Suspensory System Research Articles

Finite element model of ocular adduction with unconstrained globe translation

Details of the anatomy and behavior of the structures responsible for human eye movements have been extensively elaborated since the first modern biomechanical models were introduced. Based on these findings, a finite element model of human ocular adduction is developed based on connective anatomy and measured optic nerve (ON) properties, as well as active contractility of bilaminar extraocular muscles (EOMs), but incorporating the novel feature that globe translation is not otherwise constrained so that realistic kinematics can be simulated. Anatomy of the hemisymmetric model is defined by magnetic resonance imaging. The globe is modeled as suspended by anatomically realistic connective tissues, orbital fat, and contiguous ON. The model incorporates a material subroutine that implements active EOM contraction based on fiber twitch characteristics. Starting from the initial condition of 26° adduction, the medial rectus (MR) muscle was commanded to contract as the lateral rectus (LR) relaxed. We alternatively modeled absence or presence of orbital fat. During pursuit-like adduction from 26 to 32°, the globe translated 0.52 mm posteriorly and 0.1 mm medially with orbital fat present, but 1.2 mm posteriorly and 0.1 mm medially without fat. Maximum principal strains in the optic disk and peripapillary reached 0.05–0.06, and von-Mises stress 96 kPa. Tension in the MR orbital layer was ~ 24 g-force after 6° adduction, but only ~ 3 gm-f in the whole LR. This physiologically plausible simulation of EOM activation in an anatomically realistic globe suspensory system demonstrates that orbital connective tissues and fat are integral to the biomechanics of adduction, including loading by the ON.

From a Single Penile Suspensory Ligament to a Penile Suspensory Apparatus: Application to the Buried Penis Surgery

Abstract Goals/Purpose The ligamentous system supporting the penis is widely called « penile suspensory ligament ». It supports and attaches the penis to the abdominal wall and the pubic bone. However, the complexity of the anatomy of the penile suspensory system was underestimated. The aim of this anatomical study was to describe the different ligamentous (features, insertion sites, path) and their functions. Methods/Technique The first step consisted in a description of the different components of the penile suspensory apparatus on two cadavers embalmed by the Thiel method. The second part was an evaluation of the function of each ligament on freshly dead cadavers. In the third stage, we applied those findings to an exploratory cohort of patients undergoing a penile lengthening surgery for buried penis. Results/Complications The penile suspensory apparatus consisted in four ligaments from anterior to posterior : the fundiform ligament, the suspensory ligament, dense vertical ligament and the arcuate ligament. The first two were loose, non-stabilizing and the two posterior ones were dense and stabilizing. In our cohort, 12 patients were included. The mean BMI was 38. The mean pre-operative flaccid length was 4.1 cm [2.2 cm – 7 cm] and at 6 months 8.2 cm [5.2 cm - 11.5 cm] which represents a mean augmentation of 100%. The mean pre-operative circumference at a flaccid state was 8.2 cm [2 cm – 11.5 cm] and at 6 months post-operative was 12.6 cm [8.3 cm - 16 cm] which represents a mean augmentation of 85.7%. The most common complication was a phimosis. Conclusion We have described the detailed anatomy of the penile suspensory apparatus. It is the first time that the dense vertical ligament was brought to light. To avoid instability in penile lengthening, the posterior part of the dense vertical ligament and the arcuate ligament must be spared.

Anatomical Study of the Penile Suspensory System: A Surgical Application to Micropenis.

This study is subdivided in two parts: an anatomical analysis and a clinical analysis. The anatomical part consists of a dissection of eight male cadavers to describe the anatomy and test the stability after sectioning successively the suspensory ligaments. The clinical part consists of an analysis of 30 patients with micropenis operated on for penile lengthening by a penile suspensory ligament release and lipofilling. The suspensory apparatus consists of four distinct ligamentous structures: fundiform, suspensory, dense vertical, and arcuate ligaments. These different structures are lax superficially but become firm and tense posteriorly. The section of the fundiform and suspensory ligaments did not destabilize the penis. Penile lengthening by way of cautious suspensory ligament release can be performed without erection instability.

