Thoracolumbar fascia in the lumbar region: anatomical description and topographical relationships to the cutaneous nerves: a preliminary study.

BACKGROUND: The study aims to determine principal topographical relations between thoracolumbar fascia (TLF) and lateral branches derived from the dorsal (posterior) rami of lumbar spinal nerves and elucidate their potential link to lumbar region pain. The research protocol involves basic TLF morphological description, evaluating its relation to the nerves, and examining general histology. MATERIALS AND METHODS: The research was conducted on four male cadavers fixed in 10% neutral buffered formalin. RESULTS: The dorsal rami of the spinal nerves branched into medial and lateral divisions. The lateral divisions were about 1 mm thick and mainly visible in the subcutaneous tissue during stratigraphic dissection. They pierced the TLF superficial layer. They descended sidewards and downwards within the superficial fascia (laterally to the erector spinae muscle) to provide sensory innervation to the skin. CONCLUSIONS: Anatomical relationships between TLF, deep (intrinsic or true) back muscles, and dorsal rami of the spinal nerves are complex and may be clinically involved in low back pain etiopathogenesis.

Arthrofibrosis - a myth or true joint disorder?

Authors, mostly specialists on rehabilitation and orthopedic surgery prove that arthrofibrosis is a commonly overlooked phenomenon, which may lead to serious limitation in the range of movement, leading to limitation in patients quality of functioning. The main goal of this article is to emphasize the importance of understanding a such complex condition. Non typical patomechanism, lack of biomarkers dedicated to this dysfunction and general lack of understanding in this pathology causes that risk factors and the most effective strategies remain vastly unknown. Pathophysiology of the arthrofibrosis in the joints is definitely multifactorial, but intense production of collagen seems to be the main factor. Most modern pharmacological methods concentrate on the regulation of collagen fiber production and reducing the inflammation. Inflammation from joint contractures stimulates the proliferation of activated cells that results in the production of extracellular matrix macromolecules to form fibrotic tissue that is deposited into the capsule, thereby resulting in fibrosis. Lack of unified classification scale is caused by relatively high variation of the functions fulfilled by particular joints and each treatment plan should be constructed individually. Quality of surgical treatment and physical therapy play a major role in both prevention and treatment of such complex condition as arthrofibrosis. Both iatrogenic mistakes and overly aggressive manual therapy are some of main factors increasing the risk of this pathological condition. Introducing properly conducted physical therapy treatment in the early stage is crucial to main the range of movement and preventing this significant problem.

The deep brachial artery-A meta-analysis of its origin and diameter with a review of the literature.

The deep brachial artery (DBA) is the first and largest branch of the brachial artery. Multiple variations of the DBA's origin, termination, and diameter have been reported in the literature. Major online medical databases such as PubMed, Scopus, Embase, Web of Science, and Google Scholar were searched in order to find all studies considering origin variations and the diameter of the DBA. The prevalence of the DBA originating directly from the axillary or brachial artery was shown to be 92.87%. DBA originating indirectly from the axillary or brachial artery, as a common trunk with other arteries, was found to be 7.13%. The mean diameter of the DBA was shown to be 2.05 mm. The authors of the present study believe that this is the most accurate and up-to-date meta-analysis considering origin patterns and the diameter of the DBA. Additionally, this study contains a comprehensive literature review in which current detailed anatomical knowledge concerning the DBA was gathered. The results of this study could provide a helpful tool for physicians, especially surgeons, dealing with an upper limb in their daily practice.

The popliteofibular ligament: a cadaveric ultrasound study.

