Gait changes following robot-assisted gait training in children with cerebral palsy.

This study investigated changes of gait pattern induced by a 4-week robot-assisted gait training (RAGT) in twelve ambulatory spastic diparesis children with cerebral palsy (CP) aged 10.4+/-3.2 years old by using computerized gait analysis (CGA). Pre-post intervention CGA data of children with CP was contrasted to the normative data of typically developing children by using cross-correlation and statistically evaluated by a Wilcoxon test. Significant pre-post intervention changes (p<0.01) include: decreased muscle activity of biceps femoris, rectus femoris, and tibialis anterior; a decrease in range of internal hip joint rotation, higher cadence, step length, and increased stride time. This study suggests that RAGT can be used in muscle reeducation and improved hip joint motion range in ambulatory children with CP.

Gross anatomy of the portal vein and hepatic artery ramifications in dogs: corrosion cast study.

The anatomical variations of the portal vein and the hepatic artery ramifications were analysed on liver corrosion casts in 20 dogs as a possible aid in the surgical management of the organ. The portal vein ramified similarly in all dogs. It divided into the smaller right portal branch from which vessels for the caudate process and both right lobes arose and the substantial left portal branch, which supplied the remaining liver portions and in 12 cases also the dorsal part of the right lateral lobe. Right lateral, right medial and left branches are the major arteries originating from the hepatic artery; however, their origin and course varied among individual animals. In 10 livers, the right lateral and the left branches originated from the hepatic artery, while the right medial branch arose from the left branch and usually supplied the right medial lobe solely. In nine livers, the right medial branch arose directly from the hepatic artery and supplied quadrate lobe and gallbladder as well, while in one liver the common artery, which subsequently divided into lobar branches, branched away from the hepatic artery. An additional branch for the caudate process, originating directly from the hepatic artery, was observed in 10 livers. Certain liver portions received the arterial blood from two major branches, which was particularly characteristic for the right medial lobe (six livers) and caudate process (10 livers). The course of the major arterial branches was also variable, although they proceeded in close anatomical relationship with the portal vein branches. The left arterial branch accompanied the left portal branch on its dorsal aspect (15 cases) or crossed it from the caudal aspect (five cases). The right lateral branch crossed the initial parts of the left and right portal branches either from cranial (12 cases) or caudal aspects (eight cases), while the right medial branch always crossed the left portal branch from its caudal aspect.

Comparison of four techniques for the fixation of a collagen scaffold in the human cadaveric knee.

OBJECTIVE: Four fixation techniques for a fibrinogen and thrombin coated collagen fleece, used as a scaffold in the cartilage repair, were compared simulating the initial postoperative period in the cadaveric knee joints. METHODS: Full-thickness chondral lesions were made on the medial femoral condyles of seven human cadaveric inferior extremities. Four scaffolds without seeded chondrocytes were implanted into each lesion using four fixation techniques consecutively: self-adhesion without additional material (SA), fibrin sealant (FS), bone sutures (BS), and periosteal cover (PC). After each implantation 150 cycles of continuous passive motion (CPM) were performed. Two cases were additionally exposed to 50 cycles of 10 and 20 kg loading each after the completion of CPM. The scaffolds were evaluated after every 30 cycles, and the fixation strength was tested after the motion was completed. RESULTS: All the SA scaffolds were detached before 60 cycles. The other scaffolds remained stable throughout the testing with only minor disruptions. The endpoint fixation strength was higher for BS and PC than for the FS scaffolds. The FS scaffolds were detached as a result of additional load cycles, while the BS and PC scaffolds showed substantial deformations. CONCLUSION: SA of tested scaffold did not provide sufficient fixation. The FS fixation was easy to perform and assured satisfactory scaffold stability. BS and PC provided excellent scaffold stability, but the techniques were difficult and caused additional injuries. Regardless of the fixation technique used, the tested collagen scaffold may not be exposed to loading in the initial postoperative period.

Liver hanging maneuver for right hemiliver in situ donation--anatomical considerations.

BACKGROUND: An anatomical study was carried out to evaluate the safety of the liver hanging maneuver for the right hemiliver in living donor and in situ splitting transplantation. During this procedure a 4-6 cm blind dissection is performed between the inferior vena cava and the liver. Short subhepatic veins entering the inferior vena cava from segments 1 and 9 could be torn with consequent hemorrhage. MATERIALS AND METHODS: One hundred corrosive casts of livers were evaluated to establish the position and diameter of short subhepatic veins and the inferior right hepatic vein. RESULTS: The average distance from the right border of the inferior vena cava to the opening of segment 1 veins was 16.7+/-3.4 mm and to the entrance of segment 9 veins was 5.0+/-0.5 mm. The width of the narrowest point on the route of blind dissection was determined, with the average value being 8.7+/-2.3 mm (range 2-15 mm). DISCUSSION: The results show that the liver hanging maneuver is a safe procedure. A proposed route of dissection minimizes the risk of disrupting short subhepatic veins (7%).

