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Aliev D, Winter K, Henkelmann J, Langer MF, Steinke H. The median nerve´s system of connective tissue distal to the pronator teres to the carpal tunnel. Ann Anat 2024; 255:152295. [PMID: 38936746 DOI: 10.1016/j.aanat.2024.152295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 05/06/2024] [Accepted: 06/10/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Connective tissue serves a role beyond mere spatial filling. Furthermore, there is increasing evidence that connective tissue plays an important role in the pathogenesis of conditions such as carpal tunnel syndrome (CTS). According to our hypothesis, the median nerve (MN) is surrounded by a system of connective tissue distal to the pronator teres and extending up to, and including, the carpal tunnel. METHODS To visualize the connective tissue surrounding the median nerve, we dissected the forearms of 15 body donors from pronator teres to the carpal tunnel, created plastination slices stained with Periodic Acid-Schiff (PAS), and injected ink into the seen spaces. We verified our findings with a segmentational analysis of radiological data of 10 healthy individuals. RESULTS We macroscopically describe the median nerve´s system of connective tissue (MC) distal to the pronator teres and up to and including the carpal tunnel. This system creates, connects, and separates spaces. At least from the pronator teres to the carpal tunnel it also creates subspaces from proximal to distal. For the MC, we established a mean cross-sectional area of 153.1 mm2 (SD=37.15) in the carpal tunnel. The median nerve consistently resides at the center of this MC, which further connects to flexor muscles of the forearm, and to the radius bone. In the carpal tunnel, the MC creates subspaces inside. There, it also acts as the outermost internal layer enveloping flexor tendons, and the MN. DISCUSSION The term MC does not negate but orders the existence of other "connectives", like subsynovial connective tissue, endo-, epi- or perineuria, epimysia, periostea, or peritendinea, to a hierarchy related to the median nerve. Diseases of the MN are common. Knowing the anatomy of the MC and how it relates to MN function may help clinicians recognize and understand conditions like CTS.
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Affiliation(s)
- Dennis Aliev
- Department of Anatomy, Universitätsklinikum, Leipzig University, Leipzig, Germany
| | - Karsten Winter
- Department of Anatomy, Universitätsklinikum, Leipzig University, Leipzig, Germany
| | - Jeanette Henkelmann
- Clinics of Diagnostic and Interventional Radiology, Leipzig University, Leipzig, Germany
| | - Martin F Langer
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Münster, Münster, Germany
| | - Hanno Steinke
- Department of Anatomy, Universitätsklinikum, Leipzig University, Leipzig, Germany.
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Willegger M, Bouchard M, Schwarz GM, Hirtler L, Veljkovic A. The Evolution of Sinus Tarsi Syndrome-What Is the Underlying Pathology?-A Critical Review. J Clin Med 2023; 12:6878. [PMID: 37959343 PMCID: PMC10650822 DOI: 10.3390/jcm12216878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 09/29/2023] [Accepted: 10/28/2023] [Indexed: 11/15/2023] Open
Abstract
Background and Objectives: Sinus tarsi syndrome (STS) is defined as pain located at the lateral opening of the tarsal sinus. The exact etiology of sinus tarsi syndrome is not completely understood. Some do not believe it to be a true pathology. This review aims to clarify the definition of sinus tarsi syndrome to better understand the underlying pathologies. We further propose an algorithm to evaluate sinus tarsi pain and provide advice for consecutive treatment options. Design: This is a narrative review. By searching PubMed, the available current literature was reviewed. Articles were critically analyzed to determine the pathoanatomy, biomechanics, and etiology of sinus tarsi pain. Algorithms for clinical evaluation, diagnosis, and treatment were also recorded. Finally, the authors approach to evaluating and treating sinus tarsi pain was included in this review. Results: Reviewing the available literature, STS seems to be a catch-all phrase used to describe any pain in this anatomic region. Many causes of sinus tarsi pain were listed, including impingement, subtalar instability, and many other pathologies around the ankle. Conclusions: A thorough evaluation of patients presenting with pain in the sinus tarsi or instability of the hindfoot is essential to determining the underlying cause. When the cause of pain is still not clear after clinical exam and radiologic assessment, subtalar arthroscopy can be helpful as both a diagnostic and treatment tool. We propose that the term of STS should be avoided and that a more accurate diagnosis be used when possible. Once a diagnosis is made, appropriate treatment can be initiated.