OBJECTIVE: The popliteofibular ligament (PFL) is an important stabilizer of the knee found within the posterolateral corner (PLC) of the joint. Injuries to the PLC can cause substantial patient morbidity. Accurate PFL visualization has been historically challenging, impeding injury diagnosis and treatment. The gold standard for in vivo PFL visualization is magnetic resonance imaging (MRI), but this procedure has slice thickness limitations, is costly, and is subject to longer wait times. Ultrasonographic (US) PFL assessment is a potentially viable alternative to MRI. This study aimed to determine the viability of US PFL assessment. MATERIALS AND METHODS: Ten fresh-frozen lower limb specimens were evaluated for the presence and morphometric characteristics of the PFL via US using an 18.0-MHz linear transducer. The cadavers were then dissected and reassessed for the presence and morphometric characteristics of the PFLs for comparison with US findings. Moreover, the fracture of the fibular styloid process near the site of the insertion of the PFL (the arcuate sign) was simulated and assessed via US. RESULTS: The PFL was visualized and measured in all ten knees via both US and cadaveric assessments. There were no statistically significant differences in PFL morphometric characteristics determined via US examination and dissection. The fibular styloid fracture was easily identified in US examination. CONCLUSION: US imaging is a viable alternative for accurate and effective assessment of the normal PFL. Moreover, the arcuate sign can be evaluated via US.

Anatomy of the deep brachial artery - general overview (cadaveric study) - discussion on terminology.

There are only very few studies on the anatomy of the deep brachial artery - DBA (arteria profunda brachii), both regarding its course, branching pattern and contribution to the cubital rete. Most of the textbooks are based on data which remain unchanged for years. The aim of this article was to summarize the current knowledge on this vessel, based on the anatomical and clinical studies and other sources available including also own cadaveric study. We tried to present also some controversies regarded to the nomenclature of the branches of the DBA.

Surface Shape of the Calcaneal Tuberosity and the Occurrence of Retrocalcaneal Bursitis among Runners.

PURPOSE: The aim of the study was to establish the relationship between the shape of the calcaneal tuberosity (flat, stepped, rounded, normal) and the probability that retrocalcaneal bursitis among people who train running regularly. METHODS: The study included a group of 30 runners who suffered from retrocalcaneal bursitis in the past, and 30 people who never had symptoms of this disease. The study was based on a diagnostic survey, as well as on clinical examination. The surface of the calcaneal tuberosity and the slope of the calcaneus were assessed using X-rays. The mobility of the bursa, its surface size, the thickness of the Achilles tendon and its attachment rate were established during an ultrasound examination. RESULTS: Flat surface of the calcaneal tuberosity increases fourfold the risk of suffering from retrocalcaneal bursitis (OR = 4.3). The people whose calcaneus slope is above 25° are at increased risk of suffering from such an inflammation compared with the people whose calcaneus bone is more horizontal (OR = 2.8). The analysis shows that the thickness of the Achilles tendon (p = 0.001), the surface size of the bursa (p = 0.009), as well as the flat surface of the calcaneal tuberosity (p = 0.008) are strongly associated with the occurrence of retrocalcaneal bursitis. CONCLUSIONS: The flat shape of the calcaneal tuberosity increases the risk of bursitis. The risk of inflammation is higher when the Achilles tendon is thicker and the surface of the bursa is smaller than normal.

The course of posterior interosseous nerve in the wrist capsule. An anatomical study using the modified Sihler's staining.

The aim of the study was to assess the course of posterior interosseous nerve in the wrist capsule in the transparent method of nerve staining. MATERIAL AND METHODS: Thirty dorsal wrist capsules were collected bilaterally from 15 donors (thirty capsules) within 12 hours of death. By the dorsal incision the capsules were collected in the same manner. The specimens were stained according to the protocol of modified Sihler's staining technique. The preserved capsules were analysed under 8-16× magnification of optical microscope for the presence of major posterior interosseous nerve trunks, their major and minor branches, and nerve connections. RESULTS: Three main types of nerve course were identified within the joint capsule. Type I - the most common, with the presence of a single trunk with the excursion of the first main branch on the radial side, two main branches on the ulnar side, the presence of the prevailing number of small branches on the radial side and the presence of 3-4 branches extending beyond the level of the carpo-metacarpal joints. Type II with the presence of two main nerve trunks, running almost in parallel with the first main branch on the radial side, two main branches on the ulnar side with presence of a predominant number of small branches on the radial side and the presence of 3-4 branches running beyond the level of carpo-metacarpal joints. Type III (least often) with the presence of crossed main nerve trunks. CONCLUSION: The modified Sihler's staining technique allows for transparent visibility of the nerves innervation the dorsal wrist capsule. However does not allow accurate assessment as histological examination, especially in evaluation of nerve endings, but it gives a significantly larger area of nerve observation.

