Fabrex: a new clinical test for diagnosis gluteal tendinopathy / Fabrex: um novo teste clínico para diagnóstico de tendinopatias glúteas

ABSTRACT Objective: This study aims to describe a simple and accurate semiological method executing a specific maneuver with the lower limb to direct the semiological investigation towards the tendinopathies in the gluteus medius and minimus. Methods: Fifty patients participated in the study, with a mean age of 44.1 ± 13 years, with persistent pain on the side of the hip for more than three months. To compare the FABREX (proposed test) and Lequesne semiological tests, in the diagnosis of tendinopathies in the gluteus medius and minimus, Magnetic Resonance Imaging (MRI) was adopted as the gold standard. Results: FABREX presented high sensitivity and moderate specificity for tendinopathy in the gluteus medius and high sensitivity and specificity for tendinopathy in the gluteus minimus. Conclusion: The proposed test, when positive, can be used to determine the diagnosis of gluteal tendinopathies (high specificity). Moreover, it has high sensitivity, excluding the diagnosis when negative. This study represents the initial step for validating the FABREX test, and can therefore be considered a simple and accurate procedure to identify patients with or without gluteal tendinopathies. Level of Evidence III, Case Control Study.

RESUMO Objetivo: Esse estudo propõe descrever um método semiológico simples e acurado, por meio de uma manobra específica com o membro inferior, a fim de direcionar a investigação semiológica para as tendinopatias dos glúteos médio e mínimo. Métodos: Participaram do estudo 50 pacientes, com média de idade de 44,1 ± 13,0 anos, apresentando dor persistente na face lateral do quadril há mais de 3 meses. A RM foi adotada como padrão ouro, para fins de comparação entre as duas manobras semiológicas (FABREX (teste proposto) e teste de Lequesne) no diagnóstico das tendinopatias do glúteo médio e mínimo. Resultados: O FABREX apresentou alta sensibilidade e moderada especificidade para tendinopatia de glúteo médio e alta sensibilidade e especificidade para tendinopatia do glúteo mínimo. Conclusão: A manobra proposta, quando positiva, pode ser utilizada para determinar o diagnóstico de tendinopatias glútea (alta especificidade). Além disso, possui alta sensibilidade, descartando o diagnóstico quando negativa. O presente trabalho constitui o passo inicial para validação do teste de FABREX, podendo assim, ser considerado um procedimento simples e acurado para identificar pacientes com ou sem tendinopatias glúteas. Nível de Evidência III, Estudo de Caso Controle.

Unilateral higher division of sciatic nerve and its clinical importance

The sciatic nerve has a long course right from the pelvis to the apex of the popliteal fossa. The point of division of the sciatic nerve into tibial and common peroneal nerves is very variable. The variation in the division of the sciatic nerve described in the present study should be helpful for anaesthetists and orthopaedic surgeons. While doing the dissection and teaching of the gluteal region in the Post Graduate Department of Anatomy, government medical college, Jammu, it was found that on the left side tibial nerve and common peroneal nerve were present instead of sciatic nerve. It meant that the main nerve that is the sciatic nerve had already been divided into its terminal branches in the pelvis region. Both tibial and common peroneal nerve were seen coming out of the pelvis below the piriformis muscle, while on the right side there were no variation. The sciatic nerve was seen coming out of the pelvis below the piriformis muscle as usual. Because of this high division of the sciatic nerve in the pelvis, there are many complications like failed sciatic nerve block during anaesthesia while performing surgery, but high division of the sciatic nerve may result in escape of either tibial nerve or common peroneal nerve. The gluteal region, back of the thigh and leg of the lower limb were dissected to study further course of tibial nerve and the common peroneal nerve. Photographs were also taken.

