深低温冷冻-酶洗法制备兔组织工程气管支架的研究

目的探讨深低温冷冻-酶洗法制备的气管支架在去除气管黏膜上皮细胞、维持生物力学及保持细胞外基质方面的效果。方法 24只成年新西兰兔,随机分为气管未处理作为对照A组,深低温冷冻法处理B组,酶洗法处理C组,深低温冷冻-酶洗法D组,各组样本数均为6只。处理后将各组标本行组织学观察,电镜扫描,生物力学性能检测。结果组织学显示A组有大量完整的黏膜上皮细胞;B组见部分完整黏膜上皮细胞;C组和D组未见黏膜上皮细胞,细胞核碎裂。电镜显示A、B、D组气管支架见丰富的细胞外基质,未暴露胶原纤维,C组气管支架暴露大量胶原纤维,未见细胞外基质。组间两两比较,气管支架的最大拉伸力、最大破裂力和变异率均无统计学差异。结论综合组织学、扫面电镜和生物力学分析,应用深低温冷冻-酶洗法制备气管支架D组可以有效地去除气管黏膜上皮细胞,维持生物力学性能,并具有较完整的细胞外基质。     

肌腱内横向结扎缝合法修复肌腱的生物力学实验研究

目的：对不同方法修复肌腱的生物力学进行研究以使修复肌腱有足够张力强度．方法：对兔跟腱一侧用肌腱内横向结扎缝合法缝合（实验组），对侧用Ｋｅｓｓｌｅｒ法缝合（对照组），术后０～５周，经手术显微镜、光镜及电镜观察，并进行详细的生物力学性能测试．结果：（１）组织学观察实验组优于对照组．（２）实验组载荷、强度极限、拉伸刚度、比能及应变率分别较对照组高４８．４％、５５．３％、３３．９％、７９．２％及４６．９％，统计学分析有非常显著性差异（Ｐ＜０．０１）．结论：肌腱愈合过程中，修复方法与其生物力学性能恢复有关，该法修复的肌腱力学性能好     

大鼠肝细胞球形体低温保存条件的初步探索

目的探索有效的肝细胞球形体低温保存方法,促进生物人工肝及其他研究的应用。方法采用两步法分离大鼠肝细胞,经无血清培养基(SFM)摇摆培养48h形成肝细胞球形体。将球形体继续培养(对照组),或置于4℃SFM,SFM+1mmol/L去铁胺(Def),SFM+1μmol/L环孢霉素A(Cs A),SFM+1mmol/L Def+1μmol/L Cs A保存液中24h或48h,继续培养4d或5d后观察低温保存后肝细胞球形体的存活率、超微结构变化,以及白蛋白和尿素合成情况。结果Def和Cs A能很好地保护球形体肝细胞,在4℃SFM+Def+Cs A保存液中保存24h,肝细胞球形体功能、结构等变化及尿素合成水平与对照组比较差异无统计学意义,而单独放在SFM中进行低温保存后,细胞活性明显下降。在4℃保存48h后,球形体肝细胞超微结构发生明显变化,死亡细胞增多,但SFM+Def+Cs A组和SFM+Def组细胞结构优于SFM组和SFM+Cs A组,细胞存活率及尿素合成水平明显高于后两组(P<0.05),但合成白蛋白量均处于较低水平,各组间差异无统计学意义(P>0.05)。结论低温状态下肝细胞球形体可保持良好的存活率和功能24h,低温保存能为细胞治疗提供良好的细胞材料。     