The influence of aging on the insertion of the Achilles tendon: A magnetic resonance study.

The aim of this study was to examine the variations of the Achilles tendon (AT) insertion point into the calcaneal bone (CB) in relation to age and sex using magnetic resonance imaging (MRI). A total of 202 foot and ankle MRIs were reviewed and patients were allocated into three age groups: (I) <18, (II) 18-65, and (III) >65 years. All measurements were obtained on a mid-sagittal scan. The mean measurement values were used to assess the relationships among the AT insertion point, sex, and age. Our main findings revealed that (1) the distance between the most inferior point of the CB and the most inferior part of the AT insertion into the CB increases with age, (2) the height of the AT insertion into the posterior aspect of the CB decreases with age, and (3) the length of the AT insertion into the posterior aspect of the CB decreases with age. The terminal insertion point of the AT on the CB in younger subjects was more distal, whereas in older individuals it was more proximal. These results could help in developing novel strategies for the treatment and prophylaxis of AT injuries in particular patient age groups. Anatomical data about the AT insertion are crucial for developing a computer model of the AT and for biomechanical considerations regarding this tendon. Clin. Anat. 33:545-551, 2020. © 2019 Wiley Periodicals, Inc.

The transverse facial artery anatomy: Implications for plastic surgery procedures.

BACKGROUND: The transverse facial artery (TFA) perfuses the lateral face. Knowledge of topographical anatomy of the lateral face is crucial for safe procedural performance in aesthetic and plastic surgery, especially the face lift flap and face transplant. The aim of the present study was to assess detailed TFA morphometrical features. PATIENTS AND METHODS: One-hundred computed tomography head angiographies were analyzed. TFA numbers and origins were recorded bilaterally (200 cases). TFA diameters and lengths in addition to their positions in relation to neighboring vessels and the zygomatic arches were measured. RESULTS: TFA was present in 96% of cases (192/200, left = 97, right = 95). A single TFA was present in 95.3% and double TFAs were present in 4.7% of cases. In 91.7%, the TFA originated from the superficial temporal artery, and in 3.1%, it originated from the external carotid artery. One left TFA originated from the maxillary artery. The TFA was significantly longer on the right than on the left side (56.6±26.0 versus 47.3±22.2 mm; p = 0.03). The TFA mean diameter was 1.0±0.4 mm (range: 0.4-2.2 mm) with no difference between face sides. TFA length correlated with its diameter (r = 0.46, p <0.05). The TFA always originated below the zygomatic arch, and it should be found in the 8.8 mm wide area beginning 17.0mm below the lower border of the zygomatic arch. CONCLUSIONS: The TFA has a significant role in lateral face vascularization, and absence of this vessel is very uncommon.

Risk of injury to the sural nerve during posterolateral approach to the distal tibia: An ultrasound simulation study.

When surgeons operate on the foot and ankle, the most common complication that may arise is injury of the cutaneous nerves. The sural nerve (SN) is potentially at risk of being injured when treating fractures involving the distal tibia using the posterolateral approach. The aim of this study was to evaluate how differences in length and position of the surgical treatment of fractures involving the distal tibia can affect the risk of SN injury. The study involved 40 healthy volunteers (n = 80 lower limbs). Ultrasound simulation of each potential surgical incision site was used to locate the SN and to assess the risk of injury. The study showed that the SN predominantly travels more posteriorly at levels more proximal from the tip of the lateral malleolus. At these more proximal points of the SN's course, it was proven that there was an overall increased incidence of iatrogenic injury to the SN in incisions made closer to the Achilles tendon. Based on these results, a quasi 3 dimensional figure was created showing the anatomical structures of this region to identify areas at high risk for SN injury. By revealing how length and position of the surgical incision can influence the risk of SN injury, we hope to provide information to surgeons on the optimal technique to avoid iatrogenic SN injury while operating on the distal tibia via a posterolateral approach. Clin. Anat. 31:870-877, 2018. © 2018 Wiley Periodicals, Inc.

Oblique incisions in hamstring tendon harvesting reduce iatrogenic injuries to the infrapatellar branch of the saphenous nerve.

