The lateral ankle ligaments are interconnected: the medial connecting fibres between the anterior talofibular, calcaneofibular and posterior talofibular ligaments

PURPOSE

A deep knowledge of lateral ankle ligaments is necessary to understand its function, pathophysiology and treatment options. The ankle lateral collateral ligament is formed by the anterior talofibular ligament (ATFL), the calcaneofibular (CFL) and the posterior talofibular ligament (PTFL). Although previous studies have reported connections between these ligaments on its lateral side, no studies have specifically assessed connections on the medial side. The aim of this study was to assess the morphology and consistency of the medial connections between the components of the lateral collateral ligament complex of the ankle.

METHODS

Forty fresh-frozen ankle specimens were dissected to look for connections between the three lateral ankle ligaments. After visualization of the lateral ligaments was achieved, the fibula was amputated and ligament insertions were released at the talar and calcaneal insertion points. Observation of the connections and video analysis of the dynamic relationships of ligament connections were performed.

RESULTS

Connections were found in all cases between the ATFL and PTFL, the ATFL and CFL, and the CFL and PTFL. Connections between ATFL and PTFL were not homogeneous. Although connections between the ATFLif and PTFL were noted in all cases (40), only 17 ankles (42.5%) had connections between the ATFLsf and PTFL. The amount of fibres of connection was also variable.

CONCLUSION

Connections between the three components of the lateral collateral ligament of the ankle may be observed from the medial aspect of the ankle, and this may have important implications for arthroscopic lateral ligament repair.

IL-33 increases ST2+ Tregs and promotes metastatic tumour growth in the lungs in an amphiregulin-dependent manner

Regulatory T cells (Tregs) facilitate primary and metastatic tumour growth through the suppression of anti-tumour immunity. Emerging evidence suggests a distinct role for Tregs in mediating tissue repair and barrier integrity in the lungs by IL-33 mediated production of the growth factor amphiregulin (AREG). Dependent on the type of cancer and local microenvironment, AREG may induce tumour cell proliferation, invasion, migration or resistance to apoptosis by signaling through the epidermal growth factor receptor (EGFR). We have found that IL-33 is dramatically increased in and around metastatic tumour foci in the lungs of mice bearing orthotopic murine mammary tumours. We observed that Tregs express significantly more of the IL-33 receptor, ST2, relative to conventional T cells, that ST2⁺ Tregs accumulate in the lungs of metastatic tumour-bearing mice, and that ST2⁺ Tregs produce significantly more AREG than ST2^- Tregs. The intranasal administration of recombinant IL-33 increased the proportion of AREG producing ST2⁺ Tregs and enhanced the level of phosphorylated EGFR in the metastatic lungs. While recombinant AREG did not impact mammary tumour cell proliferation in vitro despite inducing a dose-dependent increase in phosphorylated EGFR, intranasal administration of AREG resulted in a ten-fold increase in pulmonary metastatic tumour burden in vivo. Further, the intranasal administration of recombinant IL-33 significantly increased metastatic tumour burden in the lungs in an amphiregulin-dependent manner. These data identify ST2⁺ Tregs as a microenvironmental source of AREG in the lungs of mice with orthotopic metastatic mammary tumours and highlight an important role for AREG in promoting metastatic tumour growth in the lungs.

Arthroscopic anatomical reconstruction of the lateral ankle ligaments

Chronic ankle instability secondary to lateral ligament insufficiency is common after sports injury. Many surgical techniques have been described for the treatment of the lateral ankle ligament complex. They can be classified into repair or reconstruction, and non-anatomical or anatomical. A few authors have recently published innovative techniques for arthroscopic ankle ligament management. This paper describes the arthroscopic techniques enabling anatomical lateral ligament reconstruction using gracilis autograft or allograft for chronic ankle instability. This technique and the steps have been developed by the Ankle Instability Group to make this a reproducible procedure. The purpose of this presentation is to document the technique in the future with a view to a clinical study investigating the results of such surgery in a cohort of suitable patients with chronic ankle instability.

LEVEL OF EVIDENCE

V.

Consensus in chronic ankle instability: aetiology, assessment, surgical indications and place for arthroscopy

Ankle sprains are the most common injuries sustained during sports activities. Most ankle sprains recover fully with non-operative treatment but 20-30% develop chronic ankle instability. Predicting which patients who sustain an ankle sprain will develop instability is difficult. This paper summarises a consensus on identifying which patients may require surgery, the optimal surgical intervention along with treatment of concomitant pathology given the evidence available today. It also discusses the role of arthroscopic treatment and the anatomical basis for individual procedures.

e-Health? Clinical information network interest and impediments in a community paediatric setting

BACKGROUND

Increased interest in implementing evidence-based medicine in paediatric practice has led to the development of a variety of electronic clinical and decision-making support tools. Electronic medical records and information resources have the potential to improve both the clinical and cost effectiveness of paediatric community practice at the point of care. Barriers to the successful implementation of clinical information Intranet resources include physician attitudes, as well as system and practitioner capabilities.

OBJECTIVE

To examine Ontario's community care paediatricians' electronic information resource needs and interest in accessing the proposed Central West Ontario Pediatric Information Network (CWPIN).

DESIGN

Cross-sectional, interviewer-facilitated, structured survey.

POPULATION STUDIED

Paediatricians providing community care in the Central West Ontario Health Region.

MAIN RESULTS

Three-quarters of regional community paediatricians responded to the survey. Of those surveyed, 98% expressed interest in gaining access to the CWPIN. Computer literacy, suggested by home computer and Internet use rates (88% and 81%, respectively), did not differ significantly by age or sex. Other factors that may affect network use, such as workplace computer use and allied personnel role assignment, differed by sex, indicating potentially greater CWPIN use among male practitioners.

