Zusammenfassung Gefäßerkrankungen und Diabetes mellitus nehmen als Krankheiten der modernen Zivilisation zu. Sie gehen oft mit dem Risiko einer Amputation einher. Trotz verbesserter Therapie aufgrund des medizinischen Fortschritts steigen die Amputationsraten. Besonders gefährdet sind Patienten mit Diabetes mellitus. Aufgrund des besonderen Atherosklerosebefallsmusters mit Verschluss der kruralen Gefäße bei relativer Aussparung der Oberschenkel- und Fußarterien erzielen pedale Bypässe bei diabetischen Patienten besonders gute Ergebnisse im Hinblick auf die Wiederherstellung der Fußdurchblutung. Ein pedaler Bypass kann eine drohende Amputation oft verhindern. Voraussetzungen für eine pedale Bypass-Operation sind umfassende anatomische Kenntnisse über die Variabilität der Arterien im Operationsgebiet. Die vorliegende Arbeit befasst sich mit den Gefäßvariationen an Unterschenkel und Fuß. Mit unterschiedlichen Methoden wurden Alkohol-fixierte (n=12) und Thiel-fixierte (n=10) Beinpräparate auf arterielle Variabilität untersucht. Die Alkohol-fixierten Präparate wurden makroskopisch präpariert und fotografisch dokumentiert, außerdem erfolgte eine Probenentnahme zur histologischen Untersuchung der Atherosklerosegrade in verschiedenen Gefäßregionen (n=32) und die Herstellung von zwei Dauerpräparaten. An Thiel-fixiertem Material wurde die Digitale Subtraktionsangiographie (DSA) getestet. Folgende Fragestellungen waren zu beantworten: 1. Welche Variationen der Blutgefäße finden sich für den Unterschenkel und Fuß? Wie kommunizieren die Gefäße zwischen Fußsohle und Fußrücken? 2. Wie können kleinste Gefäße am Fuß präpariert und fotografisch dokumentiert werden? 3. Lässt sich an fixiertem Leichenmaterial eine Digitale Subtraktionsangiographie durchzuführen? 4. Zeigen proximale und distale Blutgefäße des Beines einen unterschiedlichen Befall der Atherosklerose? 5. Welche Bedeutung hat die Herstellung von Dauerpräparaten für den studentischen Unterricht? 6. Welche Bedeutung hat die makroskopische Anatomie für die Klinik? Die Ergebnisse und Schlussfolgerungen sind: 1. Während der makroskopischen Präparation fanden sich folgende Variationen: Trifurkation, Truncus tibiofibularis anterior mit hohem Abgang der A. tibialis posterior und Abgang der A. tibialis anterior aus der A. fibularis, eine sehr dominante A. fibularis bei schwach ausgeprägter A. tibialis posterior, ein Arcus plantaris durch den zweiten intermetatarsalen Spalt laufend, kräftig ausgebildete A. plantaris profunda, kräftiger tiefer Ast der A. plantaris medialis, stark ausgeprägte A. arcuata. Die den Arcus plantaris versorgenden Arterien, vor allem die A. plantaris lateralis und die A. plantaris profunda, variieren stark in ihrer Ausprägung. Sie sind Teil der „Ringanastomose”, die eine Durchblutung des Fußes über die Verbindungen verschiedener Gefäße zwischen Fußsohle und Fußrücken gewährleistet. Neben der A. plantaris profunda, die auch als Ramus perforans I bezeichnet wird, gibt es zwischen den Aa. metatarsales plantares und dorsales Verbindungen, die Rr. perforantes II-IV, die bei schwach ausgeprägter A. plantaris profunda die Gefäßversorgung sicherstellen und entsprechend stärker ausgebildet sein können. Die A. fibularis kann über ihre kommunizierenden Äste, dem Ramus perforans zur A. dorsalis pedis oder dem Ramus communicans zur A. tibialis posterior, an der arteriellen Versorgung der Fußsohle beteiligt sein. Bei schwacher Ausbildung der A. tibialis posterior und/oder A. tibialis anterior kann diese durch die A. fibularis als phylogenetisch ältestes und damit konstantestes Gefäß der drei Unterschenkelarterien sogar teilweise oder vollständig ersetzt werden. Die „Ringanastomose“ hat für die Gefäßchirurgie eine große Bedeutung. Beim popliteodistalen Bypass orientiert sich die Wahl des distalen Anschlussgefäßes daran, über welches Gefäß sich der Arcus plantaris angiographisch füllt. Eine Kollateralbildung beim Erwachsenen infolge atherosklerotischer Veränderungen über ursprünglich embryologische Gegebenheiten ist denkbar. 2. Die makroskopische Präparation kleinster Gefäße am Fuß wird durch die Injektion der roten Injektionslösung Microfil® erleichtert. Zur fotografischen Dokumentation ist eine Farbmarkierung der Arterien von außen notwendig, um den Gefäßverlauf sichtbar zu machen. 3. Digitale Subtraktionsangiographie an Leichenmaterial ist nur an Thiel-fixiertem Material möglich, da diese Methode die Gewebeverhältnisse in ihrer natürlichen Konsistenz erhält. Das Einbinden der Schleusen und die Injektion von Kontrastmittel in das Gefäßsystem sind durchführbar, weil die Gefäßlumina durchgängig bleiben. Alkohol- oder Formaldehyd-fixiertes Material ist für diese Zwecke ungeeignet, da das Gewebe aushärtet und in den Gefäßen befindliche Blutreste koagulieren. Dadurch wird eine Kontrastmittel-Injektion unmöglich. 4. Dass histologische Färbungen an langzeitfixiertem Material möglich sind, konnte bestätigt werden. Nach Modifikation der Färbevorschriften erlauben sie die Bewertung des Atherosklerosegrades. Der schwerste Befall mit Grad 4 befindet sich in den Arterien der Kniekehle. Die Fußarterien sind mit Grad 2 geringer befallen. 5. Dauerpräparate verbleiben in der anatomischen Lehrsammlung bzw. im Fundus von Anschauungsmaterial. Sie werden zukünftig zur Demonstration anatomischer Strukturen im Rahmen klinischer Kurse und im Studentenunterricht verwendet. 6. Die Anatomie als Grundlagenfach der Medizin hat in der Lehre einen hohen Stellenwert und in allen Studienabschnitten eine hohe klinische Relevanz. Gemeinsame Lehrveranstaltungen von Anatomie und Klinik wecken bei Studenten großes Interesse und fördern die Motivation. Im Rahmen der ärztlichen Aus- und Weiterbildung werden in klinischen Kursen am Institut für Anatomie beispielsweise Untersuchungsmethoden und Operationsbedingungen simuliert. Kliniker wiederholen, festigen oder vertiefen ihre anatomischen Kenntnisse. Vor allem die chirurgischen Fächer profitieren von diesen praktischen Trainingsmöglichkeiten. Wie die Arbeit am Beispiel der Gefäßchirurgie zeigt, bedingt eine gute Zusammenarbeit zwischen Anatomie und Klinik eine sichere klinische Praxis und eine lebendige Anatomie mit klinischen Bezügen. / Summary Vascular diseases and diabetes mellitus show rising frequency in the Western world and are often accompanied by amputation. The amputation rate is still increasing despite major developments in diagnostics and therapy. Especially patients with diabetes mellitus are at high risk. Because of the special pattern with more severe atherosclerosis in the crural vessels than in the femoral and pedal arteries, the pedal bypass surgery provides excellent vessel patency and limb salvage rates in diabetic patients and can often prevent amputation. A solid knowledge about anatomical variations in the operating area is a precondition for bypass operations. This dissertation deals with variations of arteries from the lower leg and foot. Lower legs from alcohol-fixed and Thiel-fixed cadavers were examined with different methods: The alcohol-fixed legs (n=12) were dissected macroscopically for variations of the arteries and documented by photographes. Samples along the vessel course (n=32) were taken for histological evaluation of the atherosclerotic degrees. Two legs were plastinated with polyethylene glycol. The Thiel-fixed legs (n=10) were tested for digital subtraction angiography (DSA). The following questions had to be answered: 1. Which arterial variations can be found for the lower leg and foot? How do the vessels communicate between the sole and the dorsum of the foot? 2. How are small foot vessels dissected for photographical documentation? 3. Can Thiel-fixed material be used for DSA? 4. Do proximal and distal vessels show different degrees of atherosclerosis? 5. Which relevance does plastination have for the medical education? 