PURPOSE: Iatrogenic injury to the infrapatellar branch of the saphenous nerve (IPBSN) is associated with many surgical interventions to the medial aspect of the knee, such as anterior cruciate ligament (ACL) reconstruction. Different types of surgical incisions during hamstring tendon harvesting for ACL reconstruction are related to a variable risk of IPBSN injury. This study aimed to evaluate the risk of iatrogenic IPBSN injury during hamstring tendon harvesting for ACL reconstruction with different incision techniques over the pes anserinus. METHODS: This study was performed on 100 cadavers. Vertical, horizontal, or oblique incisions were simulated on each cadaveric limb to determine the incidence of iatrogenic IPBSN injury. RESULTS: The vertical incision caused the IPBSN injury during hamstring tendon harvesting in 101 (64.7%), the horizontal incision in 78 (50.0%), and the oblique incision in 43 (27.6%) examined lower limbs. The calculated odds ratios (OR) for risk of injury in vertical versus horizontal and horizontal versus oblique incisions were 2.4 (95% CI 1.5-3.6) and 1.8 (95% 1.2-2.8), respectively. CONCLUSIONS: The vertical incision technique over the pes anserinus should be avoided during hamstring tendon harvesting for ACL reconstruction. The adoption of an oblique incision, with the shortest possible length, will allow for the safest procedure possible, thus minimizing the risk of iatrogenic IPBSN injury, and improving patient outcomes and postoperative quality-of-life.

The surgical anatomy of the sural nerve: An ultrasound study.

The aim of this study was (a) to examine the anatomy of the sural nerve (SN) in a sample of 30 patients and (b) to analyze the incidence of different origins of the SN, and the distance of the SN from planned arthroscopic portals. An ultrasound (USG) examination of the SN was performed bilaterally on thirty healthy patients with no history of surgery or trauma of the lower limb. The SNs were classified into six main types of pattern, with an additional category for new and unclassified types. Each of Types 1 and 3 had two subdivisions. The distances from the superior border of the calcaneal tuberosity to the three simulated arthroscopy portal sites (Z1, Z1.5, Z2) to the SN were measured. A total of 30 patients (n = 60 limbs) with an average age of 27 ± 7.5 years were examined and the SN was visualized in all cases. The most common origin was Type 3A, accounting for 30% of limbs. Type 2 was the second most common seen in 18.3%. The distances of the SN from arthroscopic portal placement sites above the lateral malleolus were 2.07 ± 0.39 cm at the Z1 portal, 2.15 ± 0.38 cm at Z1.5, and 2.28 ± 0.33 cm at Z2. The variability in the anatomy of the SN warrants the use of USG to locate it accurately, thus preventing iatrogenic injury when portals are placed for arthroscopy, improving proper administration of anesthesia, and helping to localize the nerve for graft harvesting. Clin. Anat. 31:450-455, 2018. © 2017 Wiley Periodicals, Inc.

Is there a relationship between functional at foot and prevalence of non-insertional achilles tendinopathy in joggers? - a pilot study.

INTRODUCTION: Non-insertional Achilles tendinopathy is one of the most common overuse injuries experienced by joggers. The pes planus evaluation is often based only on the visual method without a dynamic test. Functionally inefficiency of longitudinal or transverse arch of the foot may be a significant risk factor affecting the lower limb biomechanics and causing of pain in the Achilles tendon area. Assumptions and purpose of the study: This is study was undertaken to determine and investigate the relationship between the functionally inefficient longitudinal and transverse arch of the foot and the prevalence of non-insertional Achilles tendinopathy. MATERIALS AND METHODS: The study group consisted of 11 regular joggers at different levels, who were diagnosed with non-insertional Achilles tendinopathy. The clinical evaluation involved pedobarographic analysis using the Footscan pressure plate. Information on loads applied to metatarsal area, the basis of the second and third metatarsal bones were subjected to statistical analysis. RESULTS: All subjects who were diagnosed with overuse injuries in the Achilles tendon area showed a functionally inefficient transverse arch of the foot. Despite their pain, the individuals subjected to the study did not cease completely their physical activity. CONCLUSIONS: Collapse of the natural arch of the foot can lead to biomechanical disorder in the lower limb joints. This is one of the risk factors for the occurrence of changes due to overuse injuries within the Achilles tendon.

