Effects of the adductor pollicis and abductor pollicis brevis on thumb metacarpophalangeal joint laxity before and after ulnar collateral ligament reconstruction

PURPOSE: The intrinsic muscles and ulnar capsuloligamentous structures (UCLS), which consist of the ulnar collateral ligament (UCL), accessory UCL, dorsal capsule, and volar plate of the thumb metacarpophalangeal (MCP) joint are important for controlling the motion and stability of the MCP joint during pinch. The purpose of this cadaveric study was to determine the effects of the adductor pollicis (AdP) and abductor pollicis brevis (APB) on the 3-dimensional MCP joint laxity before transection of the UCLS and after reconstruction of the UCL and repair of the dorsal capsule. METHODS: Loads were applied to the flexor pollicis longus (FPL) alone, to the AdP and FPL in combination, and to the APB and FPL in combination in 11 cadavers. This was done in the intact joint after the UCLS were transected and after the UCL was reconstructed for flexion angles of 0 degrees, 15 degrees, 30 degrees, and 45 degrees. The spatial positions of the proximal phalanx and the metacarpal of the MCP joint were measured with a 6-degrees-of-freedom digitizing system. RESULTS: In the intact joint combined loading of the AdP and FPL did not affect the position of the proximal phalanx. Combined loading of the APB and FPL changed the position of the phalanx from an ulnar to a radial shift and from an ulnar to a radial deviation and it increased pronation. After transection of the UCLS combined loading of the FPL and AdP increased supination of the MCP joint and combined loading of the FPL and APB increased radial shift, radial deviation, and pronation of the joint. Reconstruction of the UCL restored normal laxity to the MCP joint. CONCLUSIONS: The AdP failed to affect MCP joint motion. The ABP produced a radial shift and radial deviation of the MCP joint and increased pronation of the thumb. Transection of the UCLS increased joint laxity for each of the combined loadings and reconstruction of the UCL restored normal laxity to the MCP joint.     

Pathological study of experimental osteoporosis

Effects of uni- or bi-lateral resection of the sciatic nerve followed by calcium deficiency on the bone structure of the adult male rat were studied and the mechanism of the development of osteoporosis was discussed. After the evaluation of the thickness of the cortex and trabecula of the lower leg bone by X-ray morphometry, the bone was excised, calcium and phosphate contents of the bone were analyzed and histopathological and ultrastructural examinations were made on the calcaneus and the lower leg bone. Reduction of the bone trabecular area and of the thickness of the cortex, a loss of dry weight and of calcium and phosphate contents and decrease in the number of osteoblasts and osteocytes were induced to the bone with sciatic denervation. The ultrastructural changes of the osteogenic cells were also observed. The osteoblasts turned to be smoothly surfaced showing only a few cytoplasmic projections were connected loosely each other. These changes were enhanced by calcium deficiency. We concluded from these results that the disturbance of nerve connection and the calcium deficiency contributed to the development of experimental osteoporosis of rats.     

Instability of the distal tibiofibular syndesmosis after bimalleolar and trimalleolar ankle fractures

We studied the late results after bimalleolar and trimalleolar ankle fractures in thirty-four patients after an average follow-up of four years. Twenty-one patients had had open reduction and internal fixation of the medial malleolus only and thirteen, internal fixation of both the medial malleolus and the lateral malleolus. Twenty-four lesions were supination-external rotation fractures; six, pronation-external rotation; and four, supination-adduction fractures. All initial and post-reduction roentgenograms were evaluated, and the patients were re-evaluated two to seven years after fracture. Re-evaluation included physical examination as well as standardized and stress roentgenograms of both ankles. Criteria were developed for measuring the width of the syndesmosis and assessing the late roentgenographic, subjective, and objective results, as well as any late instability of the syndesmosis and osteoarthritis. Significant correlations were found between: (1) the adequacy of the reduction of the syndesmosis and late arthritis, (2) the adequacy of the initial reduction of the syndesmosis and the late stability of the syndesmosis, (3) the late stability of the syndesmosis and the final outcome, and (4) the adequacy of the reduction of the lateral malleolus and that of the syndesmosis. Based on the findings in this small series and on the evidence published in the literature, we concluded that adequate reduction of the syndesmosis is necessary to achieve a stable ankle following supination-external rotation and pronation-external rotation fractures of the ankle, and that the reduction of the syndesmosis will be unsatisfactory if the lateral malleolus is not well reduced.     

