Endoscopic carpal tunnel release: a cadaveric study

Monoclonal antibodies against the irreversible alkylator N-ethyl-1-[2-(4-isothiocyanothienyl)]cyclohexylamine (ITCE) of the 1-[1-(2-thienyl)cyclohexyl]piperidine (TCP) binding site of the N-methyl-D-aspartate receptor were raised. Each antibody was characterized in a competition enzyme-linked immunosorbent assay (ELISA) with a range of TCP analogs. It was found that each monoclonal antibody has a different affinity profile for the various TCP analogs. No correlation between the structure of the side chain groups of each compound and the selective affinities of the antibodies could be deduced, indicating that the overall affinity of the antibodies is determined by more than just the sum of the interaction forces with each ligand's functional groups. In addition to the possible identification of endogenous TCP-like compounds these antibodies could be used as a model to study the molecular interaction between drugs and their receptors' active sites.     

Effect of calcaneal osteotomy and lateral column lengthening on the plantar fascia: a biomechanical investigation

OBJECTIVES: To evaluate the efficacy and safety of one single intravenous methylprednisolone (IVMP) pulse therapy in myasthenia gravis. MATERIAL AND METHODS: We performed a double blind placebo controlled study (2+2 g IVMP vs placebo) in patients with moderate MG. RESULTS: A mean increase in muscle function of 27 points was found in the treatment group after one IVMP pulse as compared with a 0.7 point increase in the placebo group (P<0.01). In the IVMP group 8 of 10 patients showed a positive treatment response. The mean duration of improvement after IVMP was 8 weeks (range 4-14 weeks). No severe side effects were found. Acetylcholine receptor antibody concentrations were unchanged in spite of the positive treatment response. CONCLUSIONS: We conclude that a single IVMP treatment is efficacious and safe in the treatment of moderate MG.     

Endoscopic carpal tunnel release

The aspects of various techniques for endoscopic carpal tunnel release, including the Chow technique, the Japanese technique, and the Agee technique, are reviewed. Anesthesia, portal placement, and ligament cutting techniques are considered. Clinical results, complications, and long-term outcomes of the Chow technique are summarized.     

Endoscopic carpal tunnel release

We describe a computer program, named DNA-Protein Search (DPS), for comparing a megabase DNA sequence with a protein sequence database. The DPS program addresses the problems of frameshifts and introns in the DNA sequence. The DPS program was used to compare each of the following sequences with the Swiss-Prot database: the 1.8-megabase sequence of the Haemophilus influenzae Rd genome, the 0.58-megabase sequence of the Mycoplasma genitalium genome, and the 0.56-megabase sequence of Saccharomyces cerevisiae chromosome VIII. The comparisons found new regions that are similar to protein sequences. The sensitivity of DPS was evaluated using as test data the known coding regions of the three DNA sequences. The results demonstrate that the DPS program is a useful tool for finding the coding regions of the DNA sequence. The DPS program uses an order of magnitude less computer memory and is several times faster than the BLASTX program.     

Persistent trigeminal artery: an anatomic study

INTRODUCTION: The most frequent embryonic communication between the vertebrobasilar and carotid systems is a persistent trigeminal artery (PTA). It has been observed in 0.1 to 0.2% of cerebral angiograms. We found this variation in an anatomic specimen, and after microscopic dissection, we performed an analysis of the course of the PTA and its relationship with the abducens nerve and the meningohypophyseal trunk. METHOD: A PTA was incidentally encountered in an injected cadaver specimen during a transpetrosal approach. This embryonic variation and its anatomic relationship are discussed. RESULTS: The PTA can take either a lateral or medial course regarding its relationship with the abducens nerve. When the PTA originates from the posterolateral aspect of the posterior bend of the cavernous carotid artery (C4 segment), it crosses underneath and distorts the abducens nerve, continuing between the abducens and trigeminal nerves. When taking a medial course, the PTA arises from the posteromedial aspect of the posterior bend of the cavernous carotid at the same segment and pierces the clival dura at the dorsum sellae. Cranial nerve displacement or distortion is less likely in this variation. In an analysis of carefully described anatomic studies, the PTA and meningohypophyseal trunk were found arising from either common or separated origins. CONCLUSION: The most frequent embryological anastomosis between the carotid and vertebrobasilar system is the PTA. Its course and relationship with the cranial nerves may determine its clinical presentation.     

