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Biomedical subjects

M Sobel

Publications and source records attributed to M Sobel.

At least 37 records · Page 2Linked to original sources

Structure-function relations of antithrombin III-heparin interactions as assessed by biophysical and biological assays and molecular modeling of peptide-pentasaccharide-docked complexes.

The serine proteinase inhibitor antithrombin III (ATIII) is a key regulatory protein of intrinsic blood coagulation. ATIII attains its full biological activity only upon binding polysulfated glycosaminoglycans, such as heparin. Peptide K121-A134, based on the sequence of ATIII in the D helix region, was previously shown by us (Tyler-Cross et al., Protein Sci. 3, 620-627, 1994) to encompass part (or all) of the purported high-affinity heparin binding region of ATIII. A series of peptide analogs has now been prepared whose sequences are identical to K121-A134 except that single cationic residues of K121-A134 have been successively replaced with Ala. In one case, the Arg residue of the reference peptide corresponding to R129 of ATIII has been replaced by Gln (R129deltaQ peptide), thus mimicking the naturally occurring mutant protein, ATIII Geneva. The heparin affinity of all peptides was quantitated by isothermal titration calorimetry and by peptide/ATIII competition binding assays. Replacement of any single cationic residue with Ala had a deleterious effect on heparin binding. The greatest reduction in heparin affinity (more than 30-fold) was observed with the R129deltaQ peptide (KD = 1.5 +/- 0.06 microM vs 51 +/- 2 nM for the reference peptide, K121-A134). Furthermore, each of the Ala-replacement peptides was a less-effective inhibitor of ATIII-heparin complex formation than the reference peptide. The poorest inhibitor was the R129deltaQ peptide which showed nearly 30% decrease in inhibition potency (60% inhibition at 100 microM peptide vs 90% inhibition with the reference peptide). The relative heparin affinities of the peptides measured by biological assay were the same as determined by titration calorimetry. Consequently, we modeled the complexes formed between the pentasaccharide unit structure and the R129deltaQ peptide or the reference peptide, K121-A134. In the "docked" complex, the assumed conformation of K121-A134 permitted juxtaposition of the cationic residues of the peptide with functional anionic groups of the pentasaccharide known to be involved in binding. A docked complex could also be formed between the R129deltaQ peptide and the pentasaccharide, but misalignment of critical peptide and saccharide functional groups was observed. The structure of the R129deltaQ-pentasaccharide complex was highly irregular because F123 and Y131 were completely surface exposed, likely yielding an unfavorable structure in aqueous solution. The observations from molecular modeling allow us to suggest that ATIII Geneva displays decreased heparin binding affinity due to its inability to form a productive binding complex in which essential electrostatic contacts are made between suitably juxtaposed saccharide anionic functional groups and cationic amino acid side chains.

Amino Acid Sequence↗

Heparins designed to specifically inhibit platelet interactions with von Willebrand factor.

BACKGROUND: Platelet interactions with the injured vessel wall may contribute significantly to the early and late failures of many cardiovascular interventions; the adhesive protein von Willebrand factor (vWF) is thought to play an important role. Previously, we demonstrated that heparin interfered with platelet/vWF hemostatic mechanisms by binding to vWF within the proteins's domain responsible for binding the platelet vWF receptor, glycoprotein Ib. The purpose of the present study was to develop and refine heparins with greater potency to inhibit platelet/vWF interactions. METHODS AND RESULTS: Immobilized synthetic peptides based on a known heparin-binding domain of vWF were used to yield novel fractions of standard heparin that demonstrated a sevenfold increase in their ability to inhibit vWF-dependent platelet agglutination and vWF/platelet binding. The high vWF affinity heparin showed enhanced anti-factor Xa activity but comparable activated partial thromboplastin time activity. Chemical modification of a standard heparin by periodate oxidation and borohydride reduction enhanced its ability to inhibit platelet/vWF interactions by threefold, while eliminating more than 90% of its activated partial thromboplastin time and anti-factor Xa activity. Affinity chromatography of the chemically modified heparin yielded a heparin with an eightfold higher inhibitory potency than the original heparin. CONCLUSIONS: Subspecies of heparin can be developed with significantly enhanced potency to inhibit vWF/platelet interactions. The vWF-inhibiting property of heparin can be dissociated from its antithrombin-binding activity. Based on a growing understanding of heparin/vWF interactions, combinations of affinity separations and chemical modifications could be designed to yield heparins uniquely suitable for prevention of arterial thrombosis.