6. How important is Gross anatomy for the clinicians? Results and conclusions: 1. The following variations occurred: trifurcation, anterior tibiofibular truncus with high branching from the posterior tibial artery and the anterior tibial artery originating from the fibular artery, dominant fibular artery, plantar arch running through the second interosseus space, dominant deep plantar artery, dominant deep branch of the medial plantar artery, prominent arcuate artery. The arteries for the plantar arch, supplying most of the foot arteries, show a high diversification. They are part of the “ring anastomosis” which assures a good blood supply via different vessels connecting the dorsum and the sole of the foot. Beside the deep plantar artery, also named as “perforating branch I”, there are other connecting branches between the plantar and dorsal metatarsal arteries - the perforating braches II, III and IV. These branches are highly developed in case of an undeveloped deep plantar artery. The fibular artery can be involved in the blood supply of the foot via a communicating branch to the posterior tibial artery and the perforating branch to the dorsalis pedis artery. The fibular artery, which is phylogenetically the oldest crural vessel, can be highly developed in case of inferior anterior tibial artery and/or posterior tibial artery. The “ring anastomosis” is very important for vascular surgery. The inflow and outflow vessels of a popliteodistal bypass are chosen after angiography of the plantar arch showing the vessel for the supply of the plantar arch. 2. Macroscopical dissection of very small foot vessels can be facilitated by injection of a special plastic, Microfil®-solution. The arteries have to be additionally coloured by help of special markers for photographical documentation. 3. DSA can just be done with Thiel-fixed material. Thiel-fixation allows DSA because maintained in situ conditions. The blood is not coagulated and the vessels stay patent for contrast medium. Alcohol-fixed or formaldehyde-fixed material is not suitable for DSA because of clotted blood in the vessels impeding injection of contrast agent. 4. It is confirmed that histological examination is possible with long fixed material. After modification of the staining protocol the sections could be used for evaluation of the atherosclerotic degree. The popliteal arteries are more affected with degree 4 in comparison to the foot arteries with degree 2. 5. Plastinates are displayed in the anatomical collection of the Institute for Anatomy. They will be used for anatomical demonstrations in the lessons of students and in clinical courses. 6. Anatomy as basic knowledge is very important for teaching medical students and has a high clinical relevance in every phase of the medical course. Interdisciplinary lessons between anatomy and clinical disciplines awake interest and motivate students. Advanced medical training is obtained at the Institute for Anatomy by simulating endoscopic examination and developing new surgical techniques. Clinicians repeat, stabilize and deepen their anatomical knowledge. Especially surgeons benefit from these training possibilities. Using the example of vascular bypass surgery the present dissertation shows the value of a good cooperation between anatomy and clinic to provide a safe clinical practice and a lively anatomy with clinical references.

O autor realizou um estudo anatômico da região lateral e proximal da perna por meio de dissecção anatômica em cadáver, de exame arteriográfico e de mapeamento com Doppler em pacientes, visando a descrição da artéria denominada fibular superior, que se origina no tronco tíbio-fibular em 70% dos casos, da artéria fibular, em 20% e da artéria tibial anterior, em 10% e participa na irrigação do músculo sóleo e gastrocnêmio. Este vaso possui características adequadas para a realização de micro-anastomose. Após a conclusão da parte anatômica-descritiva, o autor aplicou o retalho derivado da artéria fibular superior, denominado retalho súpero-lateral da perna, na reconstrução de defeitos cutâneos e defeitos complexos tridimensionais, localizados no pé e tornozelo, em 10 pacientes, obtendo bons resultados / The author performed an anatomical study of the proximal and lateral aspect of the leg, consisting of cadaver dissection, arteriogram and Doppler mapping, in order to disclose the features of a new vessel, denominated superior peroneal artery. It originates from the tibiofibular trunk in 70 % of times, from the peroneal artery, 20%, and from the anterior tibial artery, 10%. It contributes to nourish the soleous and the lateral gastrocnemius muscle. The superior peroneal vessels are also suitable for microanastomosis. Therefore, the flap derived from the superior peroneal artery, called superolateral leg flap (SLL), was used for lower leg reconstructions in 10 patients, in two of them as chimeric flap for complex tridimensional defects, with good results

A instabilidade do joelho resultante da ruptura do ligamento cruzado cranial apresenta-se como sendo uma das principais causas de dor, em membro pélvico, manifestada por animais da espécie canina. Tal instabilidade pode gerar alterações como o desenvolvimento de osteoartrose e lesão de menisco, principalmente o medial. Com o intuito de restabelecer a estabilidade da articulação, muitas técnicas vêm sendo desenvolvidas de forma que as alterações provenientes de tal afecção sejam minimizadas. Com uma dimensão similar de variedades estão os materiais utilizados em diferentes técnicas ou até mesmo para o mesmo tipo de procedimento. A técnica ideal, bem como o material de escolha ainda são muito discutidos dentre os autores pesquisados. O presente trabalho avaliou a biomecânica das técnicas de sutura fabelo-tibial lateral (SFTL) e a técnica de imbricação do retináculo modificada (SFTLM), em joelhos de cadáveres de cães, na estabilização do joelho com ruptura do ligamento cruzado cranial, utilizando-se fio de náilon monofilamento leader line (60 libras). Foram avaliados rigidez articular e deslocamento craniais e caudais da tíbia em relação aos côndilos do fêmur, proporcionados pelo tipo de material e técnicas cirúrgicas, sendo os resultados obtidos comparados com os resultados do joelho íntegro e entre si. A análise estatística encontrou diferença na gaveta cranial de todos os grupos (ligamento cruzado cranial íntegro (LCCr), ligamento cruzado cranial rompido (RLCCr), SFTL e SFTLM) e na comparação da gaveta caudal entre o grupo RLCCr e SFTLM e entre o grupo SFTL e SFTLM. Outras diferenças foram encontradas na rigidez cranial dos grupos LCCr, RLCCr e reconstruído, não sendo observado diferença entre a rigidez de SFTL e SFTLM. As duas técnicas testadas diminuem a instabilidade do joelho, sendo a SFTLM mais efetiva em tal promoção, porém tal técnica influencia de forma mais evidente na biomecânica do ligamento cruzado caudal, sendo importante a avaliação de tal interferência a longo prazo. Estas duas técnicas extra-capsulares testadas, apesar de diminuirem significativamente a translação cranial da tíbia em relação ao fêmur, não restauram a rigidez articular quando comparadas com a biomecânica do joelho íntegro. / Knee instability resulting from an insufficient cranial cruciate ligament is the major cause of hind limb lameness in dogs. This instability can result in osteoarthrosis and medial meniscal injury. Many surgical techniques have been developed to restore knee stability and to reduce degenerative joint desease. There is a similarly huge variability in materials utilized for different or the same techniques. An ideal technique and material arent established yet. This study analyzed the biomechanics of the lateral fabellar suture technique (SFTL) and the modified retinacular imbrication technique (SFTLM) in stabilizing cadaveric cranial cruciate ligament deficient stifles with 60 lb nylon leader line. Articular cranio-caudal stiffness and tibial translation were evaluated and compared between different techniques and with the intact knee. The statistical analysis revealed significant differences between all groups (intact cranial cruciate ligament (LCCr), ruptured cranial cruciate ligament (RLCCr), SFTL and SFTLM) in the cranial tibial translation. In the caudal tibial translation a significant statistical difference was seen between RLCCr and SFTLM groups and between reconstructed ones. Other differences were found in the cranial stiffness between LCCr, RLCCr and reconstructed groups, but not between SFTL and SFTLM. Both techniques tested reduced joint instability but SFTLM was more efficient, although it affected the caudal cruciate ligament biomechanics more evidently when compared with the SFTL technique. This long-term evaluation of the caudal influence induced by SFTLM will be important. Despite of the reduction in the tibial cranial translation by these two different extra capsular techniques, none have maintained normal stifle stiffness.

