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Introduction Lateral tenodesis (LT) is performed to limit the risk of iterative tear following anterior cruciate ligament (ACL) reconstruction in at-risk patients. By adding an extra procedure to isolated ACL graft, LT reconstruction increases operating time and may complicate postoperative course. The objective of the present study was to evaluate the rate of early complications. The study hypothesis was that associating ALL reconstruction to ACL reconstruction does not increase the complications rate found with isolated ACL reconstruction. Material and methods A prospective multicenter study included 392 patients: 70% male; mean age, 29.9 years; treated by associated ACL and LT reconstruction. All adverse events were inventoried. Results Mean hospital stay was 2 days, with 46% day-surgery. Walking was resumed at a mean 27 days, with an advantage for patients treated by the hamstring technique. The early postoperative complications rate was 12%, with 1.7% specifically implicating LT reconstruction: pain, hematoma, stiffness in flexion and extension, and infection. There was a 5% rate of surgical revision during the first year, predominantly comprising arthrolysis for extension deficit. The 1-year recurrence rate was 2.8%. Discussion The complications rate for combined intra- and extra-articular reconstruction was no higher than for isolated intra-articular ACL reconstruction, with no increase in infection or stiffness rates. The rate of complications specific to ALL reconstruction was low, at 1.7%, and mainly involved fixation error causing lateral soft-tissue impingement. Level of evidence IV, prospective multicenter study.

Background A careful analysis of the reasons for ACL reconstruction failure is essential to selection of the optimal surgical revision technique designed to ensure good rotational stability and to minimise the risk of re-rupture. Objective To evaluate anterolateral ligament (ALL) stabilisation during revision ACL reconstruction. Hypothesis ALL stabilisation during revision ACL reconstruction provides good rotational stability without increasing the risk of complications. Material and methods This multicentre study included 349 patients, 151 retrospectively and 198 prospectively. There were 283 males and 66 females. Inclusion criteria were an indication for revision ACL reconstruction surgery with combined intra-articular reconstruction and ALL stabilisation after failed autograft ACL reconstruction, and intact PCL. Exclusion criteria were primary ACL reconstruction and concomitant peripheral medial and/or lateral lesions. Each patient underwent a clinical and radiographic evaluation before and after revision surgery. Before revision surgery, the mean IKDC score was 56.5 ± 15.5 and 96% of patients were IKDC C or D. Results Rates were 5.0% for early and 10.5% for late postoperative complications. Lachmann's test had a hard stop at last follow-up in 97% of patients. The pivot-shift test was positive in 1% of patients. The mean subjective IKDC score was 84.5 ± 13.0 and 86.5% of patients were IKDC A or B. The proportions of patients with radiographic knee osteoarthritis at last follow-up was unchanged for the lateral tibio-femoral and patello-femoral compartments but increased by 9.7% to 21.2% for the medial tibio-femoral compartment. The re-rupture rate was 1.2% and the further surgical revision rate was 5.4%. Conclusion Anterior laxity at last follow-up was consistent with previous studies of revision ACL reconstruction. However, rotational stability and the re-rupture risk were improved. ALL stabilisation is among the techniques that deserve consideration as part of the therapeutic options for revision ACL reconstruction. Level of evidence IV, retrospective and prospective cohort study.

Background Patient-specific cutting guides were recently introduced to facilitate total knee arthroplasty (TKA). Their accuracy in achieving optimal implant alignment remains controversial. The objective of this study was to evaluate postoperative radiographic outcomes of 50 TKA procedures with special attention to posterior tibial slope (PTS), which is difficult to control intraoperatively. We hypothesized that patient-specific cutting guides failed to consistently produce the planned PTS. Material and methods The Signature™ patient-specific cutting guides (Biomet) developed from magnetic resonance imaging data were used in a prospective case-series of 50 TKAs. The target PTS was 2°. Standardised digitised radiographs were obtained postoperatively and evaluated by an independent reader. Reproducibility of the radiographic measurements was assessed on 20 cases. The posterior cortical line of the proximal tibia was chosen as the reference for PTS measurement. Inaccuracy was defined as an at least 2° difference in either direction compared to the target. Results The implant PTS was within 2° of the target in 72% of knees. In the remaining 28%, PTS was either excessive ( n = 10; maximum, 9°) or reversed ( n = 4; maximum, –6°). The postoperative hip-knee-ankle angle was 0° ± 3° in 88% of knees, and the greatest deviation was 9° of varus. Conclusion These findings support our hypothesis that patient-specific instrumentation decreases PTS accuracy. They are consistent with recently published data. In contrast, patient-specific instrumentation provided accurate alignment in the coronal plane. Level of evidence IV, cohort study.

