Venous supply of horseshoe kidneys and normal kidneys: an angio-multislice computed tomography-based study.

BACKGROUND: Horseshoe kidney (HSK) is a common developmental anomaly which can be associated with many atypical anatomical variants of blood supply. The aim of this study was to identify the anatomical variants of renal veins supplying HSK, with particular emphasis on their relationship with the arterial system. MATERIALS AND METHODS: The analysis included 94 patients with HSK and 248 persons with normal kidneys (NK). Based on computed tomography-angiography, the number of renal arteries and veins was determined, along with the levels the arteries branched off the aorta and the veins communicated to their parental vessels. RESULTS: Four hundred and twenty-three renal arteries (4.5 per person) and 364 renal veins (3.78 per persons) were found in HSK group (p = 0.004), as compared with 598 arteries (2.41 per person) and 567 veins (2.29 per person) in the NK group (p = 0.025). Mean number of renal veins in women with HSK was higher than in men (4.11 vs. 3.72 per patient, p = 0.03). In the HSK group, the number of renal arteries correlated significantly with the number of renal veins only among men (ks = 0.35, p = 0.009). In patients with NK, significant correlations between the number of renal arteries and renal veins were found both in the whole group and among men and women. CONCLUSIONS: Horseshoe kidneys are drained by a higher number of renal veins than NK, especially in women; this also refers to accessory renal veins. The number of renal veins for HSK is less dependent on the number of corresponding arteries than these for NK.

The morphological variability of fibularis tertius origin in human foetuses.

BACKGROUND: The purpose of this study was to characterize the morphology of the fibularis tertius (FT) in human fetuses, and to provide a classification based on its modes of origin in human fetuses. METHODS: The material comprised 100extremities from 50 spontaneously aborted human fetuses (19 male, 31 female, 100 lowerlimbs in total), aged 18-38 weeks of gestation. These were dissected and the presence or absence of the FT muscle as well as the type of its proximal attachment were determined, and the FT was measured morphometrically. RESULTS: The FT was present in 50% of fetuses. Four types of FT muscle origin were identified. The most common was Type 2, characterized by an origin on the middle third of the fibula and the intermuscular septum. Three other types were observed: Type 1 with an origin located on proximal third of the fibula and to the intermuscular septum, Type 3 characterized by an absent muscle belly, and an independent tendon originating from the that of the extensor digitorum longus, and Type 4 with an origin located on the distal third of the fibula and the intermuscular septum. CONCLUSIONS: The fibularis tertius demonstrates high morphological variability, with the most common origin located on third of the fibula and to the intermuscular septum.

Anatomical variations of the superficial ulnar artery: case series observed on historical specimens prepared by Ludwik Karol Teichmann.

BACKGROUND: This report presents a series of cases representing variant origin and course of the ulnar artery, namely the superficial ulnar artery (SUA), observed during the review of collection of historical specimens prepared in the 19th century by the prominent Polish anatomist Ludwik Karol Teichmann and his collaborators, exhibited in the Anatomy Museum of Jagiellonian University Medical College. RESULTS: Three distinct variants of the SUA were found on anatomical specimens of the upper limb with arteries injected by using Teichmann's method. In case no. 1, the SUA originated from the brachial artery slightly above the interepicondylar line of the humerus. This aberrant vessel gave off the common interosseous artery in the upper half of the cubital fossa and then ran superficially to the bicipital aponeurosis and over the muscles arising from the medial epicondyle of the humerus. The cases no. 2 and 3 involved two similar variants of the superficial artery in which the common interosseous artery arose from the radial artery. In the unique case no. 4, the SUA arose from the radial artery. CONCLUSIONS: The SUA shows diverse anatomy regarding its topography and blood supply territory. Orthopaedic, hand, and plastic surgeons should be aware of anatomic variations of the SUA both in planning and in conducting surgeries of the upper limb.

Morphometric profile in foetuses and evolution of Achilles tendon.

