Isolated ruptures of the supraspinatus muscle

We rarely encounter isolated ruptures of the supraspinatus muscle. At the Clinic of Orthopedics at the Faculty Hospital in Olomouc, we encountered only 21 cases out of 385 arthroscopic operation cases from October 1998 to October 2003. The patients were examined by USG, 5 patients were examined arthrographically and 3 patients underwent MRI examination. Of these 21 patients, only 3 were operated for acute post-injury haemarthrosis of the shoulder joint. During arthroscopic operation, an isolated rupture of the supraspinatus muscle was discovered in all these patients. The remaining 40 patients were only treated at our clinic for problems associated with impingement syndrome after an interval of 3-11 months and were indicated for operational therapy for the rupture of the supraspinatus muscle, verified sonographically and by MRI. Surgically we performed end to end sutures in 12 patients, in 9 cases we performed refixation using 1-2 titanium MITEK anchors. We supplemented the work by a detailed anatomical study of the supraspinatus muscle on 27 cadaverous anatomical preparations. It was noted that the supraspinatus muscle may be divided into three parts, with a superficial and deep layer of muscle fascicles. An aponeurotic insertion tendon runs through the center, to which part of the superficial muscle fascicles are attached. The muscle fascicles, including the central attachment tendon, run across the superior margin of the shoulder joint and by broad tendon are attached to the superior surface of the greater tubercle of the humerus. Together with the long head of the biceps muscle, they act as a significant shoulder stabiliser. The authors believe that due to the course of the muscle fascicles, this muscle acts as a significant shoulder stabiliser and a powerful abductor and elevator in the shoulder joint. The inferior portion of the muscle fascicles acts as an external rotator of the shoulder.     

Measuring muscle and joint geometry parameters of a shoulder for modeling purposes.

An extensive set of muscle and joint geometry parameters was measured of the right shoulder of an embalmed male. For all muscles the optimal muscle fiber length was determined by laser diffraction measurements of sarcomere length. In addition, tendon length and physiological cross-sectional area were determined. The parameter set was needed to enhance the reliability of a computer model of the shoulder (Van der Helm, 1994a,b Journal of Biomechanics 27, 527-550, 551-569). With the model, an abduction of the arm was simulated in seven positions, at 30 degrees intervals. In each of the simulated arm positions, actual sarcomere lengths were calculated from the lengths of 104 muscle elements, distributed over 16 shoulder muscles. For most muscle elements, the simulated abduction appeared to take place within the sarcomere length range in which the muscle elements can exert force. The muscle elements can then act on the ascending limb as well as on the plateau and on the descending limb of the relative force-length curves of sarcomeres. The produced data set is not only important for the refinement of shoulder modeling, but also for functional analyses of shoulder movements in general.     

Untreated silicone breast implant rupture

Implant rupture is a well-known complication of breast implant surgery that can pass unnoticed by both patient and physician. To date, no prospective study has addressed the possible health implications of silicone breast implant rupture. The aim of the present study was to evaluate whether untreated ruptures are associated with changes over time in magnetic resonance imaging findings, serologic markers, or self-reported breast symptoms. A baseline magnetic resonance imaging examination was performed in 1999 on 271 women who were randomly chosen from a larger cohort of women having cosmetic breast implants for a median period of 12 years (range, 3 to 25 years). A follow-up magnetic resonance imaging examination was carried out in 2001, excluding women who underwent explantation in the period between the two magnetic resonance imaging examinations (n = 44). On the basis of these examinations, the authors identified 64 women who had at least one ruptured implant at the first magnetic resonance imaging examination and, for comparison, all women who had intact implants at both examinations (n = 98). Magnetic resonance images from the two examinations were compared and changes in rupture configuration were evaluated. Comparisons were also made for self-reported breast symptoms occurring during the study period and for changes in serum values of antinuclear antibodies, rheumatoid factor, and cardiolipin antibodies immunoglobulin G and immunoglobulin M. The majority of the women with implant rupture had no visible magnetic resonance imaging changes of their ruptured implants. For 11 implants (11 percent) in 10 women, the authors observed progression of silicone seepage, either as a conversion from intracapsular into extracapsular rupture (n = 7), as progression of extra-capsular silicone (n = 3), or as increasing herniation of the silicone within the fibrous capsule (n = 1); however, in most cases, these changes were minor. Some changes could be ascribed to trauma, but others seemed spontaneous. There was no increase in levels of autoantibodies during the study period in either study group. Women with untreated implant ruptures reported a significant increase in nonspecific breast changes (odds ratio, 2.1; 95 percent confidence interval, 1.2 to 3.8) compared with women without ruptures. On the basis of this first study of women with untreated silicone breast implant rupture, the authors conclude that implant rupture is a relatively harmless condition, which only rarely progresses and gives rise to notable symptoms. Even so, because of a small risk of silicone spread, the authors suggest that women with implant ruptures be followed clinically, if not operated on. Because implant ruptures often occur asymptomatically, any woman with silicone implants, regardless of rupture status, should be evaluated at regular intervals.     