Anatomical variations of the liver and its suspensory system: a cadaver-based study

Anatomical variations of the liver and its suspensory system: a cadaver-based study

Anatomical variations of the liver and its suspensory system: a cadaver‐based study

Introduction & ObjectiveNon‐traumatic musculoskeletal (MSK) pain has become a socio‐economic burden, being the leading cause of absenteeism and prolonged disability. Despite all medical advances, the origin of this pain is still unclear. Studies have reported theories on the role of fascia, nociceptive stimulation, and visceral (im)mobility, and provided evidence for the success of visceral manipulation therapy. The influence of viscera on the MSK system is neglected in scientific research, even though the human body functions best when its components, including the viscera, are free to move in full range. Thus, to understand the role of visceral mobility on the MSK system, this study aimed to investigate the anatomical variation of the liver’s suspensory system via physical measurements and 3D surface scanning. It is hypothesized that anatomical variations will exist.Materials & MethodsWith IRB clearance, fourteen of twenty‐two formaldehyde‐fixed donors were selected for this study; the other eight donors excluded due to pathology affecting the region of interest. Using gross dissection, livers and diaphragms were isolated. Using a string and a digital micrometer, the length and thickness of the triangular ligaments, the falciform ligament, and the circumference of the bare area was measured for each selected donor. Each isolated liver was weighed. Using a structured light scanner, each liver and suspensory system (bare area and aforementioned ligaments) were digitalized for future analysis.ResultsThe mean lengths (mm) of the left triangular ligament edges were 55.70 ± 27.1, 88.38 ± 31.69, and 63.62 ± 28.76. The mean lengths (mm) of the right triangular ligament edges were 35.32 ± 21.15, 46.98 ± 51.83, and 33.28 ± 21.83. The mean lengths (mm) of the falciform edges were 102.75 ± 30.40, 172.32 ± 35.70, and 105.51 ± 49.25. The mean thicknesses (mm) of the left and right triangular ligaments, and the falciform, were 0.32 ± 0.16, 0.32 ± 0.20, and 0.34 ± 0.31, respectively. The bare area circumference was 443.12 ± 98.38mm, and the mean liver weight was 1439.09 ± 752.39g.ConclusionThis dissection‐based study provides evidence of a broad range of anatomical variations that exists between livers and suspensory system, emphasizing the uniqueness of the human body’s anatomy.Significance/ImplicationThis was the first study to examine the morphological variation of the liver’s ligaments and bare area via meticulous physical measurements. The results suggest that the liver’s suspensory system has carefully adapted to each body’s needs and demands. Understanding and visualizing this could help train clinicians who provide visceral manipulation therapy to the liver for MSK pain. A patient’s specific liver morphology may differ greatly from standard anatomy textbook descriptions, so recognizing the anatomical variation of the liver’s suspensory system and the potential impact it has on the MSK system could lead to alternative and improved treatments. Further research could include statistical modeling from the 3D digitalized models. To understand the actual role of the liver’s suspensory system in influencing the MSK system, the biomechanical and proprioceptive properties of the ligaments should be researched.

The Evolution of the Suspensory System of the Liver: A Narrative Review

Introduction & ObjectiveIt is known that the viscera in the body of vertebrates participate in the major vital functions of the body, however the role of visceral mobility in the proper functioning of the musculoskeletal system remains insufficiently investigated. In order to understand the potential influence of viscera on the musculoskeletal system, we need to clarify how the suspensory system of viscera has evolved within the outer body of species at different evolutionary timepoints. More importantly, we need to determine how the suspensory system of high‐density organs, which are more prone to influencing the outer body due to their mass, adapted to different types of locomotion. This narrative review was undertaken to reconstruct the theoretical evolution of the liver and related peritoneal ligaments, to investigate its adaptation to bipedal locomotion.Materials & MethodsThe primary focus of this review was the evolution of the peritoneal suspensory ligaments of the liver through documented species at specific evolutionary timepoints: annelid, agnathans, gnathostomes and tetrapods (amphibians to quadrupedal and bipedal mammals). Keyword searches in SCOPUS, PubMed, Google Scholar, and McGill Library databases were conducted in addition to manual searches of other relevant journals, textbooks and dissection manuals.ResultsQualitative studies on the gross anatomy of the liver and the suspensory peritoneal ligaments of species at different evolutionary time points were identified. A theoretical timeline of the evolution of the suspensory system of the liver was assembled.Marine species, which rely on lateral undulation, and terrestrial quadrupeds both possess a highly mobile liver and few reliably seen ligaments of suspension. This is concluded to be due to environmental demands and consequent locomotive requirements, such as running, hopping, and leaping. The human liver, in contrast, is securely attached to the diaphragm and the body walls in the upper right quadrant of the abdominal cavity via consistently present ligaments.ConclusionThis study suggests that locomotive methods led to the adaptation of ligaments that suspend high‐density organs within the body, such as the liver. Compared to other mammals, the human liver has been securely suspended to the diaphragm via peritoneal ligaments and attached to the body walls in response to two‐legged locomotion.Significance/ImplicationThis study provides a theoretical timeline of the evolution of the suspensory system of the liver related to locomotion types. Like the musculoskeletal system, it appears that the visceral suspensory ligaments adapted to the different locomotion types found over the evolutionary timeline. Over time, as species adapted, more numerous ligaments provided further attachment. This adaptation is suggestive of potential mechanical influence between the musculoskeletal system and viscera, or vice‐versa. This raises questions regarding the implication of high‐density organs on some musculoskeletal disorders.To better understand the potential mechanical influence of the human liver on the musculoskeletal system, the suspensory system of the liver and anatomical variations needs to be clearly described.

