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A femoral nerve injury may result in cutaneous sensory disturbances of the anteromedial thigh and complete paralysis of the quadriceps femoris muscles resulting in an inability to extend the knee. The traditional mainstay of treatment for femoral neuropathy is early physiotherapy, knee support devices, and pain control. Case reports have used the anterior division of the obturator nerve as a donor nerve to innervate the quadriceps femoris muscles; however, a second nerve transfer or nerve grafting is often required for improved outcomes. We suggest a novel technique of combining an innervated, pedicled gracilis transfer with an adductor longus to rectus femoris nerve transfer to restore the strength and stability of the quadriceps muscles.This is a case series describing the use of a pedicled gracilis muscle transposed into the rectus femoris position with a concomitant nerve transfer from the adductor longus nerve branch into the rectus femoris nerve branch to restore quadriceps function after iatrogenic injury (hip arthroplasty) and trauma (gunshot wound).With electrodiagnostic confirmation of severe denervation of the quadriceps muscles and no evidence of elicitable motor units, 2 patients (average age, 47 years) underwent a quadriceps muscle reconstruction with a pedicled, innervated gracilis muscle and an adductor longus to recuts femoris nerve transfer. At 1 year follow-up, the patients achieved 4.5/5 British Medical Research Council full knee extension, a stable knee, and the ability to ambulate without an assistive aid.The required amount of quadriceps strength necessary to maintain quality of life has not been accurately established. In the case of femoral neuropathy, we assumed that a nerve transfer alone and a gracilis muscle transfer alone would not provide enough stability and strength to restore quadriceps function. We believe that the restoration of the quadriceps function after femoral nerve injury can be achieved by combining an innervated, pedicled gracilis transfer with an adductor longus to rectus femoris nerve transfer with low morbidity and no donor defects.

Parsonage Turner syndrome (PTS) is the development of severe, spontaneous pain with subsequent nerve palsy. Unfortunately, many patients never achieve full functional recovery, and many have chronic pain. The use of nerve transfers in PTS has not been reported in the literature. We present 4 cases of PTS treated surgically with primary nerve transfer and neurolysis of the affected nerve following the absence of clinical and electrodiagnostic recovery at 5 months from onset. In addition, we present a cadaver dissection demonstrating an interfascicular dissection of the anterior interosseous nerve (AIN) into its components to enable a fascicular transfer in partial AIN neuropathy. Two patients with complete axillary neuropathy underwent a neurorrhaphy between the nerve branch to the lateral head of the triceps and the anterior/middle deltoid nerve branch of the axillary nerve. Two patients with partial AIN neuropathy involving the FDP to the index finger (FDP2) underwent a neurorrhaphy between an extensor carpi radialis brevis nerve branch and the FDP2 nerve branch. All patients had neurolysis of the affected nerves. All subjects recovered at least M4 motor strength. The cadaver dissection demonstrates 3 separate nerve fascicles of the AIN into FPL, FDP2, and pronator quadratus that can be individually selected for reinnervation with a fascicular nerve transfer. Functional recovery for patients with PTS with neurolysis alone is variable. Surgical treatment with neurolysis and a nerve transfer to improve functional recovery when no recovery is seen by 5 months is an option.

Proximal interphalangeal joint (PIPJ) fracture dislocations are complex injuries that can result in persistent pain, stiffness, and angulation. Hemihamate arthroplasty (HHA) can be used to reconstruct the base of the middle phalanx in cases of unstable PIPJ fracture dislocations. Despite previous case series describing good outcomes with HHA, it has not gained widespread use. The purpose of this study is to describe our straightforward, reproducible technique and to demonstrate the benefit in motion after the procedure in chronic unstable PIPJ fracture dislocations.All patients with chronic, unstable PIPJ fracture dislocations requiring joint resurfacing of greater than 40% of the base of the middle phalanx treated with HHA were retrospectively reviewed. Patient demographics, injury features, surgical technique, preoperative and postoperative PIPJ range of motion and arc of motion, time to surgery, and complications were reviewed. Any fracture amenable to fixation or cases with radiographic evidence of arthritis or injury to the head of the proximal phalanx were excluded.Eleven cases were reviewed. The mean patient age was 35 years. The mean time from injury to surgery was 6 months. The mean joint surface involved was 64%. The mean PIPJ arc of motion was 17 degrees preoperatively and 63 degrees postoperatively. The mean bone block size required was 8 × 8 × 8 mm. The mean follow-up was 26 months. Postoperative pain at the PIPJ on the visual analog scale was 0.4 (scale of 0 to 10). Complications included 2 patients requiring tenolysis.Despite the lack of a perfect geometric recreation of the base of the middle phalanx with the hamate, patients recover acceptable PIPJ motion and have minimal pain. Hemihamate arthroplasty is a good option for any patient with minimal motion of their PIPJ and a chronic, unstable fracture dislocation.