Orientador: Carlos Arturo Levi D'Ancona / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-22T09:57:34Z (GMT). No. of bitstreams: 1 Perissinotto_MariaCarolinaRamos_D.pdf: 1870557 bytes, checksum: a3f8aae56bf22e41993fdf4017268274 (MD5) Previous issue date: 2013 / Resumo: Introdução: A doença de Parkinson é uma doença neurológica degenerativa de causa desconhecida que leva a alterações motoras em decorrência da diminuição dos neurotransmissores de dopamina na substância nigraestriatal. Distúrbios miccionais acometem de 37% a 70% dos pacientes com esta doença. A eletroestimulação do nervo tibial posterior é uma opção no tratamento dos sintomas do trato urinário inferior. Objetivo: Avaliar a eficácia da referida eletroestimulação na sintomatologia do trato urinário inferior em pacientes com doença de Parkinson. Métodos: A metodologia utilizada foi o estudo controlado randomizado, pela qual foram 96 pacientes com diagnóstico de doença de Parkinson com queixas de sintomas do trato urinário inferior, os quais foram alocados em dois grupos: grupo tratamento e grupo sham. Todos os pacientes foram avaliados através de escalas específicas para a doença de Parkinson, como a Unified Parkinson's Diseases Rating Scale, nos quais preencheram os questionários de qualidade de vida, de incontinência urinária e de bexiga hiperativa, através dos quais foi realizado o estudo urodinâmico. Todas as avaliações foram realizadas pré e pós-tratamento e a técnica utilizada foi a eletroestimulação do nervo tibial posterior durante dez sessões, duas vezes por semana com duração de 30 minutos cada sessão. O grupo de tratamento realizou esta eletroestimulação e o outro grupo, o procedimento sham. Resultados: Os resultados obtidos ao final do tratamento foi que o grupo de tratamento relatou melhora significativa nos sintomas urinários de urgência e noctúria em comparação ao grupo sham. Urgência (p=0,0047), entre os grupos (100,0% grupo de tratamento, 12,5% grupo sham) e noctúria no grupo de tratamento entre os tempos pré e pós (p=0,0156) (4,0 pré - 2,0 pós). Na análise da qualidade de vida, ocorreu uma melhora significativa no score total do questionário International Consultation on Incontinence Questionnaire no grupo de tratamento entre os tempos pré e pós (p=0,0191) (7,0 pré - 4,0 pós), e no questionário Overactive Bladder Questionnaire no mesmo grupo entre os tempos (p=0,0144) (29,0 pré - 21,5 pós). No estudo urodinâmico, houve melhora significativa no grupo de tratamento entre o tempo pré e pós no primeiro desejo (mediana 150 pré -185 ml pós) (p=0.0056) e volume urgência (mediana 200 pré -285 ml pós) (p= 0.0014). Conclusão: O tratamento com a eletroestimulação do nervo tibial posterior se mostrou uma técnica capaz de melhoras na sintomatologia do trato urinário inferior em pacientes com doença de Parkinson, tais como a redução da urgência e da noctúria, proporcionando, assim, melhora na qualidade de vida desses pacientes. Novos estudos são necessários para aprofundar a eficácia desta técnica em pacientes com doença de Parkinson / Abstract: Introduction: Parkinson's disease is a neurologic disorder caused by neurodegeneration of the nigrostriatal dopaminergic. Lower urinary tract symptoms, are non-motor symptoms that occur in 37% to 70% of patients throughout the course of the disease and negatively affect the Quality of Life of these patients. Aims: Evaluate the efficacy of transcutaneous posterior tibial nerve stimulation on treatment of lower urinary tract symptoms in patients with Parkinson's disease. Methods: Randomized controlled trial, twenty three patients with a diagnosis of parkinson's disease and lower urinary tract symptoms, were randomized in two groups: PNTS group (GI) and group sham (GII). Evaluation included, urinary symptoms, Unified Parkinson's Diseases Rating Scale, International Consultation on Incontinence Questionnaire, Overactive Bladder Questionnaire questionnaire and the urodynamic study, all evaluation were performed pre and post PNTS. GI intervention consisted on PNTS and GII received a sham treatment with effective stimulation. Results: At the end of the treatment the GI present's significant improvement in storage and voiding symptoms than GII. There were significant differences on the symptoms of urgency (p=0.0047) between group (100.0% GI, 12.5% GII). In nocturia occurs an improvement pre and post PNTS in GI (p=0.0156) (4.0 pre - 2.0 post). Quality of life analyses there were significant differences on questionnaire, International Consultation on Incontinence Questionnaire, GI pre and post PNTS (p=0.0191) (7.0 pre - 4.0 post) and Overactive Bladder Questionnaire, GI pre and post PNTS (p=0.0144) (29.0 pre - 21.5 post). There were statistical difference in the urodynamic study pre and post PNTS in group I in volume stronge desire (median 150 pre -185ml post) (p=0.0056) and volume urgency (Median 200 pre-285 ml post) (p= 0.0014). Conclusion: PNTS is an option in the treatment of Lower urinary tract symptoms in patients with diagnosis of parkinson's disease, contributing to reduce urgency and nocturia and improving Quality of life score. This pilot study shows a good response in treat patients with parkinson's disease and Lower urinary tract symptoms, further study should be perform to provide evidence of the potential therapeutic effects / Doutorado / Fisiopatologia Cirúrgica / Doutora em Ciências

Submitted by Nadir Basilio (nadirsb@uninove.br) on 2018-07-16T20:01:20Z No. of bitstreams: 1 Beatriz Guimarães Ribeiro.pdf: 1467862 bytes, checksum: d166e20babcfe778cdc4c7cf5708fc53 (MD5) / Made available in DSpace on 2018-07-16T20:01:20Z (GMT). No. of bitstreams: 1 Beatriz Guimarães Ribeiro.pdf: 1467862 bytes, checksum: d166e20babcfe778cdc4c7cf5708fc53 (MD5) Previous issue date: 2017-02-23 / The low level laser therapy (LLLT) is a resource capable of modulating in a positive way the different stages of the muscle repair process. However, little has been described about its effects when applied prior to injury, associated or not with post-injury treatment. The general objective of the present study was to evaluate the effect of LLLT applied prior to the muscle injury associated or not to the post-injury application on the rat skeletal muscle repair process. The aim of article 1 was to evaluate the effect of infrared LLLT applied prior to cryoinjury on the expression of IL-6, MyoD and myogenin. The aim of article 2 was to evaluate the effect of red and infrared LLLT prior to cryoinjury associated or not with post-injury application on oxidative stress. The aim of article 3 was to evaluate the effect of infrared LLLT applied prior to injury with or without post-injury application on the gene expression and protein synthesis of inflammatory cytokines TNF-α and IL-6, and muscle morphology. For the three studies, 205 Wistar rats were divided into the following experimental groups: Control; Injury; LLLT 660 nm prior to injury; LLLT 780 nm prior to injury; LLLT 660 nm pre- and post-injury; and LLLT 780 nm pre- and post-injury. The cryoinjury consisted of two applications of cane cooled in liquid nitrogen in the anterior tibial muscle (TA). The injured groups were evaluated at 1, 3, 7 and 14 days after injury (only for oxidative stress analysis, evaluation occurred at 1, 3, and 7 days). LLLT irradiation was performed with the AsGaAl laser (780 nm) at the parameters of 10 J/cm²; 40 mW; 10 seconds per point; 8 points; 3.2 J. At the end of the protocol, TA muscles were carefully removed for analysis of oxidative stress by lipid peroxidation (LPO) by chemiluminescence initiated by t-BOOH, protein oxidation through the carbonyl damage assay, and analysis of antioxidant enzymes: catalase (CAT), superoxide dismutase (SOD) and glutathione peroxidase (GPx). TNF-α and IL-6 cytokines were analyzed by quantitative real-time PCR for the detection of gene expression. In addition, a morphological analysis was performed by staining with hematoxylin and eosin. TNF-α and IL-6 cytokines were analyzed by ELISA for protein expression. Data were expressed as mean and standard error of the mean because they were parametric and the comparison between the groups was performed by ANOVA/Tukey (p<0.05). The results of article 1 demonstrate a reduction in the levels of IL-6 mRNA in the group irradiated prior to the injury, concluding that the LBP applied prior to injury was able to modulate positively this inflammatory cytokine, but had no effect on the myogenic regulatory factors MyoD and myogenin in the evaluated parameters. The results of article 2 containing the oxidative stress analysis showed that the irradiated groups presented reduction of the lipoperoxidation and positive modulation of the antioxidant enzymes during the muscle repair process, concluding the red and infrared laser were able to modulate positively the oxidative stress, being the most effective infrared laser in the