Continuous and Connective Fibers of the Lateral Ankle Ligament Complex

The lateral ankle ligament complex (LALC) is an intricate structure; therefore precise anatomic knowledge is required by the surgeon. However, the structural relationship of the LALC remains unclear. Here, the features of the posterior talofibular ligament (PTFL) and the relationship to the LALC at the distal fibula were clarified in a cadaver study. The lengths of most of the anterior and posterior parts, and the widths of the anterior-posterior and superior-inferior parts, were measured with a digital caliper. In addition, the relationship between the anterior talofibular ligament (ATFL) and PTFL inside of the capsule is described. The small fiber bundles of the PTFL were manually divided, and the footprint of each bundle at the fibula and talus was clarified. The relationship between the ATFL and CFL, outside of the capsule, was examined on axial slices at the inferior fibula. The lengths of the most anterior and most posterior parts of the PTFL were 9.8 ± 1.7 and 29.4 ± 1.9 mm, respectively. The widths of the anterior-posterior and superior-inferior parts were 10.0 ± 0.9 and 5.8 ± 1.1 mm, respectively. Approximately 83% of the fibers between the ATFL and PTFL were continuous. The anterior-inferior fibers of the PTFL were continuous with the inferior fibers of the ATFL inside of the capsule. The ATFL and CFL converged with connective tissue from outside of the capsule at the distal fibula. The results of this study should prove useful to further clarify the relationships of the LALC both inside and outside of the capsule at the distal fibula.     

Role of ions and ion channels in capacitation and acrosome reaction of spermatozoa

Capacitation and acrosome reaction are important prerequisites of the fertilization process. Capacitation is a highlycomplex phenomenon occurring in the female genital tract, rendering the spermatozoa capable of binding and fusionwith the oocyte. During capacitation various biochemical and biophysical changes occur in the spermatozoa and thespermatozoal membranes. Ions and ion channels also play important roles in governing the process of capacitation bychanging the fluxes of different ions which in turn controls various characteristics of capacitated spermatozoa. Alongwith the mobilization of ions the generation of free radicals and efflux of cholesterol also plays an impo~.nt role in thecapacitation state of the spermatozoa. The generation of free radical and efflux of cholesterol change the mechano-dynamic properties of the membrane by oxidation of the polyunsaturated lipids and by generating the cholesterol freepatches. The process of capacitation renders the spermatozoa responsive to the inducers of the acrosome reaction. Theglycoprotein zona pellucida 3 (ZP3) of the egg coat zona pellucida is the potent physiological stimulator of the acro-some reaction; progesterone, a major component of the follicular fluid, is also an inducer of the acrosome reaction.The inducers of the acrosome reaction cause the activation of the various ion-channels leading to high influxes of calci-um, sodium and bicarbonate. The efflux of cholesterol during the process of capacitation alters the permeability of themembrane to the ions and generate areas which are prone to fusion and ve.siculation process during the acrosome reactioa. this review focuses mainly on effects of the ion and ion-channels, free radicals, and membrane fluidity changesduring the process of capacitation and acrosome reaction.     

基于“重阳思想”论原发性骨质疏松症的病因病机与治疗

原发性骨质疏松症是一种常见的慢性代谢性疾病,严重影响中老年人群的生存质量。但西药治疗原发性骨质疏松症不良反应较多,因此应当发挥中医药治疗原发性骨质疏松症的优势。中医认为肾为先天之本,藏精,生髓,在体合骨;脾为后天之本,在体合肉,主四肢,为气血生化之源;脾肾二脏具有先后天相互资助的关系,二者功能的正常发挥有赖于阳气的激发、推动。"重阳思想"作为中医认识疾病的重要思想理论之一,其核心思想为阳主阴从观,认为治疗疾病应注重顾护阳气,并善用温阳之品。该文从"重阳思想"的角度出发探讨脾肾阳虚与原发性骨质疏松症发生的关系,结合现代医学对温肾健脾中药治疗原发性骨质疏松症的疗效及作用机制进行阐释,认为治疗原发性骨质疏松症应重视温肾健脾。由于目前相关作用机制的研究尚且不足,认为今后可以加强对温肾健脾中药治疗原发性骨质疏松症作用机制的研究,并发掘中医理论与现代科学的结合之处,以发扬中医药理论的优势。     