Anticoagulants↗

A functional analysis of verbal interactions of drug-exposed children and their mothers: the utility of sequential analysis.

Sequential analysis was used to conduct a functional analysis of positive and negative behaviors of five prenatally drug-exposed preschoolers while interacting with their mothers and with an unrelated adult on separate occasions. Videotaped interactions were coded for positive and negative verbal and nonverbal behaviors. Functional relations between child's target behaviors and adults' antecedent and consequent behaviors were identified and resulted in positive-compliant and negative-coercive classes of behavior. All dyads demonstrated positive-compliant patterns. Two mother-child dyads engaged in extended sequences of negative-coercive interactions whereas the unrelated adult terminated negative exchanges quickly. These sequential data suggest the need for developing specific behavioral training programs for mothers of drug-exposed children and other significant adults.

Adult↗

Gross, histological, and microvascular anatomy and biomechanical testing of the spring ligament complex.

In recent years there has been an increased interest in the treatment of acquired pes planus. The breakdown of the medial longitudinal arch is most often seen at the talonaviculocalcaneal articulation. This suggests a relationship between the ligamentous complex at this articulation and acquired pes planus. This study was undertaken to gain a better understanding of the gross, histologic, and microvascular anatomy, as well as the biomechanics of the ligamentous structures surrounding the talonaviculocalcaneal articulation. Cadaver dissections of 38 fresh-frozen feet were performed. Detailed descriptions of the gross anatomy of the superomedial calcaneonavicular ligament, inferior calcaneonavicular ligament, and the superficial deltoid ligament were recorded. Their relationships to the posterior tibialis tendon and to the bones of the talonaviculocalcaneal articulation are described. The histology and microvascularity of these structures were also studied. Preliminary biomechanical testing was performed. It was found there are two definitive anatomic structures that are commonly called the spring ligament: the superomedial calcaneonavicular ligament (SMCN) and the inferior calcaneonavicular ligament (ICN). The SMCN ligament was found to have histologic properties that suggest significant load bearing. The histology of the ICN ligament suggests a pure tensile load function. The deltoid ligament and the posterior tibialis tendon had direct attachments to the SMCN ligament in all specimens. An articular facet composed of fibrocartilage was found in each SMCN ligament specimen. The microvascular structures showed an avascular articular facet present in the ligament. The biomechanical testing showed that the SMCN ligament and ICN ligament had strength similar to ankle ligaments. This study suggests this "spring ligament complex" has more of a "sling" function for the talar head. It is hoped that the better understanding of this region will add to our understanding of the etiology of pes planus and possible treatment alternatives.

Biomechanical Phenomena↗

Mid-tarsal and tarsometatarsal arthrodesis for primary degenerative osteoarthrosis or osteoarthrosis after trauma.

We report the long-term results of arthrodesis of the mid-tarsal and tarsometatarsal joints, performed for osteoarthrosis after dislocation with or without a fracture (seventeen patients [seventeen feet]), for primary degenerative osteoarthrosis (twenty-one patients [twenty-two feet]), or for inflammatory arthritis (two patients [two feet]). All forty patients (forty-one feet) had a severe loss of function because of pain. The average age of the patients who had primary degenerative osteoarthrosis was sixty years (range, twenty-seven to seventy-five years) and that of the patients who had post-traumatic osteoarthrosis was forty years (range, twenty-three to sixty-seven years); the two patients who had inflammatory arthritis were forty-four and seventy years old. Thirty-seven patients (thirty-eight feet; 93 per cent) were satisfied with the results of the procedure after an average duration of follow-up of six years (range, two to seventeen years). Union was achieved after 176 (98 per cent) of the 179 attempted arthrodeses, and only one of the three non-unions necessitated an operative repair. A skin slough developed in two patients, one of whom needed operative débridement. Five patients noted at least one prominent metatarsal head postoperatively, but none of these patients needed débridement because of abnormal callus formation. A stress fracture of the second metatarsal developed in three patients, but all three fractures responded to immobilization of the foot. An incisional neuroma developed in three patients, but none of these patients needed additional treatment. We believe that patients who have a severe loss of function due to osteoarthrosis of the mid-tarsal or tarsometatarsal joints can be managed successfully with tarsometatarsal or mid-tarsal arthrodesis, or both.