The use of a pneumatic tourniquet can induce muscular and neurological complications in the operated limb. The genesis of these injuries could involve an ischaemia/reperfusion phenomenon and a compression under the cuff. We evaluated effects of an antioxidant, acetylcysteine and ischaemic preconditioning on the rhabdomyolysis and postoperative pain following a knee ligamentoplasty using a pneumatic tourniquet.We included 31 patients scheduled for a knee ligamentoplasty randomly assigned in three groups (control, acetylcysteine 1200 mg the day before and 600 mg at the operative day, ischaemic preconditioning).There was a moderate rise in myoglobin and creatinine phosphokinase with no significant difference between the three groups. The muscular functional parameters were similar in all the groups. However, the morphine consumption within the first 48 h was smaller in the treatment groups (0.22 +/- 0.31 mg kg-1 and 0.22 +/- 0.23 mg kg-1 in the preconditioning and antioxidant groups, respectively) than in the control group (0.47 +/- 0.33 mg kg-1, P0.05).Acetylcysteine and ischaemic preconditioning do not decrease the extent of rhabdomyolysis related to the use of a pneumatic tourniquet and do not improve the postoperative muscle recovery. On the other hand, they allow a significant reduction in the postoperative morphine consumption.

The purpose of this study was to test the hypothesis that the surgical technique using alternating fluid irrigation and carbon dioxide (CO2) gas medium as a means of knee joint distension during arthroscopy is a safe and effective method, compared to traditional fluid arthroscopy. This prospective randomized comparative study involved 94 patients undergoing the same arthroscopic ACL reconstruction surgical procedure except for the medium used to distend the joint: In a first group of 48 patients (“ACL gas” group), CO2 insufflation was mainly used, at a low pressure of 40–50 mmHg, alternating with a fluid medium for knee joint washout only. In the second group of 46 patients, classical arthroscopic joint distension by fluid was used, with a pump pressure of 50–70 mmHg. Early pre- and post-operative complications, duration of surgery, intraoperative monitoring data and particularly the end-tidal carbon dioxide (EtCO2) as a marker of CO2 blood diffusion were prospectively collected. EtCO2 and other monitoring data changes before and after tourniquet release were not different between the two groups. Tourniquet time was significantly longer when using fluid rather than gas. We observed 3 cases of small and localized subcutaneous emphysema, resolving completely within hours. Hematoma and reflex sympathetic dystrophy occurred more often in the “ACL fluid” group, with no statistical significance. Low-pressure CO2 knee joint insufflation proved to be a safe technique capable of improving surgical comfort compared with the use of fluid alone. The CO2 blood diffusion measured by end-tidal carbon dioxide monitoring during ACL arthroscopic reconstruction was similar with or without gas insufflation. Randomized controlled trial, Level I.

We have developed a host-mediated assay system for the detection of the transforming action of chemical carcinogens on peritoneal macrophages. Directly as well as indirectly acting carcinogenic substances administered intraperitoneally to NMRI mice could be examined in this way. Resident macrophages were recovered by peritoneal lavage from treated and untreated mice and were cultured in soft agar. After 5-6 days normal and transformed cells could be distinguished. Statistical analysis comparing cells, for example, from alpha-naphthylamine or diphenylhydantoin-treated animals with those from control mice proved that the test is positive at least on a significance level of 5% using the t-test. Further substances revealing a cell-transformation potential were benzene, benz(a)pyrene, 2,3,7,8-tetrachlorodibenzodioxin, N-nitrosodimethylamine, ethidium bromide, aflatoxin B1,N-methyl-N-nitrosourea, 1-methyl-3-nitro-1-nitrosoguanidine, 2-naphthylamine, dieldrin, suramin and trichloroethylene. A weak transforming potential was found for chlorambucil as well as for tetrachloroethylene. With toluene or azidothymidine no cell transformation could be observed. Several immortal cell lines could be established form NMRI mice treated with alpha-naphthylamine or N-methyl-N-nitrosourea. Athymic nu/nu mice injected subcutaneously with these cells developed tumors, establishing the oncogenic potential of these cell lines.