Hüftarthroskopie

Arthroscopy of the hip joint can be performed in the supine or lateral position. The decision whether to use the supine or lateral position appears to be more a matter of individual training or habit. Both positions have specific pros and cons. The operative experience with arthroscopy of the central and peripheral compartment shows that a combined procedure with and without traction is beneficial. Whereas arthroscopy of the central compartment in normal joints of adults is feasible only with traction, the peripheral compartment can be better scoped without traction. The combination of both techniques however is technically demanding. Particularly for arthroscopy of the central compartment with traction, the success of the operative procedure is strongly correlated with a correct technique of positioning and distraction. Precise positioning and thick padding of the counterpost, secure fixation and thick padding of the foot, and the limitation of magnitude and duration of traction are important features in order to avoid soft tissue and nerve damage. Good relaxation, joint position, and distension of the joint to break the joint vacuum significantly improve distraction of the femoral head from the socket. In combination with fluoroscopy, scope trauma to the acetabular labrum and hyaline cartilage can be minimized. For arthroscopy of the peripheral compartment without traction, the counterpost is removed and the foot taken out of the traction module for free range of motion of the leg and hip joint. This allows dynamic testing of the hip and access to different parts of the peripheral labrum, proximal femur, and soft tissues.     

Die Sprechstunde

On the theme of Linus Geisler's nine steps for a successful consultation between doctor and patient, the ability for self-criticism, the ability to be able to listen to oneself and the value of the doctor-patient relationship in the context of medical practice will be discussed. Subsequently, the framework of the consultation, the consulting room atmosphere and the complete setting of the consultation will be dealt with. The importance of active listening and the recognition of all messages, both verbal and from body language, will be particularly emphasized. The capability for empathy is presented as the necessary bridge to recognition of the feelings and inner world of the patient. Because one only sees what one is looking for and only recognizes what one knows, the recognition of typical complaints presented by patients in a consultation represents the "something" which must be specifically elucidated. The problems and symptoms which the patient brings to the doctor are surrounded by a ring of fears and apprehensions. For this reason it is decisive to uncover the accompanying cloud of fears and apprehensions with appropriate questions, to correctly assign the unsettling symptoms of the patient and to be able to correctly interpret them. As illustrated by the language of nature - the translation of deoxyribonucleic acid (DNA) triplets into amino acids - the translation of biological, psychological and social aspects of the complaints symptomatic into the level of diagnosis and the translation of the referential, social and affective meaning of the expressions used by the patient, into the level of the significance will be discussed. The role of the doctor here is that of a producer of context and a skilled translator.In the management of functional disorders and chronic diseases the construction of a shared reality is important. The therapeutic function of consultations is due to an introduction of metaphors as bridges - bridges to an improved understanding of the body, the self and the world. The role of the physician here is that of a moderator, motivator an accompanying person. Finally, Jaspers levels of good doctoring (natural science or causal level, nursing level, communicative-existential level) are stressed and the importance of a good patient-physician relationship for a patient-centered medicine is underlined.     