异种脐血干细胞移植修复兔全层关节软骨缺损的初步研究

目的 :探讨人脐血干细胞对兔全层关节软骨缺损的修复作用及免疫反应。材料和方法 :取人脐带血中脐血干细胞及幼兔的骨髓基质细胞 ,体外分离培养 ;以聚乳酸 (PLA)为载体 ,将培养的原代细胞植入PLA支架上 ,形成细胞 -PLA复合物。于 2 0只成年新西兰大白兔的股骨滑车关节面上造成直径 4.5mm深 3 .0mm的全层关节软骨缺损 ,将两种细胞 -PLA复合物分别植入关节软骨缺损处。植入异种脐血干细胞 -PLA复合物为实验组 ,植入同种异体骨髓基质细胞 -PLA复合物为阳性对照组 ,缺损不处理为阴性对照组。术后 6周、1 2周观察缺损修复情况、新生组织类型及有无免疫反应。结果 :脐血干细胞组 6周时标本为纤维组织修复 ,内有少量软骨细胞 ;1 2周时 40 %标本为软骨样组织修复 ,较薄 ;60 %标本为纤维组织修复。移植物周围无明显淋巴细胞聚集 ,部分滑膜有炎症反应。骨髓基质细胞组(阳性对照)为软骨样组织修复 ;滑膜无明显炎症反应。阴性对照组为纤维组织修复 ,无软骨形成。结论 :异种脐血干细胞移植修复软骨缺损优于缺损不处理组 (阴性对照) ,但明显差于同种骨髓基质细胞组 (阳性对照 )。脐血干细胞有可能成为软骨修复的新的种子细胞。由于种属差异的影响 ,脐血干细胞组可能存在免疫反应 ,结果需进一步研究     

肩袖肌腱损伤动物模型的建立及初步研究

目的:采用兔肩胛下肌建立肩袖肌腱损伤动物模型,验证其可行性并进行肩袖肌腱损伤生物力学、组织学研究。方法:40只成熟雄性新西兰大白兔随机编号,选取4只不进行任何处理,用于前期准备及调试工作,其数据不计入实验结果;其余36只均行右侧肩胛下肌部分离断,建立肩袖部分损伤模型,对侧行假手术进行对照。术后不限制活动。分别于术后2、4、6、8周行肩关节MRI观察肩袖肌腱愈合情况;采用HE染色观察肌腱愈合情况;采用Masson染色观察组织中肌纤维愈合情况;采用生物力学测试检测肌腱强度。结果:兔肩胛下肌具有与人相似的解剖结构和组织结构,适用于建立肩袖损伤模型,手术操作过程简便,可重复性高。除去实验麻醉死亡4只,实验动物右侧肌腱损伤后8周,HE染色及Masson染色可观察到肌腱基本愈合;MRI检查显示肌腱内信号均匀,关节腔内基本无高信号影。生物力学结果显示术后2、4、6周肌腱最大载荷均低于假手术侧,差异有统计学意义(P<0.05),术后8周肌腱最大载荷与假手术侧差异无统计学意义(P>0.05)。结论:兔肩袖肌腱损伤8周时,基本恢复正常的肌腱排列结构,肌腱的生物力学强度基本恢复正常。采用兔肩胛下肌建立肩袖损伤模型适用于肩袖疾病的研究。     

血管内皮生长因子在屈肌腱愈合中的作用机制

目的 通过应用血管内皮生长因子(VEGF)中和抗体,探讨VEGF在屈肌腱愈合中的作用机制.方法 制作兔屈肌腱损伤模型,局部应用VEGF中和抗体,分别于术后4,7,10,14,28,56 d 6个时相点取材,大体和组织学观察应用VEGF中和抗体对肌腱粘连评分、VEGF的表达、胶原合成的影响,对比应用抗体前后的肌腱生物力学,透射电镜观察修复区细胞超微结构.结果应用中和抗体后,肌腱粘连程度评分、VEGF的表达水平和肌腱的位移降低,但对胶原肌腱的断裂载荷及细胞超微结构无明显影响. 结论 VEGF可能主要是通过肌腱的外源性愈合发挥作用,局部应用VEGF中和抗体可以抑制外源性愈合,减轻肌腱粘连.     

不同牵伸强度对体外人肌腱细胞磷脂酶A2/环氧合酶表达的影响

目的 探讨不同循环牵伸强度对体外人肌腱细胞磷脂酶A2(phospholipase A2,PLA2)和环氧合酶(cyclooxygenase,COX)表达的影响。 方法 取4～6代人肌腱细胞在0.5 Hz、4h条件下施加不同牵伸强度(4％、8％、12％),未牵伸组设为对照组。静置4h后,用RT-PCR、Western blot检测胞浆性PLA2(cytosolic PLA.2,cPLA2)、COX1、COX2的表达,ELISA测定分泌性PLA2 (secretory PLA2,sPLA2)的表达。 结果 对照组、4％、8％、12％牵伸组cPLA2、COX1、COX2基因表达随牵伸强度增加呈递增趋势,4％牵伸组cPLA2、COX1蛋白表达与对照组比较增加均不明显,差异无统计学意义(P＞0.05);8％和12％牵伸组cPLA2及COX1蛋白表达与对照组比较明显增加,差异有统计学意义(P＜0.01)。4％、8％、12％牵伸组COX2与对照组比较,差异均有统计学意义(P＜0.01),且随牵伸强度增加而逐渐增加。sPLA2在4％牵伸组分泌量和对照组比较,差异无统计学意义(P＞0.05),8％和12％牵伸组增加明显(P＜0.01)。 结论 体外人肌腱细胞PLA2、COX1、COX2的表达与牵伸强度呈正相关,PLA2/COX调节系统可能成为防治肌腱病的新分子靶标。     