Comparisons have been often made between bone-tendon-bone plasty and hamstring tendon four-strand plasty. Whether a lateral tenodesis should be associated with the intra-articular reconstruction and the appropriate time between the accident and the repair remain two topics of debate. We present results obtained in a consecutive series of 50 pivoting sport atheletes reviewed retrospectively. These patients had been treated within eight days of trauma with a modified MacIntosh technique using an iliotibial band. This technique enables lateral tenodesis and reconstruction of the central pivot with only one harvesting site. We searched for responses to two questions: are our results comparable to those in other published series? could this operation be warranted as an emergency procedure?Fifty patients from a consecutive retrospective series of 62 patients (eight lost to follow-up and four excluded from the analysis) were reviewed by an independent observer at mean follow-up of 5.2 years (range 54.4 to 86.4 months). The ARPEGE and IKDC scoring systems were used. An isokinetic assessment was obtained in 38 patients at one year. The reconstruction technique used an iliotibial band measuring 40-45 mm in width. The lateral reconstruction consisted in section then translation of the lateral intermuscular partition.The overall outcome was scored as follows: IKDC A 38%, B 46%, C 12%, D 4%. Mean residual differential laxity (KT 1000) was 1.86+/-1.74 assessed manually with a negative Lachman in 48% of knees. 88% of the positive tests had been neutralized. Early anatomic failure was noted in two knees with recurrent traumatic tears at 25 and 38 months. Using the ARPEGE scoring system, outcome was excellent in 38%, good in 46%, fair in 12% and poor in 4%. At last follow-up, the level of sports activities was unchanged in 33 patients. Irreducible flexion measuring more than 5 degrees was noted in two patients, and a deficit in flexion greater than 20 degrees in three. One female athlete who had resumed her former sports level presented mobilization under narcosis. None of the patients complained of pain at the harvesting site. There was one case of muscle herniation proximally by wound dehiscence. Mean residual deficit of the quadriceps, measured at twelve months, was 10% at 90 degrees /s; mean residual deficit of the hamstrings at the same speed was 1.3%.Our overall results as measured with the IKDC scoring system were comparable with those observed in series using other autologous transplants. The risk of stiffness is greater with early reconstruction, suggesting emergency repair should be considered with caution. Recovery of muscle force demonstrates one of the advantages of using the iliotibial band which does not injure the extensor-flexor system of the knee joint. The fact that none of the patients complained of pain at the harvesting site is a favorable element for rehabilitation and resumed sports activities.

The host-mediated in vitro/in vivo assay system was used to evaluate the tumorigenic potential of the aromatic nitro compound 2-nitroanisole (2-NA). After intraperitoneal administration of the compound, resident macrophages were recovered by peritoneal lavage from treated and untreated mice and cultured in soft agar. 2-NA was shown to be carcinogenic, and the tumorigenic potential was evaluated. Additionally, by establishment of a transformed peritoneal macrophage cell line, the underlying molecular mechanism of 2-NA's carcinogenic effect was studied.

Prostaglandin D synthase (L-PGDS) is a major glycosylated polypeptide in cerebrospinal fluid (CSF). The overexpression of L-PGDS in inflamed bovine mammary glands indicates its role as biomarker. No diagnostic tool for the quantitative detection of L-PGDS in cows has been reported. Immunometric ELISA tests might help to identify inflamed bovine tissue. The isolation of pure bovine L-PGDS, which is required for the generation of monoclonal antibodies, is an important prerequisite for a diagnostic ELISA test. Our goal was to identify a suitable technique to generate pure L-PGDS from bovine substrates. In the present study a two-step method for the purification of bovine CSF using ceramic hydroxyapatite chromatography followed by size exclusion chromatography is described. Subsequently, the identification of bovine L-PGDS was demonstrated by Western blot analysis and the high grade of the pure product was shown by 2-D PAGE. The yield of purified L-PGDS was 6.8 mg/l bovine CSF. L-PGDS from bovine CSF is shown to consist of multiple isoforms identical in molecular mass and p I values to those in previously described secretions of inflamed bovine mammary glands. In addition, the method was successfully applied to the purification of L-PGDS from human CSF.