Acoustic Myography: Its Assessment of Ground Reaction Forces as Measured through Forelimb and Hind Limb of the Horse during Mild Exercise

Background: Fractures in the limbs of racehorses are common, resulting among other factors, as the result of repeated ground reaction forces on bones and joints, leading to catastrophic failure. Aim: To quantify ground impact transmission through the limb bones of un-shod healthy horses using the non-invasive technique of acoustic myography (AMG). Methods: Four sites were selected for AMG measurements at the walk and trot, hoof wall (site 1) and sites 2 - 4, metacarpal 3, carpals and the radius of the left forelimb of two healthy horses. Measurements were on both rubber and concrete. AMG of the equine hind limb suspensory system was made and analyzed (amplitude and timing) for the proximal suspensory ligament (PSL) and the SDFT/DDFT. Results: AMG signal amplitude at site 1 (1.5 ± 0.2 versus 1.1 ± 1.5) was not found to be significantly different at the trot compared to the walk; however, sites 2, 3 and 4 were all significantly different when compared between the two gaits; site 2 P = 0.008; site 3 P = 0.006; site 4 P = 0.005. AMG signals recorded on the rubber surface had smaller amplitude than the equivalent signal and site on the concrete surface. Ground Reaction Force (GRF) transmission in the equine forelimb was 22 m/sec, whilst that of the hind limb suspensory system was 25 m/sec. Conclusion: Findings indicate that GRFs are transmitted proximally along the limb at considerable speeds, that they are dampened by tissues and structures in the limb, and that the GRFs are present and detectable proximal to the fetlock joint.

Hybrid coracoclavicular and acromioclavicular reconstruction in chronic acromioclavicular joint dislocations yields good functional and radiographic results.

Optimal treatment of chronic unstable acromioclavicular (AC) joint dislocations (stage 3-5 according the Rockwood classification) is still debated. Anatomic coracoclavicular (CC) reconstruction is a reliable option in terms of two-dimensional radiographic reduction, clinical outcomes, and return to sports, but there remain concerns regarding anterior-posterior stability of the AC joint with CC ligament reconstruction alone. The aim of the present study was to describe the mid-term results of a new hybrid technique with CC and AC ligament reconstruction for chronic AC joint dislocations. Twenty-two patients surgically treated for chronic AC joint dislocations (grade 3 to 5) were retrospectively reviewed. All patients were assessed before surgery and at final follow-up with the Constant-Murley score (CMS) and the American Shoulder and Elbow Surgeons (ASES) score. The CC vertical distance (CCD) and the CCD ratio (affected side compared to unaffected side) were measured on Zanca radiographs preoperatively, at 6months postop and at final follow-up. The same surgical technique consisting in a primary fixation with a suspensory system, coracoclavicular ligaments reconstruction with a double loop of autologous gracilis and acromioclavicular ligaments reconstruction with autologous coracoacromial ligament was performed in all cases. Twenty-two shoulders in 22 patients (19 males and 3 females) were evaluated with a mean age of 34.4 ± 9years at the time of surgery. The mean interval between the injury and surgery was 53.4 ± 36.7days. The mean duration of postoperative follow-up was 49.9 ± 11.8months. According to the Rockwood classification, there were 5 (22.6%) type-III and 17 (77.2%) type-V dislocations. Mean preoperative ASES and CMS were 54.4 ± 7.6 and 64.6 ± 7.2, respectively. They improved to 91.8 ± 2.3 (p = 0.0001) and 95.2 ± 3.1 (p = 0.0001), respectively at final FU. The mean preoperative CCD was 22.4 ± 3.2mm while the mean CCD ratio was 2.1 ± 0.1. At final FU, the mean CCD was 11.9 ± 1.4mm (p = 0.002) and the mean CCD ratio was 1.1 ± 0.1 (p = 0.009). No recurrence of instability was observed. One patient developed a local infection and four patients referred some shoulder discomfort. Heterotopic ossifications were observed in three patients. The optimal treatment of chronic high-grade AC joint dislocations requires superior-inferior and anterior-posterior stability to ensure good clinical outcomes and return to overhead activities or sports. The present hybrid technique of AC and CC ligaments reconstruction showed good clinical and radiographic results and is a reliable an alternative to other reported techniques. Level IV.