Variations of intrahepatic and proximal extrahepatic bile ducts.

BACKGROUND/AIMS: The modern segmental concept of the liver with a segmental bile duct distribution is of practical importance for biliary specialists and should include information on variations of intrahepatic and extrahepatic bile ducts. The aim of this study was to find biliary variations, especially on a segmental and sectorial level, and to try to arrange them into types. METHODOLOGY: We analyzed 51 corrosion casts of the human liver, which enabled the three-dimensional study of extrahepatic, sectorial, segmental and subsegmental bile ducts, their variations in course and confluencing, and the relationship between the structures of the portal pedicle. RESULTS: The types of confluence and their frequency were determined separately for the left, right, right anterior sectorial, right posterior sectorial and common hepatic ducts. "Normal" left confluence was formed in 82% and three variations in 18%. "Normal" right confluence was formed in 75% and four variations in 25%. A complete ("normal") anterior sectorial duct was present in 35% and four variations in 65%. A complete ("normal") posterior sectorial duct was present in 61% and four variations in 39%. CONCLUSIONS: The study showed that the biliary tree variations are quite frequent, and therefore clinically important, and that they could be arranged into several types.

Anatomical variations in the pattern of the right hepatic veins: possibilities for type classification.

A morphological study of the right hepatic veins (RHVv) was conducted based on the shape and the confluence pattern of the superior right hepatic vein (SRHV) and the presence of accessory right hepatic veins. The study was performed in 110 undamaged, randomly selected, cadaveric human livers prepared using the corrosion cast methodology. The principles for classifying the RHVv into types were as follows: the length of the vein trunk, the confluence of 2 or 3 main tributaries that form a trunk, and the accessory right hepatic veins that modify the venous drainage of the right side of the liver. Four types of SRHV were identified. Type 1 (20 %), type 2 (40 %) and type 3 (25 %) were the most common, while type 4 (15 %) was linked to the accessory right hepatic veins in cases where they drain a surgically important part of the liver. Accessory right hepatic veins were found in a total of 31 casts (28 %). The hepatocaval confluence was studied and the tributary-free part of the SRHV trunk before it entered the inferior vena cava was measured. The tributary-free part of the SRHV was longer than 1 cm in 77 % of the casts. Anastomoses between the terminal tributaries of the veins involved in the drainage of the right side of the liver were also investigated.

Surgical anatomy of the medial segment (S4) of the liver with special reference to bile ducts and vessels.

BACKGROUND/AIMS: Resection of the inferior area of the medial segment (S4a) plus S5 with preservation of the superior area of the medial segment (S4b) is being performed to manage hilar bile duct carcinoma and pT2 type gallbladder carcinoma, and thus, attention has been focused on the surgical anatomy of the medial segment of the liver to identify the specific vessels and bile ducts of the areas of that segment to be resected and to be preserved. METHODOLOGY: Anatomical study of the bile duct, portal vein, middle hepatic vein, and middle hepatic artery to the medial segment branches of the liver (S4) was performed in a total of 171 specimens comprised of 71 adult cadavers, and 100 liver casts. RESULTS: 1) Two main types of bile duct branches of the medial segment (B4) were recognized. Type I included the branches which joined to the left hepatic duct on the hilar duct side (35.5%), and type II included the branches that joined on the peripheral side (54.6%). Several subtypes were also found in both types. The B2-B3 confluence was mostly on the left (41.7%) or posterior (42.7%) to the umbilical portion (UP) of the portal vein, and to the right of the UP (hilar side) in only 15.6%. 2) The portal vein of the medial segment branches (P4): P4a branched from the right angle and upper right border of the UP in every specimen. The most common morphology was 1 large and 2-3 small branches (41%). P4b was almost always found to branch posterior to the UP and lower than P4a, and the most common morphology was 1 large and 0-1 small branches (57.8%). 3) The middle hepatic vein: In 83.2% a common trunk was observed at the confluence with the inferior vena cava, and 8 types of the middle hepatic vein were recognized. 4) The middle hepatic artery: It arose from the left hepatic artery in 61.5%, from of the right hepatic artery in 27.5%, from the proper hepatic artery in 5.5%, and from both the left and the right hepatic artery in 5.5%. CONCLUSIONS: The detailed vascular and bile duct anatomy of S4 is described. This study should be helpful in identifying the specific vessels and bile ducts of the areas of the medial segment to be resected and to be preserved, thereby facilitating resection of the medial segment.