Background: Transfer of the anterior interosseous nerve (AIN) into the ulnar motor branch improves intrinsic hand function in patients with high ulnar nerve injuries. We report our outcomes of this nerve transfer and hypothesize that any improvement in intrinsic hand function is beneficial to patients. Methods: A retrospective review of all AIN-to-ulnar motor nerve transfers, including both supercharged end-to-side (SETS) and end-to-end (ETE) transfers, from 2011 to 2018 performed by 2 surgeons was conducted. All adult patients who underwent this nerve transfer for any reason with greater than 6 months’ follow-up and completed charts were included. Primary outcome measures were motor function using the British Medical Research Council (BMRC) grading system and subjective satisfaction with surgery using a visual analog scale. Secondary outcome measures included complications and donor site deficits. Results: Of the 57 patients who underwent nerve transfer, 32 patients met the inclusion criteria. The average follow-up and average time to surgery were 12 and 15.6 months, respectively. The overall average BMRC score was 2.9/5, with a trend toward better recovery in patients who received earlier surgery (

© 2019 American Society for Surgery of the Hand Purpose: Current evidence on predictors of outcomes after distal radius fracture is often based on retrospective analyses or may be confounded by fracture type. Using data from the Wrist and Radius Injury Surgical Trial (WRIST), a 24-site randomized study of distal radius fracture treatment, in which all fractures are severe enough to warrant surgery, we set out to perform a secondary data analysis to explore predictors of better or worse hand outcomes. Methods: The primary outcome measure was the Michigan Hand Outcomes Questionnaire (MHQ) summary score 12 months after treatment. We used a regression tree analysis with recursive partitioning to identify subgroups of participants who experienced similar outcomes (ie, MHQ score) and to determine which baseline or treatment factors they had in common. Results: Factors most predictive of 12-month MHQ score were pain at enrollment, education, age, and number of comorbidities. Specifically, participants who had a high school education or less and also reported severe pain had the lowest MHQ scores. Conversely, participants with less pain and more education and who were age 87 years or younger with one or no comorbid condition had the highest MHQ scores. Treatment type or radiographic measurements assessed on post-reduction films did not affect 12-month outcomes. Conclusions: These results identified patient characteristics that can be used by surgeons to identify subgroups of patients who may experience similar hand outcomes. Type of study/level of evidence: Prognostic III.

Peroneal intraneural ganglia are rare, and their management is controversial. Presently, the accepted treatment of intraneural ganglia is decompression and ligation of the articular nerve branch. Although this treatment prevents recurrence of the ganglia, the resultant motor deficit of foot drop in the case of intraneural peroneal ganglia is unsatisfying. Foot drop is classically treated with splinting or tendon transfers to the foot. We have recently published a case report of a peroneal intraneural ganglion treated by transferring a motor nerve branch of flexor hallucis longus into a nerve branch of tibialis anterior muscle in addition to articular nerve branch ligation and decompression of the intraneural ganglion to restore the patient's ability to dorsiflex. We have since performed this procedure on 4 additional patients with appropriate follow-up. Depending on the initial onset of foot drop and time to surgery, nerve transfer from flexor hallucis longus to anterior tibialis nerve branch may be considered as an adjunct to decompression and articular nerve branch ligation for the treatment of symptomatic peroneal intraneural ganglion.

In patients with brachial plexus injuries, intrinsic muscle function, wrist and digital movement, pinch, and grasp are difficult to restore with nerve grafting and nerve transfers; therefore, free functioning muscle transfers or tenodeses are currently the accepted means to restore grasp and pinch. Despite these initial surgical efforts, the patients are left with persistent flaccid/contracted wrists, flaccid thumbs in a supinated and extended position, poor pinch, and poor grasp. Wrist, first carpometacarpal, and thumb interphalangeal joint arthrodeses are used as secondary adjunctive procedures to improve hand function, hand control, and appearance by increasing stability. These arthrodeses provided maximal biomechanical advantage of the tenodeses or transferred gracilis muscle by obtaining improved finger/thumb flexion through stable joints. This chapter will specifically address the restoration of wrist stability in the adult brachial plexus patient population. An approach to restoring thumb stability and finger flexion is addressed in other chapters.