Rehabilitation after aortic valve replacement with autologous fascia lata: a sociomedical study

In a series of 50 patients who underwent aortic valve replacement with frame-supported fascia lata, 32 were seen for a combined medical and psychosocial examination 10 to 33 months postoperatively. The investigation included a psychometric test battery and an interview concerning the patient's social and psychological situation at the time of the operation and at follow-up. Twenty-seven patients had improved in their New York Heart Association Functional Classification at the time of follow-up. In most instances NYHA classification correlated well with the patients' subjective opinion on their recovery. Those who for various reasons were not able to return to work did not consider themselves recovered. The employment rate after operation was 66%. There is a great need for more information and support to families as well as for more intensive rehabilitation efforts, especially vocational, for the postoperative patient.     

The tragus as a donor area of cartilage grafts: anatomic study

The American Dental Association (ADA) has developed many resources to address growing concerns regarding HIV (human immunodeficiency virus) issues in dental practice, including continuing education courses, workshops, journal articles, and monographs. In addition, the ADA Council on Dental Practice has established a network for dentists with HIV/AIDS (acquired immune deficiency syndrome). The network has been named PEERS, which stands for Prevention, Education, Ethics, Resources, and Support. This paper provides guidelines for developing programs in each state to address the needs of dentists with HIV/AIDS.     

Translaminar facet screw placement: an anatomic study

OBJECTIVE: To compare case register data on the frequency and distribution of known dementia cases in a metropolitan area population with expected total numbers computed from a national disability survey. METHOD: Known cases were enumerated by a cross-sectional census of the Camberwell Dementia Register. Expected total numbers were calculated using the Cognitive Disability (CD) Planning Model, based on the OPCS national survey of disability, 1985-86. RESULTS: Cases ascertained by the Dementia Register census comprised one-fifth of expected total prevalence. The proportion of such cases was higher for persons in long-stay care (1 in 3) than for those in private households (1 in 7). According to the CD Planning Model, cases known to specialist agencies were on average no more severely disabled and dependent than those who were unknown. In terms of absolute numbers, the district nursing and home help services appeared to be the most important untapped sources of case detection, but other research indicates that general practice contacts (not included in the planning model) may be at least equally important. CONCLUSIONS: At any given time, a high proportion of dementia cases, whether in long-stay care or in the community, will be outside the purview of specialist services. Primary care agencies are a major potential source, and a systematic health screening of persons aged over 75 years could be used to realize this potential.     

The peritoneal free flap: an anatomic study

In view of a possible clinical application of an isolated microvascular peritoneal flap, an anatomic study was performed in order to determine the peritoneal vascular territory of the deep inferior epigastric artery. For this, the deep inferior epigastric artery was injected unilaterally with Araldite in 30 embalmed cadavers and bilaterally with india ink in 15 fresh cadavers. In 70 percent of the embalmed cadavers, a constant pattern of three branches from the deep inferior epigastric artery could be identified. The peritoneal vascular supply is not derived solely from these three branches but also from multiple small branches sprouting directly from the main stem of the deep inferior epigastric artery and from segmental and muscular branches. Therefore, classification of peritoneal branches arising from the deep inferior epigastric artery seems to be of little clinical importance. In all cases, the india ink injected in the deep inferior epigastric artery colored a similar territory of the parietal peritoneum. Considering the magnitude of the peritoneal vascularization by the deep inferior epigastric artery, implementation of an isolated free or pedicled peritoneal flap seems to be possible. Such a microvascular peritoneal flap vascularized by the deep inferior epigastric artery may be used, for example, for reconstruction of mucosal defects in the head and neck region.     