BACKGROUND: The Achilles tendon (AT) develops from the merge of the tendinous part of the gastrocnemius (GM) and soleus (SM) muscles. The AT is the structural base for the biomechanical work of the ankle joint. Understanding morphometry of the AT is crucial due to the tendon vulnerability to rupture and damage which requires further surgical repair and management. Despite its clinical significance, data concerning measurements of the AT in human foetuses are scare. The aim of our study was to assess the AT, GM and SM morphometry in human foetuses. MATERIALS AND METHODS: Thirty-seven spontaneously-aborted human foetuses (17 male, 20 female) aged 18-38 weeks of gestation were examined. The morphometry of the GM, SM and AT were evaluated. RESULTS: No significant correlation between sex or side and size of the AT in human foetuses was observed. The only significant correlation was between sex and the length of the tendon of the SM; in 3rd trimester it was longer in male than in female. In 2nd trimester the SM muscle to tendon ratio was higher in female than in male. CONCLUSIONS: There was no significant correlation between sex or side and size of the AT in human foetuses, probably due to scant muscle load during prenatal period.

Morphological variability of the fibularis tertius tendon in human foetuses.

BACKGROUND: In adults, the fibularis tertius (FT) demonstrates great morphological variation. The present study classifies the types of FT insertion in human foetuses and compares their prevalence to the prevailing classification among adults. MATERIALS AND METHODS: Fifty spontaneously-aborted human foetuses (19 male, 31 female, 100 upper limbs in total) aged 18-38 weeks of gestation at death were examined. The foetuses were obtained from spontaneous abortion after parental consent. The study was performed in accordance with the legal procedures in force in Poland and with the Body Donation Programme for both adults and foetuses. RESULTS: The most common type of FT found was type VI (32%), characterised by a bifurcated distal attachment: a main tendon inserting onto the base of the fourth metatarsal bone, and accessory bands inserting onto the fourth interosseous space. Five other types were observed: type IV (20%), with a single tendon inserting distally to the fascia covering the fourth interosseous space; type I (18%), with a single tendon inserting distally onto the shaft of the fifth metatarsal bone; type V (14%), with a bifurcated arrangement comprising a main tendon characterised by a very wide insertion onto the base of the fifth metatarsal bone and an accessory band inserting onto the base of the fourth metatarsal bone; and type III (12%) with a single tendon inserting distally onto the shaft of the fourth metatarsal bone and fascia covering the fourth interosseous space. Finally, type II (4%) was characterised by a single tendon inserting onto the base of the fifth metatarsal bone via a very wide distal insertion. CONCLUSIONS: The FT demonstrates high morphological variability, with the most common configuration found in adults - a single insertion onto metatarsal 5 - being actually uncommonly found in foetuses.

Anatomical variation of co-existing bilaminar tensor of the vastus intermedius muscle and new type of sixth head of the quadriceps femoris.

BACKGROUND: We present a case report of quadriceps femoris (QF) with co-existing bilaminar tensor of the vastus intermedius (TVI) muscle and new type of sixth head. MATERIALS AND METHODS: Cadaveric dissection of left thigh of a 72-year-old man was performed for research and teaching purposes at the Department of Anatomical Dissection and Donation, Medical University of Lodz. The left lower limb was dissected using standard techniques according to a strictly specified protocol. Each head of the muscle was photographed and subjected to further measurement. RESULTS: During dissection, an unusual type of TVI muscle was observed. It consisted of two surfaces, superficial and deep. In addition, sixth head of QF muscle grew out from the vastus medialis muscle. CONCLUSIONS: The knowledge of the existence and possible variations of additional heads of QF muscle is necessary during diagnostic process of muscle strains. Moreover, according to course of tendons that heads may take part in patella stabilisation.

"Popliteofascial muscle" or rare variant of the tensor fasciae suralis?

Anatomical variations are routinely encountered during dissections of muscles and in clinical practice, so anatomists and clinicians need to be aware of them. One such muscle is the tensor fascia suralis, a very rare muscle located in the popliteal fossa. It can originate from any of the hamstring muscles and it inserts into the fascia of the leg. This report presents a case of a variant muscle located very deep to the biceps femoris; it originated from the posterior surface of the femur and inserted into the fascia of the leg. It is unclear whether this is a rare variant of the tensor fascia suralis or a completely new muscle.

The fifth head of quadriceps femoris: for sure?

