial manifestation.

Antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized by a combination of arterial or venous thrombosis and recurrent fetal loss, accompanied by elevated titers of antiphospholipid antibodies (aPL). Catastrophic antiphospholipid syndrome (CAPS) is a small subset of APS characterized by widespread systemic thrombotic disease with multiorgan failure. We herein describe an autopsy case of CAPS who developed severe respiratory failure due to acute respiratory distress syndrome (ARDS) as the initial manifestation. Patients with APS may exhibit a broad spectrum of pulmonary diseases. ARDS is the common pulmonary complication in CAPS, although it rarely occurs in APS. Some mechanisms of ARDS in CAPS have been postulated but the precise mechanism is still not clearly understood. It is important to understand that APS or CAPS could be a cause of ARDS since ARDS might develop as the initial manifestation of APS or CAPS as seen in our case. Our case is interesting in that severe respiratory failure due to ARDS was the initial presentation of CAPS.