辛伐他汀对大鼠外周血单个核CD34+细胞动员作用的研究

 目的观察辛伐他汀动员大鼠外周血单个核CD34+细胞的作用.方法80只Wistar大鼠被随机分成辛伐他汀组和对照组.分别于给药1、2周后检测血脂水平,并用流式细胞仪行萤光激活细胞分类检测外周血单个核细胞中CD34+细胞率.结果(1)各组间血脂水平及外周血单个核细胞数无明显差别(P＞0.05).(2)无论是给药第1周后还是第2周后,辛伐他汀组外周血单个核细胞CD34+细胞率较对照组明显升高(P＜0.01).结论辛伐他汀可动员大鼠外周血单个核细胞中CD34+细胞.     

系膜增生性肾小球肾炎患者外周血单个核细胞及肾组织PD-L1/PD-L2的表达变化

目的 观察系膜增生性肾小球肾炎患者外周血单个核细胞(PBMC)及肾组织活检标本中抑制性协同刺激分子PD-L1/PD-L2表达的变化.方法 收集2007年11月-2008年5月在第三军医大学新桥医院住院的25例原发性系膜增生性肾小球肾炎患者作为病例组,另外选择10例正常人作为正常对照组.全血法多色流式细胞染色技术检测两组的PBMC CD4+和CD8+T细胞上PD-L1和PD-L2的表达水平;免疫组化方法检测肾组织活检标本中PD-L1和PD-L2的表达情况.结果 病例组患者PBMC CD4+ T细胞比例(31.78%±8.48%)明显高于正常对照组(22.17%±8.00%,P<0.05),而CD8+ T细胞比例(23.06%±10.32%)与正常对照组(21.56%±5.32%)比较差异无统计学意义(P>0.05).病例组患者PBMC CD4+和CD8+ T细胞上PD-L1表达阳性率(分别为14.21%±11.87%、12.92%±12.86%)均较正常对照组(分别为5.39%±4.92%、5.06%±4.61%)显著升高(P<0.05);而两组PBMCCD4+及CD8+T细胞上PD-12的表达很少甚至无表达,两组间差异无统计学意义(P>0.05).正常对照组中肾组织PD-L1表达很少甚至无表达,病例组肾小管上皮细胞可见PD-L1阳性表达;两组肾活检组织中均未检测到PD-L2表达.结论 系膜增生性肾小球肾炎患者中抑制性协同刺激分子PD-L1表达上调,可能参与了疾病的免疫发病机制.     

小肠黏膜下层作为肌腱组织工程支架的评价

目的评价脱细胞小肠黏膜下层(SIS)的细胞毒性、亲水性、细胞黏附性等组织工程支架性能,为其作为肌腱组织工程支架材料提供实验依据。方法制备猪小肠黏膜下层,并进行光镜和扫描电镜观察。以不同浓度(100%、50%、25%、12.5%、0)的SIS浸提液培养兔肌腱细胞,采用MTT法测定1、3、5、7、9d时肌腱细胞的增殖率以评价SIS的细胞毒性。测定SIS的吸水率以评价其亲水性,并测定SIS与兔肌腱细胞黏附率以评价其细胞黏附性。结果光镜观察显示,SIS结构疏松,无细胞碎屑残留;扫描电镜见两个表面的纤维直径不同。MTT法检测显示,各浓度SIS浸提液的细胞毒性均为0～1级。冻干SIS吸水率在6h达饱和,饱和吸水率498.2%±15.0%;兔肌腱细胞在SIS光面和糙面的黏附率分别为53.49%±5.46%和61.45%±7.84%,两者比较差异无统计学意义(P>0.05)。肌腱细胞在SIS上生长良好,部分细胞长入SIS内。结论SIS对肌腱细胞无毒性,细胞黏附性良好,适合作为组织工程肌腱的支架材料。     