Adult↗

Early results of infrageniculate arterial reconstruction using cryopreserved homograft saphenous conduit (CADVEIN) and combination low-dose systemic immunosuppression.

BACKGROUND: The search continues for the ideal conduit for infrageniculate arterial reconstructions when the autogenous vein is unsuitable or unavailable. Based on experimental observations in our laboratory demonstrating improvement in canine cryopreserved allograft vein patency using systemic immunosuppression (Imsup), and the remarkable clinical success achieved in older (greater than 60 years of age) solid organ transplant recipients using combination low-dose Imsup, we studied the effects of Imsup on patency of cryopreserved homograft saphenous vein (CADVEIN) used for infrageniculate arterial reconstructions. STUDY DESIGN: Under the Institutional Review Board protocol, 21 infrageniculate CADVEIN grafts were placed in 19 patients between July 1993 and August 1994 for limb salvage when autogenous veins were unavailable. An immunopharmacologic protocol consisting of low-dose cyclosporine A, azathioprine, prednisone, warfarin, aspirin, and vasodilators given orally was instituted. For various reasons, 15 patients in group 1 received Imsup; five patients never received Imsup, and one patient in group 2 received Imsup briefly. Follow-up examinations were completed using the time range of six to 18 months (mean, eight plus or minus one month). RESULTS: One patient died (5.3 percent) 30 days after emergency combined venous graft and bilateral CADVEIN bypass. The actuarial 12-month primary patency in group 1 was 59.4 percent compared with 16.7 percent in group 2 (p < 0.015, log-rank test). Cellular rejection was typically seen in explanted CADVEIN. Systemic morbidity related to Imsup was minimal. The CADVEIN morbidity rate was significant: three graft aneurysms and four early graft ruptures. Major amputations were necessary in eight of 12 patients with graft closure. CONCLUSIONS: The data suggest that Imsup significantly improves CADVEIN patency with limited systemic morbidity; however, complications related to the conduit itself occurred with greater frequency and cause greater morbidity than when the autogenous veins were used. Much has yet to be learned regarding the preservation characteristics of CADVEIN and the immunologic interactions in patients receiving CADVEIN grafts, before further clinical use of this conduit can be recommended.

Adult↗

Giant cell tumor of the distal radius.

We compared the outcome of patients with giant cell tumor of the distal radius treated by curettage/cryosurgery and en bloc resection, evaluating oncologic success, functional results, and complications. Thirty consecutive cases of giant cell tumor of the distal radius were treated at our institution between 1958 and 1988. Twenty-six patients were available for follow-up examination, with a minimum follow-up period of 3 years and median follow-up period of 9 years. Primary curettage/cryosurgery had a local recurrence in 3 of 12, and repeat curettage/cryosurgery achieved local control in in 16 of 18 primary and recurrent cases. The major complications in this group included skin necrosis, transient nerve palsies, and fragmentation with carpal collapse. An average of 60% of contralateral range of wrist motion was preserved. Ten patients underwent en bloc excision and arthrodesis for either primary or recurrent tumor; none developed local recurrence. The main complication in this group was failure of internal fixation and non-union at the graft-radius junction. Resultant strength and function were similar in both groups. Intralesional excision with adjunctive cryosurgery is an effective alternative to en bloc excision with the advantage of preserving the distal radius and wrist joint function, but with a notable complication rate. En bloc excision with arthrodesis is more suitable for extensive local disease with poor residual bone stock and as salvage for failed intralesional excision.

Adolescent↗

Heparinoids with low anticoagulant potency attenuate postischemic endothelial cell dysfunction.