益气温阳、活血化瘀方对兔血管成形术后再狭窄PDGF-B mRNA表达的影响

目的探讨中药复方对兔实验性经皮腔内血管成形术(PTA)血管成形术后血管壁血小板衍生生长因子B链(PDGF-B)mRNA表达的影响。方法新西兰兔54只随机分为假手术组、模型组、中药组,采用一次球囊导管损伤方法制备兔颈动脉球囊损伤模型,于术后1周、2周、4周取材,HE染色进行定量组织形态学分析和RT-PCR法半定量检测分析PDGF-B mRNA的表达。结果中药组、模型对照组与假手术组相比,管腔狭窄程度明显加重,内膜与中膜面积之和明显增大;与模型组相比,中药组在2周、4周时管腔面积明显增大、管腔的狭窄程度、内膜与中膜面积之和显著降低,在1周、2周时PDGF-B的mRNA表达水平明显增高。结论益气温阳、活血化瘀方可能通过下调血管壁PDGF-B的mRNA表达水平,从而抑制平滑肌细胞的增殖和血管成形术后再狭窄。     

Lisfranc joint displacement following sequential ligament sectioning

BACKGROUND: There are two primary radiographic patterns of Lisfranc instability, transverse and longitudinal. There is no single diagnostic method with which to consistently confirm the diagnosis of an unstable injury. Our purpose was to define which ligament disruptions produce these two injury patterns and to compare the utility of weight-bearing and stress radiographs for detecting each pattern of instability. METHODS: Ten fresh-frozen cadaveric lower extremities were dissected to expose the dorsal aspect of the midfoot. Radiographic markers were placed at the base of the second metatarsal and the distal borders of the first and second cuneiforms. The specimens underwent sectioning of the interosseous first cuneiform-second metatarsal (Lisfranc) ligament and were then divided into two groups. The transverse group underwent sectioning of the plantar ligament between the first cuneiform and the second and third metatarsals at the plantar aspect of the second cuneiform-second metatarsal joint, whereas the longitudinal group underwent sectioning of the interosseous ligament between the first and second cuneiforms. Weight-bearing, adduction, and abduction stress radiographs were made before and after each ligament was sectioned. The radiographs were digitized, and displacement was recorded. Instability was defined as >or=2 mm of displacement. RESULTS: Weight-bearing radiographs made after the Lisfranc (first cuneiform-second metatarsal) ligament alone was sectioned were diagnostic (showed instability) for one of ten specimens. Abduction stress radiographs were diagnostic for two of five specimens, and adduction stress radiographs were diagnostic for zero of five specimens. In the transverse group (sectioning of the plantar ligament between the first cuneiform and the second and third metatarsals), weight-bearing radiographs were diagnostic on the basis of first cuneiform-second metatarsal displacement for one of five specimens but were not diagnostic on the basis of second cuneiform-second metatarsal displacement for any of five specimens. Abduction stress radiographs were diagnostic on the basis of displacement of both the first cuneiform-second metatarsal and the second cuneiform-second metatarsal joints for five of five specimens. In the longitudinal group (sectioning of the interosseous ligament between the first and second cuneiforms), weight-bearing radiographs were diagnostic on the basis of first cuneiform-second metatarsal displacement for one of five specimens and were diagnostic on the basis of displacement between the first and second cuneiforms for one of five specimens. Adduction stress radiographs were diagnostic on the basis of first cuneiform-second metatarsal displacement for one of five specimens and were diagnostic on the basis of displacement between the first and second cuneiforms for four of five specimens. CONCLUSIONS: Transverse instability required sectioning of both the interosseous first cuneiform-second metatarsal ligament and the plantar ligament between the first cuneiform and the second and third metatarsals. Longitudinal instability required sectioning of both the interosseous first cuneiform-second metatarsal ligament and the interosseous ligament between the first and second cuneiforms. Compared with weight-bearing radiographs, injury-specific manual stress radiographs showed qualitatively greater displacement when used to evaluate both patterns of instability.     