Radial and ulnar bursae of the wrist: cadaveric investigation of regional anatomy with ultrasonographic-guided tenography and MR imaging

Objective To demonstrate the anatomy of the radial and ulnar bursae of the wrist using MR and US images.Design Ultrasonographic-guided tenography of the tendon sheath of flexor pollicis longus (FPL) and the common tendon sheath of the flexor digitorum of the fifth digit (FD5) of ten cadaveric hands was performed, followed by magnetic resonance imaging and gross anatomic correlation. Patterns of communication were observed between these tendon sheaths and the radial and ulnar bursae of the wrist.Results The tendon sheath of the FPL communicated with the radial bursa in 100% (10/10) of cases, and the tendon sheath of the FD5 communicated with the ulnar bursa in 80% (8/10). Communication of the radial and ulnar bursae was evident in 100% (10/10), and presented an “hourglass” configuration in the longitudinal plane.Conclusions The ulnar and radial bursae often communicate. The radial bursa communicates with the FPL tendon sheath, and the ulnar bursa may communicate with the FD5 tendon sheath.     

Magnetic resonance imaging findings in patients with medial epicondylitis

Objective To compare the MR imaging findings of 13 patients with clinically diagnosed medial epicondylitis with the MR imaging findings of 26 patients of similar age with no clinical evidence of medial epicondylitis.Design and patients The study group consisted of 13 patients with clinically diagnosed medial epicondylitis. The control group consisted of 26 patients of similar age with no clinical evidence of medial epicondylitis. The medical records and MR imaging findings of these patients were retrospectively reviewed by two fellowship-trained musculoskeletal radiologists.Results Eleven of the 13 patients in the study group had thickening and increased signal intensity of the common flexor tendon on both T1-weighted and T2-weighted images. The remaining two patients in the study group had soft tissue edema around a normal-appearing common flexor tendon. Twenty-one of the 26 patients in the control group had a normal-appearing common flexor tendon on MR imaging. Three patients in the control group had a thickened common flexor tendon which was of intermediate signal intensity on T1-weighted images but of uniform low signal intensity on T2-weighted images. Two patients in the control group had a thickened common flexor tendon which was of intermediate signal intensity on both T1-weighted and T2-weighted images. None of the patients in the control group had soft tissue edema around the common flexor tendon.Conclusion MR imaging findings of patients with clinically diagnosed medial epicondylitis included thickening and increased T1 and T2 signal intensity of the common flexor tendon and soft tissue edema around the common flexor tendon. The presence of intermediate to high T2 signal intensity or high T2 signal intensity within the common flexor tendon and the presence of paratendinous soft tissue edema were the most specific findings of medial epicondylitis on MR imaging.     

Tendon and neurovascular bundle displacement in the palm with hand flexion and extension: an MRI and gross anatomy correlative study

This study evaluated the correlative use of MRI methods and gross anatomy to monitor tendon displacement in the central region of the palm at rest and during flexion and extension of the metacarpophalangeal and interphalangeal joints with respect to the corresponding neurovascular bundles (NVBs). In all of the samples the neutral and extended positions showed the NVB to be palmar with respect to the flexor tendons, while during flexion tendon displacement caused the NVB to be dorsal to both the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) tendons. T1-weighted MR images correlated with gross anatomical slides demonstrated that significant changes occur in the relative positions of the flexor tendons and associated NVBs of the palm upon flexion and extension.     

Ⅱ区指屈肌腱损伤患者在修复术后实施虚拟情景反馈训练对手功能的恢复作用

目的探讨Ⅱ区指屈肌腱损伤患者在修复术后实施虚拟情景反馈训练对手功能的恢复作用。方法 2012年6月—2017年6月鹤壁市人民医院显微外科诊治Ⅱ区指屈肌腱损伤患者中抽取76例随机分组,对照组(n=38)在修复术后应用常规综合康复训练方式治疗,研究组(n=38)则加用修复术后实施虚拟情景反馈训练,对两组患者手功能指标(手指总活动度,手指三点捏力、侧捏力、握力和并发症发生率)进行统计学分析。结果 (1)研究组患者的手指总活动度康复优良率是97.37%,与对照组手指总活动度康复优良率84.21%相比有统计学差异(P0.05);(2)治疗前,研究组和对照组侧捏力、握力和三点捏力比较差异均无统计学意义(P0.05);治疗后,研究组患者侧捏力、握力和三点捏力明显高于对照组(P0.01);(3)研究组患者并发症发生率2.63%,低于对照组的10.53%,但差异无统计学意义(P0.05)。结论Ⅱ区指屈肌腱损伤患者在修复术后实施虚拟情景反馈训练,对恢复手功能有积极作用,可借鉴。     