The restoration of hand function in a patient with a complete brachial plexus injury remains the most difficult challenge faced by the upper extremity surgeon. The development of successful options for restitution of shoulder and elbow function have inspired surgeons to work toward developing similarly successful options for the thumb and hand. This chapter will specifically address the restoration of thumb function in the adult brachial plexus patient population. An approach to restoring wrist and finger flexion is addressed in other chapters.

Intraneural ganglion cysts, which occur within the common peroneal nerve, are a rare cause of foot drop. The current standard of treatment for intraneural ganglion cysts involving the common peroneal nerve involves (1) cyst decompression and (2) ligation of the articular nerve branch to prevent recurrence. Nerve transfers are a time-dependent strategy for recovering ankle dorsiflexion in cases of high peroneal nerve palsy; however, this modality has not been performed for intraneural ganglion cysts involving the common peroneal nerve. We present a case of common peroneal nerve palsy secondary to an intraneural ganglion cyst occurring in a 74-year-old female. The patient presented with a 5-month history of pain in the right common peroneal nerve distribution and foot drop. The patient underwent simultaneous cyst decompression, articular nerve branch ligation, and nerve transfer of the motor branch to flexor hallucis longus to a motor branch of anterior tibialis muscle. At final follow-up, the patient demonstrated complete (M4+) return of ankle dorsiflexion, no pain, no evidence of recurrence and was able to bear weight without the need for orthotic support. Given the minimal donor site morbidity and recovery of ankle dorsiflexion, this report underscores the importance of considering early nerve transfers in cases of high peroneal neuropathy due to an intraneural ganglion cyst.Les kystes mucoïdes nerveux du nerf fibulaire commun sont rarement responsables d’un pied tombant. La norme actuelle pour traiter ce type de kystes consiste à 1) décomprimer le kyste et 2) ligaturer le rameau nerveux pour éviter les récurrences. Les transferts nerveux doivent être effectués rapidement pour récupérer la dorsiflexion de la cheville en cas de paralysie importante du nerf fibulaire commun. Toutefois, cette intervention n’a jamais été effectuée en cas de kyste mucoïde nerveux. Les auteurs présentent le cas d’une femme de 74 ans atteinte d’une paralysie du nerf fibulaire commun causée par un kyste mucoïde nerveux. Cette femme a consulté parce qu’elle souffrait depuis cinq mois dans la distribution du nerf fibulaire commun droit et que son pied tombait. Elle a subi simultanément une décompression du kyste, une ligature du rameau nerveux articulaire et un transfert nerveux du rameau moteur du muscle long fléchisseur de l’hallux au rameau moteur du muscle tibial antérieur. Au dernier suivi, la patiente avait totalement retrouvé la dorsiflexion de sa cheville (M4+), ne présentait plus de douleurs ni de manifestations de récurrence et pouvait soutenir son poids sans orthèse. Étant donné la morbidité minime au site du donneur et la récupération de la dorsiflexion de la cheville, ce rapport fait ressortir l’importance d’envisager un transfert nerveux précoce en cas de neuropathie fibulaire importante causée par un kyste mucoïde nerveux.

