The extensor retinaculum of the wrist: an anatomical and biomechanical study

Through an anatomical and biochemical study, utilizing sixty-five cadaver specimens, the extensor retinaculum of the wrist was examined. It is a complex variable fibrous structure, whose functions are to prevent dorsal bowstringing of the extensor tendons and to prevent radial and ulnar displacement of extensor tendons. We recommend that a portion of the extensor retinaculum be preserved or reconstructed at the time of dorsal wrist surgery.     

The sheath of the rectus abdominis muscle: an anatomical and biomechanical study

Summary The anterior layer of the sheath of the rectus muscles is often used in the repair of incisional hernias through the linea alba. This practice has led us to undertake an anatomical and biomechanical study of its structure. Thirty fresh cadavers were divided into three groups of ten. All were dissected and biomechanical tests were carried out on the latter two groups: in Group 2 a dynamometer was used to measure the resistance to linear traction and to deformation. In Group 3 a bursting strength tester was used in order to determine the resistance to pressure. Morphological studies included measurements of the mean dimensions of the sheath, and of its composition at different levels. The biomechanical results show that the anterior sheath is more resistan to traction below the arcuate line than above it, whereas the resistance to pressure shows an opposite pattern. The resistance to traction of the posterior sheath is similar in its aponeurotic portion both above and below the umbilicus, the resistance to pressure being slightly less in the region of the arcuate line. The figures for deformation are essentially the same at all levels. The implications of these results for the repair of abdominal wall defects are discussed.     

Chronic pelvic pain syndrome: Diagnosis and management

Chronic pelvic pain syndrome (National Institutes of Health Category III [abacterial] prostatitis) is quite prevalent in the urologic outpatient setting. Evaluation to exclude serious urologic pathology and nonurologic causes must be undertaken. Treatment options include pharmacologic, behavioral, and surgical interventions. The author of this article advocates a multidisciplinary approach for the management of patients diagnosed with chronic pelvic pain.     

Diagnosis and management of chronic pelvic pain

Chronic pelvic pain is difficult to diagnose and to treat [81] because of the multiple and often overlapping causes [82]. A systematic approach aids in the thorough evaluation and appropriate therapy. At the initial visit(s), a thorough history should be taken and complete physical examination performed. Screening for co-existing conditions, such as depression, narcotic dependency, and physical, sexual, or emotional abuse is crucial so these issues may be addressed immediately while additional causes for pelvic pain are evaluated. The relative likelihood of gastrointestinal, urologic, musculoskeletal, or gynecologic etiology must be considered to guide a more thorough initial evaluation. With gynecologic chronic pelvic pain, differentiation between hormonally responsive and nonresponsive conditions is helpful for diagnosis and treatment. Therapy can then be instituted or an appropriate referral made.     

Ankle injuries: anatomical and biomechanical considerations necessary for the development of an injury prevention program

This article describes the anatomical and biomechanical principles necessary for the development of an ankle injury prevention program. The structures of the talocrural joint and the subtalar joint are discussed in detail. The biomechanics of these two joints are discussed and their relationship elucidated. The ligamentous structures of the ankle are discussed in detail. Evaluation of the ankle is discussed in conjunction with mechanisms of athletic injuries. Pertinent principles necessary for the development of an injury prevention program for the ankle are presented.J Orthop Sports Phys Ther 1980;1(3):171-     