PURPOSE: Although standard heparin has been demonstrated to reduce endothelial cell dysfunction in acute ischemia-reperfusion injury, its mechanism of action remains unknown. We hypothesized that heparin's salutary endothelial effects are independent of its conventional anticoagulant activity and are not caused by nonspecific polyanion effects. METHODS: Isolated rat hindlimbs were perfused at constant pressure with an albumin-enriched crystalloid buffer. After 60 minutes of normothermic ischemia, endothelial function was assessed by measurement of endothelial-dependent vasodilation by log increment infusion of acetylcholine. Endothelial-independent vasodilation was measured by exposure to nitroprusside. Some groups were pretreated with heparinoids possessing minimal or intermediate anticoagulant activity. RESULTS: Treatment with heparinoids with low anticoagulant activity significantly increased endothelial-dependent vasodilation when compared with the nontreated ischemic group and were statistically indistinguishable from the nonischemic control. Treatment with dextran sulfate, a randomly sulfated polymer with size and charge characteristics similar to heparin, did not change postischemic vasodilation. Endothelial-independent vasodilation was largely unaffected by ischemia-reperfusion or drug treatment. CONCLUSIONS: A heparinoid with negligible antithrombin-binding activity (Astenose) attenuated postischemic endothelial dysfunction, suggesting that its mechanism of action was independent of anticoagulant activity. Failure of dextran sulfate to be protective implied that the effect was not caused by nonspecific polyanion action.

Acute Disease↗

Anatomy of the plantar plate and its attachments in the lesser metatarsal phalangeal joint.

The plantar plate is a rarely seen, yet central structure to the lesser metatarsal phalangeal (MP) joint. Thirty cadaver lesser MP joints were studied to obtain a detailed description of the plate, including its dimensions, connections, and histology. The plate was found to be made of fibrocartilage with fiber orientation which suggests that it withstands tensile loads in line with the plantar fascia as well as the compressive loads from the metatarsal head. The plantar plate was the most substantial distal insertion of the plantar fascia. Impressive plantar plate attachments were noted to the proximal phalanx, the major longitudinal bands of the plantar fascia, and the collateral ligaments. The plate and collateral ligaments formed a substantial soft tissue box connected to the sides of the metatarsal head. From the dissections, it is apparent that malposition of the toe at the MP joint is likely over time to be associated with pathology in both the collateral ligaments and the plate. Because of these attachments and a close association with the flexor tendons to the lesser toe, the plate can be compared with the sesamoid mechanism of the first MP joint.

Adult↗

Transfer of membrane proteins from human platelets to liposomal fraction by interaction with liposomes containing an artificial boundary lipid.

The direct transfer of membrane proteins from human platelets to the liposomal fraction was examined, particularly in relation to platelet activation during the process. The incorporation of an artificial boundary lipid, 1,2-dimyristoylamido-1,2-deoxyphosphatidylcholine (DDPC), in the interacting liposome considerably enhanced the efficiency of the protein transfer. The transfer proceeded with neither significant activation nor lysis of the platelet, and the activation of the platelet with thrombin did not affect the amount of the transferred proteins. A wide range of platelet membrane proteins was transferred, and they were almost comparable to those in a sample prepared by glycerol lysis/centrifugation. In addition, they included the major surface glycoproteins GPIIb and GPIIIa without noticeable contamination of soluble cytosol proteins. The protein transfer method is a one-pot process and clearly more convenient than the conventional 'extract and reconstitute' approach. These results strongly support the use of the transfer process, especially with DDPC, as an alternative to the conventional detergent-solubilization or the solvent-extraction methods for preparation of samples of platelet membrane proteins.

Blood Platelets↗

Homeobox genes: potential candidates for the transcriptional control of the transformed and invasive phenotype.

The transformation of a cell and the acquisition of the invasive and metastatic phenotype result from the activation of a group of complex cellular processes rather than from the effect of a single gene product. It is likely that the coordination of the multiple genes involved in malignancy is under the control of a few genes that act as master genes or orchestrator genes. The latter probably code for transcription factors that control the genetic program for tumor invasion and metastasis. Homeobox genes are a family of transcription factors that contain a 183 bp highly conserved nucleotide sequence coding for a 61 amino acid domain that binds specifically to DNA. First discovered in Drosophila as genes controlling segmentation and segment identity, homeobox genes have since been identified in many other species including nematodes, frog, mouse and human. There is strong support for the suggestion that homeobox genes play a key role in development and differentiation. In humans, there are 38 homeobox genes organized in four clusters that are localized on chromosomes 2, 7, 12 and 17. The specific functions of each of these genes are generally unknown. Alterations in expression of several homeobox genes have been reported in a variety of malignant lesions, suggesting that they could play a role in the development of cancer. Using reverse transcriptase reaction coupled with polymerase chain reaction and degenerate oligonucleotides corresponding to the 5' and 3' ends of the highly conserved homeodomain, we amplified 130 bp cDNA fragments from the human breast cancer cell line MCF7 that were subsequently cloned into pBluescript vector. Sequencing of the clones, resulted in the identification of the homeodomains of four different human homeobox genes: HOXB6, HOXA1, HOXA10 and HOXC6. Further studies should determine the specific role of these four homeobox genes in the development and progression of human breast cancer and potentially determine if they might be good targets for gene therapy.