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Affiliation(s)
- Madeleine Willegger
- Department of Orthopedics and Trauma Surgery, Division of Orthopedics, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria;
- Department of Orthopaedics, Faculty of Medicine, University of British Columbia, St. Paul’s Hospital, Vancouver, BC V6T 1Z4, Canada;
| | - Maryse Bouchard
- Department of Surgery, Division of Orthopaedics, University of Toronto, Hospital for Sick Children, Toronto, ON M5S 1A1, Canada;
| | - Gilbert M. Schwarz
- Department of Orthopedics and Trauma Surgery, Division of Orthopedics, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria;
| | - Lena Hirtler
- Center for Anatomy and Cell Biology, Division of Anatomy, Medical University of Vienna, Währinger Straße 13, 1090 Vienna, Austria
| | - Andrea Veljkovic
- Department of Orthopaedics, Faculty of Medicine, University of British Columbia, St. Paul’s Hospital, Vancouver, BC V6T 1Z4, Canada;
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Lee Y, Park W, Lee H, Choi Y, Kim S, Yeo E, Lee H, Jung K, Lee B, Lee M, Kim W. Is There a Difference in the Distribution of Mechanoreceptors among the Three Sections of the Anterior Talofibular Ligament? MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1510. [PMID: 37763629 PMCID: PMC10535615 DOI: 10.3390/medicina59091510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 07/28/2023] [Accepted: 08/18/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND We investigated whether the distribution of mechanoreceptors in three sections of the anterior talofibular ligament (ATFL) differed. METHODS The ATFL was obtained from 29 ankles of 21 fresh-frozen cadavers and divided into fibular attachment, mid-ligament, and talar attachment parts. Histologically, mechanoreceptors were classified as Ruffini (type I), Vater-Pacini (type II), Golgi-Mazzoni (type III), and free nerve ending corpuscles (type IV); the presence of these mechanoreceptors was compared among the three ATFL sections. RESULTS Type I mechanoreceptors were significantly more numerous than the other receptor types. Comparing the three sections of the ATFL, the number of type I mechanoreceptors differed significantly between the mid-ligament and fibular attachment (p = 0.006), while the number of type III mechanoreceptors differed significantly between the talar and fibular attachments (p = 0.005) and between the mid-ligament and talar attachment (p = 0.011). CONCLUSIONS The four types of mechanoreceptors were distributed differently among the three sections of the ATFL. Type I mechanoreceptors were more numerous in all sections compared to the other receptors.
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Affiliation(s)
- Youngkoo Lee
- Department of Orthopaedic Surgery, College of Medicine, Soonchunhyang University Bucheon Hospital, 170, Jomaru-ro, Wonmi-gu, Bucheon-si 14584, Republic of Korea; (Y.L.); (S.K.)
| | - Wonseok Park
- Department of Orthopedic Surgery, Choonhae Hospital, 605 Jungang-daero, Busanjin-gu, Busan 47352, Republic of Korea;
| | - Hyerim Lee
- Hyangseol Clinical Laboratory, Soonchunhyang University, Asan-si 31538, Republic of Korea; (H.L.); (Y.C.)
| | - Youngsuk Choi
- Hyangseol Clinical Laboratory, Soonchunhyang University, Asan-si 31538, Republic of Korea; (H.L.); (Y.C.)
| | - Sunghwan Kim
- Department of Orthopaedic Surgery, College of Medicine, Soonchunhyang University Bucheon Hospital, 170, Jomaru-ro, Wonmi-gu, Bucheon-si 14584, Republic of Korea; (Y.L.); (S.K.)
| | - Euidong Yeo
- Department of Orthopaedic Surgery, Veterans Health Service Medical Center, Seoul 05368, Republic of Korea;
| | - Hongseop Lee
- Nowon Eulji Medical Center, Department of Foot and Ankle Surgery, Eulji University, 68, Hangeulbiseok-ro, Nowon-gu, Seoul 01830, Republic of Korea;
| | - Kijin Jung
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (K.J.); (B.L.)
| | - Byungryul Lee
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (K.J.); (B.L.)
| | - Myoungjin Lee
- Department of Orthopaedic Surgery, Dong-A University Hospital, 26, Daesingongwon-ro, Seo-gu, Busan 49201, Republic of Korea;
| | - Woojong Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (K.J.); (B.L.)
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Kudo S, Aoyagi T, Kobayashi T, Koshino Y, Edama M. Ultrasound Imaging of Subtalar Joint Instability for Chronic Ankle Instability. Healthcare (Basel) 2023; 11:2227. [PMID: 37570468 PMCID: PMC10418656 DOI: 10.3390/healthcare11152227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 08/13/2023] Open
Abstract
The purpose of this study was to develop the assessment of subtalar joint instability with chronic ankle instability (CAI) using ultrasonography. Forty-six patients with anterior talofibular ligament (ATFL) abnormalities and a history of ankle sprain were divided into CAI (21.2 ± 5.9 y/o, 7 males and 17 females) and asymptomatic groups (21.0 ± 7.4 y/o, 9 males and 12 females) on the basis of subjective ankle instability assessed using the CAIT and the Ankle Instability Instrument Tool (AIIT). Twenty-six age-matched feet participated in a control group (18.9 ± 7.0 y/o, 9 males and 17 females). Ultrasound measurements of the width of the posterior subtalar joint facet were obtained at rest and maximum ankle inversion (subtalar joint excursion; STJE). The differences in STJE among the three groups were assessed by one-way ANOVA. The relationship between STJE and subjective ankle instability was assessed using Spearman's correlation tests. The STJE value was significantly greater in the CAI group (2.3 ± 0.8 mm) than in the asymptomatic (1.0 ±0.4 mm) and control groups (0.8 ±0.2 mm) (p < 0.001, effect size: 0.64). STJE had significant negative correlations with CAIT (r = -0.71, p < 0.01), and significant positive correlations with AIIT (r = 0.74, p < 0.01). The cut-off value to distinguish between the CAI and asymptomatic groups was 1.7 mm using the ROC curve.