Muscles within muscles: Coordination of 19 muscle segments within three shoulder muscles during isometric motor tasks.

The aim of the present study was to determine how the intra-muscular segments of three shoulder muscles were coordinated to produce isometric force impulses around the shoulder joint and how muscle segment coordination was influenced by changes in movement direction, mechanical line of action and moment arm (ma). Twenty male subjects (mean age 22 years; range 18-30 years) with no known history of shoulder pathologies, volunteered to participate in this experiment. Utilising an electromyographic technique, the timing and intensity of contraction within 19 muscle segments of three superficial shoulder muscles (Pectoralis Major, Deltoid and Latissimus Dorsi) were studied and compared during the production of rapid (e.g. approximately 400ms time to peak) isometric force impulses in four different movement directions of the shoulder joint (flexion, extension, abduction and adduction). The results of this investigation have suggested that the timing and intensity of each muscle segment's activation was coordinated across muscles and influenced by the muscle segment's moment arm and its mechanical line of action in relation to the intended direction of shoulder movement (e.g. flexion, extension, abduction or adduction). There was also evidence that motor unit task groups were formed for individual motor tasks which comprise motor units from both adjacent and distant muscles. It was also confirmed that for any particular motor task, individual muscle segments can be functionally classified as prime mover, synergist or antagonist - classifications which are flexible from one movement to the next.     

Direction-specific recruitment of rotator cuff muscles during bench press and row

Recent studies indicate that rotator cuff (RC) muscles are recruited in a reciprocal, direction-specific pattern during shoulder flexion and extension exercises. The main purpose of this study was to determine if similar reciprocal RC recruitment occurs during bench press (flexion-like) and row (extension-like) exercises. In addition, shoulder muscle activity was comprehensively compared between bench press and flexion; row and extension; and bench press and row exercises. Electromyographic (EMG) activity was recorded from 9 shoulder muscles sites in 15 normal volunteers. All exercises were performed at 20, 50 and 70% of subjects’ maximal load. EMG data were normalized to standard maximal voluntary contractions. Infraspinatus activity was significantly higher than subscapularis during bench press, with the converse pattern during the row exercise. Significant differences in activity levels were found in pectoralis major, deltoid and trapezius between the bench press and flexion exercises and in lower trapezius between the row and extension exercises. During bench press and row exercises, the recruitment pattern in each active muscle did not vary with load. During bench press and row exercises, RC muscles contract in a reciprocal direction-specific manner in their role as shoulder joint dynamic stabilizers to counterbalance antero-posterior translation forces.     

The Use of Biodegradable Implants in the Fixation of Small Animal Cancellous Bone Fractures

In this study the cancellous bone fractures of 10 dogs and 2 cats were surgically treated with biodegradable implants to fixate the fractures. The implants were made of selfreinforced PGA homopolymers. The patients were allowed to walk on their operated limbs immediately after the fixation and they started to use them within one week. All patients except one used their operated limbs without lameness in 6 weeks and the twelfth case in 8 weeks, due to a postoperative periosteal infection. Radiographically, the fractures of 10 patients healed in 6 weeks and in 12 weeks in 2 cases. No other pathological reactions in the bone could be seen in the radiographs than the periosteal infection. Because the implants resolved spontaneously there was no need for a second operation to remove them.     