Anatomy of the gluteal region and its implication in liposculpture / 中华整形外科杂志

Objective@#To study the morphological characteristics and important anatomical structures of each soft tissue layer of gluteal region, and discuss the recommended levels and safe areas for liposculpture in this region.@*Methods@#Twenty-eight specimens of unilateral buttocks from 14 adult cadavers, including 16 specimens of unilateral buttocks from 8 fresh cadavers and 12 specimens from 6 formaldehyde fixed cadavers were dissected. Among the cadavers, there were 2 males with an average age of 49 years, and 12 females from 23 to 72 years old, median age 46 years. Through anatomy study of soft tissue layers of gluteal region, the morphological features of each layer were observed and documented, and the characteristics of fascia system and adipose tissue, as well as the relationship between the blood vessels and nerves with corresponding layers.@*Results@#The layers of the gluteal region that range from superficial to deep are skin, subcutaneous fat, superficial fascia system, deep fascia system, muscle and fascia compartments. Subcutaneous fat is distributed in superficial and deep layers; the superficial fascia system is well developed and dense with a layered structure; the deep fascia is thin with the characteristic of epimysium. There is a danger zone for deep fat graft in the gluteal region, with its apex at the first sacral vertebra, and its base goes along the gluteal fold, compromising the thighs′ medial two-thirds. Nearly all important blood vessels and nerves of gluteal region are located in deep layer of this danger zone.@*Conclusions@#Based on the characteristics of buttocks of Chinese people, liposuction is mainly performed in the iliolumbar region and posterolateral thigh, which can significantly increase the relative height and fullness of buttocks. For full buttocks, deep fat can be sucked appropriately, which should be longitudinal and gentle to reduce the damage to the superficial fascial system. There is a high risk for fat graft in the buttock. It is recommended to use a blunt needle with an inner diameter of more than 3 mm parallel to the fiber orientation of gluteus maximus for uniform fan-shaped injection with needle withdrawal. Satisfactory result can be obtained by injecting most fat into the subcutaneous adipose layer. Deep injection of grafts into dangerzoneis forbidden.

Muscular Injury of Iliacus and Gluteus Maximus after Mountain Climbing / 대한스포츠의학회지

Iliacus muscle is the strongest hip flexor of gluteal region that acts with psoas muscle, whereas gluteus maximus muscle is the largest muscle engaged in extension and external rotation of the hip. Mountaineering requires strong contractile force of both flexor and extensor around the hip. A 57-year-old man presented to our hospital with severe pain in left groin after mountaineering for 5 hours without a break. Magnetic resonance imaging revealed incomplete rupture of iliacus muscle and strain of gluteus maximus muscle. Conservative treatment was done. At 3 months of follow-up, he returned to normal life. If we are going to climb mountain, it is important to start warming up with some stretches, take a break while climbing, and use climbing sticks. There have been no report about athletic injury of both iliacus and gluteus maximus after mountaineering. So we report this case with a review of the literature.

Opções de retalhos da região glútea no tratamento da úlcera de pressão nas regiões isquiática e sacral / Gluteal flap as an alternative for the treatment of pressure ulcers in the ischial and sacral regions

Pressure ulcers are due to vascular insufficiency in tissues located mainly near bony prominences. More advanced wounds require microsurgical treatment using different types of flaps originating from the same or more distant areas. This study reports the use gluteal flaps for the treatment of pressure ulcers in the ischial and sacral regions. Methods: A total of 29 patients with National Pressure Sore Advisory Panel Consensus - 1989 stage III or IV pressure ulcers were followed in a tertiary hospital in metropolitan Goiânia between May 2010 and April 2012. Results: Among the 29 patients subjected to surgery, 10(34.5%)were female and 19 (65.5%) were male, aged between 17 and 67 years (mean: 37.82 years). They had paraplegia resulting mainly (79%) from motorcycle accidents. Stage III (27.5%) and IV (72.5%) ulcers were treated with fasciocutaneous flaps (38%) or myocutaneous flaps (62%). Conclusions: The use gluteal flaps for the treatment of pressure ulcers in the ischial and sacral regions is an excellent option that can aid patient recovery and rehabilitation.