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Affiliation(s)
- Shintarou Kudo
- Department of Physical Therapy, Morinomiya University of Medical Sciences, Osaka 559-8611, Japan;
| | - Tsutomu Aoyagi
- Department of Physical Therapy, Morinomiya University of Medical Sciences, Osaka 559-8611, Japan;
- Department of the Rehabilitation, Oyamadai Orthopedics Clinic Tokyo Arthroscopy Center, Tokyo 158-0082, Japan
| | - Takumi Kobayashi
- Department of Rehabilitation, Hokkaido Chitose College of Rehabilitation, Chitose 066-0055, Japan;
| | - Yuta Koshino
- Faculty of Health Sciences, Hokkaido University, Sapporo 060-0812, Japan;
| | - Mutsuaki Edama
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata 950-3102, Japan;
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Rein S, Esplugas M, Garcia-Elias M, Kremer T, Siemers F, Lühmann P. Immunofluorescence analysis of sensory nerve endings in the periarticular tissue of the human elbow joint. Arch Orthop Trauma Surg 2022:10.1007/s00402-022-04604-0. [PMID: 36070088 DOI: 10.1007/s00402-022-04604-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/24/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION To investigate the dynamic aspects of elbow stability, we aimed to analyze sensory nerve endings in the ligaments and the capsule of elbow joints. MATERIALS AND METHODS The capsule with its anterior (AJC) and posterior (PJC) parts, the radial collateral ligament (RCL), the annular ligament (AL), and the ulnar collateral ligament with its posterior (PUCL), transverse (TUCL) and anterior parts (AUCL) were dissected from eleven human cadaver elbow joints. Sensory nerve endings were analyzed in two levels per specimen as total cell amount/ cm2 after immunofluorescence staining with low-affinity neurotrophin receptor p75, protein gene product 9.5, S-100 protein and 4',6-Diamidin-2-phenylindol, Carbonic anhydrase II and choline acetyltransferase on an Apotome microscope according to Freeman and Wyke's classification. RESULTS Free nerve endings were the predominant mechanoreceptor in all seven structures followed by Ruffini, unclassifiable, Golgi-like, and Pacini corpuscles (p ≤ 0.00001, respectively). Free nerve endings were observed significant more often in the AJC than in the RCL (p < 0.00002). A higher density of Ruffini endings than Golgi-like endings was observed in the PJC (p = 0.004). The RCL contained significant more Ruffini endings than Pacini corpuscles (p = 0.004). Carbonic anhydrase II was significantly more frequently positively immunoreactive than choline acetyltransferase in all sensory nerve endings (p < 0.05). Sensory nerve endings were significant more often epifascicular distributed in all structures (p < 0.006, respectively) except for the AJC, which had a pronounced equal distribution (p < 0.00005). CONCLUSION The high density of free nerve endings in the joint capsule indicates that it has pronounced nociceptive functions. Joint position sense is mainly detected by the RCL, AUCL, PUCL, and the PJC. Proprioceptive control of the elbow joint is mainly monitored by the joint capsule and the UCL, respectively. However, the extreme range of motion is primarily controlled by the RCL mediated by Golgi-like endings.
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Affiliation(s)
- Susanne Rein
- Department of Plastic and Hand Surgery, Burn Unit, Hospital Sankt Georg, Delitzscher Straße 141, 04129, Leipzig, Germany. .,Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany.
| | - Mireia Esplugas
- Kaplan Hand Institute, Paseo de la Reina Elisenda 17, 08034, Barcelona, Spain
| | - Marc Garcia-Elias
- Kaplan Hand Institute, Paseo de la Reina Elisenda 17, 08034, Barcelona, Spain
| | - Thomas Kremer
- Department of Plastic and Hand Surgery, Burn Unit, Hospital Sankt Georg, Delitzscher Straße 141, 04129, Leipzig, Germany
| | - Frank Siemers
- Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany.,Department of Plastic and Hand Surgery, Burn Unit, Trauma Center Bergmannstrost, Merseburger Straße 165, 06112, Halle (Saale), Germany
| | - Paul Lühmann
- Department of Plastic and Hand Surgery, Burn Unit, Hospital Sankt Georg, Delitzscher Straße 141, 04129, Leipzig, Germany.,Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
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Hadano Y, Kimura T, Kubota M, Saito M. Refractory peroneal spastic flat foot successfully treated with a cast in a girl. BMJ Case Rep 2022; 15:e248979. [PMID: 35264394 PMCID: PMC8915361 DOI: 10.1136/bcr-2022-248979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2022] [Indexed: 11/03/2022] Open
Abstract
An 11-year-old girl presented with pain in the sinus tarsi and a foot deformity after spraining her left foot. She had flat foot due to spasticity of the peroneal tendon, which was difficult to correct manually. An imaging study revealed an accessory anterolateral talar facet (AALTF) and bone marrow oedema at the lateral aspect of the posterior talocalcaneal joint. We diagnosed peroneal spastic flat foot with possible involvement of sinus tarsi syndrome and AALTF. When conservative therapy failed, we applied a cast with the foot in full plantar flexion and an inverted position. After 4 weeks, the patient had a normal range of motion in the foot, the pain had resolved completely and the peroneal spasticity had disappeared. Orthopaedic treatment with a cast may be worth attempting before surgery in such cases.
