Cadaveric-biomechanical study on medial retinaculum: its stabilising role for the patella against lateral dislocation.

BACKGROUND: The aim of this study was to analyse the biomechanical role of medial retinaculum, as a stabilising factor against lateral patellar dislocation. MATERIALS AND METHODS: This cadaveric-biomechanical study included the patellae of 10 cadaveric knees, which were surgically exposed and the medial retinaculum of each one was located. A stable 24.51 N force was applied to the four parts of the quadriceps, and an increasing lateral displacing force was applied to the patella, up to 5 mm dislocation. The study was repeated for 0o, 45o, and 90o of knee flexion, with the medial retinaculum intact and dissected. The Wilcoxon signed rank test was used for data analysis. A p value < 0.05 was considered as statistical significant. RESULTS: After the dissection of medial retinaculum, the lateral displacement force was lower at every angle of knee flexion (p = 0.005, p = 0.007, p = 0.005, respectively). The lateral displacement force increased as the flexion angle increased (p = 0.005), regardless of medial retinaculum integrity. CONCLUSIONS: Medial retinaculum acts as a stabilising factor for the patella, against its lateral dislocation in lower flexion angles. Therefore, methods of surgical reinforcement or repair of medial retinaculum could provide protection against recurrent patellar dislocation.

Bilateral double testicular arteries: a case report and review of the literature. Potential embryological and surgical considerations.

The aberrancies concerning the number, origin and course of the testicular arteries are found in an incidence of approximately 4.7-20% in the literature and are documented less frequently than the respective variations of the homonymous veins. In the current study, a very rare complex of testicular arteries' variations isdescribed, in which the occurrence of bilateral double testicular arteries is recorded. Particularly, apart from the normal testicular arteries on each side, we observed an additional right testicular artery originated from the ipsilateral renal artery and an additional left testicular artery taking its origin from the abdominal aorta just above the renal artery's origin site; the latter additional testicular artery arched above the left renal vein. Both, the bilateral double testicular arteries accompanied the testicular vein on each side as their satellite arteries. We discuss the potential embryological development of that complex of arterial variants, their likely clinical and surgical applications, as well as we proceed on a brief review of the relevant literature.

The accessory deep peroneal nerve: a review of the literature.

The accessory deep peroneal nerve (ADPN) is a common variant branch of the superficial peroneal nerve. It unrarely participates in the innervation of the extensor digitorum brevis muscle and interferes with the differential diagnosis of peroneal nerve lesions. Several electrophysiological and anatomical studies have been conducted in order to document the topography, characteristics and prevalence of ADPN, presenting significantly different results. ADPN existence is of great clinical and surgical importance, thus the aim of this study is to select and present all the relevant data available in the literature.

Morphological study of the calcaneofibular ligament in cadavers.

The aim of the present study was to investigate the anatomical and morphological characteristics and the maximum elongation of the calcaneofibular ligament (CFL) in cadavers. In a sample of 72 cadaveric lower limbs the mean values of length, width, thickness, and angle with the sagittal plane were recorded for the CFL. The mean ligament's length was 31.8 mm, and the mean width and thickness were 4.4 mm and 1.5 mm respectively. The mean angle with the sagittal plane was 51.11°. In 72.2% of the lower limbs studied, the ligament presented one band, while 22.2% and 5.6% of them were two-banded and three-banded respectively. A common origin with the anterior talofibular ligament (TFL) was found in 24 of the feet (33%). There were also 4 cases in which the anterior TFL was absent. Finally, we measured the maximal elongation of the ligament during extreme inversion and simultaneous dorsal flexion and found it to be 2.88 mm on average. We noticed and statistically verified that women presented a greater elongation compared to men. A precise knowledge of the origin, insertion, direction, and morphology of CFL is critical for ligament injuries in ankle sprains and during ankle reconstruction. Ligament elasticity plays an important role in the range of ankle motion and ligament shearing. Male and female ankle joints differ in several anthropometric characteristics and thus the genre differences in ligament elongation are of great interest.

Accessory internal thoracic artery and its clinical significance.

The accessory internal thoracic artery is a relatively large branch of the initial part of the internal thoracic artery, which was found in 4.54% of 22 cadavers studied in the Institute of Anatomy of the Medical School of Aristotle University of Thessaloniki. The course of this artery lies usually in the inner surface of the anterolateral thoracic wall and its diameter is sometimes almost equivalent to that of the main trunk of the internal thoracic artery. We think, that the knowledge of this arterial branch is essential for the thoracic surgeon during the preparation of the internal thoracic artery for coronary revascularization as well as for the surgeon during the placement of thoracic drainage for pneumothorax. Furthermore, it has to be kept in mind for the interpretation of angiographies of the subclavian artery.