Office-based surgery and anesthesia

Health care delivery is undergoing a revolutionary change. It is focusing rapidly all over the world towards outpatient and home care. One of the most obvious results of these changes has been the relative explosion office-based surgery and anesthesia; however, these are not new concepts. Dentistry and office-based anesthesia have always been closely intertwined. In 1844, two dentists, Wells and Morton, changed the practice of anesthesia firstly with the use of nitrous oxide and secondly with ether for tooth extraction. Thereafter, office-based surgery and anesthesia continued to evolve. In the past two decades, the rapid development of new surgical technologies and pharmaceuticals have facilitated the movement of more invasive surgical procedures and anesthesia to less invasive settings, such as the doctor's office. The most significant recent changes in health care are changes in the consumer, the practitioner and the provider. All are demanding high quality anesthesia and surgery care at a reduced cost. Articles describing almost every type of surgical and anesthetic techniques in the office can be found in the literature. However, the success of providing safe and cost-effective surgical and anesthetic care at an office depends on major issues, including adequate selection of the surgical procedure, complete preoperative assessment of the patient's state of health and adequate equipment and design of the unit. It is incumbent upon practitioners to make certain that the safety of the hospitals is not sacrificed in the office setting. Health care has to be delivered as safely in the office as it would be elsewhere. Regulations and guidelines should be established in consultation with surgeons, anesthesiologists and administrators to ensure safe health care. These guidelines should be based on the specific type of surgery, the level of anesthetic required and the design of the office. This way the provision of adequate quality of care is ensured. Office-based anesthesia and surgery will no doubt continue to evolve because it is safe, pleasing and convenient for the patient and of low cost.     

电烧伤后肘关节纤维性强直的解剖学基础与临床治疗

目的　探讨电烧伤后肘关节纤维性强直并神经损伤的较好治疗方法。　方法　取30块健康成人肘关节固定标本,进行解剖学观察。对笔者单位10例电烧伤并发肘关节纤维性强直的患者,采用屈、伸肘功能重建的方法进行治疗,即松解尺、桡侧副韧带的前、后束与延长肱二、三头肌肌腱,同时下移内上髁处前臂屈肌群起点的附着点、前置尺神经,以生物力学观察标准进行疗效评价。　结果　通过对健康成人肘关节的解剖学观察可知,如果尺、桡侧副韧带后束与肱三头肌废用性挛缩,可引起肘关节伸直位强直;如果尺、桡侧副韧带前束与肱二头肌废用性挛缩,可引起肘关节屈曲位强直。10例电烧伤患者的术后功能恢复满意。术后随访1—3年,患者肘关节屈伸范围不变,灵活度加强。结论　重建屈、伸肘功能是治疗电烧伤后肘关节纤维性强直的关键,如同时下移内上髁处前臂屈肌群起点的附着点、前置尺神经,可进一步改善关节屈曲与神经嵌压。     

骨质疏松症治疗药物的分类与用药选择

骨质疏松症是影响老年骨骼健康的主要疾病，其致残率和致死率高，严重影响着患者的生活质量和寿命，并给家庭和社会带来巨大人力和经济负担。随着人口老龄化进程的加剧，骨质疏松症越来越为社会所关注，抗骨质疏松药物研究已成为热点。传统的分类方法是按药物作用机制进行分类，种类繁多的药物使临床用药选择困难。治疗过程中应该既要考虑药物作用机制又要考虑患者个体机能，本着方便选择用药的原则进行了重新分类。     

Biomechanik des Becken-Bein-Übergangs

The anatomical axes of the body parts and the mechanical axis of the lower extremity play a central role for the load transmission from hip to femur and tibia. These axes essentially determine both the statics and kinetics of the lower extremity. The movements of the joints (kinematics), however, are essentially determined by the anatomy and morphometry of the body parts. The maximum movement capacity of the joints is rarely exploited in the physiologic movement of the joints. Finally, the resulting forces and moments which act on the bones and the joints are partly determined by the weight and the inertia of the body parts. The major contributor to force and moment, however, results from the action of the muscles. The muscle forces and their action through short lever arms explain the substantial loads in hip and knee.     