The most common neurological defect in traumatic anterior glenohumeral dislocation is isolated axillary nerve palsy. Most recover spontaneously; however, some have persistent axillary neuropathy. An intact rotator cuff may compensate for an isolated axillary nerve injury; however, given the high rate of rotator cuff pathology with advancing age, patients with an axillary nerve injury are at risk for complete shoulder disability.To review reconstruction of the axillary nerve to alleviate shoulder pain, augment shoulder stability, abduction and external rotation to alleviate sole reliance on the rotator cuff to move and stabilize the shoulder.A retrospective review of 10 patients with an isolated axillary nerve injury and an intact rotator cuff who underwent a triceps nerve branch to axillary nerve transfer was performed. Patient demographics, surgical technique, deltoid strength, donor-site morbidity, complications and time to surgery were evaluated.Ten male patients, mean age 38.3 years (range 18 to 66 years), underwent a triceps to axillary nerve transfer for isolated axillary nerve injury 7.4 months (range five to 12 months) post-traumatic shoulder dislocation. Deltoid function was British Medical Research Council grade 0/5 in all patients preoperatively and ≥3/5 deltoid strength in eight patients at final follow-up (14.8 months [range 12 to 25 months]). There were no complications and no donor-site morbidity.A triceps to axillary nerve transfer for isolated axillary neuropathy following traumatic shoulder dislocation improved shoulder pain, stability and deltoid strength, and potentially preserves shoulder function with advancing age by alleviating sole reliance on the rotator cuff for shoulder abduction and external rotation.La paralysie isolée du nerf axillaire est la principale anomalie neurologique après une dislocation glénohumérale traumatique antérieure. La plupart guérissent spontanément, mais certains souffrent de neuropathie axillaire persistante. Une coiffe des rotateurs intacte peut compenser une lésion isolée du nerf axillaire. Cependant, compte tenu du fort taux de pathologies de la coiffe des rotateurs liées au vieillissement, les patients ayant une lésion du nerf axillaire risquent une invalidité complète de l’épaule.Examiner la reconstruction du nerf axillaire pour soulager la douleur de l’épaule et en accroître la stabilité, l’abduction et la rotation externe afin d’éviter de se fier uniquement à la coiffe des rotateurs pour bouger et stabiliser l’épaule.Les chercheurs ont procédé à l’analyse rétrospective de dix patients ayant une lésion isolée du nerf axillaire et une coiffe des rotateurs intacte qui ont subi un transfert de la branche du nerf du triceps sur le nerf axillaire. Ils ont évalué la démographie des patients, la technique chirurgicale, la force du deltoïde, la morbidité du site du donneur, les complications et le délai avant l’opération.Dix patients de sexe masculin, d’un âge moyen de 38,3 ans (plage de 18 à 66 ans), ont subi un transfert du nerf du triceps sur le nerf axillaire en raison d’une lésion isolée du nerf axillaire, et ce, 7,4 mois (plage de cinq à 12 mois) après une dislocation traumatique de l’épaule. Chez tous les patients avant l’opération, la fonction du deltoïde était de 0 sur une échelle de 5 selon leLe transfert du nerf du triceps sur le nerf axillaire pour soigner une neuropathie axillaire isolée après une dislocation traumatique de l’épaule soulageait la douleur et la stabilité de l’épaule et la force du deltoïde et assurait la préservation potentielle de la fonction de l’épaule malgré le vieillissement, car la coiffe des rotateurs n’était plus l’unique mode d’abduction et de rotation externe de l’épaule.

The purpose of this randomized clinical trial was to determine whether quality of life and function, as measured using subjective questionnaires and clinical assessment, are different after open versus arthroscopic debridement of the pathologic extensor carpi radialis brevis origin in the treatment of lateral epicondylitis at 1 year postoperatively.Patients older than 16 years with a minimum of 6 months of nonoperative management for lateral epicondylitis were recruited into this prospective, single-blinded randomized clinical trial. Patients were randomized intraoperatively to undergo open or arthroscopic release. Scores on the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure; visual analog scale (VAS); and Patient-Rated Tennis Elbow Evaluation (PRTEE) were recorded preoperatively and 3, 6, and 12 months postoperatively. Grip strength was assessed by an independent assessor. All patients followed the same physiotherapy regimen.Between 2002 and 2014, we randomized 37 patients to the open technique and 38 to the arthroscopic technique. Both groups improved significantly from preoperatively to 12 months postoperatively (P.001). There were no significant differences between the 2 groups when comparing the DASH score, VAS score, PRTEE score, or grip strength at any time point. The only significant difference between study groups was that the arthroscopic technique resulted in a longer surgery time: 34.0 minutes (standard error of the mean, 2.9 minutes) versus 22.5 minutes (standard error of the mean, 1.3 minutes) (P = .005).Comparing the open versus arthroscopic technique in the surgical management of lateral epicondylitis through a randomized clinical trial, we determined that there was no difference between the 2 operative modalities when examining the DASH score, VAS score, PRTEE score, grip strength, or complication rate at 12 months postoperatively. A shorter operative time coupled with potentially less setup time may favor open release.Level II, lower-quality randomized trial.

It is now well known that a cardiomyopathic state accompanies diabetes mellitus. Although insulin injections and conventional hypoglycemic drug therapy have been of invaluable help in reducing cardiac damage and dysfunction in diabetes, cardiac failure continues to be a common cause of death in the diabetic population. The use of alternative medicine to maintain health and treat a variety of diseases has achieved increasing popularity in recent years. The goal of alternative therapies in diabetic patients has been to lower circulating blood glucose levels and thereby treat diabetic complications. This paper will focus its discussion on the role of vanadium on diabetes and the associated cardiac dysfunction. Careful administration of a variety of forms of vanadium has produced impressive long-lasting control of blood glucose levels in both Type 1 and Type 2 diabetes in animals. This has been accompanied by, in many cases, a complete correction of the diabetic cardiomyopathy. The oral delivery of vanadium as a vanadate salt in the presence of tea has produced particularly impressive hypoglycemic effects and a restoration of cardiac function. This intriguing approach to the treatment of diabetes and its complications, however, deserves further intense investigation prior to its use as a conventional therapy for diabetic complications due to the unknown long-term effects of vanadium accumulation in the heart and other organs of the body.