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Affiliation(s)
- Yuka Hadano
- Department of Orthopaedic Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Tadashi Kimura
- Department of Orthopaedic Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Makoto Kubota
- Department of Orthopaedic Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Mitsuru Saito
- Department of Orthopaedic Surgery, Jikei University School of Medicine, Tokyo, Japan
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Middendorf JM, Ita ME, Winkelstein BA, H Barocas V. Local tissue heterogeneity may modulate neuronal responses via altered axon strain fields: insights about innervated joint capsules from a computational model. Biomech Model Mechanobiol 2021; 20:2269-2285. [PMID: 34514531 PMCID: PMC9289994 DOI: 10.1007/s10237-021-01506-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 08/12/2021] [Indexed: 02/08/2023]
Abstract
In innervated collagenous tissues, tissue scale loading may contribute to joint pain by transmitting force through collagen fibers to the embedded mechanosensitive axons. However, the highly heterogeneous collagen structures of native tissues make understanding this relationship challenging. Recently, collagen gels with embedded axons were stretched and the resulting axon signals were measured, but these experiments were unable to measure the local axon strain fields. Computational discrete fiber network models can directly determine axon strain fields due to tissue scale loading. Therefore, this study used a discrete fiber network model to identify how heterogeneous collagen networks (networks with multiple collagen fiber densities) change axon strain due to tissue scale loading. In this model, a composite cylinder (axon) was embedded in a Delaunay network (collagen). Homogeneous networks with a single collagen volume fraction and two types of heterogeneous networks with either a sparse center or dense center were created. Measurements of fiber forces show higher magnitude forces in sparse regions of heterogeneous networks and uniform force distributions in homogeneous networks. The average axon strain in the sparse center networks decreases when compared to homogeneous networks with similar collagen volume fractions. In dense center networks, the average axon strain increases compared to homogeneous networks. The top 1% of axon strains are unaffected by network heterogeneity. Based on these results, the interaction of tissue scale loading, collagen network heterogeneity, and axon strains in native musculoskeletal tissues should be considered when investigating the source of joint pain.
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Affiliation(s)
- Jill M Middendorf
- Department of Biomedical Engineering, College of Science and Engineering, University of Minnesota, Nils Hasselmo Hall, 312 Church St SE, Minneapolis, MN, USA
| | - Meagan E Ita
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Beth A Winkelstein
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Victor H Barocas
- Department of Biomedical Engineering, College of Science and Engineering, University of Minnesota, Nils Hasselmo Hall, 312 Church St SE, Minneapolis, MN, USA.
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Arshad Z, Bhatia M. Current concepts in sinus tarsi syndrome: A scoping review. Foot Ankle Surg 2021; 27:615-621. [PMID: 32978087 DOI: 10.1016/j.fas.2020.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/24/2020] [Accepted: 08/31/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Sinus tarsi syndrome is a relatively unknown condition presenting with pain and a feeling of instability. We aim to summarise evidence on the aetiology, diagnosis and treatment of the condition, whilst answering the question of whether the term should be used. METHODS Scoping review following the methodological frameworks of Arksey and O'Malley, Levac and Peters. The review protocol is registered with the Open Science Framework: (https://osf.io/wj6ct/?view_only=59445d344ec34b6fab640d2fa7a83943). RESULTS In total, 605 studies were identified, 31 of which met selection criteria. Sinus tarsi syndrome is used to describe a range of distinct underlying pathologies. MRI and arthrography show non-specific abnormalities in patients and identifying underlying pathologies is challenging. DISCUSSION The distinct range of underlying pathologies makes identifying specific imaging abnormalities and optimal treatments difficult. Further research in determining optimal treatments for specific pathologies and investigating the efficacy of conservative treatment must be conducted, before we can justify a more specific diagnosis.
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Affiliation(s)
- Zaki Arshad
- University of Cambridge School of Clinical Medicine, Box 111 Cambridge Biomedical Campus, Cambridge CB2 0SP, United Kingdom.
| | - Maneesh Bhatia
- Department of Trauma and Orthopaedic Surgery, University Hospitals Leicester, University Hospitals of Leicester Headquarters, Level 3, Balmoral Building, Leicester, United Kingdom
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Fang K, Ke Q, Wu S, Cai L, Zhang X. [Effectiveness analysis of modified tarsal sinus approach for Sanders Ⅱ- Ⅲtype calcaneal fractures]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:462-466. [PMID: 30983195 PMCID: PMC8337175 DOI: 10.7507/1002-1892.201810010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 02/13/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate the short-term effectiveness of modified tarsal sinus approach and traditional tarsal sinus approach in the treatment of Sanders Ⅱ-Ⅲ type calcaneal fractures. METHODS Between January 2015 and August 2017, 53 patients with Sanders Ⅱ-Ⅲ type calcaneal fractures were selected and divided into observation group (21 cases, using modified tarsal sinus approach for fracture reduction after exposure of the subtalar joint below the long and short fibular tendon) and control group (32 cases, using traditional tarsal sinus approach) by random number method. There was no significant difference between the two groups in terms of gender, age, side, cause of injury, fracture type, injury to operation time, and preoperative Böhler angle, Gissane angle, visual analogue scale (VAS) core ( P>0.05), which were comparable. The operation time, postoperative drainage volume, postoperative Böhler angle, Gissane angle, and postoperative angle improvement values of the two groups were recorded and compared. VAS score, American Orthopaedic Foot and Ankle Society (AOFAS) score, and short-form 36 health survey scale (SF-36) score were used to evaluate the effectiveness. RESULTS All the 53 patients successfully completed the operation without serious complications such as vascular and nerve injury and perioperative death. There was no significant difference in operation time and postoperative drainage volume between the two groups ( P>0.05). Patients in both groups were followed up 12-36 months (mean, 17 months). No infection, fracture displacement, failure of internal fixation, and malunion of fracture occurred after operation. None of the patients underwent secondary joint fusion. There was no significant difference in fracture healing time between the two groups ( t=0.30, P=0.77). The postoperative Böhler angle and Gissane angle at 2 days in the two groups were significantly improved when compared with those before operation ( P<0.05); however, there was no significant difference in Böhler angle, Gissane angle, and improvement value between the observation group and the control group at 2 days after operation ( P>0.05). VAS scores at 24 hours and 1 year after operation were significantly improved when compared with that before operation in both groups ( P<0.05). There was no significant difference in VAS scores between the two groups at 24 hours and 1 year after operation ( P>0.05). There was no significant difference in AOFAS scores between the two groups at 1 year after operation ( t=1.46, P=0.15). However, the SF-36 scale score at 1 year after operation was significantly higher than that of the control group ( t=2.08, P=0.04). At last follow-up, 2 patients in the observation group and 8 patients in the control group presented subtalar joint stiffness or pain, and there was no significant difference in the incidence between the two groups ( χ 2=1.98, P=0.16). CONCLUSION The modified tarsal sinus approach for the treatment of Sanders Ⅱ-Ⅲ type calcaneal fractures has the advantages of minimal invasion, clear reduction under direct vision, reliable reduction and fixation, and low incision complications.
