健康儿童足甲襞微循环研究

观测100例健康儿童足甲襞微循环,得出儿童足甲襞微循环十七项指标的正常数值,提出了儿童足甲襞微循环的检测方法;将该组儿童足与手甲襞微循环比较,指出足甲襞微循环的特点,为儿童足甲襞微循环的临床应用提供观测方法和客观指标.     

Cloning of a human immunoglobulin gene fragment containing both VH-D and D-JH rearrangements: Implication for VH-D as an intermediate to VH-D-JH formation

In an Epstein-Barr virus-transformed human B cell line we found an unusual immunoglobulin heavy chain gene rearrangement. Restriction mapping and sequencing analysis led us to conclude that V_H-D and D-J_H recombination took place in a single allele. Both V_H-D and D-J_H complexes still had their recombination signal sequences adjacent and the DNA sandwiched by these two complexes retained a germ line configuration, suggesting the potential for a secondary rearrangement resulting in a V_H-D(-D)-J_H formation. With this finding, we propose a novel pathway, in which the V_H-D complex is an intermediate in the formation of a functional V_H exon.     

Die Beanspruchung des menschlichen Ellenbogengelenks

Zusammenfassung Bei 80 Objekten werden die Gelenkflächen des menschlichen Ellenbogengelenks untersucht. Die Trochlea und das Capitulum humeri sowie das Caput radii zeigen keine nennenswerten Unterschiede in der Ausdehnung der mit typischem Gelenkknorpel bedeckten Flächen. Dagegen lassen sich für die Ulnazange drei charakteristische Formgruppen abgrenzen: In 3 Fällen kann eine einheitliche Knorpelfläche beobachtet werden. Bei etwa zwei Drittel der untersuchten Objekte liegt im mittleren Bereich der Incisura trochlearis in horizontaler Richtung ein 2–5 mm breiter knorpelfreier Streifen, der den Gelenkknorpel in 2 vollständig getrennte Flächen unterteilt. Das restliche Drittel der Objekte besitzt eine unvollständige Trennung der Gelenkfläche. Unter Berücksichtigung der Vorstellungen von Pauwels über die causale Histogenese der mesenchymalen Stützgewebe sowie der Materialverteilung im Knochengewebe in Abhängigkeit von der einwirkenden Spannungsgröße werden die morphologischen Befunde den für die jeweiligen Skeletelemente von Pauwels ermittelten Spannungsdiagrammen gegenübergestellt. An der Trochlea und dem Capitulum humeri und am Caput radii findet sich eine geradezu ideale Übereinstimmung in der Ausdehnung der Knorpelfläche und der Knochendichte unter den Gelenkflächen mit den entsprechenden Spannungsdiagrammen. An der Ulna trifft dies nur für einen geringen Teil der Objekte zu. Für die unterschiedliche Ausgestaltung der Incisura trochlearis werden zwei mögliche Ursachen diskutiert: 1. die Resultierende R verharre während des Bewegungsablaufes in einzelnen Positionen innerhalb der Incisura trochlearis verschieden lange; 2. der Krümmungsradius der Trochlea humeri sei größer als derjenige im mittleren Bereich der Ulnazange, so daß hier wegen des fehlenden Kontaktes der Gelenkflächen keine Druckübertragung möglich ist.

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The stress of the human elbow jointI. Functional morphology of the articular surfaces

Summary The articular surfaces of 80 human elbow joints are analysed. The trochlea and capitulum humeri and the caput radii of the investigated individuals show no particular differences in the extent of their surfaces covered with typical articular cartilage. On the other hand the form of the incisura trochlearis is rather variable. Three characteristic formgroups are to be discerned. In three objects a continuous cartilage surface has been observed. In 50 of the investigated joints there is a small intersection free from cartilage in the midst of the incisura trochlearis, dividing the articular cartilage in two isolated surfaces. In the rest of the analysed objects the articular surface is divided only partially. According to Pauwels' hypothesis on the causal histogenesis of the mesenchymal supporting tissues and of the density distribution of the bone dependence upon the magnitude of the local unit stress the morphological findings in the single investigated parts of the elbow joint are confronted with the corresponding stress diagram as described by Pauwels. In the trochlea and capitulum humeri and in the caput radii a nearly ideal correspondence of the extent of the articular surface and the density of the bone tissue with the unit stress diagrams are found. In the ulna this correspondence exists only in few of the analysed objects. For the different form of the incisura trochlearis two possible explanations are discussed: 1, during the motion the resultant of forces may stay for a different time in their single positions in the incisura trochlearis; 2. the curvature radius of the trochlea humeri may be greater than that one of the incisura trochlearis in the central area. So no pressure occurs in this part of the articular surface.