PURPOSE: The quadriceps femoris has been described as a muscle composed by four heads: rectus femoris, vastus lateralis, vastus medialis and vastus intermedius. Each head fuse with the other ones making up the quadriceps tendon, which inserts into the patella. Nevertheless, there has been described a fifth component of the quadriceps muscle in recent anatomical publications. Understanding this fifth head may be important for orthopedics and radiologist. METHODS: Cadaveric dissection of left thigh of a female 83 years old was performed to demonstrate a fifth head of the quadriceps femoris muscle. RESULTS: In this study, a fifth head of the quadriceps femoris muscle was found in the left thigh of a female cadaver 83 years old. This fifth head was made up by four independent muscular fascicles attaching in a common flat tendon that joins distally with the lateral border of the quadriceps tendon. The fifth head found was supplied by branches of the ascending branch of the lateral femoral circumflex artery and by branches of the deep lateral division of the femoral nerve. CONCLUSIONS: The incidence of this fifth belly in cadaveric studies has been reported as a range from 29 to 100%. However, no published articles refer an anatomical finding such as this multi-bellied fifth head. The knowledge of the existence and location of the fifth belly is necessary to make accurate diagnosis of QF muscle strains. Its anatomical course may be involved in patellar tracking.

The position of a duodenal diverticulum in the area of the major duodenal papilla and its potential clinical implications.

BACKGROUND: Although duodenal diverticula are associated with less frequent pathology than the colonic diverticula in the large intestine, their periampullary position may have significant clinical implications. The aim of the study was to identify any possible correlation between the type of localisation of the major duodenal papilla, duodenal diverticula, and some particular clinical issues. MATERIALS AND METHODS: In total, 628 patients (408 females and 220 males; aged 21-91 years), who underwent endoscopic retrograde cholangiopancreatography were included in this study. The patients were divided into two groups: a study group comprising 66 (10.5%) patients with periampullary position of diverticula (group A), and a control group comprising 562 (89.5%) patients without diverticula (group B). RESULTS: A duodenal diverticulum was diagnosed in the periampullary position in 66/628 (10.5%) patients: 41 women (aged 52-91 years) and 25 men (aged 54-83 years). CONCLUSIONS: Three types of localisation were observed for the major duodenal papilla with regard to the diverticula, with the most common type being next to each other (type III). In patients with diverticula, similar frequencies of gallstone occurrence are observed in men and women. Patients with papilla in the diverticulum who underwent cholecystectomy are more prone to develop lithiasis.

Types of inferior mesenteric artery: a proposal for a new classification.

BACKGROUND: The inferior mesenteric artery (IMA) is the third main branch of the abdominal aorta and arises at the level of L3, supplying the large intestine from the distal transverse colon to the upper part of the anal canal. The aim of this study was to characterise the course and morphology of the terminal branches of the IMA, and also creating a new IMA classification, which seems to be necessary for clinicians performing surgery in this area. MATERIALS AND METHODS: The anatomical variations in the branching patterns of the IMA were examined in 40 cadavers fixed in a 10% formalin solution. Morphometric measurements were then obtained twice by two researchers. RESULTS: Due to the proposed classification system, type I characterised by a common trunk preceding bifurcation into sigmoidal branches and the superior rectal artery after giving left colic artery (LCA) occurred in 57.5% of cases, type II, trifurcation type, in 25%, type III with the superior rectal arteries originating firstly from the IMA in 5%, type IV with the ascending lumbar artery in 10% of cases and type V, a novelty, in 2.5%. The origin of IMA was observed at the level of L2/L3 in 22.5% of cases, at L3 in 25% of cases, at L3/L4 in 15% of cases, at L4 in 35% of cases and at the level of L5 in 2.5% of cases. More than one third (38.1%) of total cases with additional arteries and rapidly bifurcating branches occurred in types III, IV, and V. In women, only the IMA and LCA were significantly narrower than in men. Only the diameter of the IMA correlated with the diameter of the superior rectal artery. CONCLUSIONS: The IMA is characterised by high morphological variability. The introduction of a new, structured, anatomical classification seems necessary for all clinicians.

Anatomical study on branching pattern and variations of orbital segment of the oculomotor nerve.