Double common bile duct: a case report.

The aim of our study is to present a case of double common bile duct. Specifically, we found a common bile duct that was divided into two distinct ducts, one the main and the other the accessory duct, during its course downwards. The two bile ducts had a parallel course emerging from the common bile duct after its formation and reuniting just above the head of the pancreas. Finally, they drained into the second portion of the duodenum at the site of major duodenal papilla. This anomaly is of great importance because the duplication of the common bile duct can lead to severe intraoperative injury to one of the two common bile ducts, which can be mistaken for the cystic duct and be ligated. Moreover, we present the relative international literature and the clinical significance of our finding.

Excavated-type of rhomboid fossa of the clavicle: a radiological study.

The excavated type of rhomboid fossa of the clavicle is a relatively neglected anatomical structure that can potentially cause diagnostic problems. Its unilateral occurrence may be confused by the physician as avascular necrosis, osteomyelitis, or even a tumour. We studied 80 routine chest radiographs and identified the clavicles with excavated type of rhomboid fossa. The sex, sidedness, and handedness were recorded. An excavated type of rhomboid fossa was present in 43 clavicles (26.88%), appearing more frequently in males than in females. In addition, the incidence of the excavated type of rhomboid fossa was greater on the right side than on the left. That type of fossa was also present more frequently on the right side in right-handed specimens and on the left side in left-handed specimens. The high incidence of the excavated type of rhomboid fossa on the dominant hand supports the mechanical theory of fossa formation. Radiologists and physicians should be aware of this fossa, as it may resemble a pathological condition.

Adamantinoma of the tibia: local resection and distraction osteogenesis.

We describe a case of adamantinoma of the distal tibia in a 31-year-old woman. Segmental resection of the part of the tibia containing the tumour in normal bone was done and the bone defect was bridged with bone transport and external fixation. The tibia healed uneventfully and one year after the operation the patient resumed full activity. Three years postoperatively no local recurrence or metastasis has occurred.

Morphological parameters of the acromion.

The purpose of this study was to record the basic morphometric values of the acromion. Forty-four pairs of dried scapulas were reviewed. Acromial shape was evaluated in relation to sex, symmetry and presence of subacromial enthesophytes and classified according to Bigliani with the following results: type I (flat): 26.1%, type II (curved): 55.6% and type III (hooked): 18.1%. There was a greater percentage of type III in men (56.2% vs. 43.7%) and type I in women (56.5% vs. 43.4%). Acromial morphology was symmetric in 29 acromia (65.9%). Enthesophytes were most common in type III (75%). A rough inferior surface of the acromion was most frequently found in type III (81.2%). Nine other scapular osteological parameters were also measured. Many differences were noted between male and female scapulae. The great variety of morphological features is assumed to be related to rotator cuff pathology and other shoulder impairments.

Evidence of lateral antebrachial cutaneous nerve entrapment during autopsy.

Compression of the lateral cutaneous nerve of the forearm is a rare clinical entrapment syndrome. This report describes the compression of the lateral antebrachial cutaneous nerve at the level of the lateral margin of the biceps brachii tendon identified during autopsy. This is the first cadaveric case reported in the literature. The anatomy, the possible areas of entrapment, the most frequent diagnostic problems and the main therapeutic options for this rare occurrence are also discussed.

Failure of palmaris longus muscle duplication and its clinical application.

A case of failure of palmaris longus muscle duplication was found in the left forearm of a male cadaver. Specifically, two distinct palmaris longus muscles had failed to separate, and were united from the medial epicondyle to the palmar aponeurosis. We studied the exact morphology of the abnormal muscle, which, to our knowledge, has not been reported elsewhere in the literature. It also provided data for palmaris longus muscle morphology and may have clinical implications, as the knowledge of such an anomalous muscle should be useful for hand surgeons and radiologists.

Variability in superior hypogastric plexus morphology and its clinical applications: a cadaveric study.