CONCLUSIONS

Physicians reported an overwhelming interest in gaining access to and using the CWPIN. Disparities in current workplace but not home-based computer use by sex indicate that workplace role allocation, rather than computer literacy, may explain sex differences in CWPIN use rates. Attitudinal and computer proficiency issues did not appear to be obstacles to implementing the clinical information Intranet resource in the region.

Health information provided by retail health food outlets

Alternative health practices have become increasingly popular in recent years. Many patients visit specific complementary practitioners, while others attempt to educate themselves, trusting advice from employees at local health food stores or the Internet. Thirty-two retail health food stores were surveyed on the nature of the information provided by their staff. A research assistant visited the stores and presented as the mother of a child in whom Crohn's disease had been diagnosed. Seventy-two per cent (23 of 32) of store employees offered advice, such as to take nutritional and herbal supplements. Of the 23 stores where recommendations were made, 15 (65%) based their recommendation on a source of information. Fourteen of the 15 stores using information sources used the same reference book. This had a significant impact on the recommendations; the use of nutritional supplements was favoured. In conclusion, retail health food stores are not as inconsistent as hypothesized, although there are many variances in the types of supplements recommended for the same chronic disease.

Testing the measurement properties of the Short Form-36 Health Survey in a frail elderly population

The Short Form-36 Health Survey (SF-36) is a widely used measure of health-related quality of life, however, its suitability for frail older persons is not well documented. This study examines the measurement properties of the SF-36 in a frail older patient population. Patients consecutively admitted to two geriatric services (n = 146) were administered the SF-36 and comparative measures on admission and discharge. Internal consistency (0.75-0.91) and test-retest reliability (0.24-0.80) did not meet standards for clinical application of the tool. Four subscales were moderately correlated with comparative measures (Physical Function 0.53 to -0.76; Bodily Pain -0.61; Vitality -0.58; Mental Health -0.63). The results of effect size, standardized response mean, and relative efficiency statistics were consistent in documenting only minimal change for the SF-36 subscales. The SF-36 appears to be reliable and valid, although its ability to monitor clinical change for frail older patients is questionable.

Interaction of Lindane Isomers with Chloride Currents in Insect Membranes: Steric Requirements for Channel Modulation and Block

Electrophysiological methods were used to characterize the modulatory effects of hexachlorocyclohexane isomers on GABA-activated chloride currents in dissociated locust neurones. Conductance changes associated with hyperpolarising responses (or outward voltage-clamped currents), evoked by brief GABA pulses, were inhibited by the gamma-isomer at 0.01-1 &mu;M. The antagonistic action was noncompetitive and voltage-independent: the concentration required for half-maximal block was <0.01 &mu;M. The rate of equilibration with the membrane/receptor was inversely proportional to the concentration applied and was not dependent upon agonist-induced channel gating: effects were only partially reversible with extensive washing. In contrast the noninsecticidal beta-isomer was a low-affinity (>/=10 &mu;M) positive modulator of the inhibitory chloride channels. The modulatory action was voltage-dependent (more pronounced for inward currents at hyperpolarised potentials), did not reflect changes in chloride equilibrium potential, and was completely reversible. Nicotinic acetylcholine receptors were consistently antagonised by the beta-isomer at 10 &mu;M. The above results were interpreted by computer-assisted modelling and are discussed in the context of a pharmacophore model for picrotoxinin and convulsant insecticides. The gamma-isomer overlays well with picrotoxinin and a convulsant butyrolactone whereas the beta-isomer and anticonvulsant butyrolactones conform to a different template. Liganding mechanisms and comparative/species differences in chloride channel pharmacology are discussed in the context of potential for development of invertebrate-selective pesticides.

Difficult direct laryngoscopy in patients with cervical spine disease

Two hundred and fifty three patients were examined before surgery for cervical spine disease. The grade of glottic visibility was determined at direct laryngoscopy, using the classification proposed by Cormack and Lehane. The overall prevalence of difficulty (grades 3 and 4) was 20%. Patients with disease that includes the occipito-atlanto-axial complex have a higher prevalence of difficulty than those with disease below the axis vertebra. Occipito-atlanto-axial disease is associated with poor mandibular protrusion. The best single predictor of difficulty was reduced separation of the posterior elements of the first and second cervical vertebrae on lateral radiographs. The Mallampati examination was the best single predictor on physical examination. The Mallampati may be an indicator of poor cranio-cervical extension. Difficulty was rare in patients with class A mandibular protrusion, and invariable in patients with class C protrusion.

Exacerbations of chronic bronchitis: exogenous or endogenous infection?

Six male patients with chronic bronchitis, who were known previously to have excreted Streptococcus pneumoniae and/or Haemophilus influenzae, both at the times of exacerbations and during remission, were studied for 43 to 52 months. Sputum was examined fortnightly and at the time of exacerbations. Strains of Strep. pneumoniae were serotyped and those of Haemophilus species were typed by antibiograms along with other supporting methods. Sera collected before or at the time of an exacerbation and seven and 30 days afterwards were examined by complement fixation tests against respiratory viruses and Mycoplasma pneumoniae. In 18 out of 25 exacerbations there was evidence of a new type of Strep. pneumoniae and/or Haemophilus spp. or of a current virus infection, suggesting exogenous infection in the majority of these cases. There was a possible reason for failure to detect a new pathogen in three of the seven cases in which none was found. In five further exacerbations adequate investigation was not possible.

Talo-calcaneal bridging in an Anglo-Saxon

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Meckel's diverticulum presenting as fistula-in-ano

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