BACKGROUND: This study aims to revisit the anatomy of orbital segment of the third cranial nerve (CN III). The study also involved morphometric measurements of CN III muscular branches. Detailed description of observed anatomical variations and their incidence was also included. The study supplements earlier findings with detailed observations of the neuromuscular relations. MATERIALS AND METHODS: The study was conducted on 52 orbits taken from 26 cadaveric heads (10 males and 16 females; Central European population). RESULTS: Anatomical variations of the orbital segment of the CN III observed on the examined material involved both the superior and inferior branch of this nerve. The muscular branch innervating the levator palpebrae superioris muscle occasionally pierces the superior rectus muscle. The nerve to the inferior oblique muscle may pierce and innervate the inferior rectus muscle. In rare instances, duplication of the parasympathetic root of the ciliary ganglion may also occur. Among the muscular branches, the smallest diameter reached the branch to the levator palpebrae superioris muscle. Among the three muscular branches derived from the inferior branch of the CN III, the nerve to the inferior oblique was the longest one. Its length varied from 28.9 mm to 37.4 mm. The shortest was the muscular branch to the inferior rectus muscle. Its length varied from 0 mm (when muscular sub-branches arose directly from the nerve to the inferior oblique muscle) to 7.58 mm. CONCLUSIONS: This study presented the characteristic of orbital segment of the CN III, including anatomical variations and morphometric measurements relevant to intraorbital procedures.

A bifurcated plantaris muscle: another confirmation of its high morphological variability? Another type of plantaris muscle.

The plantaris muscle usually begins with a short, narrow belly in the popliteal fossa at the lateral supracondylar line of the femur and the knee joint capsule. Then it forms a long and slender tendon and usually inserts into the calcaneal tuberosity on the medial side of Achilles tendon. Nevertheless, many anatomical variations of distal attachment have been described. Cases of atypical proximal origin are reported less frequently. In this paper, we have presented a case of a two headed plantaris muscle. First head attached to the condyle of the femoral bone, medially and inferiorly to the lateral head of the gastrocnemius muscle. The second one originated from the popliteal surface of the femur, just above the intercondylar fossa. According to present literature, no such case with atypical proximal origin was presented. Such information has potentially clinical significance during the surgical procedures performed in the area of the popliteal fossa.

Potential compression of the musculocutaneous, median and ulnar nerves by a very rare variant of the coracobrachialis longus muscle.

The coracobrachialis longus muscle (CBL) is an extremely rare variant of the coracobrachialis muscle (CRM). The CBL originates from the apex of the coracoid process together with the short head of the biceps brachii and inserts on the olecranon of the ulna. The CBL consists of three parts: a superior part (classical CRM - length 137.88 mm), a middle fibrous layer (23.41 mm), and an inferior part (185.37 mm). A rare relationship between the CBL and median, musculocutaneous and ulnar nerves was observed with potential compression at these three parts. In addition, this case report describes a connection between CBL and the medial head of the triceps brachii, as well as a third head of the biceps brachii, which originate from the fibrous layer. This case report highlights the relationships between the CBL and the median, ulnar and musculocutaneous nerves.

Is the plantaris muscle the most undefined human skeletal muscle?

The plantaris muscle is located in the posterior aspect of the superficial compartment of the lower leg, running from the lateral condyle of the femur to the calcaneal tuberosity. Classically, it is characterized by a small and fusiform muscle belly, which then changes into a long slender tendon. From the evolutionary point of view, the muscle is considered vestigial. However, it has recently been suspected of being a highly specialized sensory muscle because of its high density of muscle spindles. It has a noticeable tendency to vary in respect of both origin and insertion. Researchers have published many reports on the potential clinical significance of the muscle belly and tendon, including mid-portion Achilles tendinopathy, 'tennis leg syndrome', and popliteal artery entrapment syndrome. The right knee joint area was subjected to classical anatomical dissection, during which an atypical plantaris muscle was found and examined in detail. Accurate morphometric measurements were made. The muscle belly was assessed as bifurcated. Morphologically, superior and inferior parts were presented. There was a tendinous connection (named band A) with the iliotibial tract and an additional insertion (named band B) to the semimembranosus tendon. Both bands A and B presented very broad fan-shaped attachments. The human plantaris muscle is of considerable interest and has frequent morphological variations in its proximal part. Its specific characteristics can cause clinical problems and lead to confusion in diagnosis. More studies are needed to define its actual features and functions.