Desire for perioperative information in adult patients: a cross-sectional study

Ninety-one patients burn-injured in their childhood were assessed by mailed interview and clinical re-examination in 1994. On average, the patients had sustained injuries to 11.9 per cent (SD = 8.8) of their TBSA (maximum 50 per cent), the injuries were mainly scalds (90.1 per cent). Nineteen patients (20.9 per cent) remembered the event and 23 (25.3 per cent) remembered their hospitalisation. The hospitalisation vignettes were significantly associated with painful memories among children older than 3 yr (Fisher's exact test P = 0.04). Seventeen patients (18.7 per cent) had recollections of pain during hospitalisation. They had been confined for an average of 30.9 days. Twenty-one patients (23.1 per cent) had a fear of hot water and fire, and 39 (42.9 per cent) were cautious. The median age at the time of admission was 1.7 yr. The re-examined patients had good school marks and their rate of educational qualifications did not differ from the Finnish national average. No less than one fifth (20.8 per cent, N = 11) had some difficulties with contact with the opposite gender in their adolescence but only one had difficulties later. Fifty-five patients (mostly female, chi 2 = 13.06, DF = 2, P < 0.01) expressed annoyance at their scars, but no more than one third (N = 17) kept them covered continuously. Only five (5.5 per cent) with visible scars had no memories or special psychosocial sequelae. Almost everyone burn-injured in childhood will have some memories of burn care as an adult. However, the negative psychosocial sequale are modest after the typical paediatric burns, scalds, in early childhood.     

The compartments of the hand: an anatomic study

To determine the nature and number of enclosed myofascial spaces in the hand, an anatomic study that included 21 cadaver hands was conducted using a gelatin injection method. Data were collected from the prepared cross-sections of each specimen. The results showed the thenar space to comprise 2 or more discrete compartments in 52% of the hands. In 76% of the specimens, the hypothenar space demonstrated at least 2 compartments. The adductor pollicis and first dorsal interosseous muscles were discrete compartments in 71% of the hands. The interosseous compartments demonstrated significant variability. The dorsal and palmar interosseous muscles were discrete compartments within the second interosseous compartment in 48% of the hands, within the third interosseous compartment in 67%, and within the fourth interosseous compartment in 33%. Subcompartmentalization of the enclosed myofascial spaces of the hand should be anticipated in cases requiring fasciotomy. Thorough inspection within anatomic areas or generous release of the muscular origin along the metacarpal at the time of fasciotomy is suggested to ensure complete inspection.     

Nutritional influences on bone mineral density: a cross-sectional study in premenopausal women

The association between current and past dietary intake and bone mineral density (BMD) was investigated in 994 healthy premenopausal women aged 45-49 y. BMD was measured with dual-energy X-ray absorptiometry (DXA). Dietary intake was assessed with a food-frequency questionnaire (FFQ). Energy-adjusted nutrient intakes were grouped into quartiles and mean BMD at the lumbar spine (LS), femoral neck (FN), femoral trochanter (FT), and femoral Wards (FW) were calculated. With higher intakes of zinc, magnesium, potassium, and fiber, LS BMD was significantly higher (P < 0.05-0.006), and a significant difference in LS BMD was also found between the lowest and highest quartiles for these nutrients and vitamin C intake (P < 0.05-0.01). These results remained significant after adjustment for important confounding factors. LS BMD and FT BMD were lower in women reporting a low intake of milk and fruit in early adulthood than in women with a medium or high intake (P < 0.01). High, long-term intake of these nutrients may be important to bone health, possibly because of their beneficial effect on acid-base balance.     

Angiosomes of the leg: anatomic study and clinical implications

In 1987, Taylor and Palmer introduced the angiosome concept. This anatomical study defined the three-dimensional vascular territories supplied by source arteries and veins to each tissue layer between the skin and the bone. This report, however, was an overview investigation and did not study each region of the body in fine detail. In 1996, Inoue and Taylor studied the angiosomes of the forearm in much greater detail. They showed, among other findings, that the zone between the angiosomes, formed by reduced caliber (choke) vessels or similar caliber (true) anastomotic arteries, occurred usually within tissues, especially the muscles, not between them. This study focuses on the same region in the lower limb to draw a comparison and to fill certain voids in our knowledge--the leg. Twelve lower limbs from fresh cadavers were investigated over a 2-year period after perfusing each with a mixture containing radio-opaque lead oxide. The anatomy of the arterial supply to the skin, the muscles, and the periosteum of the bones of the leg was examined. The contribution to each tissue was defined by dissection, by metal clip tagging of vessels, by radiography, and by mapping the branches with colored pins, coded to match the respective source arteries. A subtraction technique was used to study the muscles whereby the bones of the limb were replaced with radiolucent balloons to obtain an unobscured picture of the vasculature of the leg. The muscles were then segregated one by one from the muscle mass and x-rayed again. Next, cross-section studies were made in two legs to complete the three-dimensional picture, tracing the branches from the source arteries to each layer. Finally, the contribution to each tissue from the popliteal, sural, anterior tibial, posterior tibial, and peroneal vessels were color coded to match these source arteries, thus defining the angiosomes of the leg. Results, as in the forearm, showed that in most cases the connections between adjacent angiosomes occurred within tissues, not between them. The skin, the bones, and most muscles received branches from two or more angiosomes, thus revealing one of the important anastomotic pathways through which the circulation is reconstituted when a source artery is interrupted by disease or trauma. Notably, however, the muscles of the anterior compartment of the leg were supplied from one angiosome. This finding, coupled with the anatomy of the rigid fascial compartments of the leg, helps explain the variable clinical pictures and syndromes seen in cases in which the circulation is compromised or interrupted. Finally, this anatomical study adds further information to help design or redesign flaps in the leg for local or free transfer. Similarly, the information reveals the pathways through which the supply to the remaining tissues is reconstituted when one of the source arteries is harvested with a free flap, especially when multiple tissues are included in the transplant.     