Assessment of biomechanical parameters of the shoulder joint at the operated side versus non-operated side in patients treated surgically for breast cancer

Aim

Isokinetic assessment of biomechanical parameters of the shoulder joint at the operated side versus non-operated side in patients treated surgically for breast cancer according to the type of surgery performed.

Direct cord implantation in brachial plexus avulsions: revised technique using a single stage combined anterior (first) posterior (second) approach and end-to-side side-to-side grafting neurorrhaphy

Background

The superiority of a single stage combined anterior (first) posterior (second) approach and end-to-side side-to-side grafting neurorrhaphy in direct cord implantation was investigated as to providing adequate exposure to both the cervical cord and the brachial plexus, as to causing less tissue damage and as to being more extensible than current surgical approaches.

Methods

The front and back of the neck, the front and back of the chest up to the midline and the whole affected upper limb were sterilized while the patient was in the lateral position; the patient was next turned into the supine position, the plexus explored anteriorly and the grafts were placed; the patient was then turned again into the lateral position, and a posterior cervical laminectomy was done. The grafts were retrieved posteriorly and side grafted to the anterior cord. Using this approach, 5 patients suffering from complete traumatic brachial plexus palsy, 4 adults and 1 obstetric case were operated upon and followed up for 2 years. 2 were C5,6 ruptures and C7,8T1 avulsions. 3 were C5,6,7,8T1 avulsions. C5,6 ruptures were grafted and all avulsions were cord implanted.

Results

Surgery in complete avulsions led to Grade 4 improvement in shoulder abduction/flexion and elbow flexion. Cocontractions occurred between the lateral deltoid and biceps on active shoulder abduction. No cocontractions occurred after surgery in C5,6 ruptures and C7,8T1 avulsions, muscle power improvement extended into the forearm and hand; pain disappeared.

Limitations include

spontaneous recovery despite MRI appearance of avulsions, fallacies in determining intraoperative avulsions (wrong diagnosis, wrong level); small sample size; no controls rule out superiority of this technique versus other direct cord reimplantation techniques or other neurotization procedures; intra- and interobserver variability in testing muscle power and cocontractions.

Conclusion

Through providing proper exposure to the brachial plexus and to the cervical cord, the single stage combined anterior (first) and posterior (second) approach might stimulate brachial plexus surgeons to go more for direct cord implantation. In this study, it allowed for placing side grafts along an extensive donor recipient area by end-to-side, side-to-side grafting neurorrhaphy and thus improved results.

Level of evidence

Level IV, prospective case series.     

Electromyographic analysis of rotator cuff muscles in patients with rotator cuff tendinopathy: A systematic review

The shoulder is inherently an unstable joint which heavily relies on the neuromuscular activation of the rotator cuff (RC) complex for stability during movement. Currently, there is no consensus regarding how the activity of RC muscles is affected among individuals with a RC tendinopathy (RCTe). This study reviewed the evidence of studies comparing the electromyographic (EMG) activity of any RC muscle of shoulders with a symptomatic RCTe to asymptomatic shoulders. Eight databases were searched. Data from 343 participants (201 symptomatic and 209 asymptomatic shoulders) were analyzed from 10 out of 402 included studies. Strong evidence for the infraspinatus and supraspinatus during isometric contractions and limited evidence for the supraspinatus and infraspinatus during isokinetic contractions suggest that the muscular activity is not altered among individuals with a RCTe during these types of contraction. Very limited evidence indicates reduced muscle activity for the infraspinatus and subscapularis in the presence of a RCTe during isotonic contractions, and no alterations for the supraspinatus or teres minor were identified. Lastly, conflicting to moderate evidence suggests alterations in RC muscle activity during unrestrained movements and swimming. These findings indicate that EMG deficits associated with a RCTe can best be appreciated during unrestrained movements.     