几丁聚糖影响肌腱愈合的实验研究及临床应用

目的　研究几丁聚糖对肌腱愈合的影响。　方法　以24只新西兰兔为实验动物，实验组于Ⅱ区将屈趾深肌腱切断并吻合后，腱鞘内注入几丁聚糖0.1ml，对照组不注入。术后3，4周后对其局部肌腱行大体标本观察、生物力学测试、光镜和透射电镜观察。临床Ⅱ区屈指肌腱断裂病人40例,Ⅰ组20例肌腱吻合后腱鞘内注入几丁聚糖0.2ml，Ⅱ组不注入，随访检查其握力，计算屈指肌腱总主动活动度(TAM)。　结果　（1）大体标本观察实验组肌腱较对照组愈合好，粘连轻。生物力学测试结果表明，两组比较差异具有显著性意义（P<0.05）。（2）组织学检查光镜和电镜示两组3，4周比较差异有显著性意义(P<0.05)。(3)临床应用中的握力及屈指TAMⅠ组握力为健侧的58%～96%，平均83.3%；Ⅱ组为49%～86%，平均72.6%。Ⅰ组TAM优9例，良7例，差1例；Ⅱ组优5例，良7例，可5例，差3例。两组比较差异有非常显著性意义（P<0.01)。　结论　几丁聚糖具有预防肌腱粘连的作用，且能促进肌腱愈合。     

Biomechanical behavior of the plantar flexor muscle-tendon unit after an Achilles tendon rupture

The purpose of this study was to examine the biomechanical behavior of the plantar flexor muscle-tendon unit in subjects who had ruptured their Achilles tendon. Twenty-six men and 14 women volunteered for the study. Eighteen subjects had been treated operatively and 22, nonoperatively. All subjects had ruptured their Achilles tendon more than 1 year before the study, and 28 of the 40 ruptures occurred 5 years or less before the day of testing. A KinCom dynamometer was used to measure ankle joint angle, passive torque, and maximal isometric plantar flexor torque. During a 2-minute passive calf stretch, stiffness and torque relaxation were calculated. Isometric torque and peak passive torque were 17% and 10% greater for the uninvolved versus the involved limb, whereas stiffness and torque relaxation were not different between limbs. The time since injury did not influence the results, nor did the mode of initial treatment, that is, whether the subjects were treated operatively or nonoperatively. These findings suggest that changes in strength and peak passive torque may be chronic adaptations associated with Achilles tendon rupture.     

手部陈旧性屈指肌腱断裂的重建修复治疗分析

目的研究手部陈旧性屈指肌腱断裂的重建修复方案的治疗效果。方法选择2014年1月—2016年1月青海大学附属医院创伤骨科收治的手部陈旧性屈指肌腱断裂患者63例,根据损伤肌腱部位按照解剖区域分为Ⅰ~Ⅴ五区。随机分为治疗组32例和对照组31例。其中,治疗组采取分期改良手术即一期植入硅胶管、二期植入掌长肌(由可吸收生物膜即脑磷脂和卵磷脂材料包裹)重建其屈指肌腱结构并恢复其功能;对照组患者给予延迟活动治疗。两组患者术后通过总主动活动度(total active movement,TAM)测定以及功能独立性评定(functional independence measure,FIM)综合评估患者屈指肌腱功能重建情况,分析治疗效果。结果随访第12周,TAM评级治疗组为优者26例,对照组7例,治疗组明显优于对照组(χ~2=15.00,P0.05);FIM评分治疗组(36.1±6.2),对照组(24.8±8.3),治疗组活动度范围显著优于对照组(t=5.97,P0.05),治疗组其术后功能重建效果满意。结论改良手术能够明显提高手部陈旧性屈指肌腱断裂患者的重建修复效果,手术效果的提升得益于肌腱粘连的避免,值得临床深入研究和推广。     