BACKGROUND: The superior hypogastric plexus (SHP) that is formed anterior to the aorta and the sacral promontory and is located anterior to the L5-S1 vertebrae, normally continues as the inferior hypogastric plexus. Several variations have been described from a single trunk to a plexiform arrangement. MATERIALS AND METHODS: The SHP was dissected in 35 formalized cadavers. RESULTS: A single thin and rounded nerve was found in 17.14% of subjects. The type of a wide reticular formation was observed in 28.57% of specimens. Interestingly, a band-like nerve trunk consisting of nerve bundles connected with loose connective tissue was evident in 22.85% of cadavers. Eventually, two distinct nerves at a short distance with each other were found in 31.44% of subjects. Furthermore, we found that branches of the major and minor splanchnic nerves contributed to SHP constitution. We provided, additionally, the topographic anatomy of the SHP with regard to the sacral promontory and the abdomen midline. CONCLUSION: A detailed knowledge of the course, the morphology, the various forms and the topography of the SHP is of outmost significance for several clinical specialties.

Accessory muscles in the lower part of the anterior compartment of the arm that may entrap neurovascular elements.

The aim of this study was to evaluate the incidence of abnormal muscular bands of the anterior compartment of the arm that may compress the median, the ulnar, and the medial antebrachial cutaneous nerve as well as the brachial artery and vein, thus causing entrapment at and above the elbow. A total of 56 adult cadavers were studied during routine dissections that occurred in our laboratory. In the 112 upper limbs studied, we found three variant muscles of the flexor compartment of the arm (2.68%) entrapping nerves and vessels. The first muscle was emerging from the tendon of long head of biceps brachii and coracobrachialis muscle insertion. The second muscle inserted partially into the belly of biceps brachii and should be considered as a supernumenary head of biceps brachii. The third muscle, in fact, represents an accessory fascicle of the brachialis muscle that is an embryonic remnant of that muscle. A number of structures cross anterior to the median, ulnar, and medial antebrachial cutaneous nerve as well as the brachial artery and vein. Compression of nerves and vessels may be caused by additional muscular bundles that pass anterior to these structures. These additional muscular bundles arise either from the brachialis, coracobrachialis, or biceps brachii muscle. Such variations have clinical implications and should be considered in patients, with a high median or ulnar or medial antebrachial cutaneous nerve paralysis with symptoms of lower brachial artery or brachial vein compression.

An accessory middle scalene muscle causing thoracic outlet syndrome.

The aim of our study is to present a very rare accessory middle scalene muscle, leading to thoracic outlet syndrome. In particular, a muscular bundle was discovered on a male cadaver connecting the middle portion of the middle scalene muscle with the anterior scalene muscle insertion to Lisfranc's tubercle. This triangular accessory muscle and, especially, its sharp medial border compressed the middle and lower trunk of the brachial plexus and the subclavian artery. This anomaly is of great importance because it emphasises the fact that it is not primarily the anterior scalene muscle that produces symptoms of thoracic outlet syndrome but the anterior displacement of the middle scalene muscle or its accessory muscular bands. We also present the relative international literature and the clinical significance of our finding.

An accessory double cystic duct with single gallbladder.

A case of double cystic duct was detected during preparation of cadavers for educational purposes in a 76 year old woman. The two cystic ducts formed a triangular formation with the common hepatic duct. That is the fifteenth reported case in the literature. We report on the exact description of the macroscopic anatomy of that rare congenital abnormality, the pathogenesis of that anomaly and the possible surgical implications following misdiagnosis of that anomaly.

A study on the morphology of the popliteus muscle and arcuate popliteal ligament.

The aim of this study was to investigate the origins and morphological features of the popliteus muscle in cadavers. In a sample of 40 lower limbs taken from cadavers the exact morphological features of the popliteus muscle were examined. In 100% of the cases studied we noticed, apart from the known femoral origin from the lateral femoral epicondyle, a fibular origin from the styloid process of the head of the fibula directed obliquely and blending with the main femoral origin, forming the arms of a Y-shaped structure. In all the cases a capsular origin was presented, while in 91.67% an origin lateral to it from the superior border of the posterior horn of the lateral meniscus was found. The capsular and meniscal origins formed the base of the Y-shaped structure that corresponded to the known arcuate ligament. We consider that the additional origins of the popliteus muscle form the arcuate ligament, which is not a distinct anatomical structure as it is described in traditional anatomical textbooks. In addition, we have analysed the exact morphological features of the capsular, fibular and meniscal origins of the popliteal muscle.