Analysis of protein secretion was performed for a macrophage-like cell line, which was established from the peritoneal cells of NMRI mice treated with 17 alpha-ethinylestradiol. The protein secretion pattern was investigated by computerized analysis of high resolution two-dimensional gel electrophoresis (2-D PAGE) and compared to that of control macrophages, intraperitoneally activated by bacterial lipopolysaccharide. The transformed cells encode a number of low molecular weight proteins (10-20 kDa), which were not observed in control cells under identical experimental conditions. In conclusion the transformation of peritoneal macrophages by 17 alpha-ethinylestradiol leads to an upregulation of polypeptides, in particular of low molecular weight proteins. A high similarity between the induced low molecular weight protein secretion by macrophages of 17 alpha-ethinylestradiol-treated and that of 2,3,7,8-tetrabromodibenzo-p-dioxin-treated mice was found.

Somatosensory evoked potentials were performed in 38 patients with traumatic spine pre, per and postoperatively. In 3 cases, the S.E.Ps altered before surgery, were improved after decompression and reduction. This S.E.Ps improvement was associated to clinical improvement. Even though this study was carried out on few cases, it shows prognosis and diagnosis value of intraoperative S.E.Ps in traumatic spine surgery.

The authors present the anatomical and functional results of the systematic use of Letournel's extensive lateral approach for internal fixation of the fractures of the acetabulum involving the two columns.This prospective study concerns 25 patients. Mean age was 38 years. Mean follow-up was 4 years and 6 months (with extremes of 1 year and 9 years 9 months). 13 cases had a minimum of 4 years of follow-up. There were 1 transversal fracture, 9 transversal fractures associated with a posterior wall fracture, 2 anterior column fractures associated with a hemitransversal posterior fracture, 6 "T" shaped fractures, 7 fractures of the two columns. During the procedure, a trochanterotomy was carried out. Not any of the patients was irradiated postoperatively and they did not take any indomethacin. The patients were operated on 10 days after the accident, on average (with the extremes of 2 and 60 days). The average time of the procedure was 4 H 20 and 1080 cc of globular sediment were used during the intervention on average. The same surgeons participated in each operation.The anatomical results were analysed according to Matta's criteria and the congruence study head-roof and head-acetabulum of the SOFCOT symposium in 1981. The functional results were analysed using the quotation of Merle d'Aubigné. Complications were searched systematically. The appearance of heterotopic ossifications was analysed according to Brooker.23 patients had a satisfactory anatomical reduction and 11 patients out of 13 did not present any arthrosis after a minimum of 4 years follow-up. 12 patients had very good or good functional results. 3 patients had no heterotopic ossifications, 7 were grade I, 5 grade II, 8 grade III, and 2 grade IV. The gluteus medius was quoted 4 in 18 patients and 5 in 5 patients. There were 2 cases of deep suppuration, one of them was a patient who died 6 months later of a pancreas cancer unrecognized at the time of the accident. There were 5 aseptic osteonecroses and 3 cases of regressive paralysis of the sciatic nerve. 4 total hip prosthesis were inserted secondarily.The Letournel extensive lateral approach was efficient to obtain an anatomical reduction but, functionally, it was only efficient in one case out of two. For the moment, the authors associate systematically a postoperative irradiation to reduce the ossifications (10 to 12 gray in 5 sessions). On the other hand, they try to obtain a more efficient reinsertion of the glutei muscles, thank to a bone fragment of the iliac crest.The authors limit their indications of the Letournel's extensive lateral approach to the fractures of the two columns, not older than 10 days or to the comminuted ones.

