Fascial Structures Research Articles

The use of paratenon, polyethylene film, or silastic sheeting to prevent restricting adhesions to tendons in the hand

We treated 132 patients by insertion of paratenon, polyethylene, or Silastic between a digital tendon and a bone, ligament, or fixed fascial structure to prevent adhesions. From 1950 to 1974, autogenous paratenon was used in thirty patients; from 1956 to 1965, polyethylene film was used in sixty-three patients; and from 1965 to 1974, Silastic sheeting was used in thirty-nine patients. By comparing the preoperative and postoperative measurements of joint motion and the changes in the distance separating the pulp of a finger from the palm during flexion, these patients were calssified as improved, unchanged, or worse. In some areas the material used appeared to make little difference, but in other areas one or the other was superior. Silastic sheeting (non-reinforced) proved to be the best material for most conditions, but it should not be employed when the skin is of poor quality or beneath a pedicle flap, and it should not be used adjacent to a tendon graft in an area that has recovered from an infection. Under those circumstances, paratenon is the preferred material.

Epitheloid sarcoma. A sarcoma simulating a granuloma or a carcinoma.

This article reviews the pathologic features and the behavior of 62 cases of a peculiar form of sarcoma that has repeatedly been confused with a chronic inflammatory processa necrotizing granulomaand a squamous cell carcinoma. The tumor occurs chiefly in young adults (median age 23 years) and most commonly affects the soft tissues of the handthe forearmand the pretibial region. It tends to grow in a nodular or multinodular manner along fascial structures and tendonsoften with central necrosis of the tumor nodules and ulceration of the overlying skin. Most of the tumors grow slowlyand many of our cases had been present for months or years prior to surgery. Microscopicallythe tumor consists of irregular nodular masses of largedeeply acidophilic polygonal cells merging with spindle cellsfrequently associated with large amounts of hyalinized collagen. Follow-up information on 54 patients (87%) revealed slowrelentless clinical course with frequent recurrence (85%) and late metastasis (30%). Cure may be achieved by wide local excision at early stage of disease.

Musculature of the prostate gland.

SUMMARY The pattern of prostatic musculature may be outlined as follows: 1 The ureters enter the bladder, give rise to the trigonal musculature, and contribute elements to the bladder musculature. 2 The fibres of the trigonal muscle decussate in the midline and veer ventrally, giving rise to the internai sphincter and contributing fibres to the fibromuscular plate encircling the internai urethral orifice. 3 The internai sphincter surrounds the internai urethral orifice and decussates ventrally to the urethra, contributing elements to the urethra, external sphincter and prostatic parenchyma. 4 Henle's muscle arises from the puboprostatic muscle and in association with the external sphincter surrounds the urethra just distal to the prostate. It then passes ventrally and superiorly to insert into the glandular capsule of the prostate, the prostatic parenchyma and the tri go ne. 5 The ventral component of bladder musculature arises from the pubo-vesical ligament, the lateral true ligament of the bladder, and the fascial capsule of the prostate. The dorsal component arises from the glandular capsule of the prostate, the tendinous yoke under the uvula, and the prostatic parenchyma. 6 The longitudinal musculature of the urethra arises principally from the fibromuscular plate, but is also supplemented by elements from the glandular capsule, internai sphincter and prostatic parenchyma. 7 The double layered prostatic glandular capsule is contributed to by or gives rise to most of the muscular elements associated with the prostate gland, except the ventral longitudinal bladder musculature. 8 The external sphincter is formed by the distal prolongation of the anteriorly decussating fibres of the internai sphincter, and is separated from the deep perineal sphincter by the superior levator fascia. 9 The prostatic parenchymal musculature consists of ramifying septa extending between the middle third of the prostatic urethra and the prostatic glandular capsule. 10 Several prominent muscle groups envelop neuromuscular elements associated with the prostate gland and radiate into the adjacent supporting fascial structures.

A new technique for the repair of inguinal and incisional hernias.