Amino Acid Sequence↗

Heparin binding domain peptides of antithrombin III: analysis by isothermal titration calorimetry and circular dichroism spectroscopy.

The serine proteinase inhibitor antithrombin III (ATIII) is a key regulatory protein of intrinsic blood coagulation. ATIII attains its full biological activity only upon binding polysulfated oligosaccharides, such as heparin. A series of synthetic peptides have been prepared based on the proposed heparin binding regions of ATIII and their ability to bind heparin has been assessed by CD spectrometry, by isothermal titration calorimetry, and by the ability of the peptides to compete with ATIII for binding heparin in a factor Xa procoagulant enzyme assay. Peptide F123-G148, which encompasses both the purported high-affinity pentasaccharide binding region and an adjacent, C-terminally directed segment of ATIII, was found to bind heparin with good affinity, but amino-terminal truncations of this sequence, including L130-G148 and K136-G148 displayed attenuated heparin binding activities. In fact, K136-G148 appears to encompass only a low-affinity heparin binding site. In contrast, peptides based solely on the high-affinity binding site (K121-A134) displayed much higher affinities for heparin. By CD spectrometry, these high-affinity peptides are chiefly random coil in nature, but low microM concentrations of heparin induce significant alpha-helix conformation. K121-A134 also effectively competes with ATIII for binding heparin. Thus, through the use of synthetic peptides that encompass part, if not all, of the heparin binding site(s) within ATIII, we have further elucidated the structure-function relations of heparin-ATIII interactions.

Amino Acid Sequence↗

Catheter-directed thrombolysis following vena cava filtration for severe deep venous thrombosis.

Massive deep venous thrombosis with marked venous outflow obstruction can result in limb loss or end-organ injury. Systemically administered drugs may not reach thrombi in therapeutic concentrations and surgical and thrombolytic strategies carry a small but real risk of pulmonary embolus--similar to the risks with anticoagulation alone. We therefore developed a strategy in which catheter-directed thrombolysis was used to deliver high concentrations of a plasminogen activator directly to the thrombus combined with placement of a downstream Greenfield filter to protect patients from pulmonary embolus. From 1984 to 1993 six patients were treated with this regimen. All had severe symptoms of less than 4 days' duration. On radiologic evaluation four patients had large iliofemoral and/or inferior vena cava thrombosis, one had subclavian/innominate vein thrombosis, and one had transplant renal vein/iliofemoral/inferior vena cava thrombosis. A Greenfield filter was first placed downstream prior to imbedding an infusion catheter in the greatest mass of thrombus for subsequent infusion of urokinase (n = 4) or streptokinase (n = 2). In four patients the catheter traversed the Greenfield filter. All patients were given bolus lytic therapy followed by maintenance infusions ranging in duration from 24 hours to 12 days. Five patients remained on heparin simultaneously. Clot lysis was achieved in all patients with hemodynamic, symptomatic, and arteriographic improvement. There were no deaths, pulmonary emboli, or complications of filter placement. One patient had minor bleeding at the puncture site and another had catheter-related infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

Extended evaluation of the titanium Greenfield vena caval filter.

PURPOSE: The purpose of this study was to evaluate the long-term safety and efficacy of the titanium Greenfield filter-modified hook for prevention of pulmonary embolism. METHODS: We conducted a prospective study in 173 patients from four institutions who underwent clinical examination, abdominal radiography, and duplex ultrasound examinations of the vena cava and lower extremities. If indicated by protocol or clinical presentation, computed tomography scans, pulmonary angiograms, or venacavograms were obtained. RESULTS: The most common procedural event was filter limb asymmetry (10%), which had no clinical significance. A variety of other minor procedural events occurred in another 10% of cases. Early follow-up (< 6 months) was completed in 149 patients, and long-term evaluation was completed in 113 (> 12 months). Deaths in 24 patients were from nonembolic causes in all but one. There were four suspected or confirmed recurrent pulmonary emboli, for an incidence of 3.5% (four of 113), with one death (0.9%). Four patients had inferior vena cava occlusion at early follow-up and at long-term evaluation, only one remained occluded (1%). Insertion site venous thrombosis was seen in only two patients (2%). CONCLUSION: The titanium Greenfield filter provides protection comparable to the standard stainless steel Greenfield filter after 1 year with a low incidence of recurrent pulmonary embolism (3.5%) and a high caval patency rate (99%).