The expression of the epitope H recognized by the monoclonal antibody H is higher in astrocytomas compared to anaplastic astrocytomas and glioblastomas.

The epitope H contains an O-linked N-acetylglucosamine residue in a specific conformation and/or environment recognized by the monoclonal antibody H (mAbH). mAbH stains two bands with Mr x0.001 of 209 and 62 in lysates of cultured rat astrocytes. In normal human brains epitope H is absent from the overwhelming majority of normal astrocytes and only sparse reactivity is observed, confined mostly to fibrous astrocytes. Upregulation of the epitope H takes place in reactive astrocytes. In the present study we used the mAbH to investigate the immunohistochemical expression of the epitope H in 41 cases of astrocytic tumors including 19 cases of astrocytomas, 8 cases of anaplastic astrocytomas and 14 cases of glioblastomas. Seven out of 19 cases (37%) of astrocytomas showed weak staining, 10 cases (53%) moderate staining and 2 cases (10%) intense staining. Two out of 8 cases (25%) of anaplastic astrocytomas appeared negative, 3 cases (37.5%) showed weak staining and 3 cases (37.5%) moderate staining. Four out of 14 cases (28.5) of glioblastomas appeared negative, 7 cases (50%) showed weak staining, 2 cases (14%) showed moderate staining and only one case (7.5%) showed intense staining. There was a statistically significant elevation of the expression of the epitope H in astrocytomas compared to anaplastic astrocytomas and glioblastomas (p=0.047). These results indicate that the expression of the epitope H decreases in parallel with the increase of the grade of astrocytic tumors from low to higher grade neoplasms. This could be of interest for predicting the progression of an astrocytic tumor since it is documented that astrocytomas progress to tumors of higher grade of malignancy. Further investigation of the antigens bearing the epitope H might help to gain further insight into the mechanisms which regulate the progression of astrocytic tumors and to examine the relevance of the mAbH staining with respect to the prognosis of these neoplasms.

The treatment of Reflex Sympathetic Dystrophy in a 9 year-old boy with long standing symptoms.

Reflex sympathetic dystrophy is an uncommonly reported entity in children and it continues to be underdiagnosed. Compared with adult, childhood reflex sympathetic dystrophy is of unknown etiology and has a better prognosis. The most common therapy in children is progressive mobilization supported by antiphlogistic, analgesic drugs, psychological and physical therapy. We report an interesting case of reflex sympathetic dystrophy of the left knee joint of a nine years old child with symptoms insisting more than four years and recalcitrant to the above treatments. The use of intravenous regional anaesthesia with lidocaine 0.5% and methylprednisolone was successful. No other reports seem to exist on the use of lidocaine 0.5% and methylprednisolone for the therapy of reflex sympathetic dystrophy in children. The treatment is simple, safe and well tolerated by children. Psychological factors should not be underestimated. Early diagnosis and aggressive therapy are important factors for the full recovery of the patients.

Back pain caused by benign tumors and tumor-like lesions of the thoracolumbar spine.

Twenty-two patients with benign tumors or tumor-like lesions of the spine (vertebral echinococcal cysts, eosinophilic granuloma) presented with back pain and deformity. The duration of pain ranged from 1 to 6 years. Five patients had incomplete paraplegia at admission. Spine deformity was observed in patients with osteoid osteoma, osteoblastoma, hemangioma, and vertebral echinococcal involvement. All patients underwent clinical evaluation, laboratory studies, and histologic studies. Electromyogram studies were performed in patients who had a neurologic deficit or nerve root irritation. Imaging evaluation consisted of plain films, bone scans, computed tomography scans, and magnetic resonance imaging scans. Fifteen patients had lumbar involvement; 7 had thoracic involvement. For 18 patients, management included tumor excision and thorough debridement of the lesion. Spinal instrumentation and fusion were used to correct the deformity and treat the instability in 5 patients. Patients were followed for 1 to 8 years. Of the 5 patients with incomplete paraplegia, 4 recovered completely, and the fifth (who had spinal cord hemangioma) improved 2 grades on Frankel's scale. The remaining patients were disease free and returned to routine daily activities. Benign tumors or tumor-like lesions of the thoracolumbar or lumbar spine are very rare and easily misdiagnosed in patients with persistent back pain. Patients whose symptoms progress or fail to respond over an appropriate period of time should be evaluated further. Complete excision of the tumor followed by spinal instrumentation in the presence of deformity or instability is the treatment of choice.