Characterizing upper limb muscle volume and strength in older adults: a comparison with young adults

Aging is associated with the loss of muscle volume (MV) and force leading to difficulties with activities of daily living. However, the relationship between upper limb MV and joint strength has not been characterized for older adults. Quantifying this relationship may help our understanding of the functional declines of the upper limb that older adults experience. Our objective was to assess the relationship between upper limb MV and maximal isometric joint moment-generating capacity (IJM) in a single cohort of healthy older adults (age ≥ 65 years) for 6 major functional groups (32 muscles). MV was determined from MRI for 18 participants (75.1±4.3 years). IJM at the shoulder (abduction/adduction), elbow (flexion/extension), and wrist (flexion/extension) was measured. MV and IJM measurements were compared to previous reports for young adults (28.6±4.5 years). On average older adults had 16.5% less total upper limb MV compared to young adults. Additionally, older adult wrist extensors composed a significantly increased percentage of upper limb MV. Older adult IJM was reduced across all joints, with significant differences for shoulder abductors (p<0.0001), adductors (p=0.01), and wrist flexors (p<0.0001). Young adults were strongest at the shoulder, which was not the case for older adults. In older adults, 40.6% of the variation in IJM was accounted for by MV changes (p≤0.027), compared to 81.0% in young adults. We conclude that for older adults, MV and IJM are, on average, reduced but the significant linear relationship between MV and IJM is maintained. These results suggest that older adult MV and IJM cannot be simply scaled from young adults.     

INJURIES OF THE MUSCULOTENDINOUS CUFF OF THE SHOULDER

Injuries of the musculotendinous cuff are frequent and often cause long periods of disability.The cuff is subject to progressive degenerative changes which are visible microscopically in most persons past 30 years of age, and visible grossly in those past 40. The cuff ruptures through areas of degeneration.A great majority of patients recover good shoulder function under conservative treatment.Operation is not urgent. Accurate diagnosis of a complete tear of the cuff cannot be made until the acute phase of injury has passed, and delay in operating does not decrease chances of good results.     

Complications after hip rearthroplastics with revision endoprosthesis

The stability of the revision endoprosthesis components is more difficult to achieve than in primary endoprosthesis due to large bone defects and/or decreased bone mass quality. That is the reason for more frequent complications for revision than in primary arthroplasty. The aim of this study was to investigate the frequency of complications in 122 patients who were operated with the revision endoprosthesis in the Department of Orthopedics in University Hospital Split in the period of 1998 to 2007 and accepted to participate in this study. There were 3 patients treated on bought hips. The average follow up time was four years (0.6-10.6). There were 32 (26.2%) males and 90 (73.8%) females. The average age was 70.66 +/- 7.63 years. The average time from operation to physical therapy was 3.53 +/- 2.56 days. There were 27 (21.6%) complications. The most common complication was infection in 9 (7.2%) cases. From those cases, 4 (3.2%) had superficial, and 5 (4%) had deep infection. From other complications, there were 5 (4%) endoprosthesis reluxations, 2 (1.6%) periprosthetic femur fractures, 5 (4%) urinary infections, and 6 (4.8%) other complications (lung mycroembolia, heart infarction, lumbal plexus lesion from L2, spinal cord infarction with paraplegia, pneumonia and severe sacral bed-sore). There were 10 (8%) re-interventions following the revision arthroplasty. The result was good or excellent in 80% of operated patients, satisfied in 17%, and bad in 3%. The revision hip procedures are characterized with a high complications incidence rate. Our results are comparable with the results from literature.     

Axillary artery injury combined with delayed brachial plexus palsy due to compressive hematoma in a young patient: a case report

Aim

To prove the possibility of axillary nerve conduction changes following shoulder subluxation due to hemiplegia, in order to investigate the usefulness of screening nerve conduction studies in patients with hemiplegia for finding peripheral neuropathy.