Clinical Outcome of a Modified Coracoid Tunnel-Free Coracoclavicular Sling Technique With Remnant Preservation for the Treatment of High-Grade Acromioclavicular Joint Separation: A Report of 48 Cases With 2 to 5 Years of Follow-up

Background: High-grade acromioclavicular (AC) joint separation injuries (Rockwood type IV or V) are surgically indicated because of complete disruption of the AC and coracoclavicular (CC) ligaments, leading to instability and pain. In surgical techniques that require a suspensory system, coracoid tunnel-related complications are not uncommon. Purpose: To report subjective and objective clinical outcomes and complication rates of a modified coracoid tunnel-free CC sling technique combined with CC ligament remnant preservation for a minimum 2-year follow-up. Study Design: Case series; Level of evidence, 4. Methods: Between January 2014 and January 2017, we prospectively enrolled patients who underwent a modified CC sling technique performed by 1 senior surgeon using the AC TightRope System in a coracoid tunnel-free fashion. The CC distance (CCD) and Rockwood AC joint classification were evaluated on radiographs preoperatively, immediately postoperatively, and at the final follow-up. The visual analog pain score, range of motion, American Shoulder and Elbow Surgeons score, Constant-Murley score, and University of California Los Angeles score were recorded preoperatively and at the final follow-up. Results: In total, 48 of 54 patients (88.9%) were included for the evaluation with a mean ± SD follow-up of 39.3 ± 8.9 months (range, 24.7-64.3 months). The CCD was significantly decreased from 22.7 ± 4.2 to 9.8 ± 2.3 mm (P < .01) immediately after surgery and to 11.2 ± 1.8 mm (P < .01) at final follow-up. At the final follow-up, the side-to-side difference of CCD was 3.5 ± 0.6 mm. Compared with the preoperative level, all subjective evaluations were significantly improved at the final follow-up. We observed that 4 of the 48 patients (8.3%) had a loss of reduction at the final follow-up, but no pain or instability was documented. Further, no coracoid-related complication or other complications were recorded. Conclusion: The coracoid tunnel-free CC sling technique using the AC TightRope System combined with CC ligament remnant preservation demonstrated significant improvement regarding both clinical and radiological outcomes, with a reduction loss rate of 8.3%. It is a safe method that could achieve satisfactory result without any coracoid drilling-related complications.

Osseous Healing With Nonrigid Suture Fixation in the Arthroscopic Latarjet Procedure.