模拟失重可能损害心内膜内皮

４周的尾部悬吊引起大鼠乳头肌等长收缩发展张力（ＤＴ）降低２９．２％，达到张力峰值的时间（ＴＰＴ）延长１０．４％和舒张一半时间（Ｔ１／２Ｒ）呈降低趋势。解除悬吊１周大鼠的心肌收缩性能并未恢复，其表现为ＤＴ仍降低２４．Ｏ％、ＴＰＴ未见延长，但Ｔ１／２Ｒ却显著地缩短了１３．３％。用ＴｒｉｔｏｎＸ－ｌ００处理乳头肌行干预实验发现，对照大鼠的ＤＴ仅稍降低，而ＴＰＴ与Ｔ１／２Ｒ则明显缩短。与此截然相反，悬吊和恢复大鼠的ＤＴ明显降低，而ＴＰＴ与Ｔ１／２Ｒ却无改变。扫描电镜显示悬吊与恢复大鼠乳头肌内皮细胞核隆起形成的起伏消失，这些均提示模拟失重可能使大鼠心内膜内皮产生一定程度的萎缩或损伤。因此，在探讨模拟失重心血管功能失调变化机理时，心内膜内皮的作用不应忽视。     

The effect of initial graft tension in anterior cruciate ligament reconstruction on the mechanical behaviors of the femur-graft-tibia complex during cyclic loading

BACKGROUND: Initial graft tension influences clinical results of anterior cruciate ligament reconstruction. HYPOTHESIS: Under repetitive loading conditions, the effect of initial graft tension on the biomechanical behavior of the femur-graft-tibia complex may depend on the graft and the fixation. STUDY DESIGN: Ex vivo biomechanical laboratory study. METHODS: After anterior cruciate ligament reconstruction, initial graft tension of 20, 80, or 140 N was applied to the complex for 2 minutes. Then, a cyclic force-relaxation test was performed for 5000 cycles so that the graft was stretched by 2 mm. RESULTS: In a patellar tendon graft with interference screws, the average peak load values at the 5000 th cycle were 105, 157, and 205 N for the complexes with initial tension of 20, 80, and 140 N, respectively. In a flexor tendon graft with interference screws, the values were 27, 41, and 39 N. In a flexor tendon graft with Endobutton fixation, the values were 17, 40, and 77 N. CONCLUSIONS: Considering the tension of the normal anterior cruciate ligament (16 to 87 N), an initial tension of 20 N appears to be high enough for a patellar tendon graft. For a flexor tendon graft with interference screws, an increase in initial tension above 80 N has no biomechanical advantages.     

Correlation of morphologic and pathologic features of the various tendon groups around the ankle: MR imaging investigation

Objective

To determine if a statistical association exists between abnormalities in one ankle tendon group (i.e., peroneal, medial flexor, or Achilles) and those in another.

Materials and methods

A retrospective analysis of 1.5-T and 3-T MR ankle examinations in 100 patients conducted between November 1, 2011 and April 1, 2012 was performed. The cross-sectional areas and diameters of the ankle tendons—Achilles (ACH), peroneus brevis (PB) and longus (PL), tibialis posterior (TP), flexor digitorum longus (FDL), and flexor hallux longus (FHL)—were measured, and the results were correlated to determine any association with the presence of qualitative abnormalities (tenosynovitis, tendinosis, and tendon tearing).

Results

Subjects with larger diameters of the ACH tendon also revealed larger PL, TP, FDL, and FHL tendon diameters and sectional areas. Furthermore, subjects with larger PL tendons generally revealed larger flexor tendons and the same was also true when medial compartment tendons were individually assessed and measurements compared among the three of them. There was a statistically significant association with regard to the presence of tendon abnormalities (tendinosis, tenosynovitis, and tearing) in both the peroneal and medial flexor tendons. The presence of an abnormality in the ACH tendon correlated strongly with increasing diameters and areas of all the other ankle tendons except for the PB tendon.

Conclusions

There is an association between quantitative and qualitative abnormalities of one group of tendons when compared with the others with respect to the ACH, medial flexor, and peroneal tendons of the ankle, which is perhaps explained by a retinacular and fascial complex that anatomically connects the three groups.