modulation of antioxidant enzymes. The results of article 3 demonstrated a reduction in the gene expression of TNF-α in the group irradiated prior to injury. In the pre-and post-injury irradiated group, IL-6 and TNF-α mRNA levels increased during the skeletal muscle repair process, concluding that the infrared laser was able to positive modulation these inflammatory cytokines in the two forms of application. Therefore, it is concluded that the LLLT irradiated prior to injury associated or not with the post-injury application has a beneficial effect on inflammatory cytokines and oxidative stress during the repair of the skeletal muscle of rats. / O laser de baixa potência (LBP) é um recurso capaz de modular de forma positiva as diferentes etapas do processo de reparo muscular. Contudo, pouco há descrito sobre seus efeitos quando aplicado previamente a uma lesão, associado ou não a um tratamento pós-lesão. O objetivo geral do presente estudo foi avaliar o efeito do LBP aplicado previamente à lesão muscular associado ou não a aplicação pós-lesão sobre o processo de reparo musculo esquelético de rato. O objetivo do artigo 1 foi avaliar o efeito do LBP infravermelho aplicado previamente à criolesão sobre a expressão de IL-6, MyoD e miogenina. O objetivo do artigo 2 foi avaliar o efeito do LBP vermelho e infravermelho previamente a criolesão associado ou não a aplicação pós-lesão sobre o estresse oxidativo. O objetivo do artigo 3 foi avaliar o efeito do LBP infravermelho aplicado previamente à criolesão associado ou não a aplicação pós-lesão sobre a expressão gênica e síntese proteica das citocinas inflamatórias TNF-α e IL-6, e morfologia muscular. Para a realização dos três estudos, foram utilizados 205 ratos Wistar, divididos nos seguintes grupos experimentais: Controle; Somente lesão; LBP 660 nm previamente à lesão; LBP 780 nm previamente à lesão; LBP 660 nm pré e pós-lesão; e LBP 780 nm pré e pós-lesão. A criolesão consistiu de duas aplicações de bastão resfriado em nitrogênio líquido no músculo tibial anterior (TA). Os grupos lesionados foram avaliados em 1, 3, 7 e 14 dias após a lesão (somente para análise de estresse oxidativo, a avaliação ocorreu em 1, 3, e 7 dias). A irradiação com LBP foi realizada com o laser AsGaAl (780 nm) nos parâmetros de 10 J/cm²; 40 mW; 10 segundos por ponto; 8 pontos; 3.2 J. Ao término do protocolo, os músculos TA foram retirados cuidadosamente para análise de estresse oxidativo pela lipoperoxidação (LPO) por quimiluminescência iniciada por t-BOOH, pela oxidação proteica através do ensaio de dano as carbonilas, e pela análise das enzimas antioxidantes: catalase (CAT), superóxido dismutase (SOD) e glutationa peroxidase (GPx). Também foram analisadas as citocinas TNF-α e IL-6 por PCR em tempo real quantitativo para detecção da expressão gênica. Além disso, foi realizada análise morfológica por coloração com hematoxilina e eosina. As citocinas TNF-α e IL-6 também foram analisadas por ELISA para detecção da expressão proteica. Os dados foram expressos em média e erro-padrão da média por se apresentarem paramétricos e a comparação entre os grupos foi realizada pelo ANOVA/ Tukey (p<0,05). Os resultados do artigo 1 demonstram redução nos níveis de mRNA IL-6 no grupo irradiado previamente à lesão, concluindo que o LBP aplicado previamente à lesão foi capaz de modular positivamente essa citocina inflamatória, mas não teve efeito sobre os fatores regulatórios miogênicos MyoD e miogenina nos parâmetros avaliados. Os resultados do artigo 2 contendo a análise de estresse oxidativo demonstram que os grupos irradiados apresentaram redução da lipoperoxidação e modulação positiva das enzimas antioxidantes durante o processo de reparo muscular, concluindo que tanto o laser vermelho como infravermelho foram capazes de modular positivamente o estresse oxidativo sendo o laser infravermelho mais eficaz na modulação de enzimas antioxidantes. Os resultados do artigo 3 demonstram uma redução na expressão gênica de TNF-α no grupo irradiado previamente a lesão. Já no grupo irradiado pré e pós-lesão, houve aumento dos níveis de mRNA IL-6 e TNF-α durante o processo de reparo musculo esquelético, concluindo que o laser infravermelho foi capaz de modular de forma positiva essas citocinas inflamatórias nas duas formas de aplicação. Portanto, conclui-se de forma geral que o LBP utilizado previamente à lesão associado ou não a aplicação pós-lesão tem efeito benéfico sobre a modulação de citocinas inflamatórias e do estresse oxidativo durante o reparo do músculo esquelético de ratos.

The dachshund, a chondrodystrophic dog breed, presents a unique challenge in the treatment of tibial fractures by having short and curvaceous tibiae, leading to high implant failure risk. In this study, intramedullary pins with full cerclage wires as an option in the treatment of oblique diaphyseal tibial fractures was studied in vitro. This fixation technique was biomechanically compared with the current gold standard in internal stabilization, namely bone plates and screws. Twenty tibiae recovered from adult dachshund cadavers were randomly allocated into two groups of ten bones each. Oblique fractures running in a proximo-cranial-disto-caudal direction in the middle third of the tibial diaphysis were simulated by osteotomy and each bone repaired by using one of the following methods: <ul> <li> Pre-bent intramedullary pin, filling 40% to 60% of the medullary cavity at its narrowest point, inserted normograde and combined with a set of three full cerclage wires (group 1).</li> <li> Lag screw at the osteotomy site, combined with a six hole 2.7 mm contoured dynamic compression plate and cortical screws in neutral mode (group 2).</li> </ul> Each test specimen was subjected to a two point single cycle axial compression test by applying a standardized, increasing compression load to the point of fixation failure or bone collapse. A stress-strain graph for each test specimen was drawn from the raw data. Radiographs and digital photographs were made pre-osteotomy, post-osteotomy, post-repair and post-test, and modes of failure noted for each test specimen. Stress (applied load) and strain (deformation) at yield, ultimate strength, and at failure were determined for each test specimen from the stress-strain graphs and the mean values statistically compared between the groups using the ANCOVA method. Significance levels of p < 0.05 were used, while p < 0.1 and p < 0.01 were also indicated. In group 1, 50% specimens failed due to unraveling or slippage with displacement of the cerclage wires, 30% due to bone fracture at a cerclage wire, and 20% due to bone fracture elsewhere. In group 2, 80% specimens failed due to bone fracture at one or more of the screw holes, whereas 20% failed due to bone fracture not directly associated with implants. No bone plate or screw underwent plastic (permanent) deformation, whereas 80% of the intramedullary pins and 30% of the cerclage wires underwent plastic deformation. Mean stress at the yield point in groups 1 and 2 were 0.323 MPa and 0.403 MPa respectively, at the point of ultimate strength 0.383 MPa and 0.431 MPa respectively, and at the failure point 0.345 MPa and 0.403 MPa respectively. Mean strain at the yield point in groups 1 and 2 were 0.296% and 0.362% respectively, at the point of ultimate strength 0.412% and 0.472% respectively, and at the failure point 0.713% and 0.838% respectively. Clinically, there was an indication that plates and screws were more resistant to deformation by the loads applied than intramedullary pins and cerclage wires. However, statistically, there were no significant differences in stress at yield (p = 0.299), ultimate strength (p = 0.275), or failure (p = 0.137) between the two groups. Similarly, there were no significant differences in strain at yield (p = 0.684), ultimate strength (p = 0.778), or failure (p = 0.505) between the two groups. Main limitations of the study were the relatively small number of specimens tested, the smoothness of the osteotomy cuts which limited interdigitation between the fragments, and that only three of the five recognized loads acting on bones in vivo, were tested in vitro. In conclusion, this study did not show enough evidence to prove a significant difference between the two methods of fixation. Therefore, it is suggested that intramedullary pins and full cerclage wires be used as an acceptable alternative to bone plates and screws in the treatment of oblique mid-diaphyseal tibial fractures in chondrodystrophic dog breeds. / Die dachshund, ‘n chondrodistrofiese honderas, bied ‘n unieke uitdaging in die behandeling van frakture van die tibia, deurdat hulle tibias kort en krom is, wat lei tot ‘n hoë risiko van inplantaat mislukking. In hierdie studie is intramedullêre penne met vol sirkeldrade as ‘n keuse in die behandeling van skuins frakture van die tibiale skag in vitro bestudeer. Hierdie tegniek van herstel is vergelyk met die huidige goue standaard in interne stabilisering, naamlik beenplate en skroewe. Twintig tibias wat van volwasse dachshund kadawers herwin is, is lukraak aan twee groepe van tien bene elk toegewys. Skuins frakture in ‘n proksimo-kranio-disto-koudale rigting in die middelste derde van die tibiale skag is nageboots deur ‘n osteotomie, waarna elke been herstel is deur die gebruik van een van die volgende metodes: <ul> <li> Vooraf gebuigde intramedullêre pen, wat 40% tot 60% van die murgholte by die dunste punt vul, normograad geplaas en gekombineer met ‘n stel van drie vol sirkeldrade (groep 1).