微动解剖型肩锁钢板的研制及生物力学研究

目的 研制一种符合肩锁关节微动牛理特点的微动解剖犁肩锁钢板,并对其进行生物力学研究,了解该钢板是否符合肩锁关节微动生理特点.方法 根据肩锁关节的解剖学形态及微动生理特点,设计制作出微动解剖型肩锁钢板.牛物力学测试:成人新鲜上肢标本10具,用MTS模拟上肢重力作用对标本进行加载,运用激光扣描仪测量每个标本在正常状态(对照组)、肩锁韧带完全断裂(肩锁组)、肩锁韧带及喙锁韧带均断裂(喙锁组)、克氏针钢丝张力带固定(克氏针组)、AO钩钢板同定(钩钢板组)、微动解剖型肩锁钢板固定(肩锁钢板组)及Dewar手术(Dewar组)后肩锁关节在X、Y、Z轴向的位移及旋转情况.结果微动解剖型肩锁钢板具有微动特点,固定肩锁关节后肩锁钢板组与对照组在各轴向的位移及旋转活动相比较差异均无统计学意义(P＞0.05);肩锁钢板组与克氏针组比较筹异有统计学意义(P＜0.01);在Z轴向上的旋转及Y轴向的位移,肩锁钢板组与钩钢板组比较差异无统计学意义(P值分别为0.85、0.54),但肩锁钢板组与钩钢板组在X、Z轴向上的位移及X、Y轴向的旋转有差异有统计学意义(P＜0.05);肩锁钢板纽与Dewar组在各轴向的比较差异无统计学意义(P＞0.05).结论 微动解剖型肩锁钢板符合肩锁关节的生理微动特点,固定肩锁关节后保留了肩锁关节的活动.＃     

Short isthmic versus long trans-isthmic C2 screw: anatomical and biomechanical evaluation

Introduction

The Harms technique is now considered as the gold standard to stabilize C1–C2 cervical spine. It has been reported to decrease the risk of vertebral artery injury. However, the risk of vascular injury does not totally disappear, particularly due to the proximity of the trans-isthmic C2 screw with the foramen transversarium of C2. In order to decrease this risk of vertebral artery injury, it has been proposed to use a shorter screw which stops before the foramen transversarium.

Object

The main objective was to compare the pull-out strength of long trans-isthmic screw (LS) versus short isthmic screw (SS) C2 screw. An additional morphological study was also performed.

Method

Thirteen fresh-frozen human cadaveric cervical spines were included in the study. Orientation, width and height of the isthmus of C2 were measured on CT scan. Then, 3.5-mm titanium screws were inserted in C2 isthmus according to the Harms technique. Each specimen received a LS and a SS. The side and the order of placement were determined with a randomization table. Pull-out strengths and stiffness were evaluated with a testing machine, and paired samples were compared using Wilcoxon signed-rank test and also the Kaplan–Meier method.

Results

The mean isthmus transversal orientation was 20° ± 6°. The mean width of C2 isthmus was less than 3.5 mm in 35 % of the cases. The mean pull-out strength for LS was 340 ± 85 versus 213 ± 104 N for SS (p = 0.004). The mean stiffness for the LS was 144 ± 40 and 97 ± 54 N/mm for the SS (p = 0.02).

Discussion

The pull-out strength of trans-isthmic C2 screws was significantly higher (60 % additional pull-out resistance) than SSs. Although associated with an inferior resistance, SSs may be used in case of narrow isthmus which contraindicates 3.5-mm screw insertion but does not represent the first option for C2 instrumentation.

Level of evidence

Level V.

     

Analysis of follow-up data from an outpatient pain management program for refractory chronic pain

Background

Numerous reports indicate that multifaceted pain management programs based on cognitive-behavioral principles are associated with clinically meaningful long-term improvements in chronic pain. However, this has not yet been investigated in Japan. This study investigated the effects of a multifaceted pain management program in Japanese patients with chronic pain, both immediately after the program and 6 months thereafter.

前臂骨间膜的解剖及生物力学研究

目的 探讨前臂骨间膜(interosseous membrane,IOM)的解剖及生物力学特性.方法 从10个新鲜冰冻上肢标本中取出尺桡骨连同骨间膜结构,测量腱性部分的长度、宽度及厚度.测量完毕后将骨间膜腱性部分同其尺桡骨附着端一并分离,将标本的桡骨近端及尺骨远端分别用牙托粉包埋固定,标本夹持固定于MTS 858型生物材料试验机上.使用10000N力传感器进行测定,以50mm/min的速度拉伸骨间膜,直至骨间膜断裂.通过计算机采集数据描绘载荷一位移曲线,同时测定骨间膜的最大载荷和刚度.结果 (1)前臂骨间膜由三部分组成:中央腱性部分、两端膜性部分及背侧附属斜索.3个标本中未观察剑背侧附属斜索.骨间膜在前臂中立位时伸展,在前臂旋前及旋后时弯曲.(2)6个标本发生骨间膜腱性部分撕裂,最大载荷为(1021.50+250.13)N,刚度为(138.24±24.29)N/mm,骨间膜的拉伸长度为(9.77+1.77)mm;4个标本在腱性部分撕裂之前发生尺骨固定端骨折,最大载荷为(744.40+109.85)N,刚度为(151.17+30.68)N/mm,骨间膜的拉伸长度为(6.51+0.51)mm.结论 前臂骨间膜是尺桡骨之间具有韧带性质的结构,对维持前臂的纵向稳定至关重要.其解剖学及生物力学数据可以作为评估前臂骨间膜重建方法的客观标准.     