The majority of hernias can be satisfactorily repaired by utilizing the tissues at hand. The use of a mesh prosthesis should be restricted to those few hernias in which tension or lack of good fascial structures prevents a secure primary repair. This group includes large direct inguinal hernias and incisional hernias in which the defect is too large to close primarily without undue tension. Most recurrent hernias, because of this factor of tension, are best repaired with a mesh prosthesis. The conventional method of using a mesh prosthesis has been to do a primary closure of the defect and then to suture the mesh over this repair as a reinforcement. In time the mesh becomes infiltrated with fibrous tissue which adds to the total strength of the repair. If, however, tissues are approximated under too much tension, separation will occur and recurrence will take place regardless of whether or not

BONE LENGTHENING

1. Two inches of lengthening may be gained in the femur, and three inches in the tibia and fibula, without complication. 2. More than this may be secured at the risk of temporary external popliteal paresis. 3. Lengthening of the tibia and fibula is more certain and more easy to control than lengthening of the femur. 4. Traction, and counter-traction through the bone, with complete lateral rigidity, are essential to success. 5. In applying this technique to the femur there is a danger of knee stiffness. The farther from the knee the skeletal traction pins are inserted, the less is the risk. The operation should therefore be planned as high as possible in the shaft of the femur. 6. The most delicate structure, and the one least tolerant of stretching, is the external popliteal nerve. 7. An oblique osteotomy, started by closely spaced drill-holes, is the best. 8. Certain vascular complications experienced by other surgeons are attributable to subperiosteal bone exposure, and to dividing the periosteum and fascial structures transversely.

LIGAMENT OF LOCKWOOD IN RELATION TO SURGERY OF THE INFERIOR OBLIQUE AND INFERIOR RECTUS MUSCLES

AN ANATOMIC study of the suspensory ligament of the eye, (ligament of Lockwood) based on a series of dissections, is presented. Certain phases of the anatomic structure of the ligament which seem to be of importance in the management of abnormalities of the inferior oblique and inferior rectus muscles are presented. The suspensory ligament, as described by Lockwood, consists of a blending of the sheaths of the inferior oblique and inferior rectus muscles to form a special thickening of the fascial structure. The lateral expansion of this sheath extends upward laterally and medially to join the sheaths of the lateral and medial rectus muscles, thereby gaining indirect attachment to the orbital margin. There is thus formed a continuous band about 0.1 inch (0.25 mm.) thick beneath the globe, which supports it like a hammock. Generally speaking, the ligament is thought of as a ``suspensory hammock" which functions as a support

THE AETIOLOGY, DIAGNOSIS, AND TREATMENT OF PROLAPSED INTERVERTEBRAL DISK, WITH A REVIEW OF 300 CASES OF SCIATICA

An account is given of the symptoms, physical signs, and treatment of a number of patients suffering from sciatic pain. Trauma plays an important part in the production of an intervertebral disk prolapse, but has little relevance to the myofascial type of sciatica. The symptoms of intervertebral disk prolapse may be divided into two stages; the stage in which pain is confined to the back, and the stage in which pain is also present in the leg. Remissions are characteristic and are largely independent of treatment. The symptoms of myofascial sciatica are less constant, but the diagnosis from pain due to a disk protrusion may be impossible in the early stages of the latter condition. The characteristic physical signs of intervertebral disk protrusion are described. They fall into two groups, the mechanical and the neurological. The former are mainly due to changes in ligamentous and fascial structures in the lumbar spine, the latter are due to pressure upon the nerve root by the disk protrusion itself. Surgical treatment of prolapsed disk is by no means certain to result in cure, certainly not immediate cure, and in some cases it is doubtful whether the slow improvement which results is directly attributable to surgery. From these results it would also seem justifiable to assume that removal of the protrusion itself will only relieve the symptoms of root compression, the relief of myofascial symptoms depending upon the removal of other affected structures in the course of the operation and perhaps upon the process of repair stimulated by the trauma incidental to the operation. It is the writer's opinion that surgery should be reserved for those patients in whom prolonged rest has failed to give relief or for those in whom economic reasons render the prospect of a rather more speedy return to work desirable. Further, it is considered that a history of pain in the back and thigh without evidence of root compression does not alone constitute sufficient grounds for the performance of laminectomy; although a disk protrusion may be found in such cases, there is insufficient evidence to show that it is the primary cause of symptoms. A comparison of the results of conservative and operative treatment of intervertebral disk prolapse leads to the suggestion that caution should be exercised in recommending the latter course. In addition there is reason to believe that sciatica, with the exception of the symptomatic variety, is a self-limiting disease, and that operation is practically speaking only a short cut in an otherwise tediously protracted disease. The surgeons concerned in the operative treatment of these cases were: Mr. B. H. Burns, Mr. R. H. Young, Mr. Harvey Jackson, Mr. E. B. C. Hughes, Mr. H. L. C. Wood, aud Mr. R. H. Boggon, to all of whom the writer expresses thanks for permission to utilize their case notes and record their operative findings.