Surgical anatomy of the bile duct branches of the medial segment (B4) of the liver in relation to hilar carcinoma.

In some patients, hilar bile duct carcinoma can easily spread to the bile duct branches of the caudate lobe (B1) as well as to the bile duct branches of the medial segment (B4), and resection of the inferior portion of the medial segment (S4a) is then required. It is therefore important to understand the detailed anatomy of the B4, its confluence patterns, and its relation to the B1 in order to be able to identify such patients. The confluence pattern of the B4 was studied in 141 specimens (68 adult cadavers and 73 liver casts) and the distance between the left bile duct branches of the caudate lobe (B11) and the B4 was measured in 56 of the 73 casts in which both B11 and B4 were present. Two main gross types of B4 were recognized: type I, in which B4 joined the left hepatic duct (LHD) close to the hilar confluence (35.5%), and type II, in which B4 joined the LHD far from the hilar confluence (54.6%). Analysis of the relationship between B11 and B4 revealed a mean distance between B11 and B4 of 8 mm in type 1, and 17 mm in type II. When the distance is less than 10 mm, B11 and B4 are considered to be located very close to each other, and in such individuals hilar bile duct carcinoma can infiltrate the B4 easily, thereby necessitating the resection of S4a, together with a caudate lobectomy for curative resection. Also, the confluence pattern of the B4 often creates a problem when the LHD is divided and reconstructed during hepatectomy, because of the numerous anatomical variations of the B4 itself. We therefore concluded that a good anatomical knowledge of the B4 and its relation to the B11 is essential in making the decision to perform S4a resection in selected patients with hilar bile duct carcinoma with the aim of curative resection.

Venous drainage of the dorsal sector of the liver: differences between segments I and IX. A study on corrosion casts of the human liver.

The aim of this study was to determine the venous drainage of the dorsal sector of the liver in order to define the differences between segments I and IX and their implications for sectorially and segmentally oriented hepatic surgery. The study was based on corrosion casts of 61 macroscopically healthy livers. The drainage pathways of veins at least 10 mm long and 1 mm wide were evaluated and statistically analysed. On average, 9 veins drained the two segments and three veins from both segments entered the inferior vena cava. In 95% of cases the veins from segment I drained predominantly into the inferior vena cava, whereas in segment IX this pathway was dominant in only 30% of cases. In 64% of cases a vein originating in segment IX entered the right hepatic v. The difference in the venous drainage of the two segments suggests that segment IX partly belongs to the neighbouring segments and may thus be only a paracaval region of the right liver.

[Models of the epigastric cavity, the liver vessels and bile ducts as an anatomic and surgical teaching tool]. / Modelle des oberen Bauchraumes, der Lebergefässe und der Gallengänge als anatomische und chirurgische Lehrmittel.

During the "Alps-Adria Hepatobiliary School" in Ljubljana a workshop was held at which various liver surgery techniques were performed in practice. These techniques required the introduction of original methods which enabled practical exercise on isolated liver. Plastic casts of the upper part of the abdominal cavity were made, as well as the corrosion models of the hepatic vessels and bile ducts. Isolated livers were conserved by means of freezing. The results showed that the freezing and thawing did not alter the consistency of livers, which made them useful material for surgical practice. Corrosion casts were used for studying three-dimensional structure of the vessels and bile ducts before the surgical techniques were applied. Various possibilities of further use and application of models and corrosion casts are discussed. The role of working on the models and casts for a better performance of a surgery workshop is emphasized.

Histochemical characteristics of bulbospongiosus and ischiocavernosus muscles in man.

The histochemical profiles of the bulbospongiosus (BS) and ischiocavernosus (IC) muscles were investigated on autopsy samples obtained from 13 men aged 18 to 33. Adenosine triphosphatase (ATPase) reactions were used for differentiation of muscle fibres into type 1 (slow twitch, tonic), and type 2 (fast twitch, phasic) and subtypes 2A, 2B, 2C. The activity of oxidative and glycolytic enzymes was also assayed. Because the percentage and diameters of both fibre types varied considerably in different areas of the same muscle, two methods of counting were applied and at least two fields of each sample were evaluated. The mean percentage of type 1 fibres in BS muscles was 34.8% and 23.2%, that in IC muscles 49.7% and 39.7%. The mean diameter of type 1 fibres was 31.0 microns (BS) and 26.2 microns (IC), that of type 2 fibres ranged from 30.0 microns (BS) to 36.6 microns (IC). The comparison of BS and IC muscles with other nonskeletal voluntary muscles revealed that BS and IC muscles are similar to the striated sphincters, particularly with regard to the numerical distribution of fibre types and fibre diameters.