Types of inferior phrenic arteries: a new point of view based on a cadaveric study.

BACKGROUND: The diaphragm is supplied by the superior and inferior phrenic arteries. This present study focusses on the latter. The inferior phrenic arteries (IPA) usually originate from the abdominal aorta. The two arteries have different origins, and knowledge of these is important when performing related surgical interventions and interventional radiological procedures. The aim of this study was to identify variations in the origin of the IPA and conduct relevant morphometric analyses. MATERIALS AND METHODS: The anatomical variations in the origins of the left inferior phrenic artery (LIPA) and the right inferior phrenic artery (RIPA) were examined in 48 cadavers fixed in 10% formalin solution. A dissection of the abdominal region of the cadavers was performed according to a pre-established protocol using traditional techniques. Morphometric measurements were then taken twice by two of the researchers. RESULTS: In the cadavers, six types of origin were observed. In type 1, the most common type, the RIPA and LIPA originate from the abdominal aorta (AA) (14 = 29.12%). In type 2, the RIPA and the LIPA originate from the coeliac trunk (CT) (12 = 24.96%). In type 3, the RIPA and the LIPA originate from the left gastric artery, with no CT observed (3 = 6.24%). Type 4 has two subtypes: 4A, in which the LIPA originates from the AA and the RIPA originates from the CT (9 = 18.72%) and 4B, in which the RIPA originates from the AA and the LIPA originates from the CT (6 = 12.48%). In type 5, the LIPA originates from the AA and the RIPA originates from the AA (1 = 2.08%). Type 6 is characterised by the RIPA and LIPA forming a common trunk originating from the CT (3 = 6.24%). CONCLUSIONS: Our findings suggest the presence of six different types of LIPA and RIPA origin. The most common form is type 1, characterised by an IPA originating from the abdominal aorta, while the second most common is type 2, in which the IPA originates from the AA by a common trunk. The diversity of other types of origin is associated with the occurrence of coeliac trunk variation (type 3). No significant differences in RIPA diameter could be found, whereas LIPA diameter could vary significantly. No significant differences in RIPA and the LIPA diameter could be found according to sex.

Case report of a bifurcated fibular (lateral) collateral ligament: which band is the dominant one?

BACKGROUND: The fibular collateral ligament is a permanent and extracapsular ligament of the knee joint. It is located on the lateral aspect of the knee and extends from the lateral epicondyle of the femur to the lateral surface of the head of the fibula. As one of the main knee joint ligaments it is a stabilizer of the posterolateral corner of the knee and resists varus stress. The case report displays the bifurcated variant of the fibular collateral ligament. The aim of this study is to determine which of those bands should be considered dominant. MATERIALS AND METHODS: Classical anatomical dissection was performed on the left knee joint. The fibular collateral ligament was thoroughly cleansed around its origin, distal attachments, and course. Appropriate morphometric measurements were collected. RESULTS: A bifurcated variant of the fibular collateral ligament with inverted proportions of its two bands (main and accessory one) constitutes our findings. It originated on the lateral epicondyle of the femur. Then it divided into two bands (A1 and A2). Band A1 inserted to the head of the fibula. A bony attachment of band A2 was located on the lateral aspect of the lateral condyle of the tibia. CONCLUSIONS: Although the fibular collateral ligament is a permanent structure it presents morphological variations. It is important to constantly extend morphological knowledge for all scientists concerned in anatomy.

A three-headed plantaris muscle: evidence that the plantaris is not a vestigial muscle?

The plantaris is a small muscle that typically originates at the lateral supracondylar line of the femur and the knee joint capsule, from where it continues distally, forming a long and slender tendon. However, considerable controversy surrounds the status of this seemingly inconspicuous muscle: is it a residual muscle, or one that it is just developing? In addition, both the proximal and distal attachments are highly morphologically variable. These variations can lead to many diseases. Interestingly, the course of the PM tendon is also variable. The present case study presents a new description of a complex origin type and a rare course of the PM tendon. Understanding of the PM and its tendon has clear clinical value and is a significant indicator of the development of interest in this overlooked muscle.