Background:The Latarjet procedure is a popular means to surgically address anterior glenohumeral joint instability. Although the Latarjet procedure is becoming increasingly common, challenges persist and include postoperative complications secondary to use of the conventional 2 bicortical fixation screws. Recently, a novel surgical technique using a guided surgical approach for graft positioning with nonrigid fixation via a suture suspensory system has been described.Purpose:To evaluate healing rates and stability of the grafts in patients who underwent this new Latarjet technique.Study Design:Case series; Level of evidence, 4.Methods:We retrospectively gathered anonymized computed tomography (CT) data sets from a total of 107 patients who underwent nonrigid suture fixation using a cortical button fixation for anterior glenohumeral instability. Of the 107 patients, 45 had CT scans performed at 2 different time periods. The CT scans of each patient were compared by 2 fellowship-trained musculoskeletal radiologists. Data recorded included age, sex, date of scan, initial graft position on the glenoid, presence and degree of graft migration relative to the equator on follow-up scan, and percentage of osseous healing (as assessed by osseous bridging) on the follow-up scan. Descriptive statistics were calculated to evaluate the average migration and average percentage of healing at both time points.Results:Our population (n = 45) consisted of 38 men (84.4%) and 7 women (15.6%). The mean age was 27.1 ± 1.1 years. The mean time between initial CT scan (2 weeks postoperatively) and follow-up CT scan was 26 ± 2 weeks. On follow-up scan, reviewer 1 found 75.6% of patients had greater than 75% healing, and reviewer 2 found 70.2% of patients had greater than 75% healing. The center of the graft was measured at or below the equator on follow-up examination in 43 of 45 (95.6%) patients by reviewer 1 and 44 of 45 (97.8%) patients by reviewer 2.Conclusion:Based on these findings, nonrigid suture fixation using a cortical button device offers an effective alternative to traditional screw fixation for the Latarjet procedure with a high level of osseous healing and minimal graft migration.

A quantitative approach to shortening the levator palpebrae superioris to correct congenital ptosis in children

AIM: To develop a feasible method to correct congenital ptosis in children. METHODS: Sixty-four patients (102 eyelids) were divided into three groups based on the degree of ptosis: mild (&lt;2 mm); moderate (3-4 mm); and severe (&gt;4 mm). All patients underwent the same levator resection surgery in which the suspensory system of the LPS is retained. After capturing a standard photograph of primary position, the height of the superior palpebral margin was measured preoperatively by using Image J software to calculate its ideal height required during surgery. Postoperative outcome measures included upper eyelid margin height, degree of scleral exposure and exposure keratitis. The patients were followed-up at 1wk, 1mo and 6mo postoperatively. RESULTS: In the early postoperative period, except two cases with overcorrection, the positions of the eyelid upper margins were normal in all cases in the mild and moderate groups. Six months postoperatively, the eye with overcorrection in the moderate group showed improvement, while the eye in the mild group did not. Seven eyes in the severe group exhibited residual ptosis to varying degrees. The eyelids exhibited appropriate closing functionality; exposure keratitis was absent. CONCLUSION: Using this preoperative quantification technique to guide surgery not only provide a gauge for LPS shortening under general anesthesia, but also increase the success rate of surgery.

Morfologija vimena, proizvodnja mlijeka i zdravlje mliječne žlijezde malih preživača

In recent years there has been an increasing trend in research of sheep and goat udder morphology, not only from the view of its suitability for machine milking, but also in terms of milk yield and mammary gland health. More precisely, herds consisting of high-yielding sheep and goats as a result of long-term and one-sided selection to increase milk yield, have been characterised by distortion of the udder morphology caused by increasing the pressure of udder weight on its suspensory system. Along with the deteriorated milking traits, which is negatively reflected on the udder health, some udder morphology traits are often emphasized as factor of production longevity of dairy sheep and goats. Since the intention of farmers and breeders nowadays is to increase the milk yield of sheep and goats while maintaining desirable udder morphology and udder health, the aim of this paper is to give a detailed overview of the current knowledge about the relationship of morphological udder traits with milk yield, and the health of the mammary gland of sheep and goats. External measures of udder size (circumference, width and depth of the udder) are strongly correlated with milk production in sheep and goats. The morphological udder traits determining its suitability for machine milking (such as teat position and teat angle, udder depth, teat size, cistern height) are related to the mammary gland health in sheep and goats. Thus, the incidence of mastitis is noticeably higher in the udders of unsuitable shape for machine milking (deep and hung udders, unfavourable position of teats, etc.). Consequently, the morphological udder traits that affect the milkability of sheep and goats are indirectly related to milk yield.

Osseous Healing With Non-Rigid Suture Fixation Offers a Compelling Alternative to Conventional Latarjet Procedure