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Affiliation(s)
- Kaibin Fang
- Department of Orthopedics, the Second Affiliated Hospital of Fujian Medical University, Quanzhou Fujian, 362000, P.R.China
| | - Qingfeng Ke
- Department of Orthopedics, the Second Affiliated Hospital of Fujian Medical University, Quanzhou Fujian, 362000, P.R.China
| | - Shiqiang Wu
- Department of Orthopedics, the Second Affiliated Hospital of Fujian Medical University, Quanzhou Fujian, 362000, P.R.China
| | - Liquan Cai
- Department of Orthopedics, the Second Affiliated Hospital of Fujian Medical University, Quanzhou Fujian, 362000, P.R.China
| | - Xiaolu Zhang
- Department of Orthopedics, the Second Affiliated Hospital of Fujian Medical University, Quanzhou Fujian, 362000,
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Mansur NSB, Baumfeld TS, Lemos AVKC, Azevedo RMD, Fonseca LFD, Doering J, Nery CAS. Subtalar arthroscopic debridment for the treatment of sinus tarsi syndrome: case series. ACTA ACUST UNITED AC 2019; 65:370-374. [PMID: 30994835 DOI: 10.1590/1806-9282.65.3.370] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 07/10/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The objective of this study is to report the results of arthroscopic debridement of the subtalar joint in eight patients with Sinus Tarsi Syndrome (STS) refractory to conservative treatment. METHODS This is a retrospective study of eight patients with STS who underwent subtalar arthroscopy for debridement of the sinus tarsi between January 2015 and January 2017 after six months of conservative treatment. All patients answered an epidemiological questionnaire and underwent functional evaluation with the Visual Analogue Pain Scale (VAS) and the American Orthopedic Foot and Ankle Society Score (AOFAS) in the preoperative and in the last evaluation (average of 12 months - 6-24 months). RESULTS All patients showed severe synovitis in the region. Seven patients had remnants of the talocalcaneal ligaments and six of the cervical ligament. AOFAS increased by 30 points on average (51.75 in the preoperative period to 82.62 in the last follow-up) and the VAS decreased on average by 5 points (7.37 preoperatively to 2.12 in the last follow-up). These results were statistically significant with p = 0.043 and p = 0.032 respectively. Six patients described the result as excellent and two as good. No complications were reported. All patients returned to sports after six months of follow-up. CONCLUSION The arthroscopic debridement of the subtalar joint is an effective and safe alternative in the treatment of STS refractory to conservative treatment. More studies, with a prospective methodology, are necessary to prove the results of this technique.
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Affiliation(s)
| | - Tiago Soares Baumfeld
- Department of Orthopedics and Traumatology, Escola Paulista de Medicina, Federal University of São Paulo, SP, Brasil
| | | | - Rafael Mohriak de Azevedo
- Department of Orthopedics and Traumatology, Escola Paulista de Medicina, Federal University of São Paulo, SP, Brasil
| | - Lucas Furtado da Fonseca
- Department of Orthopedics and Traumatology, Escola Paulista de Medicina, Federal University of São Paulo, SP, Brasil
| | - Juliana Doering
- Department of Orthopedics and Traumatology, Escola Paulista de Medicina, Federal University of São Paulo, SP, Brasil
| | - Caio Augusto Souza Nery
- Department of Orthopedics and Traumatology, Escola Paulista de Medicina, Federal University of São Paulo, SP, Brasil
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Yamaguchi R, Nimura A, Amaha K, Yamaguchi K, Segawa Y, Okawa A, Akita K. Anatomy of the Tarsal Canal and Sinus in Relation to the Subtalar Joint Capsule. Foot Ankle Int 2018; 39:1360-1369. [PMID: 30052059 DOI: 10.1177/1071100718788038] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Anatomical knowledge of the tarsal canal and sinus is still unclear owing to the complexity of the ligamentous structures within them, particularly the relationship with the capsules of the subtalar joints. The aim of this study was to examine the anatomical relationship between the fibrous tissues of the tarsal canal and sinus and the articular capsules of the subtalar joint. METHODS We conducted a descriptive anatomical study of 21 embalmed cadaveric ankles. For a macroscopic overview of the subtalar joint, we removed the talus in 18 ankles and separated the fibrous tissues from the surrounding connective tissues to analyze the layered relationship between the inferior extensor retinaculum (IER) and the subtalar joint capsule. Additionally, we histologically analyzed the tarsal canal and the medial and lateral sides of the tarsal sinus using Masson's trichrome staining in 3 ankles. RESULTS The medial and intermediate roots of the IER and interosseous talocalcaneal ligament (ITCL) were located in the same layer and were connected to each other, between the capsules of the posterior talocalcaneal and talocalcaneonavicular joints. The intermediate root of the IER and the cervical ligament (CL) had adjacent attachments on the tarsal sinus, and synovial tissues originating from the joint capsules filled the remaining area in the tarsal canal and sinus. CONCLUSION We determined that the tarsal canal and sinus tarsi contained 3 layered structures: the anterior capsule of the posterior talocalcaneal joint, including the anterior capsule ligament; the layer of ITCL and IER; and the posterior capsule of the talocalcaneonavicular joint, including the CL. CLINICAL RELEVANCE The results of this study may help with the understanding of the pathomechanism of subtalar instability and sinus tarsi syndrome, resulting in better treatment.