Residua of thymus in the mediastinum - clinical aspects - cadaveric study.

The main goal of this study was to investigate possible residua of thymic tissue in 100 adult cadavers with no thoracic pathology known before, by dissection of standard locations of thymic tissue in perithyroid, periaortic, peritracheal and retrotracheal spaces, as well as areas located next to the course of phrenic, vagus and left recurrent laryngeal nerves. Thus obtained tissue samples were studied by two pathologists independently. The remnants of the thymic tissue were found in 61 out of 100 specimens studied. It means that residua of ectopic thymic tissue is common, which may have a huge impact on the results of treatment of many diseases i.e. myasthenia gravis in course of thymoma.

Vascular density of inferior tibiofibular joint - cadaveric experimental study.

The study was carried out on 50 human lower legs obtained during autopsies (KBET: 122.6120.315.2016). The anatomy of the joint was studied using classical anatomical description methods. Based also on literature we have reviewed the current knowledge on the inferior tibiofibular joint blood supply considering the important clinically aspect - vascular density. Authors of this paper postulate relatively low vascular density of the region described and potential worse condition for healing in case of injury or after surgical procedures performed. We also postulate that ligament screws should be positioned with special respect to time limit which enables proper healing of the syndesmosis.

Assessment of the impact of individual therapy on upper limb function in patients diagnosed with painful shoulder syndrome.

INTRODUCTION: Functional disorders of the shoulder girdle affect 1/3 of the population. The diagnosis of "painful shoulder" or shoulder impingement syndrome is vague and imprecise. It can relay to so tissue pathology as well as to limitation of mobility of the joint. In this case an appropriate diagnosis, followed by a quick and effective treatment, is crucial. A physiotherapy assessment, performed during an individual therapy session sets out a way forward for targeted rehabilitation. Objectives and purpose of the article: The aim of this publication is to assess the impact of individual therapy on the function of the shoulder girdle in patients subject to health resort treatment. METHODS AND MATERIALS: The study included 30 patients diagnosed with shoulder joint conditions before and a er individual therapy with a physical therapist. The clinical study involved basic measurements of the range of mobility and standardized functional tests. The patients were surveyed to evaluate changes in the performance of daily activities before and a er the therapy. Pain assessment was conducted using the Visual Analogue Scale (VAS). The results were subjected to statistical analysis. RESULTS: The use of individual health resort treatment therapy significantly improved individual functional capacity of the patients. Self-evaluation of the patients on the performance of daily activities has shown improvement of the quality of those activities. According to VAS scale, a difference between the level of perceived pain before (mean = 6.2) and a er physical therapy treatment (mean = 3.7) as well as an improvement of the range of mobility have been observed. CONCLUSIONS: The results of the study confirmed that the treatment has significantly reduced the pain. Individual work with a physical therapist, focused on the improvement of the range of mobility of the shoulder girdle and functional tasks, clearly reduces limitations of daily activities of the patients and can improve the quality of their life.

Risk of iatrogenic injury to the infrapatellar branch of the saphenous nerve during hamstring tendon harvesting: A meta-analysis.

INTRODUCTION: Our goal was to conduct a comprehensive analysis of studies reporting data on the rate of injury to the infrapatellar branch of the saphenous nerve following hamstring tendon graft harvesting with respect to the type of incision over the pes anserinus. METHODS: A broad search through all major electronic databases was conducted to identify articles eligible for inclusion. All available data were extracted and pooled into the analysis. RESULTS: Eleven studies (n = 1,050 patients) were included in the meta-analysis. The study revealed that a vertical incision during hamstring tendon harvesting over the pes anserinus was associated with the highest rate of injury with a pooled rate of 51.4% (95% confidence interval [CI], 34.6-67.2%). This was followed by oblique and horizontal incisions with pooled rates of 26.0% (95% CI,1.3-61.3%) and 22.4% (95% CI, 5.4-45.5%), respectively. CONCLUSIONS: We highly recommend the use of the shortest possible oblique incision during hamstring tendon harvesting over the pes anserinus. Muscle Nerve 56: 930-937, 2017.

Anatomical variability and histological structure of the ulnar nerve in the Guyon's canal.