Objectives: The Latarjet procedure, both open and arthroscopically, is a popular means to surgically address anterior glenohumeral (GH) joint instability. Though the arthroscopic approach to the Latarjet is becoming increasingly common, challenges persist: (1) technical difficulty positioning the bone block flush with the glenoid and the screws parallel to the glenoid surface (2) postoperative complications secondary to the two bicortical fixation screws, and (3) considerable risk of neurological injury. Recently, a novel surgical technique has been described which uses a guided surgical approach for graft positioning with non-rigid fixation via a suture suspensory system. The objective of our retrospective study was to evaluate healing rates and long-term stability of shoulders who underwent this new technique of anterior glenoid augmentation. The specific aims of our study were to assess (1) if this non-rigid suture fixation system is stable enough to allow the autograft bone to heal onto the native glenoid appropriately and (2) if the autograft bone could be reliably placed without migration of the graft. Methods: In this retrospective study, we gathered anonymized DICOM computed tomography (CT) datasets from a total of 107 patients who underwent non-rigid suture fixation with a cortical button fixation device in lieu of the traditional bicortical screws during arthroscopic Latarjet procedure. Of the 107 patients, only 75 patients had at least two CT scans performed at two different time periods which could be compared in terms of osseous healing and potential migration. The first CT scan for each patient was 2 weeks postoperative. Each patient’s CT scans were compared side-by-side by the same fellowship-trained musculoskeletal radiologist on a diagnostic workstation. Data recorded included the age, gender, date of each scan, initial graft position on the glenoid, presence and degree of graft migration on delayed follow-up scan (minimum 3 months), and the percentage of osseous healing (as assessed by osseous bridging) on the delayed follow-up scan. A minority of patients had several delayed timepoint scans (several years out), and those were evaluated as well. Descriptive statistics were calculated evaluating the average migration and average percent healing at both timepoints. Results: Our population (n=75) consisted of 61 men (81.3%) and 14 women (18.7%). The mean age of was 27.3 ± 1.1 years. The mean time period between initial CT scan (2 weeks postoperative) and follow-up CT scan to assess for healing and migration was 27 ± 2 weeks. At delayed follow-up scan, the average percent healing on follow-up scan was 78% ± 4%. A total of 61 out of 75 (81%) patients had greater than 75% healing on follow-up scan. The average migration of the coracoid graft in our study was 1.45 ± 0.23 mm, ranging from 0 mm to 8.75 mm. A total of 37/75 (49.3%) of the patients had no migration at all on follow-up scan, and 63/75 (84%) had migration of &lt; 2 mm. Conclusion: Based on these findings, non-rigid suture fixation with a cortical button device offers a safe alternative to traditional screw fixation for the Latarjet procedure. Though a non-rigid fixation system, osseous healing with minimal migration of the graft can be predicted. [Figure: see text]

Nail Anatomy, Nail Psoriasis, and Nail Extensor Enthesitis Theory: What Is the Link?

The concept of the nail unit as a musculoskeletal appendage has become popular in the dermatological and rheumatological literature. However, an exact knowledge of the characteristics of mesenchyme surrounding the nail such as the composition of the collagen and elastic fibers and their arrangement is fundamental before one can propose a constitutive model. To the best of my knowledge, there is no study in the literature concerning the elastic network of the ligamentous connective tissue of the base of the distal phalanx. This study by means of elastic stains demonstrates that the so-called superficial, deep, and lateral laminae of the extensor tendon correspond to 3 different microanatomic structures: the nail dermis and its fibrous root, the subcutaneous proximal nail fold, and the periosteum. The complex fascial and adipose connective tissue of the proximal nail fold surrounds the matrical dermis and could viewed as a kind of suspensory system for the proximal nail unit. Such suspensory system protects the nail matrix epithelium from the biomechanical strain of the extensor mechanism. Near the ulnar and radial edge of the base of the phalanx, focal interconnections between the fibrous root of the apex of the matrix and the periosteum through a fascia-like structure are visible. In its most lateral zone, the matrical horns lie on a thick dermis connected to the interosseous ligament. Such lateral laminar system serves as anchoring ropes for the vault of the nail plate. The nail-extensor enthesitis theory relies on an oversimplified anatomy because the nail unit is an epidermal appendage with a specialized connection with the lateral periosteum, but not a musculoskeletal appendage. Finally, I would like to emphasize, the practical importance of recognizing the matrical hypoderm. In nail surgery, the interface between the matrical nail dermis and its submatrical loose connective tissue is potentially a new, relatively superficial, surgical cleaving plane, beside the classical deep surgical procedure usually extending to the periosteum. Recognition of this additional cleaving plane leads to an optimal nail tangential biopsy.