Methods

Forty-four shoulders of twenty-two patients with a first-time stroke having flaccid hemiplegia were tested, 43 ± 12 days after stroke onset. Wasting and weakness of the deltoid were present in the involved side. Motor nerve conduction latency and compound muscle action potential (CMAP) amplitude were measured along the axillary nerve, comparing the paralyzed to the sound shoulder. The stimulation was done at the Erb's point whilst the recording needle electrode was inserted into the deltoid muscle 4 cm directly beneath the lateral border of the acromion. Wilcoxon signed rank test was used to compare the motor conduction between the sound and the paralytic shoulder. Mann-Whitney test was used to compare between plegic and sound shoulder in each side.

Results

Mean motor nerve conduction latency time to the deltoid muscle was 8.49, SD 4.36 ms in the paralyzed shoulder and 5.17, SD 1.35 ms in the sound shoulder (p < 0.001). Mean compound muscle action potential (CMAP) amplitude was 2.83, SD 2.50 mV in the paralyzed shoulder and was 7.44, SD 5.47 mV in the sound shoulder (p < 0.001). Patients with right paralyzed shoulder compared to patients with right sound shoulder (p < 0.001, 1-sided for latency; p = 0.003, 1-sided for amplitude), and patients with left paralyzed shoulder compared to patients with left sound shoulder (p = 0.011, 1-sided for latency, p = 0.001, 1-sided for amplitude), support the same outcomes. The electro-physiological changes in the axillary nerve may appear during the first six weeks after stroke breakout.

Conclusion

Continuous traction of the axillary nerve, as in hypotonic shoulder, may affect the electro-physiological properties of the nerve. It most probably results from subluxation of the head of the humerus, causing demyelinization and even axonopathy. Slowing of the conduction velocities of the axillary nerve in the paralyzed shoulders may be related also to the lowering of the skin temperature and muscular atrophy in the same limb. The usefulness of routine screening nerve conduction studies in the shoulder of hemiplegic patients seems to be advocated.     

C-Reactive Protein,Erythrocyte Sedimentation Rate and Orthopedic Implant Infection

Background

C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) have been shown to be useful for diagnosis of prosthetic hip and knee infection. Little information is available on CRP and ESR in patients undergoing revision or resection of shoulder arthroplasties or spine implants.

Methods/Results

We analyzed preoperative CRP and ESR in 636 subjects who underwent knee (n = 297), hip (n = 221) or shoulder (n = 64) arthroplasty, or spine implant (n = 54) removal. A standardized definition of orthopedic implant-associated infection was applied. Receiver operating curve analysis was used to determine ideal cutoff values for differentiating infected from non-infected cases. ESR was significantly different in subjects with aseptic failure infection of knee (median 11 and 53.5 mm/h, respectively, p = <0.0001) and hip (median 11 and 30 mm/h, respectively, p = <0.0001) arthroplasties and spine implants (median 10 and 48.5 mm/h, respectively, p = 0.0033), but not shoulder arthroplasties (median 10 and 9 mm/h, respectively, p = 0.9883). Optimized ESR cutoffs for knee, hip and shoulder arthroplasties and spine implants were 19, 13, 26, and 45 mm/h, respectively. Using these cutoffs, sensitivity and specificity to detect infection were 89 and 74% for knee, 82 and 60% for hip, and 32 and 93% for shoulder arthroplasties, and 57 and 90% for spine implants. CRP was significantly different in subjects with aseptic failure and infection of knee (median 4 and 51 mg/l, respectively, p<0.0001), hip (median 3 and 18 mg/l, respectively, p<0.0001), and shoulder (median 3 and 10 mg/l, respectively, p = 0.01) arthroplasties, and spine implants (median 3 and 20 mg/l, respectively, p = 0.0011). Optimized CRP cutoffs for knee, hip, and shoulder arthroplasties, and spine implants were 14.5, 10.3, 7, and 4.6 mg/l, respectively. Using these cutoffs, sensitivity and specificity to detect infection were 79 and 88% for knee, 74 and 79% for hip, and 63 and 73% for shoulder arthroplasties, and 79 and 68% for spine implants.