OBJECTIVES: The goal of our study was to analyze the prevalence of variations, branching patterns, and histology of the ulnar nerve (UN) in Guyon's canal to address its importance in hand surgery, particularly decompression of the UN. METHODS: Fifty fresh cadavers were dissected bilaterally, and the nerve in the area of Guyon's canal was visualized. Samples for histology were also taken and prepared. The collected data were then analyzed. RESULTS: Morphometric measurements of the hands and histological studies were not found to have significant differences when compared by left or right side or by sex. Three major branching patterns were found, with division into deep and superficial UN being the most common (85%). Additional findings included a majority (70%) presenting with a cutaneous branch within the canal and/or with an anastomosis of its distant branches with those of the median nerve (57%). CONCLUSION: The UN is most commonly found to divide into a superficial and deep ulnar branch within Guyon's canal. However, additional branches and anastomoses are common and should be taken into careful consideration when approached during surgery in the area, particularly during decompression procedures of Guyon's canal.

The Vascular Microarchitecture of the Human Fetal Pancreas: A Corrosion Casting and Scanning Electron Microscopy Study.

OBJECTIVES: Detailed knowledge on the development of the pancreas is required to understand the variability in its blood supply. The aim of our study was to use the corrosion casting method combined with scanning electron microscopy to study the organization of the pancreatic microcirculation in human fetuses. METHODS: The study was conducted on 28 human fetuses aged 18 to 25 gestational weeks. The fetal vasculature was appropriately prepared and then perfused with a low-viscosity Mercox CL-2R resin. The prepared vascular casts of the surface of the fetal pancreas were then examined in scanning electron microscopy and digitally analyzed. RESULTS: The lobular structure of the pancreas has a strong impact on the organization of the microvasculature. The lobular networks were supplied by the interlobular arteries and drained by the interlobular veins. The vascular system of fetal human pancreas has many portal connections, including islet-lobule and islet-duct portal circulations, which likely play a key role in the coordination of both endocrine and exocrine pancreatic functions. CONCLUSIONS: The organization of the microvascular network of the human pancreas in fetuses aged 18 to 25 gestational weeks is very similar to that of an adult but with more prominent features suggesting active processes of angiogenesis and vascular remodeling.

The Variable Emergence of the Infrapatellar Branch of the Saphenous Nerve.

The infrapatellar branch of the saphenous nerve (IPBSN) is a cutaneous nerve of the lower limb, which arises distal to the adductor canal. High variability in the emergence, course, branching, termination, and morphometrics of the IPBSN poses an increased risk of injury to the nerve during surgical interventions on the anteromedial aspect of the knee. The aim of this study was to describe the anatomical characteristics of the IPBSN. This study utilized cadaveric (n = 100) and ultrasonography (n = 30) assessments, and meta-analysis. In the cadaveric study, the presence of IPBSN and its emergence mode in relation to the sartorius muscle (SaM) was determined (type A-anterior; type B-posterior; type C-penetrating the SaM). Ultrasonography examinations were conducted on healthy volunteers to determine the presence and mode of the emergence of the nerve. Finally, from electronic databases searching, all studies reporting the IPBSN emergence data were pooled into a meta-analysis. The mean distance between the medial border of the patellar ligament (MBPL) and the IPBSN at the level of the patellar apex (PA) was also analyzed in the cadaveric, ultrasonography, and meta-analysis portions of the study. Six studies (n = 336 limbs), including the present cadaveric study, were pooled into the meta-analysis of emergence. The most prevalent IPBSN emergence mode was type C (42.9%) followed by type B (41.9%) and type A (15.4%). In the ultrasonography assessment, type A was found to be the most common (82.8%). The mean distance between the MBPL and the IPBSN at the level of the PA was 4.89 ± 0.22 cm, and 5.57 ± 0.91 cm, for the cadaveric and meta-analysis studies combined, and the ultrasonography assessment, respectively. This multimodality study shows that the most common type of IPBSN emergence is type C. The horizontal distance between the MBPL and the IPBSN at the level of the PA is usually between 4.5 and 5.6 cm. Understanding the anatomy of IPBSN emergence is crucial for orthopedic surgeons to minimize the risks of iatrogenic nerve injury during surgical procedures in the region.