</li> <li> Trekskroef by die osteotomie area, gekombineer met ‘n ses-gat 2.7 mm gekontoerde dinamiese drukplaat en kortikale skroewe geplaas op neutrale wyse (groep 2).</li> </ul> Elke toetsmonster is onderwerp aan ‘n twee-punt enkel siklus aksiale druktoets deur die toepassing van ‘n gestandardiseerde, verhogende druklading tot by die punt van fiksasie breuk of kollaps van die been. ‘n Druk-spanning grafiek vir elke toetsmonster is vanaf die rou data saamgestel. X-straalfoto’s en digitale foto’s van elke been is pre-osteotomie, post-osteotomie, post-herstel and post-toets geneem en die maniere van faal vir elke toetsmonster aangeteken. Druk (toegepaste lading) en spanning (vervorming) by meegee (“yield”), treksterkte (“ultimate strength”) en faal (“failure”) is vir elke toetsmonster bepaal vanaf die druk-spanning grafieke en die gemiddelde waardes statisties vergelyk tussen die groepe deur gebruik te maak van die ANCOVA metode. Beduidenis vlakke van p < 0.05 is gebruik, terwyl p < 0.1 en p < 0.01 ook aangedui is. In groep 1 het 50% toetsmonsters gefaal as gevolg van losgaan of gly van die sirkeldrade met verplasing, 30% as gevolg van beenfrakture by ‘n sirkeldraad, en 20% as gevolg van beenfrakture elders. In groep 2 het 80% toetsmonsters gefaal as gevolg van beenfrakture by een of meer skroefgate, terwyl 20% gefaal het as gevolg van beenfrakture wat nie direk met die inplantate geassosieer is nie. Geen beenplaat of skroef het plastiese (permanente) vervorming ondergaan nie, terwyl 80% van die IM penne en 30% van die sirkeldrade plastiese vervorming ondergaan het. Gemiddelde druk by die meegeepunt in groepe 1 en 2 was 0.323 MPa en 0.403 MPa onderskeidelik, by die punt van treksterkte 0.383 MPa en 0.431 MPa onderskeidelik, en by die faalpunt 0.345 MPa en 0.403 MPa onderskeidelik. Gemiddelde spanning by die meegeepunt in groepe 1 en 2 was 0.296% en 0.362% onderskeidelik, by die punt van treksterkte 0.412% en 0.472% onderskeidelik, en by die faalpunt 0.713% en 0.838% onderskeidelik. Klinies was daar ‘n indikasie dat plate en skroewe meer weerstandbiedend was teen vervorming deur die toegepaste ladings as intramedullêre penne en sirkeldrade. Statisties was die druk wat die toetsmonster laat meegee (p = 0.299), en die druk by die treksterkte- (p = 0.275) en faalpunte (p = 0.137) egter nie beduidend verskillend tussen die twee groepe nie. Net so was die spanning by die meegee- (p = 0.684), treksterkte- (p = 0.778) en faalpunte (p = 0.505) nie beduidend verskillend tussen die twee groepe nie. Hoof beperkings van die studie was die relatief klein getal monsters wat getoets is, die gladheid van die osteotomie-snitte wat interdigitasie tussen die fragmente beperk het, en dat slegs drie van die vyf erkende ladings wat op bene in vivo inwerk, in vitro getoets kon word. Laastens het hierdie studie nie genoeg getuienis opgelewer om ‘n beduidende verskil te bewys trussen die twee metodes van herstel nie. Derhalwe word voorgestel dat IM-penne en vol sirkeldrade gebruik word as aanvarbare alternatief tot beenplate en skroewe in die behandeling van skuins midskag tibia frakture in chondrodistrofiese honderasse. / Dissertation (MSc)--University of Pretoria, 2012. / Companion Animal Clinical Studies / unrestricted

Zusammenfassung Gefäßerkrankungen und Diabetes mellitus nehmen als Krankheiten der modernen Zivilisation zu. Sie gehen oft mit dem Risiko einer Amputation einher. Trotz verbesserter Therapie aufgrund des medizinischen Fortschritts steigen die Amputationsraten. Besonders gefährdet sind Patienten mit Diabetes mellitus. Aufgrund des besonderen Atherosklerosebefallsmusters mit Verschluss der kruralen Gefäße bei relativer Aussparung der Oberschenkel- und Fußarterien erzielen pedale Bypässe bei diabetischen Patienten besonders gute Ergebnisse im Hinblick auf die Wiederherstellung der Fußdurchblutung. Ein pedaler Bypass kann eine drohende Amputation oft verhindern. Voraussetzungen für eine pedale Bypass-Operation sind umfassende anatomische Kenntnisse über die Variabilität der Arterien im Operationsgebiet. Die vorliegende Arbeit befasst sich mit den Gefäßvariationen an Unterschenkel und Fuß. Mit unterschiedlichen Methoden wurden Alkohol-fixierte (n=12) und Thiel-fixierte (n=10) Beinpräparate auf arterielle Variabilität untersucht. Die Alkohol-fixierten Präparate wurden makroskopisch präpariert und fotografisch dokumentiert, außerdem erfolgte eine Probenentnahme zur histologischen Untersuchung der Atherosklerosegrade in verschiedenen Gefäßregionen (n=32) und die Herstellung von zwei Dauerpräparaten. An Thiel-fixiertem Material wurde die Digitale Subtraktionsangiographie (DSA) getestet. Folgende Fragestellungen waren zu beantworten: 1. Welche Variationen der Blutgefäße finden sich für den Unterschenkel und Fuß? Wie kommunizieren die Gefäße zwischen Fußsohle und Fußrücken? 2. Wie können kleinste Gefäße am Fuß präpariert und fotografisch dokumentiert werden? 3. Lässt sich an fixiertem Leichenmaterial eine Digitale Subtraktionsangiographie durchzuführen? 4. Zeigen proximale und distale Blutgefäße des Beines einen unterschiedlichen Befall der Atherosklerose? 5. Welche Bedeutung hat die Herstellung von Dauerpräparaten für den studentischen Unterricht? 6. Welche Bedeutung hat die makroskopische Anatomie für die Klinik? Die Ergebnisse und Schlussfolgerungen sind: 1. Während der makroskopischen Präparation fanden sich folgende Variationen: Trifurkation, Truncus tibiofibularis anterior mit hohem Abgang der A. tibialis posterior und Abgang der A. tibialis anterior aus der A. fibularis, eine sehr dominante A. fibularis bei schwach ausgeprägter A. tibialis posterior, ein Arcus plantaris durch den zweiten intermetatarsalen Spalt laufend, kräftig ausgebildete A. plantaris profunda, kräftiger tiefer Ast der A. plantaris medialis, stark ausgeprägte A. arcuata. Die den Arcus plantaris versorgenden Arterien, vor allem die A. plantaris lateralis und die A. plantaris profunda, variieren stark in ihrer Ausprägung. Sie sind Teil der „Ringanastomose”, die eine Durchblutung des Fußes über die Verbindungen verschiedener Gefäße zwischen Fußsohle und Fußrücken gewährleistet. Neben der A. plantaris profunda, die auch als Ramus perforans I bezeichnet wird, gibt es zwischen den Aa. metatarsales plantares und dorsales Verbindungen, die Rr. perforantes II-IV, die bei schwach ausgeprägter A. plantaris profunda die Gefäßversorgung sicherstellen und entsprechend stärker ausgebildet sein können. Die A. fibularis kann über ihre kommunizierenden Äste, dem Ramus perforans zur A. dorsalis pedis oder dem Ramus communicans zur A. tibialis posterior, an der arteriellen Versorgung der Fußsohle beteiligt sein. Bei schwacher Ausbildung der A. tibialis posterior und/oder A. tibialis anterior kann diese durch die A. fibularis als phylogenetisch ältestes und damit konstantestes Gefäß der drei Unterschenkelarterien sogar teilweise oder vollständig ersetzt werden. Die „Ringanastomose“ hat für die Gefäßchirurgie eine große Bedeutung. Beim popliteodistalen Bypass orientiert sich die Wahl des distalen Anschlussgefäßes daran, über welches Gefäß sich der Arcus plantaris angiographisch füllt. Eine Kollateralbildung beim Erwachsenen infolge atherosklerotischer Veränderungen über ursprünglich embryologische Gegebenheiten ist denkbar. 2. Die makroskopische Präparation kleinster Gefäße am Fuß wird durch die Injektion der roten Injektionslösung Microfil® erleichtert. Zur fotografischen Dokumentation ist eine Farbmarkierung der Arterien von außen notwendig, um den Gefäßverlauf sichtbar zu machen. 3. Digitale Subtraktionsangiographie an Leichenmaterial ist nur an Thiel-fixiertem Material möglich, da diese Methode die Gewebeverhältnisse in ihrer natürlichen Konsistenz erhält. Das Einbinden der Schleusen und die Injektion von Kontrastmittel in das Gefäßsystem sind durchführbar, weil die Gefäßlumina durchgängig bleiben. Alkohol- oder Formaldehyd-fixiertes Material ist für diese Zwecke ungeeignet, da das Gewebe aushärtet und in den Gefäßen befindliche Blutreste koagulieren. Dadurch wird eine Kontrastmittel-Injektion unmöglich. 4. Dass histologische Färbungen an langzeitfixiertem Material möglich sind, konnte bestätigt werden. Nach Modifikation der Färbevorschriften erlauben sie die Bewertung des Atherosklerosegrades. Der schwerste Befall mit Grad 4 befindet sich in den Arterien der Kniekehle. Die Fußarterien sind mit Grad 2 geringer befallen. 