Mit freundlicher Unterstützung durch die Deutsche Forschungsgemeinschaft.     

Transducers for foot pressure measurement: survey of recent developments

Recent advances in the development of transducers for the measurement of vertical and shear forces acting on the plantar surface of the foot are reviewed. Barefoot and in-shoe discrete and matrix transducers are reviewed in terms of structure, operation, performance and limitations. Examples of capacitive, piezoelectric, optical, conductive and resistive types of transducer are presented. Where available, the current clinical status is specified.     

Strategies and determinants for selection of alternate foot placement during human locomotion: influence of spatial and temporal constraints

During locomotion in a cluttered terrain, certain terrain surfaces such as an icy one are not appropriate for foot placement; an alternate choice is required. In a previous study we showed that the selection of foot placement is not random but systematic; the dominant choices made are not uniquely defined by the available or predicted sensory inputs. We argued that selection is guided by specific rules and involves minimal displacement of the foot from its normal landing spot. The experimental protocol involved implicit spatial constraint by requiring individuals to step on the force plate that could trigger a lighted area to be avoided, thereby requiring individuals to respond within one step-cycle. Alternate foot placement was visually identified, but not measured. The purpose of this study was to directly measure foot placement, validate and/or refine the rules used to guide selection, and identify whether the alternate foot placement choices are influenced by spatial and temporal constraints on response selection. The area to be avoided was visible from the start and therefore individuals could plan and implement appropriate avoidance strategies without any temporal constraint. Spatial constraint introduced in this experiment included requirement both to step on a specific location and to avoid stepping on a specific location on the next step. The results provide support for the rules previously identified in guiding foot placement to an alternate location. Minimal displacement of the foot from its normal landing spot was validated as an important factor for selecting alternate foot placement. When several choices satisfied this factor, additional factors guide alternate foot placement. Modifications in the plane of progression are preferred while stepping wide is avoided. When no temporal constraints are imposed on the response selection, enhancing forward progression of the body becomes the dominant determinant followed by stability and lastly by energy costs associated with the modifications. A decision algorithm for selecting foot placement is proposed based on these findings. It is clear that while visual input plays a critical role in guiding foot placement, it is not entirely based on reactive control. This has implications for implementing visually guided adaptive locomotion in legged robots.     

Radiologic anatomy of the metacarpophalangeal joints II to V

Summary The metacarpophalangeal (MCP) joints II to V of 21 hands were examined radiologically and arthrographically. Different recesses of the joint cavity were demonstrated both radiologically and macroscopically, with a dominating dorsal recess. The existing forms of the dorsal recess were one-tailed, two-tailed, three-tailed, symmetric and caplike. Additionally, a palmar recess was found in the specimens examined, which presented as a small protrusion of the capsule and lay between the metacarpal head and the palmar plate. Furthermore, a distal recess was filled and unfolded in almost all the cases. Lateral recesses were found in the radial and ulnar directions beneath the collateral ligaments. The dorsal recess, due to its ability to collect fluid, is of clinical importance in pathologic processes causing effusions, while the clinical importance of the lateral recesses lie in their proximity to the stabilizing collateral ligaments of the metacarpophalangeal joints. The above mentioned recesses were seen as normal formations of the MCP joints and should therefore be taken into account in pathologic processes in this area.