A úlcera de pressão é o resultado de insuficiência vascular em tecidos localizados preferencialmente em áreas de proeminência óssea. O tratamento cirúrgico dessa lesão abrange fases mais avançadas dessa ferida, podendo ser realizados vários retalhos de origem local ou mesmo distante, por meio do uso da microcirurgia. Este estudo relata a experiência com o uso de retalhos da região glútea no tratamento da úlcera de pressão nas regiões sacral e isquiática. Método: Foram estudados 29 pacientes portadores de úlcera de pressão com estágios III e IV (National Pressure Sore Advisory Panel Consensus - 1989), acompanhados em hospital terciário da região metropolitana de Goiânia no período de maio de 2010 a abril de 2012. Resultados: Dos 29 pacientes submetidos a cirurgia, 10 (34,5%) eram do sexo feminino e 19 (65,5%), do masculino, com idade variando de 17 anos a 67 anos (média, 37,82 anos), com paraplegia decorrente, em grande parte (79%), de acidente motociclístico. As úlceras eram de estágios III (27 ,5%) e IV (72,5%), e foram tratadas com retalhos fasciocutâneos (38%) ou miocutâneos (62%). Conclusões: O uso de retalhos da região glútea no tratamento da úlcera de pressão nas regiões isquiática e sacral é uma ótima opção, podendo beneficiar o paciente em sua recuperação e reabilitação.

An unusual formation of sciatic nerve.

Sciatic nerve is the largest nerve and a branch of sacral plexus that controls hamstrings and all muscles of the lower limb below the knee. We are reporting a bilateral variant formation of the sciatic nerve found in a male human cadaver. The commencement of single sciatic nerve trunk formation was found to be in the lower gluteal region instead of the pelvic region. All the roots of the sciatic nerve, namely, the lumbosacral trunk (L4, L5), S1, S2, and S3 were observed to remain separate up to the lower part of the gluteal region. Incidence of this variation in general population needs to be investigated so as to create awareness among surgeons and anesthetists about the degree and extent of variation in sciatic nerve formation. Complete sciatic nerve blockages will fail even after multiple punctures and attempts if the sciatic nerve is present as separately sheathed bundles until the lower gluteal level.

Variaciones del Nervio Isquiático en Relación al Músculo Piriforme / Variations of the Sciatic Nerve in Relation to the Piriformis Muscle

El nervio isquiático nace del plexo sacro y sale de la pelvis a través del foramen isquiático mayor por debajo del musculo piriforme como un tronco común. En ocasiones, este nervio puede emerger dividido en sus dos componentes: el nervio fibular común y nervio tibial, encontrándose, variaciones que podrían dar origen a una condición de compresión nerviosa. En este trabajo se exponen dos variaciones del nervio isquiático en un mismo individuo, donde en la primera el nervio fibular común atraviesa el músculo piriforme y luego desciende junto al nervio tibial y la segunda, donde el nervio fibular común se forma a partir de un ramo superior que perfora el músculo piriforme y el otro inferior que pasa debajo de él, para unirse luego en el margen inferior de éste músculo y formar el nervio fibular común, que desciende junto al nervio tibial. Las variaciones del nervio isquiático en relación al músculo piriforme podrían explicar el síndrome del músculo piriforme.

The sciatic nerve arises from the sacral plexus and exits the pelvis through the greater sciatic foramen below the piriformis muscle as a common trunk. Sometimes this nerve can emerge divided into two components: the common fibular nerve and tibial nerve, finding variations that could give rise to a condition of nerve compression. In this paper we describe two variations of the sciatic nerve in the same individual, where in the first common fibular nerve passes through the piriformis and then descends along the tibial nerve and the second, where the common fibular nerve is formed from a higher branch that pierce to piriform muscle and a lower branch passing under him, then join at the inferior margin of this muscle and form the common fibular nerve, which descends with the tibial nerve. Variations of the sciatic nerve in relation to the piriformis muscle could explain the piriformis syndrome.