5. Dauerpräparate verbleiben in der anatomischen Lehrsammlung bzw. im Fundus von Anschauungsmaterial. Sie werden zukünftig zur Demonstration anatomischer Strukturen im Rahmen klinischer Kurse und im Studentenunterricht verwendet. 6. Die Anatomie als Grundlagenfach der Medizin hat in der Lehre einen hohen Stellenwert und in allen Studienabschnitten eine hohe klinische Relevanz. Gemeinsame Lehrveranstaltungen von Anatomie und Klinik wecken bei Studenten großes Interesse und fördern die Motivation. Im Rahmen der ärztlichen Aus- und Weiterbildung werden in klinischen Kursen am Institut für Anatomie beispielsweise Untersuchungsmethoden und Operationsbedingungen simuliert. Kliniker wiederholen, festigen oder vertiefen ihre anatomischen Kenntnisse. Vor allem die chirurgischen Fächer profitieren von diesen praktischen Trainingsmöglichkeiten. Wie die Arbeit am Beispiel der Gefäßchirurgie zeigt, bedingt eine gute Zusammenarbeit zwischen Anatomie und Klinik eine sichere klinische Praxis und eine lebendige Anatomie mit klinischen Bezügen. / Summary Vascular diseases and diabetes mellitus show rising frequency in the Western world and are often accompanied by amputation. The amputation rate is still increasing despite major developments in diagnostics and therapy. Especially patients with diabetes mellitus are at high risk. Because of the special pattern with more severe atherosclerosis in the crural vessels than in the femoral and pedal arteries, the pedal bypass surgery provides excellent vessel patency and limb salvage rates in diabetic patients and can often prevent amputation. A solid knowledge about anatomical variations in the operating area is a precondition for bypass operations. This dissertation deals with variations of arteries from the lower leg and foot. Lower legs from alcohol-fixed and Thiel-fixed cadavers were examined with different methods: The alcohol-fixed legs (n=12) were dissected macroscopically for variations of the arteries and documented by photographes. Samples along the vessel course (n=32) were taken for histological evaluation of the atherosclerotic degrees. Two legs were plastinated with polyethylene glycol. The Thiel-fixed legs (n=10) were tested for digital subtraction angiography (DSA). The following questions had to be answered: 1. Which arterial variations can be found for the lower leg and foot? How do the vessels communicate between the sole and the dorsum of the foot? 2. How are small foot vessels dissected for photographical documentation? 3. Can Thiel-fixed material be used for DSA? 4. Do proximal and distal vessels show different degrees of atherosclerosis? 5. Which relevance does plastination have for the medical education? 6. How important is Gross anatomy for the clinicians? Results and conclusions: 1. The following variations occurred: trifurcation, anterior tibiofibular truncus with high branching from the posterior tibial artery and the anterior tibial artery originating from the fibular artery, dominant fibular artery, plantar arch running through the second interosseus space, dominant deep plantar artery, dominant deep branch of the medial plantar artery, prominent arcuate artery. The arteries for the plantar arch, supplying most of the foot arteries, show a high diversification. They are part of the “ring anastomosis” which assures a good blood supply via different vessels connecting the dorsum and the sole of the foot. Beside the deep plantar artery, also named as “perforating branch I”, there are other connecting branches between the plantar and dorsal metatarsal arteries - the perforating braches II, III and IV. These branches are highly developed in case of an undeveloped deep plantar artery. The fibular artery can be involved in the blood supply of the foot via a communicating branch to the posterior tibial artery and the perforating branch to the dorsalis pedis artery. The fibular artery, which is phylogenetically the oldest crural vessel, can be highly developed in case of inferior anterior tibial artery and/or posterior tibial artery. The “ring anastomosis” is very important for vascular surgery. The inflow and outflow vessels of a popliteodistal bypass are chosen after angiography of the plantar arch showing the vessel for the supply of the plantar arch. 2. Macroscopical dissection of very small foot vessels can be facilitated by injection of a special plastic, Microfil®-solution. The arteries have to be additionally coloured by help of special markers for photographical documentation. 3. DSA can just be done with Thiel-fixed material. Thiel-fixation allows DSA because maintained in situ conditions. The blood is not coagulated and the vessels stay patent for contrast medium. Alcohol-fixed or formaldehyde-fixed material is not suitable for DSA because of clotted blood in the vessels impeding injection of contrast agent. 4. It is confirmed that histological examination is possible with long fixed material. After modification of the staining protocol the sections could be used for evaluation of the atherosclerotic degree. The popliteal arteries are more affected with degree 4 in comparison to the foot arteries with degree 2. 5. Plastinates are displayed in the anatomical collection of the Institute for Anatomy. They will be used for anatomical demonstrations in the lessons of students and in clinical courses. 6. Anatomy as basic knowledge is very important for teaching medical students and has a high clinical relevance in every phase of the medical course. Interdisciplinary lessons between anatomy and clinical disciplines awake interest and motivate students. Advanced medical training is obtained at the Institute for Anatomy by simulating endoscopic examination and developing new surgical techniques. Clinicians repeat, stabilize and deepen their anatomical knowledge. Especially surgeons benefit from these training possibilities. Using the example of vascular bypass surgery the present dissertation shows the value of a good cooperation between anatomy and clinic to provide a safe clinical practice and a lively anatomy with clinical references.

Background: We performed a biomechanical comparison of 2 methods for operative stabilization of pronation-abduction stage III ankle fractures; group 1: Anterior-posterior lag screws fixing the posterior tibial fragment and lateral fibula plating (LSLFP) versus group 2: locked plate fixation of the posterior tibial fragment and posterior antiglide plate fixation of the fibula (LPFP). Methods: Seven pairs of fresh-frozen osteoligamentous lower leg specimens (2 male, and 5 female donors) were used for the biomechanical testing. Bone mineral density (BMD) of each specimen was assessed by means of dual-energy x-ray absorptiometry. After open transection of the deltoid ligament, an osteotomy model of pronation abduction stage III ankle fracture was created. Specimens were systematically assigned to LSLFP (group 1, left ankles) or LPPFP (group 2, right ankles). After surgery, all specimens were evaluated via CT to verify reduction and fixation. Axial load was then applied onto each specimen using a servohydraulic testing machine starting from 0 N (Zwick/Roell, Ulm, Germany) at a speed of 10 N/s with the foot fixed in a 10 degrees pronation and 15 degrees dorsiflexion position. Construct stiffness, yield, and ultimate strength were measured and dislocation patterns were documented with a high-speed camera. The normal distribution of all data was analyzed using Shapiro-Wilk test. The group comparison was performed using paired Student t test. Statistical significance was assumed at a P value of .05. Results: All specimens had BMD values consistent with osteoporosis. BMD values did not differ between the left and right ankles of the same pair (P = .762). The mean BMD values between feet of men (0.603 g/cm²) and women (0.329 g/cm²) were statistically different (P = .005). The ultimate strength for LSLFP (group 1) with 1139 ± 669 N and LPPFP (group 2) with 2008 ± 943 N was statistically different (P = .036) as well as the yield in LSLFP (group 1) 812 ± 452 N and LPPFD (group 2) 1292 ± 625 N (P = .016). Construct stiffness trended to be higher in group 2 (179 ± 100 kNn) compared to group 1 (127 ± 73 kN/m) but this difference was not statistically significant (P = .120). BMD correlated with bone-construct failure. Conclusion: Fixation of the posterior tibial edge with a posterolateral locking plate resulted in higher biomechanical stability than anterior-posterior lag screw fixation in an osteoporotic pronation-abduction fracture model. Clinical Relevance: The clinical implication of this biomechanical study is that the posterior antiglide plating might be advantageous in patients with osteoporotic pronation abduction stage III ankle fracture.