Vanadium can induce potent hypoglycemic effects in type 1 and type 2 diabetes mellitus animals, but toxic adverse effects have inhibited the translation of these findings. Administration of vanadate in a black tea decoction has shown impressive hypoglycemic effects without evidence of toxicity in short-term studies. The purpose of this study was to investigate the hypoglycemic action and the toxic adverse effects of a tea/vanadate (T/V) decoction in diabetic rats over a 14-month treatment period. Streptozotocin-induced type 1 diabetes mellitus rats were orally gavaged with 40 mg sodium vanadate in a black tea decoction only when blood glucose levels were greater than 10 mmol/L. Glycemic status and liver and kidney function were monitored over 14 months. All of the diabetic rats in this treatment group (n = 25) required treatment with the T/V decoction at the start of the study to reduce blood glucose levels to less than 10 mmol/L. Diarrhea was uncommon among the T/V-treated animals during the first week of T/V treatment and was absent thereafter. There was no evidence of liver or kidney dysfunction or injury. From 2 to 6 months, fewer animals required the T/V treatment to maintain their blood glucose levels. After 9 months of treatment, none of the diabetic animals required any T/V to maintain their blood glucose levels at less than 10 mmol/L. Oral administration of a T/V decoction provides safe, long-acting hypoglycemic effects in type 1 diabetes mellitus rats. The typical glycemic signs of diabetes were absent for the last 5 months of the study.

Purpose To determine the cumulative prevalence of septic arthritis presenting to the emergency department of an academic medical center and evaluate the use of clinical data to diagnose infection versus inflammation. Methods We conducted a records review of a single institution with 80,000 annual emergency room visits. We included a consecutive series of patients with suspected wrist infection from January 1, 2007, to December 31, 2008. Adults complaining of atraumatic wrist pain with either erythema or swelling on physical examination or a final diagnosis of septic arthritis, gout, pseudogout, cellulitis, wrist hematoma/edema, or wrist arthritic flare were suspected to have infection. We collected data using a standardized data abstraction form. Results We reviewed 804 patient records. A total of 104 patients meeting inclusion criteria for suspected wrist joint infection during the 2-year study period were included. Mean age was 62.5 years (SD, 20.2 y); 63 were men. There were 12 patients with a history of gout, 4 with a history of pseudogout, and 19 with a history of diabetes. Wrist arthrocentesis was performed in 31 patients, and 11 underwent surgical treatment. There were 16 patients with a final diagnosis of gout, 11 with pseudogout, 43 with cellulitis, 13 with upper extremity hematoma/edema, and 15 with wrist arthritic flare. The cumulative prevalence of septic arthritis was 5%. Conclusions In this series of emergency department patients with suspected wrist joint infection, gout, pseudogout, and cellulitis were the most common etiologies. The cumulative incidence of septic wrist arthritis was low.

Diabetes mellitus is associated with abnormal cardiomyocyte Ca(2+) transients and contractile performance. We investigated the possibility that an alteration in inositol trisphosphate/phospholipase C (IP₃/PLC) signalling may be involved in this dysfunction. Phosphatidic acid stimulates cardiomyocyte contraction through an IP₃/PLC signaling cascade. We also tested a novel therapeutic intervention to assess its efficacy in reversing any potential defects. Diabetes was induced in Sprague-Dawley rats by streptozotocin treatment and maintained for an 8 week experimental period. Active cell shortening was significantly depressed in cardiomyocytes obtained from diabetic and insulin-treated diabetic rats in comparison to normal control animals. Perfusion of the cells with phosphatidic acid induced an increase in contraction of control rat cardiomyocytes whereas its effect was inhibitory in cells from streptozotocin-induced diabetic rats. Diabetic rats were also treated orally with vanadate administered in a black tea extract (T/V) for the 8 week period. T/V treatment resulted in a contractile response that was not different from cells of control animals. Furthermore, cardiomyocytes from T/V-treated animals exhibited significantly improved Ca(2+) transients in comparison to diabetic animals and exhibited a normalized response to phosphatidic acid perfusion. It is concluded that a T/V glycemic therapy is capable of preventing the defect in IP₃/PLC signaling that occurs in diabetes and can restore normal cardiac contractile function.