Aspectos anatómicos y topográficos del nervio pudendo en la región glútea / Anatomical and topographical aspects of the pudendal nerve in gluteal region

El nervio pudendo distribuye ramos motores y sensitivos para la región perineal y órganos genitales externos. Tiene importancia funcional en la micción, defecación, erección y parto. Desde el punto de vista clínico, se realiza bloqueo anestésico del mismo en la práctica obstétrica, se electroestimula en casos de incontinencia fecal o urinaria, entre otros procedimientos. Investigaciones anatómicas han señalado que puede presentar variaciones en su conformación y topografía. Con el propósito de complementar el conocimiento sobre este nervio en su trayecto por la región glútea, se estudió su conformación, biometría y relaciones con los vasos pudendos internos y ligamentos adyacentes. Se disecaron 30 regiones glúteas de 15 cadáveres formolizados de individuos brasileños, adultos, de ambos sexos, observando la conformación del nervio, número de ramos, disposición respecto a los vasos pudendos internos y ligamentos sacrotuberoso y sacroespinoso, registrando también su ancho en el trayecto entre los forámenes isquiático mayor y menor. El nervio pudendo se presentó como tronco único en 53,3 por ciento de los casos y dividido en ramos en 46,7 por ciento (dos ramos en 36,7 por ciento, tres en 6,7 por ciento y cuatro en 3,3 por ciento). Cuando estaba dividido, en 36,7 por ciento los ramos permanecieron separados y en 10 por ciento se unieron antes de ingresar en el foramen isquiático menor. El nervio (único o dividido) fue medial a los vasos pudendo internos en 70 por ciento y lateral a ellos en 3,3 por ciento. En el 26,7 por ciento restante, estaba dividido en dos o tres ramos, que se situaban medial y lateralmente a los vasos o los cruzaban posteriormente. Su posición fue anterior al ligamento sacrotuberoso en 93,3 por ciento. El nervio pudendo presenta interesantes variaciones en su conformación y topografía, que deben ser consideradas durante los procedimientos clínicos y quirúrgicos que lo involucren.

The pudendal nerve distributes motor and sensory branches to the perineum and genital external organs. It has functional importance in the micturition, defecation, erection and labor. From the clinical point of view, anaesthetic blockade of the same one is realized in the obstetric practice, electroestimulation in cases of fecal or urinary incontinence, among other procedures. Anatomical investigations have indicated that it can present variations in its conformation and topography. The objective of this study was complete knowledge about this nerve in its course through the gluteal region, its conformation, biometry and its relationship with the internal pudendal vessels and adjacent ligaments were studied. We dissected 30 gluteal regions of 15 corpses fixed in formaldehyde 10 percent of Brazilian individuals, adult, of both sexes, observing the conformation of the nerve, number of branches, disposition with regard to the internal pudendal vessels and sacrotuberous and sacrospinous ligaments, also recording its external diameter in the distance between greater sciatic foramen and lesser sciatic foramen. The pudendal nerve appeared as a single trunk in 53.3 percent of the cases and divided in branches in 46.7 percent (two branches in 36.7 percent, three in 6.7 percent and four in 3.3 percent). When it was divided, in 36,7 percent the branches remained separated and in 10 percent they joined before the lesser sciatic foramen. The nerve (single or divided) was medial to the internal pudendal vessels in 70 percent and lateral to them in 3.3 percent. In 26.7 percent, it was divided in two or three branches, which were located medially and laterally to these vessels or crossing posterior to them. Its position was anterior to the sacrotuberous ligament in 93.3 percent. The pudendal nerve presents interesting variations in its conformation and topography which must be considered during the clinical and surgical procedures.