Introdução: A síndrome SPOAN é uma doença neurodegenerativa, de transmissão genética autossômica recessiva, até o momento reconhecida apenas no Brasil, que caracteriza-se por: paraplegia espástica, de início nos primeiros anos de vida e caráter progressivo; atrofia óptica congênita; neuropatia periférica sensitivo-motora axonal, de início a partir da primeira década de vida; sobressaltos à estimulação sonora, disartria, deformidades de coluna e pés e sinais extra piramidais. A sua caracterização foi feita por nosso grupo, que avaliou clinicamente 71 indivíduos, originários do Rio Grande do Norte. Estudo de ligação mapeou o locus responsável pela síndrome SPOAN em uma região de 2 Mb no cromossomo 11q13. O gene responsável pela síndrome SPOAN permanece desconhecido. A síndrome SPOAN é considerada uma forma complicada de paraplegia espástica. A associação entre neuropatia e paraplegia espástica está relacionada à perda progressiva de axônios longos e tem sido relatada em algumas formas complicadas de neuropatias e paraplegias espásticas hereditárias. Casuística e métodos: Foi realizada a avaliação de 27 pacientes, 20 mulheres, com idade variando entre 4 e 58 anos. Todos os indivíduos compartilhavam o mesmo fenótipo (paraplegia espástica, atrofia de nervo óptico e neuropatia periférica) e tinham o mesmo haplótipo 11q13. Pacientes com história de diabetes mellitus ou alcoolismo foram excluídos do estudo. A avaliação neurológica incluiu a pesquisa dos escores modificados de sintomas e comprometimento neuropáticos. A força muscular foi testada e graduada conforme a escala MRC (Medical Research Council). Foi realizada a pesquisa da sensibilidade dolorosa, térmica, tátil, vibratória e artrestésica. O trofismo foi avaliado pela presença de deformidades na coluna e atrofia nos membros inferiores. Os reflexos profundos e o cutâneo plantar também foram analisados. Os estudos da condução nervosa foram realizados em um aparelho portátil Nicolet - Viking Quest, (Viasys, USA). Para os estudos de condução motora foram analisados os nervos axillar, mediano, ulnar, femoral, tibial e fibular direito. A condução sensitiva foi analisada nos nervos mediano, ulnar, radial, sural e fibular direito. O reflexo H e as ondas F foram avaliados com técnicas padrão. Alguns testes não puderam ser realizados devido à intensa atrofia e deformidades esqueléticas. O coeficiente de correlação de Pearson foi calculado entre a idade e os parâmetros, velocidade de condução, latência e amplitude. Valores de P < 0,05 foram considerados estatisticamente significantes. Resultados: Avaliação clínica: Todos os pacientes obtiveram escore de sinais neuropáticos graves e demonstraram déficit de força e atrofia distal. Deformidades dos pés estavam presentes em todos os pacientes e deformidades na coluna, em 58%. Os reflexos profundos dos membros superiores estavam exaltados em 92% dos casos e o reflexo patelar, em 63%. O reflexo Aquileu estava ausente em todos os pacientes. Todas as modalidades de sensibilidade foram afetadas, principalmente nos membros inferiores. Os dados do exame de sensibilidade na paciente de 4 anos foram desconsiderados. Estudo da condução nervosa sensitiva: Os SNAPs dos nervos mediano, sural e fibular estavam ausentes em todos os pacientes. SNAPs do nervo ulnar estavam ausentes em 96% da amostra e do nervo radial, em 80%. Estudo da condução nervosa motora: As latências motoras dos nervos axilar e femoral estavam normais em todos os pacientes. As amplitudes dos CMAPs estavam reduzidas em 15 e 52% da amostra nos nervos mediano e ulnar, respectivamente. Velocidades de condução estavam reduzidas em 50 e 41% desta casuística nos nervos mediano e ulnar, respectivamente. Velocidades de condução estavam acima de 80% do limite inferior da normalidade, em todos os nervos, exceto em 1 paciente que apresentou redução de 27% no nervo ulnar. Entretanto, este mesmo paciente apresentou amplitude menor que 2mV. Ondas F apresentavam aumento da latência, de acordo com a altura, em 100% dos casos. CMAPs estavam ausentes em 93 e 84% da amostra nos nervos fibular e tibial, respectivamente. Reflexo H estava ausente em 88% dos pacientes. Não houve correlação entre idade e a velocidade de condução, latência e amplitude dos nervos mediano e ulnar. Discussão: O estudo da condução nervosa neste grupo preencheu critérios para uma neuropatia primária axonal. Nenhum paciente apresentou bloqueio de condução ou dispersão temporal. As alterações encontradas na velocidade de condução provavelmente se devem à perda de fibras nervosas de condução rápida. Fenótipos SPOAN-like foram descritos em famílias com mutações nos genes C12orf65, TFG e OPA1. No entanto, não existem detalhes sobre a condução nervosa nestes pacientes. Neuropatia axonal de início tardio foi relacionada à SPG55 e DOA (dominant optic atrophy), enquanto neuropatia axonal e desmielinizante com leve comprometimento sensitivo foi descrita na família com mutação no gene TFG. Conclusão: Os pacientes com a síndrome SPOAN apresentam uma acentuada neuropatia axonal, sensitivo motora. As alterações encontradas na condução nervosa dos pacientes com síndrome SPOAN não são específicas, no entanto, resultados normais excluem esta condição em adultos. A paciente mais jovem desta casuística já apresentava alterações ao exame, o que pode sugerir um início precoce da neuropatia. Entretanto, não temos dados suficientes para afirmar que este seja um achado comum a todos os pacientes SPOAN / Introduction: SPOAN syndrome (Spastic Paraplegia, Optic Atrophy and Neuropathy) is a progressive neurodegenerative disorder of autosomal recessive inheritance described by our group in a large inbred family from Northeastern Brazil. The clinical picture is characterized by non-progressive congenital optic atrophy, progressive spastic paraplegia, axonal neuropathy, auditory startles, dysarthria, spinal and foot deformities and also extrapyramidal signs. Linkage studies mapped the responsible locus for the syndrome to a 2Mb region on chromosome 11q13. The gene responsible for SPOAN syndrome remains elusive. Materials and Methods: This is a cross sectional study which was conducted from 2009 to 2011. We evaluated 27 patients (20 females), with a0ges ranging from 4 to 58 years. All patients shared the same phenotype (spastic paraplegia, optic atrophy and peripheral neuropathy) and had the same 11q13 haplotype in homozygosis. Patients with history of diabetes mellitus or alcoholism were excluded from this study. All patients were evaluated by the same clinical researcher (SA). Neurological evaluation included determination of modified neuropathy symptoms (NSS) and neuropathy disability (NDS) scores. Motor strength was assessed using MRC scale. Sensibility assessment included small-fiber (pain and temperature) and large-fiber modalities (vibration-128Hz diapason, 10g monofilament and joint position sense). Spine deformities and atrophy in the lower limbs were observed. We also evaluated osteotendineous reflexes and cutaneous plantar reflexes. Nerve conduction studies were performed using a portable Nicolet - Viking Quest, (Viasys,USA). Motor conduction studies included axillary, median, ulnar, femoral, tibial and fibular nerves on the right side. Sensory nerve action potentials of median, ulnar, sural and superficial fibular nerves were recorded using a bar electrode of 3 cm and standard fixed distances. Tibial H-reflex was evaluated with standard technique. Minimal F wave latencies were obtained from ulnar and tibial nerves. A few tests could not be done in every patient due to severe deformities. We calculated Pearson\'s correlation coefficients between age and nerve conduction parameters, including velocities, latencies and amplitudes. P values <0.05 were considered statistically significant. Results: Clinical data: Neuropathic symptoms such as pain and paresthesias were rare. All patients had signs of severe neuropathy. All subjects demonstrated weakness and atrophy that were more significant distally than proximally. Foot deformities were present in all patients and spine deformities were seen in 58%. Upper limb deep tendon reflexes were exalted in 92% and patelar reflex in 63%. Ankle reflex was absent in all patients. In one patient, who was 4 years-old, sensory evaluation was inconsistent and the results were not considered. In all the other ones, sensory modalities were affected and occurred predominantly in the lower limbs. Electrodiagnostic data: Sensory nerve conduction: Median nerve SNAP was absent in all 27 patients. Ulnar nerve SNAPs were absent in 96%, whereas radial nerve