DUPUYTREN'S CONTRACTURE

The material of the present study has been evaluated under three headings: (1) the gross anatomy of the human palmar fascia as revealed in a study of 60 hands presenting no gross abnormality of this structure; (2) the microscopic anatomy of the palmar fascia in 27 grossly normal hands, and (3) the histology of the tissue removed in 35 cases of Dupuytren's contracture. GROSS ANATOMY OF THE NORMAL HUMAN PALMAR FASCIA—ITS RELATION TO THE DEVELOPMENT AND THE SURGICAL CORRECTION OF THE DEFORMITY IN DUPUYTREN'S CONTRACTURE The material consisted of 60 hands from 30 cadavers of men between 22 and 85 years of age. It was felt that the anatomic descriptions should include not only the superficial palmar layer and its attachments but also the deep interosseous fascia and the interfascial septums. All of these structures bear an intimate relation, proximally, to the fascial structures of the volar surface of the

THE INTRA-ABDOMINAL METHOD OF REMOVING INGUINAL AND FEMORAL HERNIA

Whatever else may be necessary as a part of the operative procedure for the cure of hernia, complete removal of the sac followed by high ligation or suture of the peritoneum is essential. All surgeons recognize this as the most important part of the procedure and many believe that in small-sized indirect hernias in children and young persons success is apt to follow regardless of the method employed for closing the canal. For hernias of large size, for direct hernia with imperfect development or absence of the conjoined tendon and for postoperative rupture, it is necessary to suture together certain fascial structures, such as the conjoined tendon and the shelf of Poupart's ligament. In many cases the use of fascial strips as recommended by Gallie is extremely important. The numerous modifications of the original operations of Bassini and of Halsted have been directed largely, if not solely, to methods of

Observations and conclusions on plastic operations in gynecology

I T IS my purpose to present in the paper which follows some of ml observations and my practice in the performance of vaginal plastic operations in the clinic of the Woman’s Hospital where I have been associated for the past eight years. The experiences encountered during this period have been most interestin, 0~ and instructive, and I wish at the outset to acknowledge my genuine gratitude to t.he chief surgeon and to other senior members of the staff for the opportunity to study and compare their several excellent methods of work. A thorough knowledge of the anatomy of the pelvic organs and particularly of their surrounding fascial structures is admittedly a prerequisite to the intelligent handlin g of all conditions where plastic repair is indicated. At the same time it cannot be denied that there has been an extraordinary amount of detailed and often confusing description of the musculofascial planes in this region. The result is that the beginner, and even the man of practical experience, is often despairingly confused when he undertakes their study. Among the most lucid descriptions of these structures to be found in English may be mentioned the papers of Frank, Ward, Bissell and Goff and Farrar’s chapter in the recent Kelly’s G$jnecoZogy. All of these quote freely from the European observers, Martin, Tandler, Halban and others, and offer admirable illustrations. A perusal of these papers brings out the following facts which may be regarded as salient, and quite indispensable to the discerning surgeon. The two distinct systems concerned in the support of the female generative organs, as well as of the urinary bladder and the rectum, are t,he lower or supporting apparatus and the upper or holding apparatus. The first of these two groups consists of the levator ani and coccygeus muscles with t.heir fascial investments a,nd the triangular ligament in which is ensheathed the deep transversus perinei. This supporting apparatus, called sometimes the pelvic diaphragm, has been aptly likened by Frank to the shock absorbers in a mechanical device and, in my opinion, plays an important coordinating, but none the less minor, part in the prevention of prolapse of the uterus and vaginal walls. The major factors operatmg to control normal relations are the numerous musculofascial planes radiating in all directions from the upper part of the cervix, and it is to these structures that the term “holding apparatus” has been applied. This division Frank has again