The effect of di(2-ethylhexyl)phthalate (DEHP) on diethylnitrosamine (DEN)-initiated preneoplastic liver lesions with expression of gamma-glutamyltranspeptidase (GGTase) and loss of adenosine triphosphatase (ATPase) as well as alterations of hepatic carbohydrate metabolism in male and female Sprague-Dawley rats have been investigated. Two treatment schedules have been compared with respect to their sensitivity by the histochemical demonstration of preneoplastic islands and by the biochemical determination of alterations in enzyme activities of liver homogenates and of serum, the last indicating hepatotoxicity. For initiation, a single dose of DEN was given, followed by treatment with various doses of DEHP given three times weekly by gavage for 7 or 11 consecutive weeks. As histochemical enzyme markers, the expression of positive GGTase as well as the deficiency in ATPase were used for identification of liver foci. The weanling female rats (protocol A) were found to be more sensitive to the carcinogenic effect of DEN in view of foci incidence than the mature male rats which underwent partial hepatectomy prior to DEN application. The administration of 200 mg DEHP/kg body wt increased the incidence of ATPase-deficient foci in both male and female rats; however, concentrations of 1000 and 2000 mg DEHP/kg decreased the incidence of liver foci. The number of foci with expression of GGTase was only slightly increased in female rats following a DEHP concentration of 50 mg/kg, and 200 mg/kg body wt. DEHP alone did not induce preneoplastic lesions that could be identified by these two markers. Biochemical investigations indicate that DEHP alters the metabolic pattern in liver. An increase of the NADP-linked enzymes glucose-6-phosphate dehydrogenase (G6PDH), malic enzyme, extra-mitochondrial ICDH as well as an enhancement of NAD-dependent α-G3PDH and lactate dehydrogenase were found following DEHP administration. On the other hand the glycolytic enzymes pyruvate kinase (PK) and enolase as well as the gluconeogenetic enzyme fructose-1,6-bisphosphatase (FBPase) were significantly reduced. In protocol B (male rats) the reactions of PK, FBPase and malic enzyme were more altered after DEHP exposure than in protocol A, while the activity of G6PDH was more increased in protocol A. Most enzymes being involved in the carbohydrate metabolism are influenced by DEHP in a dose-dependent manner. There was no increase in serum FBPase activity in both male and female rats after DEHP treatment but a reduction of glutamate-oxalate-transaminase and glutamate-pyruvate-transaminase activities was observed. This and the fact that the control and DEHP-treated animals had similar weight gains indicate that DEHP does not exert a significant hepatotoxicity effect.

Summary Introduction Lower extremity alignment remains one essential objective during total knee replacement. Implants positioning analysis requires selecting reliable skeletal landmarks. Our objective was to in vivo evaluate the precision of the implemented skeletal landmarks. This evaluation was based on multiple three-dimensional (3D) computer reconstructions of the lower extremity derived from an EOS ® biplanar low-dose X-ray system acquisition. A 3D angle measurement protocol was used. Hypothesis Currently defined landmarks carry a tolerable uncertainty margin, which can still probably be further improved. Material and methods Nine lower extremity 3D computer reconstructions were obtained from an EOS protocol based on seven simultaneous A–P and lateral views performed in standing position. A database was established by four operators; finally, building up a total of 99 in vivo 3D reconstructions of these nine lower extremities. Specific algorithms were used for such 3D reconstructions of lower extremities based on bone points and pre-identified contours on X-ray. Four femoral landmarks and four tibial landmarks were thus defined. For each bone and each landmark studied, a mean landmark for the 11 consecutive series elements was established. The deviation from each constructed landmark to the corresponding mean landmark was calculated based on the anteroposterior ( x ), longitudinal ( y ) and mediolateral axes ( z ), in translation (T x , T y , T z ) and in rotation (R x , R y , R z ). Uncertainty was estimated by the 95% confidence interval (95% CI). Results The landmarks located at the middle of the segment joining the center of each posterior condyle and at the barycenter of the plateaux showed a greater reliability; these landmarks uncertainty (95% CI) of T x , T y , T z was less than 1, 0.5, 1.5 mm for the femur and 1.5, 0.6, 0.6 mm for the tibia, respectively. The femoral landmarks using the center or posterior edge of the posterior condyles to define the mediolateral axis were retained; for rotations R x , R y , and R z , uncertainty remained less than 0.3, 4, and 0.5°. All of the tibial landmarks had a comparable reliability in rotation, 95% of the R x and R z deviations were under 0.5 and 1.3°, respectively, with a mean error less than 1°. For the tibial rotation R y , the mean error was greater (4°), with uncertainty (95% CI) at 11.2°. All tibial translations showed a mean error of 1 mm. The 3D implantation angles were measured on two patients using preoperative 3D skeletal reconstructions and 3D geometric models of the implants repositioned on postoperative EOS ® knee X-rays. Discussion The posterior condyles are rarely involved in the arthritic wear process, making them an anatomic landmark of choice in the analysis of the femoral component positioning. The femoral landmarks using the posterior condyles were sufficiently reliable for clinical use. However, the posterior contours of the tibial plateaux were less precise. The knees should be staggered from an anteroposterior perspective on the EOS ® lateral images so that they can be visualized separately. The anatomic zones on which the skeletal landmarks are based are usually removed by the bone cuts, making it preferable to save the preoperative computer reconstructions to analyze the postimplantation 3D reconstruction. Conclusion The lower extremity skeletal landmarks precision relates to the quality of the corresponding 3D reconstructions. Except for tibial rotation, all the translation and rotation parameters were estimated within a mean error margin inferior to 1.2 mm and 1.3°, respectively. Making the reconstruction algorithms more robust would render certain anatomic zones even more precise. Biplanar low-dose EOS ® X-ray system is a tool of the future to generate 3D knee X-rays that can improve the evaluation and follow-up of total knee arthroplasty patients. Level of evidence: level IV, diagnostic study.