Possible effect of morphological variations of plantaris muscle tendon on harvesting at reconstruction surgery-case report.

PURPOSE: Seemingly a well-known, weak, and vestigial plantaris muscle should not be a revelation. However, recent studies have shown that this structure is incredibly underestimated and perceived only as an infirm flexor of the talocrural joint, the knee joint or a great source of graft tissue. Usually, the origin of this inconspicuous muscle begins at the lateral supracondylar line of the femur and the knee joint capsule. It continues distally, forming a long and slender tendon. In most cases, it inserts onto the calcaneal tuberosity on the medial side of the Achilles tendon. However, many morphological variations have been discovered during anatomical dissections and surgical procedures. Nevertheless, according to the present literature, no other studies presented such a complex insertion variant, with indisputable clinical value and significant proof of development of this forgotten muscle. METHODS: The dissection of the right thigh, knee, crural and talocrural region was performed using standard techniques according to a strictly specified protocol. RESULTS: Four different insertion points were observed. The first band (A) inserted near to the tarsal canal flexor retinaculum. The second band (B) bifurcates into two branches-B1 and B2. B1 is located on the medial side and B2 is located on the lateral side of the calcaneal tuberosity. The third band (C) is inserted into the superior nonarticular calcaneal surface of the calcaneus anteriorly to the Achilles tendon. CONCLUSION: A differently shaped plantaris tendon could be considered a cause of harvesting procedure failure. In the light of new case reports perhaps what we are now witnessing is remodeling and transformation of the Plantaris muscle. If so, the awareness of the influence on the onset of Achilles midportion tendinopathy or a potential role in tibialis posterior conflict can be crucial for every clinician.

A highly complex variant of the plantaris tendon insertion and its potential clinical relevance.

The body is home to a number of unique and intriguing anatomical structures, plenty of which concern the muscles and their tendons. Of these, the plantaris muscle is reported to present a particularly high range of morphological variations. The muscle, passing distally throughout the length of the lower leg, consists of a small muscle belly and a long, thin tendon. It originates, traditionally, on the popliteal surface of the femur and the knee joint capsule, and then inserts to the calcaneal tuberosity. It has been suggested that mid-portion Achilles tendinopathy may be caused by certain plantaris tendon morphologies. This case report describes a new anomalous plantaris tendon insertion, closely related to the Achilles tendon. It comprise four distinct insertions and one direct merge with the calcaneal tendon. The current classification should be extended to accommodate such 'rare cases' to facilitate more successful Achilles tendinopathy treatment.

Intramuscular innervation of plantaris muscle evaluated using a modified Sihler's staining protocol - Proposal for a new classification.

PURPOSE: The plantaris muscle is a morphologically variable structure with regard to both its origin and insertion, and the course of the tendon. We here determined the pattern of branching and distribution of intramuscular nerves of the plantaris muscle to determine its usability for autologous transplantation. No information exists on the innervation of the plantaris muscle using Sihler's staining technique, and hence its intramuscular nerves. The main purpose of the work is to determine the pattern of branching and distribution of the intramuscular nerves of the plantaris muscle. Is the plantaris muscle a good transplant candidate? MATERIALS AND METHODS: Eighty lower limbs from cadavers (40 left, 40 right, 40 male, 40 female, age range 41-94 years) were fixed in 10% formalin solution and examined macroscopically as well as morphometrically with regard to the innervation pattern of the respective plantaris muscle. Afterwards Sihler's staining was used in all 80 plantaris muscles to identify the exact distribution of the muscular branch originating from the main nerve trunk in the muscle belly. RESULTS: Two patterns of branching and nerve distribution could be intensified in the plantaris muscle: Type I, with a single pattern entire up to the muscle and then divided into superior and inferior intramuscular branches.; type II with a double innervation pattern (superior and inferior). The superior and inferior pattern were not connected to each other. CONCLUSION: The plantaris muscle reveals variability with two different innervation patterns. Type II is ideally suited for autologous transplantation. New classifications of innervation are desirable for individual muscles rather than a generalized approach.