Diagnosis and management of the hypothyroid patient with chest pain

A retrospective analysis of 38 patients undergoing cardiac catheterization with the diagnoses of hypothyroidism and chest pain revealed 23 to be euthyroid while receiving replacement therapy and 15 to be hypothyroid. Cardiac index was significantly reduced (p less than 0.01) in hypothyroid and euthyroid patients with thyroxine values between 4 and 7 micrograms/dl (2.8 +/- 0.7 and 3.0 +/- 0.9 L/min/m2, respectively), compared to euthyroid patients with thyroxine values greater than 7 micrograms/dl with or without coronary artery disease (4.0 +/- 1.2 and 4.0 +/- 0.7 L/min/m2, respectively). Ten hypothyroid patients underwent coronary artery bypass. There were no deaths, and only one patient required prolonged postoperative intubation. With a mean follow-up of 36 months, there have been no myocardial infarctions and one late death, which occurred at 7 years secondary to stroke. We conclude that preoperative thyroid replacement therapy is theoretically dangerous and may not significantly improve hemodynamics until full replacement is achieved. Coronary bypass grafting can be performed safely despite hypothyroidism with excellent early results.     

Photodynamic Diagnosis in Urology: State-of-the-Art

Objectives

To provide an overview on the methodology and clinical relevance of fluorescence diagnosis with exogenous fluorochromes or fluorochrome prodrugs in urology.

Methods

The methodology is summarised on the basis of our experience and the relevant literature. Clinical results and perspectives are reported and concluded after we scanned and evaluated sources from PubMed. Search items were “aminolev*” or “hypericin” or “photodyn*” or “porphyrin” or “fluorescence” or “autofluorescence” and “bladder” or “prostate” or “kidney” or “peni*” or “condylo*”. Some literature was also obtained from journals not indexed.

Results

A large number of clinical trials have shown that photodynamic diagnosis (PDD) improves the ability to detect inconspicuous urothelial carcinoma of the bladder. Fluorescence diagnosis has recently been approved in Europe for the detection of bladder cancer after instillation of a hexaminolevulinate (Hexvix^®) solution. PDD is recommended by the European Association of Urology for the diagnosis of carcinoma in situ of the bladder. To date, the major weakness of PDD for the detection of bladder cancer is its relatively low specificity. Initial results with PDD for the detection of penile carcinoma, prostate cancer, kidney tumours, and urethral condylomata are promising.

Conclusions

To determine the actual impact of PDD on recurrence and progression rates of bladder cancer, further long-term observational studies are necessary. These studies also will clarify whether PDD is cost efficient.     

Ketamine in chronic pain management: an evidence-based review

Ketamine has diverse effects that may be of relevance to chronic pain including: N-methyl-D-aspartic acid, alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid, kainate, gamma-aminobutyric acid(A) receptors; inhibition of voltage gated Na(+) and K(+) channels and serotonin, dopamine re-uptake. Ketamine has been in clinical practice for over 30 yr; however, there has been little formal research on the effectiveness of ketamine for chronic pain management. In this review we evaluate the available clinical data as a basis for defining the potential use of ketamine for chronic pain. Literature referenced in this review was obtained from a computer search of EMBASE and MEDLINE from 1966 through August, 2002. Search terms included ketamine, ketalar, pain, painful, analgesic, and analgesia. Abstracts were screened for relevance and publications relating to chronic pain use were obtained. Levels of evidence were stratified according to accepted guidelines (level I-IV). For central pain, there is level II and level IV evidence of efficacy for parenteral and oral ketamine. For complex regional pain syndromes, there is only level IV evidence of efficacy of epidural ketamine. For fibromyalgia, there is level II evidence of pain relief, reduced tenderness at trigger points, and increased endurance. For ischemic pain, a level II study reported a potent dose-dependent analgesic effect, but with a narrow therapeutic window. For nonspecific neuropathic pain, level II and level IV studies reported divergent results with questionable long-term effects on pain. For phantom limb pain and postherpetic neuralgia, level II and level II studies provided objective evidence of reduced hyperpathia and pain relief was usually substantial either after parenteral or oral ketamine. Acute on chronic episodes of severe neuropathic pain represented the most frequent use of ketamine as a "third line analgesic," often by IV or subcutaneous infusion (level IV). In conclusion, the evidence for efficacy of ketamine for treatment of chronic pain is moderate to weak. However, in situations where standard analgesic options have failed ketamine is a reasonable "third line" option. Further controlled studies are needed.     