烧伤休克微循环障碍及其与TNF的关系

为了探讨大鼠烧伤休克早期血浆 TNF 含量和微循环的变化,以及虎杖4号对上述变化的影响,我们采用复制的大鼠 TBSA 35%～40%烧伤休克模型。用 L929细胞株生物法测定了血浆 TNF含量的变化。在显微电视放大4000倍条件下观察大鼠脊斜肌微循环变化,对部分动物的肺做了病理形态学观察,并观察了虎杖4号对上述改变的影响。结果表明,大鼠烧伤休克早期血浆肿瘤坏死因子(TNF)含量即明显升高,其升高程度与微循环中 WBC 附壁粘着及毛细血管的关闭程度呈明显的正相关。应用虎杖4号可明显抑制烫伤后血浆 TNF 的升高。同时亦明显减轻 WBC 的附壁粘着和肺损伤。提示烫伤后血浆 TNF 的升高参与了 WBC 的粘着和微循环紊乱的发生。     

基于平调阴阳理论防治糖皮质激素性骨质疏松症

糖皮质激素性骨质疏松症（glucocorticoid osteoporosis，GIOP）是长期或过量使用糖皮质激素，从而影响骨重建过程造成的。依据糖皮质激素在体内的生理病理作用和动态变化，中医学认为糖皮质激素造成的机体阴阳失衡是GIOP发病的根本原因；病变关键在肾，肾阴阳失衡是病机发展转化的核心，表现为“肾阴虚-肾阳虚-肾阴阳两虚”的演变规律；脏腑亏虚，气血阻滞，骨骼失养是核心病机，病理变化始终强调动态性和复合性。据此确立“平调阴阳”的治疗大法，基于平调肾阴阳理论防治GIOP，一方面强调平调阴阳一定是一个动态平衡过程，另一方面在平调肾阴阳的同时调节一身阴阳的平衡以病证结合、辨证论治，并平调原发病之阴阳以治未病，最终达到阴阳平衡、血脉通利、筋骨得养的状态。现代研究表明细胞自噬是阴阳动态平衡的微观机制，是“平调阴阳”法改善GIOP的防治靶点。可见，平调阴阳是临床防治GIOP的一个重要思路。     

The operative cure of hallux valgus and bunions

The main basic factors in the etiology of hallux valgus and bunions are the adduction of the metatarsal bone of the big toe and the obliquity of its tarsometatarsal joint.The conspicuous and obvious causes of the discomfort and disability are the valgus of the big toe, bony overgrowth at the base of the big toe and the overlying bursa or bunion.The author's operation aims to correct all of the pathological changes without disturbing the function of the big toe joint or the weight bearing surface of the head of the first metatarsal.The adduction of the first metatarsal bone is corrected by the removal of a double wedge from the tarsometatarsal joint, the mobilization of the metatarsal bone and the manual approximation of the first and the second metatarsal.The overgrowth of bone on the head of the metatarsal and the bunion are excised through a separate incision.The correction of the valgus of the big toe is assured by securing to the metatarsal bone a tongue of strong tissue, consisting of bursal wall and capsule, which is attached to the base of the phalanx.Care is exercised not to remove or in any way disturb the articulating portion of the head of the metatarsal bone. This accomplishes two results, namely, the support of the forefoot is not altered and the mobility of the big toe is not diminished.By bringing the big toe into line with the inner border of the foot, the sesamoid bones are returned to their normal relation to the head of the metatarsal, and the dorsal and plantar tendons of the big toe are brought into a normal or nearly normal position, where they can function properly.     

The effect of the methods of anesthesiological assistance and blood oxygenation on the oxygen-transport properties of the blood in reconstructive interventions on the abdominal aorta and vessels of the lower extremities]

Methemoglobin (MtHb) formation was studied during reconstructive operations on the abdominal aorta and its branches. It was established that the appearance of pain at rest and trophic tissue disorders in the lower extremities causes intensification of MtHb formation. The intensity of MtHb formation increases sharply during the operation and is determined by the injurious character of the intervention, level of arterial blood oxygenation, and the efficacy of nociceptive pulsation block. Arterial blood hyperoxia proved to be among the most important factors of increased MtHb formation and decreased blood oxygen capacity. Nociceptive pulsation block is less effective in general anesthesia than in epidural anesthesia and also increases the content of MtHb in the blood and the severity of the stress and reperfusion damages of the tissues and organs. On the basis of the results of the study it is concluded that normoxia of arterial blood and denervation of the operative zone reduce the risk of ischemic and hypoxic complications in patients with generalized atherosclerosis.