Flexor tendon pulley reconstruction is relatively uncommon, and many technical treatment options have been described. The paucity of evidence in the literature supporting one technique can make these surgical decisions and surgeries challenging. Here, we present a focused review of the triple loop pulley reconstruction technique.

Despite advances in understanding the anatomy and biomechanics of wrist motion, intrinsic carpal ligament injuries are difficult to diagnose and treat. Even when an accurate diagnosis is made, there is no consensus on the most appropriate and reliable treatment. Injury predisposes to a progressive decline in wrist function and a predictable pattern of degenerative arthritis. To prevent inadequate outcomes, many treatment options exist, all having inherent benefits and complications. This article reviews the complications of intrinsic carpal ligament injuries and complications of their treatment. Methods to prevent and principles to manage the complications are discussed.

Red wine and its components have been shown to possess cardioprotective and anti-atherogenic effects. Additionally, red wine and many of its components like catechin, epicatechin, rutin, transresveratrol and quercetin possess antioxidant properties. Oxidized low density lipoprotein (LDL) is involved in the development of an atherosclerotic lesion. Red wine, therefore, may be anti-atherogenic because of its antioxidant effects on LDL modification. This study examined the antioxidant effects of catechin, epicatechin, rutin, transresveratrol, quercetin and Merlot wines on LDL oxidation. Merlot was chosen because although other red wines have been tested, limited information exists for this variety. Oxidation was carried out with AAPH (2,2'-Azo-bis(2-amidinopropane) dihydrochloride) and AMVN (2,2'-Azo-bis(2,4-dimethylvaleronitrile)), as water and lipid soluble peroxyl radical generating systems (FRGS), respectively. This allowed us to determine the lipophilic antioxidant characteristics of the wine and its components. Conjugated diene assays were used to measure LDL oxidation over 6 hrs. In an AAPH system, all polyphenolic compounds except transresveratrol displayed an antioxidant effect. LDL oxidation by AAPH was also inhibited by aliquots of Merlot wine. No antioxidant effects were observed in an AMVN environment except for a mild antioxidant effect by quercetin. Surprisingly, incubation of LDL with Merlot wine strongly protected against oxidation by AMVN. In summary, the five phenolic compounds displayed antioxidant effects in a water soluble free radical generating system, but only quercetin showed this in a lipid soluble one. However, red wine inhibited LDL oxidation by both water and lipid soluble free radical generating systems. Our data suggest, therefore, that red wines contain unidentified antioxidants that provide protection against LDL oxidation within a lipid soluble environment. (Mol Cell Biochem 263: 211-215, 2004).

Diabetes is a serious medical and financial burden on western societies. It is the seventh leading cause of death in the United States and Canada. The disease is due to a primary defect in glucose tolerance and carbohydrate metabolism resulting from either a deficiency of insulin (Insulin-dependent (type I) diabetes mellitus - IDDM) or a state of insulin resistance (Non-insulin-dependent (type II) diabetes mellitus - NIDDM). NIDDM comprises greater than 80% of total diabetic cases. Associated with the primary metabolic defects are equally deleterious secondary complications affecting the renal, ocular, nervous and cardiovascular systems. The cardiovascular complications account for a major proportion of diabetic mortality. As such, it is of paramount importance to develop or find an animal model expressing complications homologous to the human condition. Many models of NIDDM are available to the diabetic researcher but choosing an accurate one can be difficult. The following compares the advantages and limitations of one such model, the JCR:LA-cp rat to other NIDDM models commonly used today.