Nature and Architecture of the Puboprostatic Ligament: A Macro- and Microscopic Cadaveric Study Using Epoxy Sheet Plastination

To investigate the nature and the architecture of the puboprostatic ligament (PPL) and its relationship with surroundings. Six adult male cadaveric pelvises (age range, 46-87 years) were prepared as serial transverse (2 sets), coronal (1 set), or sagittal (3 sets) plastinated sections, and were examined under a stereoscope and a confocal microscope. The thickness of the section was 2.5 mm, the interval between 2 adjacent sections was about 0.9 mm, and a total of about 70 serial sections per set were collected. First, the musculotendinous sheet of the pubococcygeus contributed to the visceral endopelvic fascia, decussated in front of the detrusor apron, and fixed to the pubis. Second, anteriorly to the prostate, the detrusor apron split up into anterior, middle, and posterior layers, which contributed to the PPL, the fascial sheaths of the dorsal vascular complex, and the anterior fibromuscular stroma of the prostate, respectively. Third, the PPL originated from both the detrusor apron and the decussated and undecussated fibers of the pubococcygeus, and inserted onto the pubis. This study revealed the nature and the architecture of the PPL and its relationship with surroundings. These findings provide new insights in the "suspensory system" involving the urinary continence and may incite for future surgical techniques that aim to preserve the decussated pubococcygeus and the intactness of a pubococcygeus-detrusor apron complex during radical retropubic prostatectomy.

A Modified Levator Resection Technique Involving Retention of the Levator Palpebrae Superioris Muscle Suspension System for Treatment of Congenital Ptosis.

The classical levator resection (LR) technique for correcting ptosis involves separating the levator palpebrae superioris muscle (LPS) completely, which will inevitably collapse the muscle. The modified surgical method involving retention of the LPS suspensory system can allow for more contractility of the levator muscle and thus maximize protection of the eyelid structure. Ninety patients (132 eyelids) with different degrees of ptosis were enrolled. The same levator resection surgery whereby the suspensory system of the LPS is retained was performed in each patient. Postoperative outcome measures included the following: position of the upper eyelid margin, eyelid contour and plumpness, degree of scleral exposure, and exposure keratitis. Postoperative follow-up time points were 1week, 1month, and 6months. The positions of the eyelid upper margins were normal in all cases, and lagophthalmos only existed in severe cases in the early stage after surgery. Six months after surgery, 32% of the eyes had residual ptosis to varying degrees among severe cases, and the mild and moderate cases exhibited good surgical outcomes. The eyelids had appropriate closing functionality, and exposure keratitis was not observed in any case. Eyelid contour and plumpness was satisfactory in all patients. Retaining the suspensory system of the LPS for LR with a modified surgery can protect the normal function and morphology of the eyelids. The surgery had a high success rate, especially for cases of mild and moderate ptosis. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Arthroscopic treatment of displaced tibial eminence fractures using a suspensory fixation.

Background:Avulsion fractures of the tibial intercondylar eminence are fairly common injuries requiring surgery for the optimal functional outcome. The purpose of this study was to assess the clinical and radiological outcomes of an arthroscopic treatment of displaced tibial intercondylar eminence fractures using a suspensory device.Material and Methods:Five patients with type 2 and 3 displaced tibial intercondylar eminence fractures who received an arthroscopically assisted fixation using a double button device were enrolled from 2011 to 2012. Clinical assessment included the patient demographics, cause of injury, the delay before surgery, time for surgery, time to return to work and sport, the International Knee Documentation Committee (IKDC) and Lysholm knee scores. Stability was measured with the KT-2000 arthrometer with a force of 134 N. A side to side difference on the KT-2000 examination superior to 3 mm was considered as a significant and abnormal increase in the anterior translation. Radiological examination consisted of anteroposterior and lateral radiographs, as well as computed tomography (CT) scan of the affected knee. Clinical and radiological followup was done at 1, 2, 3, 6, and 12 months postoperatively and at final followup. CT-scan was performed before surgery and at 3 months followup.Results:The median age of patients was 31 years. Mean followup was 27 ± 5.1 months. The average delay before surgery was 3 days. At final followup, the mean IKDC and Lysholm knee scores were, 93.9 and 94.5 respectively. All patients had a complete functional recovery and were able to return to work and to resume their sport activities. No secondary surgeries were required to remove hardware. No complication was noted. Bony union was achieved in all patients.Conclusion:The arthroscopic treatment of displaced tibial intercondylar eminence fractures using a suspensory system provided a satisfactory clinical and radiological outcome at a followup of 2 years.