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Affiliation(s)
- Reiko Yamaguchi
- 1 Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.,2 Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Akimoto Nimura
- 3 Department of Functional Joint Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kentaro Amaha
- 2 Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kumiko Yamaguchi
- 2 Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuko Segawa
- 1 Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Atsushi Okawa
- 1 Department of Orthopaedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Keiichi Akita
- 2 Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Çabuk H, Kuşku Çabuk F. Mechanoreceptors of the ligaments and tendons around the knee. Clin Anat 2016; 29:789-95. [PMID: 27376635 DOI: 10.1002/ca.22743] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 06/21/2016] [Accepted: 06/30/2016] [Indexed: 11/06/2022]
Abstract
Proprioceptive inputs from the joints and limbs arise from mechanoreceptors in the muscles, ligaments and tendons. The knee joint has a wide range of movements, and proper neuroanatomical organization is critical for knee stability. Four ligaments (the anterior (ACL) and posterior (PCL) cruciate ligaments and the medial (MCL) and lateral (LCL) collateral ligaments) and four tendons (the semitendinosus (STT), gracilis (GT), popliteal (PoT), and patellar (PaT) tendons) from eight fresh frozen cadavers were harvested. Each harvested tissue was divided into its bone insertion side and its tendinous part for immunohistochemical examination using S100 staining. Freeman-Wyke's classification was used to identify the mechanoreceptors. The mechanoreceptors were usually located close to the bone insertion. Free nerve endings followed by Ruffini endings were the most common mechanoreceptors overall. No Pacini corpuscles were observed; free nerve endings and Golgi-like endings were most frequent in the PCL (PCL-PaT: P = 0.0.1, PCL-STT: P = 0.00), and Ruffini endings in the popliteal tendon (PoT-PaT: P = 0.00, Pot-STT: P = 0.00, PoT-LCL: P = 0.00, PoT-GT: P = 0.00, PoT-ACL: P = 0.09). The cruciate ligaments had more mechanoreceptors than the medial structures (MS) or the patellar tendon (CR-Pat: P = 0.000, CR-MS: P = 0.01). The differences in mechanoreceptor distributions between the ligaments and tendons could reflect the different roles of these structures in the dynamic coordination of knee motion. Clin. Anat. 29:789-795, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Haluk Çabuk
- Department of Orthopedics and Traumatology, Okmeydanı Training and Research Hospital, Istanbul, 34384, Turkey
| | - Fatmagül Kuşku Çabuk
- Department of Orthopedics and Traumatology, Okmeydanı Training and Research Hospital, Istanbul, 34384, Turkey.,Department of Medical Pathology, İstanbul Bilim University, Istanbul, 34349, Turkey
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Yeo ED, Rhyu IJ, Kim HJ, Kim DS, Ahn JH, Lee YK. Can Bassett's ligament be removed? Knee Surg Sports Traumatol Arthrosc 2016; 24:1236-42. [PMID: 26685686 DOI: 10.1007/s00167-015-3903-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 11/26/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE To investigate the functional characteristics of Bassett's ligament in the ankle, focusing on mechanoreceptors and potential problems following resection of Bassett's ligament. METHODS Bassett's ligament, the anterior talofibular ligament (ATFL), and synovium were obtained from 20 ankles of 10 fresh-frozen cadavers. Histologically, mechanoreceptors were identified and classified as Ruffini (type I), Vater-Pacini (type II), Golgi-Mazzoni (type III) corpuscles, and free nerve endings (type IV). Differences in receptor densities were compared. RESULTS Type I clusters were observed with three to six ramifications; type II mechanoreceptors were encapsulated in clusters of two to four with ovoid or cylindrical shape; type III were amorphous, long and wide, and fusiform- or spindle-shaped; and type IV were long and fine without a defined shape. Differences in the densities of the mechanoreceptors inside three soft tissues (Bassett's ligament, ATFL, and synovium) were not significant. CONCLUSION There were no significant differences in the densities of the four types of mechanoreceptors among the soft tissues studied. In Bassett's ligament, type I mechanoreceptors were present at significantly higher densities than the other receptors.