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Radioanatomie des articulations métacarpo-phalangiennes des 2ème au 5ème doigts

Résumé Les articulations métacarpophalangiennes (MCP) des 2ème au 5ème doigts de 21 mains ont été explorées en radiographie standard et en arthrographie. Plusieurs récessus articulaires, dont un récessus dorsal prédominant, ont été mis en évidence à la fois sur les radiographies et macroscopiquement. Les récessus dorsaux observés pouvaient comprendre une, deux ou trois cornes ou prendre un aspect de coiffe. Un récessus palmaire a été également trouvé sur 49 pièces sous la forme d'une petite expansion capsulaire entre la tête métacarpienne et la plaque palmaire. Un récessus distal était de plus rempli dans presque tous les cas. Des récessus latéraux étaient trouvés sur les bords radial et ulnaire, entre les ligaments latéraux. Les épanchements articulaires se collectent volontiers dans le récessus dorsal qui se manifeste cliniquement. Les récessus latéraux sont cliniquement intéressants par leur proximité avec les ligaments latéraux des MCP. Les récessus décrits sont des structures normales des MCP et ne doivent pas être pris pour des éléments pathologiques.

     

Retrospective review of complications following long tourniquet time in foot and ankle surgery

BackgroundTourniquet use is ubiquitous in orthopaedic surgery to create a bloodless field and to facilitate safe surgery, however, we know of the potential complications that can occur as a result of prolonged tourniquet time. Experimental and clinical research has helped define the safe time limits but there is not much literature specific to foot and ankle surgery.MethodsA retrospective review of the postoperative course of patients with prolonged tourniquet time (longer than 180 min) for foot and ankle procedures was done. Data related to the patient factors and the surgical procedure was collected. The length of stay, re-admissions and complications were the important indicators of the individual patient’s recovery.ResultsTwenty patients were identified with longer than 180-min tourniquet times for complex foot and ankle procedures. The average uninterrupted tourniquet time was 191 min. Eight of the twenty procedures were revision surgeries. The average length of stay was 3 days and there were no re-admissions within 30 days. Eight patients (40%) had at least one recorded complication. The complications seen in this group were transient sensory loss, wound issues, superficial infection, ongoing pain and non-union.ConclusionsThis case series has not revealed any major systemic complications resulting from the prolonged tourniquet such as pulmonary embolism or renal dysfunction. Unlike past literature on knee procedures with extended tourniquet times, no major nerve palsies were seen in our patient group. Our understanding of the local and systemic effects of tourniquet is not complete and this study demonstrates that the complications do not necessarily increase in a linear fashion in relation to the tourniquet time.     

Our experience of reinnervation of sole in diabetic sensorimotor polyneuropathy: A chance to change the natural history of disease

Diabetic sensorimotor polyneuropathy (DSPN) is the commonest form of neuropathy which leads to insensate sole, diabetic foot ulcers (DFU) and its complications. We share our experience in recovery of sensation in the sole after prophylactic surgery such as nerve decompression (ND) or sensory neurotization by nerve transfer (NT) in patients having Diabetic sensorimotor polyneuropathy DSPN. 32 patients (46 feet) were selected for either nerve decompression or sensory neurotization depending upon presence or absence of Tinel’s sign at tarsal tunnel. At 6 month post-operatively perception of touch and pain recovered in all feet; temperature and pressure perception recovered in ∼95% feet; average vibration perception threshold returned to normal range and 2-Point Discrimination came down significantly. There were no ulcers or amputation in operated limbs during follow up period of 6 months. Prophylactic surgery in the form of ND and NT can be offered with minimal complications which significantly improve sensations in the sole in selected cases of DSPN. These have the potential to improve the quality of life of patient and change the natural course of disease.     