Cohort Studies↗

Postischemic extremities exhibit immediate release of tumor necrosis factor.

PURPOSE: Although reperfusion of acutely ischemic extremities can cause cardiopulmonary collapse and death, the humoral agent(s) released from limbs promoting this distant organ injury are not well characterized. We hypothesized that tumor necrosis factor-alpha (TNF-alpha), a cytokine that causes cardiopulmonary dysfunction in septic shock, may be released from postischemic extremities. METHODS: Isolated rat hindlimbs were perfused at constant pressure with a nonrecirculating crystalloid-based buffer. After 60 or 120 minutes of normothermic ischemia, TNF activity was measured in sequential samples of venous effluent by L929 bioassay. Associated limb injury was assessed by the extent of no-reflow after reperfusion, changes in endothelial permeability to iodine 125-labeled albumin and skeletal muscle injury by uptake of technetium 99 pyrophosphate. RESULTS: After 120 minutes of normothermic ischemia (n = 10), a 15-fold increase in TNF-alpha activity in venous effluent occurred, with peak activity at 1.5 minutes of reperfusion (30.6 +/- 8.7 U/ml) falling to near control levels by 5 minutes. This group had a 3.3-fold increase in vascular permeability, a 2.2-fold increase in the muscle injury index and a 71.2% decline in reperfusion flow (all p < 0.05 vs control). Pretreatment of extremities with an anti-TNF-alpha antibody in a second group of limbs undergoing 120 minutes of ischemia (n = 10) decreased TNF activity to levels not significantly different from the nonischemic control group (n = 12). The extent of no-reflow in limbs treated with antibodies was significantly attenuated (flow 44.9% of control vs 29.8% [untreated], p < 0.05). Antibody treatment affected neither muscle injury nor vascular permeability. CONCLUSIONS: Postischemic extremities exhibited a transient, early burst of TNF release on reperfusion, which likely represented washout of TNF produced during ischemia. Suppression of TNF activity with an antibody to TNF-alpha resulted in a salutary increase in postischemic flow rates, suggesting that TNF may play a role in the no-reflow phenomenon.

Animals↗

Painful os peroneum syndrome: a spectrum of conditions responsible for plantar lateral foot pain.

Plantar lateral foot pain may be caused by various entities and the painful os peroneum syndrome (a term coined by the authors) should be included in the differential diagnosis. Painful os peroneum syndrome results from a spectrum of conditions that includes one or more of the following: (1) an acute os peroneum fracture or a diastasis of a multipartite os peroneum, either of which may result in a discontinuity of the peroneus longus tendon; (2) chronic (healing or healed) os peroneum fracture or diastasis of a multipartite os peroneum with callus formation, either of which results in a stenosing peroneus longus tenosynovitis; (3) attrition or partial rupture of the peroneus longus tendon, proximal or distal to the os peroneum; (4) frank rupture of the peroneus longus tendon with discontinuity proximal or distal to the os peroneum; and/or (5) the presence of a gigantic peroneal tubercle on the lateral aspect of the calcaneus which entraps the peroneus longus tendon and/or the os peroneum during tendon excursion. Familiarity with the various clinical and radiographic findings and the spectrum of conditions represented by the painful os peroneum syndrome can prevent prolonged undiagnosed plantar lateral foot pain. Clinical diagnosis of the painful os peroneum syndrome can be facilitated by the single stance heel rise and varus inversion stress test as well as by resisted plantarflexion of the first ray, which can localize tenderness along the distal course of the peroneus longus tendon at the cuboid tunnel.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

The superior peroneal retinaculum: an anatomic study.

The superior peroneal retinaculum is thought to be the primary restraint to subluxation and/or dislocation of the peroneal tendons as they pass posterior to the distal fibula. The descriptions in anatomy texts vary widely. This anatomical study describes the different patterns of insertions for the superior peroneal retinaculum and its relationship to the peroneal tendons and the ligaments of the lateral ankle.

Ankle Joint↗