Conclusion

CRP and ESR have poor sensitivity for the diagnosis of shoulder implant infection. A CRP of 4.6 mg/l had a sensitivity of 79 and a specificity of 68% to detect infection of spine implants.     

Self-reported diseases and symptoms by rupture status among unselected Danish women with cosmetic silicone breast implants

Epidemiologic evidence does not support an association between silicone breast implants and connective tissue or other rheumatic diseases. However, a recent study has suggested that women with ruptured implants may be at increased risk of developing fibromyalgia. An analysis of adverse health outcomes according to breast implant rupture status was conducted in 238 unselected Danish women with cosmetic silicone breast implants. Ninety-two of the women had definite implant rupture, and 146 had intact implants as determined by magnetic resonance imaging. Before undergoing imaging, the women provided blood samples and completed a self-administered questionnaire. Women with ruptured implants overall, and the subgroup with extracapsular ruptures (n = 23), were compared with women with intact implants regarding a number of self-reported diseases and symptoms and the presence of specific autoantibodies, such as antinuclear antibodies, rheumatoid factor, and cardiolipin immunoglobulin G and M antibodies. Overall, there were no differences in the occurrence of self-reported diseases or symptoms or in the presence of autoantibodies between women with intact implants and women with ruptured implants, including extracapsular rupture. The only exception was capsular contracture, which was reported six times more frequently by women with extracapsular ruptures than by women with intact implants (OR, 6.3; 95 percent CI, 1.7 to 23.5). In conclusion, this study of unselected women with silicone breast implants could establish no association between silicone implant rupture and specific diseases or symptoms related to connective tissue disease or other rheumatic conditions, except for an excess of capsular contracture among women with extracapsular rupture.     

Capacities of ultrasound study in a follow-up of patients with lower extremity varicose veins after phlebectomy

The study was undertaken to estimate the capacities of triplex ultrasound angioscanning in patients with lower extremity varicose veins in the late period after phlebectomy. Seventy patients operated on for the underlying disease were examined. According to the duration of the underlying disease, all the patients were divided into 4 groups: 1) 4 (5.7%) patients had a 5-year history of lower limb varicose veins; 2) 16 (22.9%) had a 5-to-15-year history; 3) 42 (60%) had a 15-to-25-year history; 4) 8 (11.4%) had a more than 25-year history. The ultrasonic marker of recurrent lower limb varicose veins was the re-emergence of dilated saphenous and perforating veins, as well as valve apparatus failure in the operated leg. In groups 1, 2, and 3, a recurrence of the underlying disease was detected just 2 years after surgical treatment. Good results could be obtained with multimodality treatment: phlebosclerotherapy at early stages of the disease, followed by phlebectomy, or multiple phlebosclerotherapy from the earliest stages. Ultrasound study (USS) is the most rational method for screening diagnosis in case of abnormal veins of the lower extremities in the postoperative period. USS carried out at early disease stages and in the postoperative period permits prevention of recurrent lower limb varicose veins.     

Mechanical,histological, and functional properties remain inferior in conservatively treated Achilles tendons in rodents: Long term evaluation

Conservative treatment (non-operative) of Achilles tendon ruptures is suggested to produce equivalent capacity for return to function; however, long term results and the role of return to activity (RTA) for this treatment paradigm remain unclear. Therefore, the objective of this study was to evaluate the long term response of conservatively treated Achilles tendons in rodents with varied RTA. Sprague Dawley rats (n = 32) received unilateral blunt transection of the Achilles tendon followed by randomization into groups that returned to activity after 1-week (RTA1) or 3-weeks (RTA3) of limb casting in plantarflexion, before being euthanized at 16-weeks post-injury. Uninjured age-matched control animals were used as a control group (n = 10). Limb function, passive joint mechanics, tendon properties (mechanical, histological), and muscle properties (histological, immunohistochemical) were evaluated. Results showed that although hindlimb ground reaction forces and range of motion returned to baseline levels by 16-weeks post-injury regardless of RTA, ankle joint stiffness remained altered. RTA1 and RTA3 groups both exhibited no differences in fatigue properties; however, the secant modulus, hysteresis, and laxity were inferior compared to uninjured age-matched control tendons. Despite these changes, tendons 16-weeks post-injury achieved secant stiffness levels of uninjured tendons. RTA1 and RTA3 groups had no differences in histological properties, but had higher cell numbers compared to control tendons. No changes in gastrocnemius fiber size or type in the superficial or deep regions were detected, except for type 2x fiber fraction. Together, this work highlights RTA-dependent deficits in limb function and tissue-level properties in long-term Achilles tendon and muscle healing.     

