Concomitant injuries after upper ankle joint dislocations

Functional treatment with the Air Stirrup Ankle Brace recommended by C. N. Stover in 1979 can reduce pathological inversion of the ankle joint. In our retrospective study of 109 patients treated by this kind of ankle brace we found 96 patients (88%) with excellent results. Only 13 patients (12%) reported moderate to good results. To detect and characterize their painful conditions of ankles we did a clinical, radiological and MRI-Investigation. In only 2 cases we found a moderate instability after clinical investigation, anterior stress roentgenogram and talar tilt. By using the MRI-investigation 1.0 Tesla with a 512 x 360 Matrix we could find 10 cases with osteochondral lesions of the ankle. In 7 cases there was separated ossicle in the fibulotalar joint, in 1 case we detected a fracture of the processus anterior tali, in another case we could see a posttraumatic lesion of the talus and calcaneus with bone bruise and at least one osteochondral fracture of the distal tibia. The capability of the MRI to detect particularly osteo-chondral lesions of the talus and the tibiofibular joint was shown in 10 of 13 cases. Therefore we recommend to do an MRI-investigation on all patients after ankle sprain if there are painful conditions within the ankle after conservative treatment.     

Arthroscopy of the knee joint

A manual version and mechanized versions for several types of analyzers are described for the kinetic determination of glucose with glucose dehydrogenase. Results of glucose determinations with and without deproteinization of samples are discussed. The correlation of results with the hexokinase method is shown.     

Current indications for reimplantation of the upper extremity

In the last decades there has been a great development in microsurgery that has enabled successful replantation of totally severed parts. Nowadays, the important issue is to decide which segments should be replanted, in order to achieve a good functional result. In this paper we study the indications and contraindications of replantation, based in our experience and we present a review of the recent literature. We consider the following aspects: general condition and age of the patient, mechanism of lesion, amputation level, ischemic time and also economic aspects. We conclude that replantation should be attempted in thumb and multiple digits amputations, in amputations at the palm, wrist and forearm, in single digit amputations distal to the flexor superficialis insertion and in any case in children.     

Therapy of ankle joint fractures (author's transl)

Even severely dislocated ankle joint fractures can be fixed in the right position and healed by immediate reposition. Irreponible fractures, ruptures of the syndesmosis, shortening of the fibula and abruptions of tibial edges require timely operative treatment with osteosynthesis, the individual forms of which are demonstrated. The screws fixing the syndesmosis must be removed in time in order to prevent their loosening or breaking. Fixations in hypercorrective position have proved to be unphysiological. Walking plaster, however, are better than training with crutches without the possibility of loading. The combination of osteosynthesis and walking plaster will contribute to the development of an early self-sufficiency on the part of the operated patient.     

Contribution of the anterolateral joint capsule to the mechanical stability of the ankle

Published reports describe the clinical efficacy of modified Brostrom anatomic repairs, surgical procedures that involve repair and fortification of the lateral capsuloligamentous complex of the ankle for patients suffering from chronic lateral instability of this joint. A cadaveric serial sectioning study of the anterior talofibular ligament, the calcaneofibular ligament, and the remainder of the anterolateral joint capsule was completed to quantitate the contribution of the superior portion of the anterolateral joint capsule, independent of the other two structures, to the overall mechanical stability of the lateral ankle. Using 20 fresh frozen specimens, talar tilt and anterior drawer stress radiographs were taken before and after sectioning these anatomic structures in an order established by one of two protocols. Sectioning of the superior anterolateral joint capsule caused 17% to 18% of the total displacement in a Grade II sprain simulation and 29% to 33% of the total displacement in a Grade III sprain simulation. This work suggests that disruption of the segment of ankle joint capsule superior to the anterior talofibular ligament creates approximately 30% of the overall laxity encountered in a Grade III inversion sprain, substantiating the principle of restoring the integrity of the entire anterolateral joint capsule when operating on a chronically unstable ankle.     

External rotational injury of tha ankle joint with displacement of the talus

The mechanism of second-degree external rotational injury of the ankle, with fracture of the lower end of the fibula, is discussed with reference to experiments on an anatomical model. It is concluded that with this type of injury there is lateral displacement of the talus because the deltoid ligament is ruptured, but there is no diastasis of the inferior tibiofibular syndesmosis. The results of conservative treatment of 10 patients with second-degree external rotational injury of tha ankle are reviewed.     