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Affiliation(s)
- Eui Dong Yeo
- Department of Orthopaedic Surgery, Veterans Health Service Medical Center, 53, Jinhawngdo-ro 61 gil, Gangdong-gu, Seoul, 134-791, Republic of Korea
| | - Im Joo Rhyu
- Department of Anatomy, Korea University College of Medicine University, 73 Inchon-ro, Seongbuk-gu, Seoul, Republic of Korea
| | - Hak Jun Kim
- Department of Orthopaedic Surgery and Department of Sports Medicine, Guro Hospital, College of Medicine, Korea Univeristy, 80 Gurodong, Gurogu, Seoul, 152-703, Republic of Korea
| | - Da Som Kim
- Department of Anatomy, Korea University College of Medicine University, 73 Inchon-ro, Seongbuk-gu, Seoul, Republic of Korea
| | - Joong-Hyeon Ahn
- Department of Orthopaedic Surgery, Bucheon Hospital, College of Medicine, Soonchunhyang University, 170, Jomaru-ro, Wonmi-gu, Bucheon-si, Gyeonggi-do, 420-767, Republic of Korea
| | - Young Koo Lee
- Department of Orthopaedic Surgery, Bucheon Hospital, College of Medicine, Soonchunhyang University, 170, Jomaru-ro, Wonmi-gu, Bucheon-si, Gyeonggi-do, 420-767, Republic of Korea.
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Rein S, Semisch M, Garcia-Elias M, Lluch A, Zwipp H, Hagert E. Immunohistochemical Mapping of Sensory Nerve Endings in the Human Triangular Fibrocartilage Complex. Clin Orthop Relat Res 2015; 473:3245-53. [PMID: 26024577 PMCID: PMC4562925 DOI: 10.1007/s11999-015-4357-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 05/12/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND The triangular fibrocartilage complex is the main stabilizer of the distal radioulnar joint. While static joint stability is constituted by osseous and ligamentous integrity, the dynamic aspects of joint stability chiefly concern proprioceptive control of the compressive and directional muscular forces acting on the joint. Therefore, an investigation of the pattern and types of sensory nerve endings gives more insight in dynamic distal radioulnar joint stability. QUESTIONS/PURPOSES We aimed to (1) analyze the general distribution of sensory nerve endings and blood vessels; (2) examine interstructural distribution of sensory nerve endings and blood vessels; (3) compare the number and types of mechanoreceptors in each part; and (4) analyze intrastructural distribution of nerve endings at different tissue depth. METHODS The subsheath of the extensor carpi ulnaris tendon sheath, the ulnocarpal meniscoid, the articular disc, the dorsal and volar radioulnar ligaments, and the ulnolunate and ulnotriquetral ligaments were dissected from 11 human cadaver wrists. Sensory nerve endings were counted in five levels per specimen as total cell amount/cm(2) after staining with low-affinity neurotrophin receptor p75, protein gene product 9.5, and S-100 protein and thereafter classified according to Freeman and Wyke. RESULTS All types of sensory corpuscles were found in the various structures of the triangular fibrocartilage complex with the exception of the ulnolunate ligament, which contained only Golgi-like endings, free nerve endings, and unclassifiable corpuscles. The articular disc had only free nerve endings. Furthermore, free nerve endings were the predominant sensory nerve ending (median, 72.6/cm(2); range, 0-469.4/cm(2)) and more prevalent than all other types of mechanoreceptors: Ruffini (median, 0; range, 0-5.6/cm(2); difference of medians, 72.6; p < 0.001), Pacini (median, 0; range, 0-3.8/cm(2); difference of medians, 72.6; p < 0.001), Golgi-like (median, 0; range, 0-2.1/cm(2); difference of medians, 72.6; p < 0.001), and unclassifiable corpuscles (median, 0; range, 0-2.5/cm(2); difference of medians, 72.6; p < 0.001). The articular disc contained fewer free nerve endings (median, 1.8; range, 0-17.8/cm(2)) and fewer blood vessels (median, 29.8; range, 0-112.2/cm(2); difference of medians: 255.9) than all other structures of the triangular fibrocartilage complex (p ≤ 0.001, respectively) except the ulnolunate ligament. More blood vessels were seen in the volar radioulnar ligament (median, 363.62; range, 117.8-871.8/cm(2)) compared with the ulnolunate ligament (median, 107.7; range, 15.9-410.3/cm(2); difference of medians: 255.91; p = 0.002) and the dorsal radioulnar ligament (median, 116.2; range, 53.9-185.1/cm(2); difference of medians: 247.47; p = 0.001). Free nerve endings were obtained in each structure more often than all other types of sensory nerve endings (p < 0.001, respectively). The intrastructural analysis revealed no differences in mechanoreceptor distribution in all investigated specimens with the numbers available, showing a homogenous distribution of proprioceptive qualities in all seven parts of the triangular fibrocartilage complex. CONCLUSIONS Nociception has a primary proprioceptive role in the neuromuscular stability of the distal radioulnar joint. The articular disc and ulnolunate ligament rarely are innervated, which implies mainly mechanical functions, whereas all other structures have pronounced proprioceptive qualities, prerequisite for dynamic joint stability. CLINICAL RELEVANCE Lesions of the volar and dorsal radioulnar ligaments have immense consequences not only for mechanical but also for dynamic stability of the distal radioulnar joint, and surgical reconstruction in instances of radioulnar ligament injury is important.