The Gluteal Artery Perforator Sparing Gluteal Fasciocutaneous Rotation Advancement Flap with V-Y Closure

PURPOSE: The management of gluteal wound originated with burn is same as pressure sore. Pressure sores are managed surgically with two therapeutic components. One is a gross and sharp debridement and the other is a flap providing well-vascularized tissue to cover wounds. Central to the flap considerations is the tendency for recurrence mainly due to a poor blood supply, failure of tension-free closure and naive nursing care after operation, when reconstructive surgeons employ numerous surgical techniques in sores repair. The author used the gluteal artery perforator sparing and gluteal fasciocutaneous rotation advancement flap with V-Y closure to manage gluteal wound originated from burn. METHODS: Three cases of gluteal wound were treated with the gluteal artery perforator sparing gluteal fasciocutaneous rotation advancement flap with V-Y closure. The skin incision of conventional gluteal rotation flap is shortened to get a minimized flap size and adapts an advancement flap in a back cut pattern, supported laterally with V-Y closure for a tension-free closure. This superiorly (or inferiorly) based flap is elevated subfascially until one or two large musculocutaneous perforators of the inferior gluteal artery are encountered. The perforator down to its emergent point at the level of the piriformis muscle is dissected intramuscularly by splitting fibers of the gluteus maximus muscle in order to pivot freely. Then, the dead space is obliterated with a portion of the gluteus muscle transposed independently. The skin paddle is rotated to the defect area with the saved perforator(s) and closed the defect area. RESULTS: This technique encompasses the advantages of a perforator sparing flap, a fasciocutaneous rotation flap and an advancement flap with V-Y closure, providing a better vascularity, the flexibility of rerotation in the event of recurrence, preservation of the gluteus maximus muscle for ambulatory function, tension-free mobilization. Compared with other flaps which are previously used to manage pressure sores, one advantage is noted that the minimized operation wound is effective not only to improve the quality of patient's life in terms of position care but also to mitigate the associated wound- healing problems. CONCLUSION: This technique can be chosen primarily for management of various types of gluteal region wound including burn.

Divisão alta e bilateral do nervo ciático: relato de caso / Bilateral high division of the sciatic nerves: a case report

Em um cadáver de um homem de aproximadamente 50 anos, foi observada a divisão alta e bilateral do nervo ciático. Nos dois antímeros, o nervo entrou na região glútea dividido com a porção fibular comum, atravessando o músculo piriforme e a porção tibial, passando pela sua borda inferior. No antímero direito, as porções divididas do nervo ciático voltaram a se unir na região glútea e, no esquerdo, permaneceram divididas em todo o seu trajeto. O conhecimento da divisão alta do nervo ciático, bem como do seu trajeto, tem importância durante as abordagens cirúrgicas em casos de lesões que o afetam em suas partes glúteas ou femorais e também correlacionadas com a passagem anormal através do músculo piriforme, levando a uma síndrome de compressão nervosa.

Bilateral high division of the sciatic nerve was observed in a 50-year-old male cadaver. In the two antimers, the nerve entered the gluteal region divided with the common fibular portion, crossing the piriformis muscle and tibial portion and passing through its inferior border. In the right antimer, the divided portions of the sciatic nerve became again united in the gluteal region. In the left antimer, the portions continued to be divided throughout their trajectory. The understanding of the high division of the sciatic nerve as well as of its trajectory is important for surgical procedures, in cases of injuries that affect its gluteal or femoral parts, and also in relation to its abnormal passage through the piriformis muscle, causing a nerve compression syndrome.

Anomalous Branch of Internal Pudendal Artery / Rama Anómala de la Arteria Pudenda Interna

The ischiatic artery classically described as a branch of the inferior gluteal artery, is a long and thin vessel that is related to the ischiatic nerve. In a dissection was observed that this artery emerges from the internal pudendal artery with a caliber larger than the ones described in the literature. The knowledge of anatomical variations is important to the surgeons, radiologists and anatomists.

La arteria isquiática se describe clásicamente como una rama de la arteria glútea inferior, es un vaso largo y delgado que se relaciona con el nervio isquiático. En una disección se observó que esta arteria surge de la arteria pudenda interna con un calibre más grande que lo descrito en la literatura. El conocimiento de variaciones anatómicas es importante para los cirujanos, radiólogos y anatomistas.