Long-term results of frontal lobe suspension in children with congenital dystrophic ptosis

Long-term results achieved by our own operative technique in children with congenital dystrophic ptosis, with frontal muscle lobe shaping with or without shaping of corrugator muscle lobe attached to the tarsal plate, are presented. Data on 146 patients with congenital dystrophic ptosis operated on during the 1984-1998 period at Zagreb University Hospital Center were retrospectively analyzed. Postoperative success was defined as a situation with eyes open in which 1) upper eyelid covers the cornea at 12 o'clock position by 1-2 mm; 2) there is a good contour of the eyelid margin; 3) there is no lagophthalmos; and 4) there is symmetry with the other eye. Immediate re-operation due to undercorrection was required in 26 of 146 (18%) patients. Upon re-operation, 133 (91%) patients met the criteria for successful outcome at 6 months, 124 (85%) at one year, and 121 (83%) at 5 years. Correction of congenital dystrophic ptosis using a shaped frontal/corrugator lobe is an efficient and safe procedure ensuring long-lasting success.     

Stimulation of lens regeneration from the newt dorsal iris when implanted into the blastema of the regenerating limb

Dorsal iris from the eyes of adult Notophthalmus viridescens was transplanted into the blastema of regenerating limbs, subcutaneously in the limb or shoulder region, into the dorsal fin of larval newts and into the hindbrain of larval Ambystoma maculatum. The iris implants into the blastema regenerated lens vesicles or lenses with fibers in 40–75% of the cases. Multiple lenses were found in a few instances. No lenses developed from iris implants into the dorsal fin. Twenty percent of subcutaneous implants of iris formed lenses or lens vesicles, but lens regeneration from implants into the brain occurred only rarely. Denervation of the limb at the time of iris transplantation into the blastema greatly reduced the number of lenses regenerated. Studies on nerve fiber distribution in dorsal fin, subcutaneous areas, and denervated and innervated regenerating limbs, using the Bodian method, showed a general correlation between density of nerve fibers in the implant site and the incidence of lens regeneration from iris implants into that site. These results provide some evidence for a trophic action of nerve fibers on lens regeneration from the iris.     

Upper limb loadings of gait with crutches

Long-term crutch users and patients with arthritis are particularly susceptible to upper limb joint degeneration during aided gait. The function of the walking aid for stability, support, and restraint/propulsion must be optimized with the upper limb loadings caused by the aids. Post-operative total hip replacement (THR) patients, tibial fracture, and paraplegic subjects using sticks and elbow crutches were analyzed in this study. Elbow and shoulder joint centers and aid orientations were monitored simultaneously in three dimensions and combined with aid forces to determine upper limb moment loadings. Three loading effects were observed: tendency for the aids to cause 1) the elbow to flex and shoulder to extend, 2) the elbow and shoulder to extend, and 3) the shoulder to abduct. Moment values of up to 0.10 Nm per body weight (BW) causing the shoulder to extend were measured, i.e., of similar magnitude to the moments at the hip in unaided gait. A modification of the elbow crutch, designed to improve medial-lateral stability, was unsuccessful in use due to wrist instability. This reinforced the requirement that crutch designs integrate the aid's function in gait with the ability of the upper limb joints to balance the applied loads.