Biomechanical consequences of plantar fascial release or rupture during gait: part I--disruptions in longitudinal arch conformation

To examine whether conformational changes induced by plantar fascial division may progress during gait, we loaded the feet of seven cadavers using an apparatus that simulates the actions of the extrinsic plantarflexors. We measured the effects of plantar fasciotomy at two instants in the terminal-stance phase of gait. Radiographic measurements of height of the arch, base length of the arch, and talo first-metatarsal angle were used to assess contributions to arch support made by the plantar fascia, tibialis posterior, peroneus longus and brevis, and digital flexor muscles. Complete fasciotomy caused significant collapse of the arch in the sagittal plane. Early in terminal stance, at the instant after heel-off, mean height of the arch decreased from 47 to 45 mm. Late in terminal stance, at the instant preceding contralateral heel strike, mean height of the arch decreased from 46 to 43. Effects of division of the central band, though significant, were mild. Medial base length of the arch increased from 163 to 167 mm in the absence of tibialis posterior contraction at late terminal stance. Arch-supporting abilities of the other extrinsic muscles were insignificant.     

The angiosomes of the forearm: anatomic study and clinical implications

The angiosome concept was introduced in 1987 by Taylor and Palmer. Their anatomic study correlated the blood supply to the skin from the named segmental or distributing "source" arteries with their supply to the underlying muscles, tendons, nerves, and bones. Although this investigation encompassed the body, there were areas where the supply to individual tissues was not examined in detail. The present study, therefore, examines one of these regions where certain voids in our knowledge still exist--the forearm. Ten upper limbs from fresh cadavers were studied over an 18-month period after perfusing each with a radiopaque lead oxide mixture. The arterial supply to the skin and the bones of the forearm, together with that of a total of 200 muscles, was examined. The contribution to each was defined by dissection, by metal clip tagging of vessels, by radiography, and by mapping the branches with colored pins coded to match the respective source arteries. In the case of the muscles, a subtraction technique was used whereby the bones of the extremity were replaced with radiolucent balloons to obtain an unobscured picture of the forearm vasculature. Then the muscles were removed one by one from the muscle mass and x-rayed again. In this way, the angiosomes in the forearm, provided by the brachial, radial, ulnar, and interosseous arteries, were defined. Similarly, the contribution from each angiosome to the skin, to each muscle, and to the radius and the ulna was identified and the territories were color-coded to match these source arteries. Results showed that in most cases the connections between adjacent angiosomes occurred within tissues, not between them. The skin, the bones, and most muscles received branches from the source arteries of at least two angiosomes, thus revealing one of the important anastomotic pathways by which the circulation is reconstituted in those cases where a source artery is interrupted by disease or trauma. Several muscles, however, were supplied within one angiosome. This helps explain the variable clinical pictures seen in cases where the circulation is interrupted, such as that which occurs in a Volkmann's ischemic contracture. Finally, this anatomic study provides further information to help design various flaps from the forearm for local or free transfer. In the case of muscles, the supply to most from multiple angiosomes allows for refinements whereby a portion only of a muscle can be used. Similarly, this anatomic information reveals the pathway by which the supply to remaining muscle groups is reconstituted when one of the source arteries is harvested with a skin flap, a muscle, or part thereof.