Right to left differences in the ankle joint complex range of motion

In most eukaryotic cells, synthesis of the iron storage protein, ferritin is regulated by iron levels and redox conditions. Proper iron storage is important to protect against damaging iron-catalysed free radical reactions. Although iron-catalysed reactions are believed to contribute to oxidative damage and cataractogenesis, little is known about iron storage in the lens. In this study, ferritin concentration was measured in cultured canine lens epithelial cells. Baseline ferritin concentration ranged from 76-163 ng (mg protein)-1; cells cultured in low-iron media had significantly lower ferritin levels than cells cultured in iron-supplemented media. Addition of a large excess of iron as hemin resulted in an eight-fold increase in ferritin concentration. The iron chelator, Desferal, significantly decreased ferritin concentration. The reducing agent dithiothreitol decreased the hemin-induced increase in ferritin levels, but not baseline levels. In contrast, ascorbic acid induced a large increase in ferritin content. Other studies have shown that induction of ferritin synthesis can protect against oxidative damage. Regulation of ferritin levels may represent a mechanism by which the lens epithelium is protected from oxidative damage. In vivo, epithelial cells are normally exposed to much lower iron concentrations than the cultured lens epithelial cells in this study. However, in pathological circumstances, the iron content and redox state of the aqueous humor is dramatically altered and may affect the steady state levels of ferritin within the lens. This remains to be determined.     

Control of torque direction by spinal pathways at the cat ankle joint

To study the biomechanics of the calcaneal tendon's complex insertion onto the calcaneus, we measured torque-time trajectories exerted by the triceps surae and tibialis anterior muscles in eight unanesthetized decerebrate cats using a multi-axis force-moment sensor placed at the ankle joint. The ankle was constrained to an angle of 110 degrees plantarflexion. Muscles were activated using crossed-extension (XER), flexion (FWR), and caudal cutaneous sural nerve (SNR) reflexes. Torque contributions of other muscles activated by these reflexes were eliminated by denervation or tenotomy. In two animals, miniature pressure transducers were implanted among tendon fibers from the lateral gastrocnemius (LG) muscle that insert straight into the calcaneus or among tendon fibers from the medial gastrocnemius (MG) that cross over and insert on the lateral aspect of calcaneus. Reflexively evoked torques had the following directions: FWR, dorsiflexion and adduction; SNR, plantarflexion and abduction; and XER, plantarflexion and modest abduction or adduction. The proportion of abduction torque to plantarflexion torque was always greater for SNR than XER; this difference was about 50% of the magnitude of abduction torque generated by tetanic stimulation of the peronei. During SNR, pressures were higher in regions of the calcaneal tendon originating from MG than regions originating from LG. Similarly, pressures within the MG portion of the calcaneal tendon were higher during SNR than during XER, although these two reflexes produced matched ankle plantarflexion forces. Selective tenotomies and electromyographic recordings further demonstrated that MG generated most of the torque in response to SNR, while soleus, LG, and MG all generated torques in response to XER.(ABSTRACT TRUNCATED AT 250 WORDS)     

Arthroscopy of the knee

Arthroscopy of the knee was first performed early this century. However, it became generally accepted and grew to be a major contributor to orthopaedic surgery only during the last two decades. It has improved our understanding of numerous knee pathologies and allowed us to treat many of these disorders with considerably less morbidity. But there remain areas that warrant attention. Training in arthroscopic technique needs to be intensified and our knowledge of knee conditions should be improved if we are to avoid certain pitfalls and complications during arthroscopic surgery. Another issue that must be addressed is the inappropriate use and abuses of arthroscopic surgery of the knee. Improved audit, that insist on photographic documentation of the lesion before and after treatment is suggested to curb this latter problem.     