Closed Transverse Pinning for Reduction and Fixation of Metatarsal Neck Fractures: Surgical Technique

Most metatarsal neck fractures can be successfully treated non-operatively in a cast boot. Displaced metatarsal neck fractures tend to be less stable and have a propensity for the distal fragment to angulate, secondary to the strong flexor tendons, which often forces the distal fracture fragment in a plantar direction and leads to relative metatarsal shortening. Most literature is focussed on antegrade fixation of metatarsal neck fractures using pre-bent K wires or thin elastic nails. Apart from the technical challenges, this technique is limited when bones are osteoporotic as the pre-bent distal end of the K-wire may penetrate the plantar cortex of the proximal metatarsal and prevent the wire from entering the medullary canal of the metatarsal and advancing to the fracture site. Furthermore, when the medullary canal is narrow especially in Asian patients, it may be difficult to pass a bent K-wire through the isthmus of the metatarsal shaft. We describe an innovative technique of closed transverse wiring of the metatarsal head necks that has a distinct advantage in Asian population with osteoporotic bones. With percutaneous manipulation using digital pressure, closed reduction of fracture fragments of the most displaced fracture is done under fluoroscopic guidance to achieve a satisfactory alignment followed by closed transverse wiring of the metatarsal heads. With this procedure, adjacent fractures remain stable within an acceptable range because of intermetatarsal ligaments connected to the adjacent intact head. Our technique has a relatively short operating time and allows for early motion of the metatarso-phalangeal joint. This is especially useful for those with osteoporosis, narrow canal, soft tissue compromise, intra-operative failure of ante-grade pinning and in scenarios of limited surgical equipment/expertise.     

后路凸侧椎板楔形截骨经肋椎关节松解胸椎间隙治疗青少年重度脊柱侧后凸

【摘要】 目的：评价经后路凸侧椎板楔形截骨经肋椎关节松解胸椎间隙矫形治疗青少年重度脊柱侧后凸畸形的安全性和早期临床效果。方法：2014年5月~2016年12月对我院15例青少年重度脊柱侧后凸患者行经后路凸侧椎板楔形截骨经肋椎关节松解胸椎间隙手术治疗,术前仅1例严重脊柱侧后凸患者行头盆环牵引。男6例,女9例,年龄13～18岁（16.1±1.6岁）。其中先天性脊柱侧后凸3例,特发性11例,神经纤维瘤病性1例。术前侧凸Cobb角82°～144°（102.5°±17.6°）,侧凸的柔韧性为6.4％～28.5％[（21.56±5.70）%];后凸50°～95°（68.1°±15.3°）,冠状位躯干偏移距离（C7中垂线与骶骨中垂线距离）2.0～6.8cm（3.40±1.37cm）。术前四肢肌力及感觉均正常。观察治疗效果。结果：椎板楔形截骨5.20±0.56个（4~6个）,松解椎间隙5.20±0.56个（4~6个）,手术时间6.1～7.9h（7.00±0.51h）,术中出血量1050～2500ml（1450.0±521.3ml）。术后侧凸Cobb角18°～40°（28.0°±6.6°）,矫正率72.5%;后凸22°～42°（27.8°±6.1°）,矫正率58.4%;冠状位躯干偏移距离0～2cm（0.85±0.74cm）,矫正率72.8%。随访25～41个月（33.1±5.4个月）。末次随访时侧凸Cobb角19°～43°（30.0°±6.9°）,矫正率70.6%;后凸22°～42°（28.6°±6.5°）,矫正率57.2%;冠状位躯干偏移距离0.2～2.3cm（1.10±0.72cm）,矫正率71.3%。无胸膜破裂,无假关节形成,无内固定断裂及松动,矫正度无显著丢失。1例患者术前骨盆牵引发生钉道感染,经局部换药及抗生素应用,2周后感染控制;1例术后第3天发生十二指肠系膜上动脉综合征,采取禁食水、持续胃肠减压、维持水电解质平衡、左侧卧位,术后2周痊愈;1例T4左侧椎弓根螺钉侵入椎管压迫神经,术后5h发生左下肢不完全性瘫痪,术后8h去除T4左侧椎弓根螺钉,术后5个月左下肢功能完全恢复。结论：采用后路凸侧椎板楔形截骨经肋椎关节松解胸椎间隙治疗青少年重度脊柱侧后凸畸形,不需要剥离椎体侧方胸膜,手术解剖层次表浅和创伤小,不仅有助于增加脊柱柔韧性,而且可提供足够的压缩和闭合空间来矫正脊柱侧后凸,能获得良好的脊柱三维矫正。