Objectives: The primary objective of this study was to determine if quality of life and function are different following arthroscopic versus open tennis elbow release surgery. Based on retrospective studies, both approaches have been found to be beneficial, but no prospective randomized comparison has been conducted to date. Methods: Following a minimum six-months of conservative treatment, seventy-one patients (>16 yrs old) were randomized intraoperatively to undergo either arthroscopic or open lateral release. Outcome measures were the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), a 5-question VAS Pain Scale, and grip strength. Study assessments took place pre-, and 6-week, 3-, 6-, and 12-months post-surgery. Comparisons between groups and within groups over time were conducted using repeated measures ANOVA. A minimal clinically significant difference for the DASH had been previously identified as 15 points, and was used to compare groups as well at 12-months post-operative (Beaton et al. 2001). Results: Fifteen women and 19 men underwent the open procedure with a mean age of 47.1 years (6.7) and 13 women and 21 men were in the arthroscopic group with a mean age of 45.0 (6.9). No pre-surgery differences were found between groups based on age, sex, DASH or VAS scores. Both groups demonstrated a significant improvement in subjective measures and grip strength by 12-months post-surgery, and no significant differences were found between groups at any time point. The DASH, our primary outcome, decreased from a mean (SD) of 47.5 (14.5) pre-surgery to 21.9 (21.8) at 12-months post-surgery in the Open group and from 52.7 (16.0) to 22.6 (21.1) in the Arthroscopic group. VAS-pain scores (%) decreased in the Open group from 62.5 (17.2) pre-operatively to 30.0 (26.5) at 12-months. In the arthroscopic group, scores decreased from 63.7 (15.9) to 26.2 (24.6). Grip strength (kg) increased on the affected side from 23.6 (14.9) to 29.3 (16.3) and 21.4 (15.4) to 29.8 (15.4) for Open and Arthroscopic groups, respectively. The number of participants to reach the minimum clinically significant change did not differ between groups, 17 in the open group and 19 in the arthroscopic group. Ten in each group did not reach this threshold. Based on post hoc regression analysis, no factors (age, gender, WCB status, or smoking status) were found to be significant predictors of DASH or VAS outcome at 12-months post-surgery. However, this study was not adequately powered to draw any specific conclusions in this regard. The only significant difference between study groups was that the arthroscopic technique resulted in longer surgery time, 34.0 versus 22.5 minutes (p=0.005). Conclusion: Based on this study, there is no difference between arthroscopic and open tennis elbow release surgery in subjective outcome, specifically DASH and VAS pain scale, or in function, specifically, grip strength, at 12-months post-operative. Therefore, there may not be any benefit to the increased experience and operating room time required to perform a lateral release arthroscopically versus an open approach.

Prolonged exposure to high-intensity noise has been associated with noise-induced hearing loss, hypertension, psychological stress, and irritability. The National Institute of Occupational Safety and Health considers levels above 85 decibels (dB) as harmful. In the study reported here, we sought to determine whether noise levels in orthopedic cast clinics were within safe limits. A calibrated noise dosimeter was worn by cast technologists during 7 adult and 7 pediatric cast clinics, and noise levels were recorded. Mean equivalent continuous noise levels were 77.8 dB (adult clinics) and 76.5 dB (pediatric clinics), mean noise levels adjusted for an 8-hour day were 76.6 dB (adult) and 75.9 dB (pediatric), and mean peak noise levels were 140.0 dB (adult) and 140.7 dB (pediatric). Mean noise levels in cast clinics were within safe limits and there was no statistical difference in noise levels between adult and pediatric clinics. However, peak noise levels in all clinics exceeded recommended limits, and even brief exposure to noise of this intensity may be hazardous.

Sodium orthovanadate suspended in a lichee black tea decoction effectively regulates blood glucose levels in rats with insulin-dependent, streptozotocin (STZ)-induced diabetes. The primary advantage of vanadate delivery with the tea decoction over conventional systems that use water suspensions of vanadate is a significant reduction in the toxic side effects of vanadate. It is unknown if the tea alters the bioavailability of vanadate. Male Sprague-Dawley rats were administered an intravenous injection of STZ to induce diabetes. Four days later, the diabetic rats were treated by oral gavage with 40 mg of Na-orthovanadate suspended in double-distilled, deionized water (V/H2O), tea/vanadate (TV) decoction, or were treated with the tea decoction alone. Vanadium concentrations were measured in blood and various tissues at 1 to 24 hours posttreatment using graphite furnace atomic absorption spectrophotometry. With the exception of bone, maximal vanadium concentration in plasma and tissue samples were observed 2 hours after ingestion, but steadily decreased after that. Plasma vanadium levels continued to decrease until 16 hours. In contrast, vanadium steadily accumulated in bone over the 24-hour period. Overall, rats treated with V/H2O contained similar or significantly higher concentrations of vanadium in all tissues compared with TV treatment. The pattern of vanadium accumulation was also similar over time in both treatment groups. Vanadium levels were highest in bone > kidney > liver > pancreas > lung > heart > muscle > brain in both TV- and V/H2O-treated animals. This study demonstrates that the accumulation of vanadium in diabetic rats is reduced when coadministered with a black tea decoction in comparison to administration of vanadium in water. However, this effect is unlikely to be of a magnitude to explain the full capacity of TV to reduce the toxic side effects of vanadate.