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Affiliation(s)
- Susanne Rein
- Department of Hand and Plastic Surgery, Trauma Center Bergmannstrost, Halle/Saale, Germany ,Center for Orthopedics and Trauma Surgery, University Hospital “Carl Gustav Carus”, Fetscherstraße 74, 01307 Dresden, Germany
| | - Manuel Semisch
- Center for Orthopedics and Trauma Surgery, University Hospital “Carl Gustav Carus”, Fetscherstraße 74, 01307 Dresden, Germany
| | | | - Alex Lluch
- Institut Kaplan, Hand and Upper Extremity Surgery, Barcelona, Spain
| | - Hans Zwipp
- Center for Orthopedics and Trauma Surgery, University Hospital “Carl Gustav Carus”, Fetscherstraße 74, 01307 Dresden, Germany
| | - Elisabet Hagert
- Department of Clinical Science and Education, Hand and Foot Surgery Center, Karolinska Institutet, Stockholm, Sweden
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Morphological study of mechanoreceptors in collateral ligaments of the ankle joint. J Orthop Surg Res 2015; 10:92. [PMID: 26063220 PMCID: PMC4469580 DOI: 10.1186/s13018-015-0215-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 05/05/2015] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The aim of this study was to analyze the pattern and types of sensory nerve endings in ankle collateral ligaments using histological techniques, in order to observe the morphology and distribution of mechanoreceptors in the collateral ligaments of cadaver ankle joint, and to provide the morphological evidence for the role of the ligament in joint sensory function. METHODS Twelve lateral collateral ligaments including anterior talofibular ligament (ATFL; n = 6), posterior talofibular ligament (PTFL; n = 6), and calcaneofibular ligament (CFL; n = 6) were harvested from six fresh frozen cadavers. The ligaments were embedded in paraffin, sectioned at 4 μm, and then stained using a modified gold-chloride staining methods. The collateral ligament was divided into three segments: proximal, middle, and distal segments. Fifty-four ATFL slides, 90 PTFL slides, and 108 CFL slides were analyzed. Mechanoreceptors were classified based on Freemen and Wyke's classification. Mechanoreceptor distribution was analyzed statistically. One-way ANOVA (postHoc LSD) was used for statistical analysis. RESULTS All the four typical types of nerve endings (the Ruffini corpuscles, Pacinian corpuscles, Golgi tendon organs, and free nerve endings) were identified in these ligaments. Pacinian corpuscles were the predominant in all four complexes. More mechanoreceptors were found in synovial membrane near both ends of the ligaments attached to the bone. No statistical differences were found in the amount of mechanoreceptors among distal, middle, and proximal parts of the ligaments. CONCLUSIONS The four typical types of mechanoreceptors were all identified in the collateral ligaments of the human ankle. Pacinian corpuscles were the predominant in all four complexes. This indicates that the main function of ankle collateral ligaments is to sense joint speeds in motions.
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Rein S, Hagert E, Schneiders W, Fieguth A, Zwipp H. Histological analysis of the structural composition of ankle ligaments. Foot Ankle Int 2015; 36:211-24. [PMID: 25583955 DOI: 10.1177/1071100714554003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Various ankle ligaments have different structural composition. The aim of this study was to analyze the morphological structure of ankle ligaments to further understand their function in ankle stability. METHODS One hundred forty ligaments from 10 fresh-frozen cadaver ankle joints were dissected: the calcaneofibular, anterior, and posterior talofibular ligaments; the inferior extensor retinaculum, the talocalcaneal oblique ligament, the canalis tarsi ligament; the deltoid ligament; and the anterior tibiofibular ligament. Hematoxylin-eosin and Elastica van Gieson stains were used for determination of tissue morphology. RESULTS Three different morphological compositions were identified: dense, mixed, and interlaced compositions. Densely packed ligaments, characterized by parallel bundles of collagen, were primarily seen in the lateral region, the canalis tarsi, and the anterior tibiofibular ligaments. Ligaments with mixed tight and loose parallel bundles of collagenous connective tissue were mainly found in the inferior extensor retinaculum and talocalcaneal oblique ligament. Densely packed and fiber-rich interlacing collagen was primarily seen in the areas of ligament insertion into bone of the deltoid ligament. CONCLUSIONS Ligaments of the lateral region, the canalis tarsi, and the anterior tibiofibular ligaments have tightly packed, parallel collagen bundles and thus can resist high tensile forces. The mixed tight and loose, parallel oriented collagenous connective tissue of the inferior extensor retinaculum and the talocalcaneal oblique ligament support the dynamic positioning of the foot on the ground. The interlacing collagen bundles seen at the insertion of the deltoid ligament suggest that these insertion areas are susceptible to tension in a multitude of directions. CLINICAL RELEVANCE The morphology and mechanical properties of ankle ligaments may provide an understanding of their response to the loads to which they are subjected.
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Affiliation(s)
- Susanne Rein
- Department of Orthopaedic and Trauma Surgery, University Hospital "Carl Gustav Carus," Dresden, Germany Department for Hand Surgery, Rhön-Klinikum, Germany
| | - Elisabet Hagert
- Department of Clinical Science and Education, Karolinska Institutet, Hand & Foot Surgery Center, Stockholm, Sweden
| | - Wolfgang Schneiders
- Department of Orthopaedic and Trauma Surgery, University Hospital "Carl Gustav Carus," Dresden, Germany
| | - Armin Fieguth
- Institute of Legal Medicine, University of Hannover, Hannover, Germany
| | - Hans Zwipp
- Department of Orthopaedic and Trauma Surgery, University Hospital "Carl Gustav Carus," Dresden, Germany
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