Acute upper respiratory tract infections and indications for tonsillectomy in children. I. Immunoglobulin synthesis in the palatine tonsil tissue

Current viewpoints and practice concerning indications for tonsillectomy are presented. The annual specific risk for upper respiratory infection in children aged up to 15 is 1.1. The risk is higher in the youngest age group, in whom it rises to 1.8, decreasing with age and being lowest among children aged 12-15 years (0.5). The proportion of tonsillitis among acute upper respiratory tract infections is highest in the age group up to 3 years (36.9%); at the age of 4-5 years it is 37.1%, and is lowest among children aged 12-15 years (21.9%). The risk of tonsillitis caused by streptococci is highest among children aged up to 5 years. Statistical significance of differences in the synthesis of immunoglobulins (G, M, A and sA) and lysozymes in the palatine tonsil tissue of tonsillectomized children and healthy volunteers was tested by non-parametric tests for independent samples. Significant differences of the above mentioned syntheses were found in all entities studied. Any contribution to the documentation on the nature and cause of each tonsillitis in childhood is of great clinical value, because it is the only basis for rational consideration of indications for tonsillectomy.     

Histological indications of a progressive snorers disease in an upper airway muscle

The etiology of upper airway collapsibility in patients with snoring and obstructive sleep apnea (OSA) remains unclear. Local muscular abnormalities, including neurogenic lesions, could be a contributory factor. The aim of this study was to histologically evaluate the hypothesis of a progressive snorers disease. Biopsies of palatopharyngeal muscle were obtained from 21 patients with habitual snoring and different degrees of upper airway obstruction (10 patients with OSA) and 10 nonsnoring control subjects. Morphological abnormalities, including neurogenic signs (e.g., type grouping), were blindly quantified. The degree of abnormality was significantly increased in patients compared with control subjects. The individual score of abnormalities was significantly correlated to the percentage periodic obstructive breathing but not to oxygen desaturation index. Analyses of the individual fiber-size spectra demonstrated a significantly increased number of hypertrophied and/or atrophied fibers in patients compared with controls. The subjects were also divided into three groups according to their type of nocturnal breathing, i.e., nonsnorers, patients with < 20%, and patients with > or = 45% obstructive breathing. These groups correlated significantly with the degree of abnormality and pathological fiber-size spectra. In conclusion, these results support the hypothesis of a progressive local neurogenic lesion, caused by the trauma of snoring, as a possible contributory factor to upper airway collapsibility.     

Force and motion analysis of the normal, diseased, and prosthetic ankle joint

A 2-dimensional motion and force study of the ankle joint during gait has been carried out on normal subjects and patients with ankle joint disease, before and 1 year following total ankle replacemetn. The methods employed involved the use of high-speed motion picture film, force plate and foot-switch data. The Achilles and anterior tibial tendon forces, the compressive and tangential (shear) forces across the ankle during stance phase of gait were determined, based on a quasi-static analysis. During stance phase of gait normal subjects used a mean of 24.4 degree of sagittal plane ankle motion. Patients with ankle joint disease showed reduced motion which returned to near normal values 1 year following total ankle replacement. Compressive force across the ankle joint rose to about 5 times body weight during the latter part of stance phase. Backward, or aft, shear forces or nearly full body weight were demonstrated during all but the last 20% of stance phase. Patients with ankle joint disease apparently altered their gait to markedly reduce these forces. Following total ankle replacement, shear forces returned toward more normal values, but compressive forces were not significantly changed.     

Age-related indications for cheiloplasty in congenital and acquired defects of the upper lip--an anthropological study

Age-related changes in width (cheilion-cheilion) and height (subnasale-stomion) of the upper lip are studied in 2300 healthy Bulgarians, with ages ranging from three days to 102 years, for the needs of cheiloplasty in both surgery and fine arts. As shown by the results, at birth the upper lip in either gender appears to be one of the most developed organs of the human body, continuing to augment in size up to the eighth decade of life. In preschool age it terminates its intensive development, and in the puberty period it fails to exhibit the growth leap characteristic of the organism as a whole. Throughout the period of postnatal ontogeny, with the exception of early infancy, the lip in the male gender remains bigger, with the difference for height being rather markedly expressed during the ninth decade (3, 8 mm), and for width--thereafter (5.24 mm). The conclusion is reached that cheiloplasty may be undertaken regardless of the patient's age, during the early postnatal days inclusive, and the dimensions recorded for the age intervals being examined may serve as standard values.