Interstitial cystitis/bladder pain syndrome: diagnosis and management

Introduction and hypothesis

The bladder pain syndrome (BPS) is a spectrum of urological symptoms characterised by bladder pain with typical cystoscopic features. Diagnosis and management of this syndrome may be difficult. There is no evidence-based management approach for the diagnosis or treatment of BPS. The objective of this study was to critically review and summarise the evidence relating to the diagnosis and treatment of the bladder pain syndrome.

Methods

A review of published data on the diagnosis and treatment of the BPS was performed. Our search was limited to English-language articles, on the “diagnosis”, and “management” or “treatment” of “interstitial cystitis” and the “bladder pain syndrome” in “humans.”

Results

Frequency, urgency and pain on bladder filling are the most common symptoms of BPS. All urodynamic volumes are reduced in patients with BPS. Associated conditions include psychological distress, depression, history of sexual assault, irritable bowel syndrome and fibromyalgia. Cystoscopy remains the test for definitive diagnosis, with visualisation of haemorrhage on cystoreduction. A multidisciplinary treatment approach is essential in the management of this condition. Orally administered amitriptyline is an efficacious medical treatment for BPS. Intravesical hyaluronic acid and local anaesthetic, with/without hydrodistension are among new treatment strategies. Sacral or pudendal neuromodulation is effective, minimally invasive and safe. Surgery is reserved for refractory cases.

Conclusions

There remains a paucity of evidence for the diagnosis and treatment of BPS. We encountered significant heterogeneity in the assessment of symptoms, duration of treatment and follow up of patients in our literature review.     

Diagnosis and management of ureteric injury: an evidence-based analysis

The Consensus on Genitourinary Trauma continues this month with an evidence‐based analysis, by a team of experts under the chairmanship of Dr Jack McAninch, of current reports on the diagnosis and management of ureteric trauma. This is quite a unique document, and of interest to all urologists; not only as a consensus on how this condition should be managed, but also as a model of how to review current publications.      

Diagnosis and management of sebaceous carcinoma: an Australian experience

Background: Cutaneous sebaceous carcinoma (SC) is a rare malignancy derived from adnexal epithelium of sebaceous glands. Periorbital SC is approximately three times more common than extraorbital SC. To date, there are few data from an Australian source to document the prevalence or clinical outcome of this tumour. Methods: A retrospective review was undertaken of the cases from the Institute of Clinical Pathology and Medical Research using their histopathology database for patients with a diagnosis of SC. Patients were identified over a period of 34 years from 1971–2005 and their management and follow up are reported. Results: There were 25 patients in all. Seventeen were men and eight were women. Of the 25 cases, 12 were extraorbital and 13 were periorbital. Three metastases and one tumour showed extensive local invasion. There were nine cases of incomplete excisions and 13 patients were reoperated on for either incomplete excisions, to obtain a wider margin or for local recurrences. Adjuvant radiotherapy was used on five patients, three of whom had lymph node deposits. Conclusion: Sebaceous carcinoma is a rare tumour. Extraorbital SC is an aggressive and invasive malignancy. Excision margins may need to be wider than previously thought. Exposure to ultraviolet radiation (sunlight) may play a role in the aetiology. Wide excision and selective use of radiotherapy remain the treatment of choice.