A novel black tea decoction containing vanadate has successfully replaced insulin in a rat model of insulin-dependent diabetes but is untested in non-insulin-dependent diabetic animals. A tea-vanadate decoction (TV) containing 30 or 40 mg sodium orthovanadate was administered by oral gavage to two groups of Zucker diabetic fatty rats and a conventional water vehicle containing 30 or 40 mg of sodium orthovanadate to two others. In the latter group receiving the 30-mg dose, vanadate induced diarrhea in 50% of the rats and death in 10%. In contrast, TV-treated rats had no incidence of diarrhea and no deaths. Symptoms were more severe in both groups with higher vanadate doses, so these were discontinued. After ~16 weeks, the level of vanadium in plasma and tissue extracts was negligible in a further group of untreated rats but highly elevated after vanadate treatment. Vanadium levels were not significantly different between the TV-treated diabetic rats and the diabetic rats given vanadate in a water vehicle. Over the 115 days of the study, blood glucose levels increased from ~17 to 25 mmol/L in untreated diabetic rats. This was effectively lowered (to

Oral administration of vanadate has a strong hypoglycemic effect but results in toxic side effects like life-threatening diarrhea. Tea is known to have potent antidiarrhea effects. We investigated the potential of suspending the vanadate in a tea decoction to reduce the diarrheatic action of vanadate. A concentrated extract of Lichee black tea was, therefore, added to sodium orthovanadate. Streptozotocin (STZ)-induced diabetic rats were orally gavaged with vanadate suspended in water or in the tea decoction, or with the tea extract alone. Blood glucose levels were assessed daily over 11 weeks with levels greater than 10 mmol/L warranting therapeutic intervention. Both the vanadate/water and vanadate/tea solutions acutely reduced blood glucose. The tea extract alone had no effect. The majority of vanadate/water-treated rats developed diarrhea and mortality rates approached 40%. Vanadate/tea-treated diabetic rats experienced no diarrhea or mortality and liver and kidney analyses (plasma ALT and creatinine, blood urea nitrogen [BUN], and urine-specific gravity) were normal. Animals treated with vanadate/tea retained blood glucose levels less than 10 mmol/L for an average of 24 consecutive days without subsequent treatments. Cataract formation was completely prevented. The mechanism of action of vanadate may have involved beta-cell stimulation because vanadate/tea-treated diabetic rats exhibited normal plasma insulin levels. In summary, because of its long-lasting effects, oral administration, and lack of side effects, vanadate/tea represents a potentially important alternative therapy for an insulin-deficient diabetic state.

Over the past twenty years vanadium compounds have garnered much attention with respect to the treatment of diabetes. Vanadium’s attraction as a hypoglycaemic agent lies in its oral route of administration. Several different vanadium salts have been used to treat both Type 1 and Type 2 diabetes in vivo, including sodium orthovanadate, sodium meta-vanadate and vanadyl sulphate. In addition to the hypoglycaemic action of these agents, several biochemical and cellular changes common in diabetes have been positively affected. However, stepping from the animal model to the human diabetic patient has been hindered by the toxicity of these compounds. Gastrointestinal toxicity has been common while other com-plications including hepatotoxicity and body weight changes remain controversial. Many approaches are being investigated in attempts to reduce the toxicity of vanadium compounds, These include dosing alterations, combining vanadium with chelating agents, organic modi-fication of the species itself and most recently combining nutraceuticals with the treatment. The anti-diabetic actions of vanadium salts and the toxicity of these substances are reviewed here with mention of the more recent approaches to limiting the toxicity.

There is a great deal of information presently available documenting a cardiomyopathic condition in insulin-deficient models of diabetes. Less information is available documenting a similar status in non insulin-dependent models of diabetes. We have studied the functional integrity of the myofibrils isolated from hearts of JCR:LA rats. The JCR:LA rat is hyperinsulinemic, hyperlipidemic, glucose intolerant and obese. As such, it carries many of the characteristics found in humans with non insulin-dependent diabetes mellitus. These animals also have many indications of heart disease. However, it is not clear if the hearts suffer from vascular complications or are cardiomyopathic in nature. We examined Mg2+ - dependent myofibrillar ATPase in hearts of JCR:LA-cp/cp rats and their corresponding control animals (+/?) and found no significant differences (P> 0.05). This is in striking contrast to the depression in this activity exhibited by cardiac myofibrils isolated from insulin-deficient models of diabetes. Our data demonstrate that myofibrillar functional integrity is normal in JCR:LA-cp rats and suggest that these hearts are not in a cardiomyopathic state. Insulin status may be critical in generating a cardiomyopathic condition in diabetes.