SNPAs were absent in 80%. Superficial fibular and sural SNAPs were absent in all patients. Motor nerve conduction: The motor latencies of axillary and femoral nerves were normal in all patients. CMAP amplitudes were reduced in 15% of the median nerves and in 52% of the ulnar nerves. Conduction velocities (CV) were reduced in 50% of the median nerves and in 41% of the ulnar nerves. CV was above 80% of the lower normal limit for all nerves, except for one patient who showed a 27% reduction of ulnar CV, but had also a CMAP amplitude of less than 2 mV. F waves were prolonged according to the height in 100%. Only one patient who presented significant motor CV reduction of the ulnar nerve. CMAPs were absent in 93% of the fibular nerves and in 84% of the tibial nerves. A single fibular nerve showed more than 20% of CV reduction, but also had severely reduced CMAP amplitude. H reflex was absent in 88% of the patients. There was no correlation between age and neurophysiological parameters, such as median or ulnar CV, latencies or CMAP amplitudes. Discussion: Nerve conduction studies in this group fulfill criteria for primary axonal neuropathy. No patient showed conduction block or temporal dispersion. Abnormalities seen in CV and F waves are probably related to loss of fast conduction fiber nerves. We could not demonstrate correlation between age and nerve conduction parameters, including velocities, latencies and amplitudes. SPOAN-like phenotype has been found in families with mutations in C12orf65, TFG and OPA1 genes, however there is no detailed report on nerve conduction studies in these conditions. Axonal neuropathy is also described in SPG55 and DOA plus, but usually with a later onset than on SPOAN syndrome. Peripheral neuropathy is also described in the family with mutation in TFG gene, but this presents a different pattern characterized as a mixed axonal demyelinating neuropathy with mild sensory involvement. Although the nerve conduction abnormalities seen in SPOAN syndrome are not specific, normal results seem to rule out this condition, at least in adult patients. The younger patient in our series was 4-years-old, and her neurophysiological study was severely abnormal, suggesting an early-onset neuropathy. However, we do not have a comprehensive study of several young patients to support that this feature is

Este estudo mostra como o rolamento do pé de pacientes com polineuropatia diabética pode ser melhorado com exercícios para pés e tornozelos, visando a recuperação muscular e articular comprometidos pela doença. Um ensaio clínico randomizado, paralelo, com um braço de crossover, e avaliador cego, foi conduzido. Cinquenta e cinco pacientes com polineuropatia diabética foram randomizados e alocados para o grupo controle (n=29) e grupo intervenção (n=26). A intervenção foi aplicada por 12 semanas, 2 vezes por semana, por 40 a 60 minutos cada sessão. As variáveis primárias foram definidas como as que descrevem o rolamento do pé: pressão plantar em seis regiões plantares de interesse. As variáveis secundárias foram a cinética e cinemática de tornozelo no plano sagital, e as medidas clínicas da função de pés e tornozelo (teste de função muscular manual, testes funcionais), de sinais e sintomas da polineuropatia diabética, exame físico dos pés e teste de confiança e equilíbrio em atividades da marcha. Os efeitos de tempo (baseline e 12 semanas), de grupo (controle e intervenção) e de interação foram calculados por meio de ANOVAs casewise 2 fatores, e para as comparações intragrupo do grupo intervenção (baseline, 12 semanas e 24 semanas) foram usadas ANOVAs para medidas repetidas. As variáveis não paramétricas foram comparadas entre grupos por meio de testes de Mann-Whitney e entre os tempos de intervenção por meio do teste de Wilcoxon. Adotou-se um ? de 5% para diferenças estatísticas e o coeficiente d de Cohen para descrição do tamanho do efeito da intervenção. Após 12 semanas de exercícios, observou-se mudanças positivas no rolamento do pé. Houve uma suavização do contato do calcanhar no apoio inicial, refletido pelo aumento do tempo do pico de pressão e da integral do pico de pressão. O médio-pé aumentou sua participação no rolamento observado pela diminuição da velocidade média do deslocamento do centro de pressão e aumento da integral do pico de pressão. O antepé lateral passou a realizar o apoio no solo antecipadamente em relação ao antepé medial, que previamente à intervenção aconteciam concomitantemente, e esse resultado foi evidenciado pela antecipação do tempo do pico de pressão em antepé lateral após a intervenção. A ação de hálux e dedos também aumentou (aumento de integral do pico de pressão e picos de pressão), em uma patologia marcada pela diminuição do contato do hálux e desenvolvimento de dedos em garra, que diminui o contato dos dedos com o solo. O grupo controle apresentou algumas pioras com relação à função muscular e parâmetros cinéticos e cinemáticos de tornozelo, enquanto que o grupo intervenção mostrou melhora na função de muitos grupos musculares, em testes funcionais e no pico de momento extensor na fase de aplainamento do pé. Apesar do protocolo de intervenção ter sido construído de modo a permitir que o paciente incorpore os exercícios na sua rotina diária, a aderência a este tipo de intervenção deve ser estudada, já que grande parte das variáveis retornaram ao baseline após o período de follow up. Ações preventivas são fundamentais para diminuir as complicações devastadoras da neuropatia diabética / This study shows how the foot rollover process during gait of patients with diabetic polyneuropathy can be improved with exercises for foot and ankle, aiming at the recovery of the muscles and joints affected by the disease. A clinical trial randomized, parallel, one arm of crossover, with blind assessment was conducted. Fifty-five patients with diabetic polineuropathy were randomly allocated to the control group (n = 29) and intervention group (n = 26). The intervention was applied for 12 weeks, twice a week, for 40 to 60 minutes per session. The primary variables were defined as those that describe the foot rollover: plantar pressure in 6 plantar areas of interest. The secondary variables were kinetic and kinematics of the ankle in the sagittal plane were calculated, and the clinical measures of foot and ankle function (manual muscle function testing, functional testing), signs and symptoms of diabetic polyneuropathy, physical examination of the feet and balance and confidence test in gait activities. The time effects (baseline and 12 weeks), group effects (control and intervention groups) and interaction effects were calculated using casewise two factos ANOVAs, and for intragroup comparisons of intervention group (baseline, 12 weeks and 24 weeks) it was used ANOVAs for repeated measures. The nonparametric variables were compared between groups using Mann-Whitney tests and between periods of assessment using Wilcoxon test. We adopted an ? of 5% for statistical differences and the Cohen\'s d coefficient for description of the effect size. After 12 weeks ofexercises, there were positive changes in the foot rollover process. There was a softening of heel contact in initial contact, reflected by the increase in time to peak pressure and the pressure time integral. The midfoot increased its participation observed by the decrease in speed of displacement of the center of pressure and increased pressure time integral. The lateral forefoot contact was earlier relative to the medial forefoot, that occurred at the same time before intervention, observed by the early time to peak pressure of lateral forefoot after the intervention. The participation of the hallux and toes also increased (increase of pressure time integral and peak pressure), in a pathology that is marked by decreased contact of the hallux and development of claw toes, which reduces contact of the toes with the ground. CG showed some worsening in relation to muscle function and kinematic and kinetic parameters of the ankle, while the IG showed improvement in the function of many muscles groups, functional tests and peak extensor moment during the forefoot contact. The intervention protocol was constructed to allow the patient to incorporate exercise into their daily routine, but adherence to treatment should be studied and motivational strategies need to be applied, since most of the variables returned to baseline after the follow up period (12 weeks after the intervention). Preventive actions are critical to reducing the devastating complications of diabetic neuropathy