Introduction The causes of failure of anterior cruciate ligament (ACL) reconstruction mainly involve incorrect tunnel positioning. There is no intraoperative tool allowing the surgeon to test graft biomechanics and to confirm that the new graft is in an optimal position. Hypothesis Control is improved with computer assisted navigation. Material and methods In this retrospective study, revision ACL reconstruction was performed with a new autologous graft in a continuous series of 52 failed ACL reconstructions. A computer assisted navigation system was used intraoperatively in all knees. Evaluation with this system confirmed the position of old and new tunnels as well as intraoperative laxity. Results Evaluation of tunnel position based on traditional radiological criteria found in the literature significantly underestimated graft biomechanics: 69% of the cases presented with unfavorable graft ansiometry (mean: 13 ± 2.2 mm) while the correct position of the tibial tunnel was identified in 64% of cases on radiography and the femoral tunnel in 48%. All new grafts were optimally positioned by the computer assisted navigation system with a mean isometery of 3.2 (±0.7) mm. Comparative pre- and postoperative evaluation of laxity showed a statistically significant improvement (P

Three rat liver foci bioassays have been compared with respect to their sensitivity by the histochemical demonstration of preneoplastic foci, and by the biochemical determination of alterations in enzyme activities of serum indicating hepatotoxicity. We studied the initiation/promotion schedules according to Oesterle and Deml (A), and according to Pereira (B, Broad Spectrum Protocol), and the initiation/selection protocol according to Tatematsu et al. (C), with diethylnitrosamine (DEN), given as a single initiating dose of 10 and 30 mg/kg body wt respectively. With all schedules Sprague-Dawley rats, either females, 3 weeks old (A), or males, 6 weeks old (B, C) were used. For promotion polychlorinated biphenyls (A) or phenobarbital (B) were administered. Selection was performed with 2-acetylaminofluorene (C). The rats in schemes (B) and (C) underwent partial hepatectomy one day prior to initiation. The number and total area of foci deficient in adenosine-5'-triphosphatase (ATPase) and positive in gamma-glutamyltranspeptidase (GGTase) was evaluated. In the complete schedule with 30 mg of DEN in system (A) foci incidence exceeded that of the other systems by about 7-fold (ATPase) and 2-fold (GGTase) respectively. The lower dose of DEN and all control experiments resulted in a respective lower foci yield. With scheme (C), but not with schemes (A) and (B), e.g. serum fructose-1.6-bisphosphatase and alkaline phosphatase were increased, suggesting liver cell damage. Thus tested with DEN, scheme (A) is most sensitive and causes a low impairment of animals' welfare.