Lumbopelvic muscle activation patterns in three stances under graded loading conditions: Proposing a tensegrity model for load transfer through the sacroiliac joints

According to the conventional arch model of the pelvis, stability of the sacroiliac joints may require a predominance of form and force closure mechanisms: the greater the vertical shear force at the sacroiliac joints, the greater the reliance on self-bracing by horizontally or obliquely oriented muscles (such as the internal oblique). But what happens to the arch model when a person stands on one leg? In such cases, the pelvis no longer has imposts, leaving both the arch, and the arch model theory, without support. Do lumbopelvic muscle activation patterns in one-legged stances under load suggest compatibility with a different model? This study compares lumbopelvic muscle activation patterns in two-legged and one-legged stances in response to four levels of graded trunk loading in order to further our understanding the stabilization of the sacroiliac joints. Thirty male subjects experienced four levels of trunk loading (0%, 5%, 10% and 15% of body weight) by holding a bucket at one side, at three conditions: 1) two-legged standing with the bucket in the dominant hand, 2) ipsilateral loading: one-legged standing with the bucket in the dominant hand while using the same-side leg, and 3) contralateral loading: one-legged standing using the same leg used in condition 2, but with the bucket in the non-dominant hand. During these tasks, EMG signals from eight lumbopelvic muscles were collected. ANOVA with repeated design was performed on normalized EMG's to test the main effect of load and condition, and interaction effects of load by condition. Latissimus dorsi and erector spinae muscles showed an antagonistic pattern of activity toward the direction of load which may suggest these muscles as lateral trunk stabilizers. Internal oblique muscles showed a co-activation pattern with increasing task demand, which may function to increase lumbopelvic stability (P < 0.05). No unilateral pattern of the internal obliques was observed during all trials. Our results suggest that the lumbopelvic region uses a similar strategy for load transfer in both double and single leg support positions which is not compatible with the arch analogy. Our findings are more consistent with a suspensory system (wire-spoke wheel model). If our proposed model holds true, the pelvic ring can only be integrated by adjusting tension in the spokes and by preserving rim integrity or continuity. Thus, we propose that in order to restore tension integrity throughout the pelvic ring, efforts to unlock restrictions, muscular correction of positional faults and lumbopelvic or even respiratory exercises following sacroiliac joint dysfunctions must be taken into consideration. Our hypothetical model may initiate thinking and act as a guide to future work based on a biomechanical approach to the problem of sacroiliac joint dysfunction.

Rhinoplasty Using Nácul’s Suspensor System: A Preliminary Report

A minimally invasive procedure based on a "suspensory system" is presented for the aesthetic correction of the flat nose. A Goretex monofilament is inserted between the connective tissue and the perichondrium from the septal, upper lateral, and alar cartilages in a quadrangular fashion. When tightened, it shortens the nose and elevates the tip. The procedure is performed on an outpatient basis with the patient under local anesthesia. It offers the patient immediate evaluation of the result. No edema or bruises have been observed. At this writing, 8 months after an application of this procedure, no extrusions or collateral reactions have been found.

Is the large size of the pinna of the ear of the European hare (Lepus europaeus) due to its role in thermoregulation or in anterior capital shock absorption?

Large pinnae are characteristic of the Leporids, and the pinna is known to have a thermoregulatory role. Another role has been hypothesized for the pinna of Lepus spp., as a part of a suspensory system for the greater portion of the head, absorbing shock that might otherwise interfere with vision during high-speed locomotion. We compared the lengths of the pinnae of adult European hares Lepus europaeus from the source population in the cooler climate of England with those of the introduced population in the warmer climate of Australia, and we compared the lengths of the pinnae of hares that had grown in cooler weather with those that had grown in warmer weather. There were no significant differences between each of the comparisons, indicating that the size of the pinna is not determined by thermoregulatory requirements at rest. We compared the growth in length of the pinnae and the legs with growth in body mass, and growth in the mass of the pinnae with the masses of the head and the eyeballs, and found support for the suspension hypothesis. We suggest that the rapid growth of the pinna is because visual acuity is a function of absolute eye size, not relative eye size, yet juvenile hares are subject to the same predator pressure as adult hares, and equally need to maximize visual acuity while running at high speeds in dim light. We believe that the large size of the pinna is determined by its role in anterior capital suspension, not in thermoregulation.