Intermuscular Septum Research Articles

Foot compartments. How many and it’s clinical relevance

IntroductionSeveral authors have assessed the foot with diverse methods, with discrepancies towards the number of compartments. Treatment for foot compartment syndrome is not standardized, but primarily consists of liberating pressure from these, to avoid ischemia, nerve damage, and malformation. Our objective is to synthesize the existing evidence regarding the compartmental anatomy of the footMaterials and methodsA systematic review of all publications evaluating normal foot compartment anatomy was performed using the MEDLINE, Scopus, Web of Science, and EMBASE databases. Data were recorded and analyzed by the reviewers.ResultsAfter filtering results, 10 studies were included in the final analysis. All were performed in cadavers except one. The primary difference was the region studied, half focusing on the plantar region, and the other half evaluating the whole foot. There seems to be an agreement regarding the number of compartments in the plantar region (three major compartments divided by the medial and lateral intermuscular septum), nevertheless, disagreements across authors tend to arise when describing its dorsal section. Only two studies were ranked with an overall low risk of bias using the AQUA checklist. These two agreed on 9 total compartments, however, one included the skin as a 10th compartment, although by definition (space occupied by tissue and bound by fascia or bone) it is not a compartment.ConclusionDiscrepancies in the number of compartments exist between authors. This review provides the best available evidence with an anatomical analysis of data and concludes 9 compartments of the foot. This anatomical description should be taken into account and referenced in clinical reports of foot compartment syndrome treatment to determine the best treatment in a future meta‐analysis based on the same classification.

THE CONSTRAINING EFFECT OF THE LATERAL FEMORAL INTERMUSCULAR SEPTUM ON PASSIVE HIP ADDUCTION IN UN-EMBALMED CADAVERS

Due to the lack of verifiable iliotibial band elongation in response to stretching, the anatomical, biomechanical, and physiological responses to treatment of iliotibial band syndrome remain unclear. The lateral intermuscular septum, consisting of multiple myofibroblasts, firmly anchors the iliotibial band to the femur. The purpose of this in-situ study was to examine the constraining effect of the lateral intermuscular septum on available passive hip adduction range of motion in un-embalmed cadavers. It was hypothesized that an iliotibial band-septum-complex release would significantly increase passive hip adduction. Within-specimen repeated measures in-situ design. Anatomy laboratory. Metal markers were inserted into selected anatomical landmarks in eleven (11) un-embalmed human cadavers. With the specimen supine, the test-side lower limb was passively adducted until maximum passive hip adduction was reached. This movement was repeated three times each within two conditions: (1) band-septum-complex intact and (2) band-septum-complex dissected. Digital video of marker displacement was captured throughout each trial. Still images from a start and an end position were extracted from each video sequence. A custom Matlab program was used to calculate frontal plane hip adduction angle changes from obtained images. Mean change in passive hip adduction after band-septum-complex release was -0.3 ° (SD 1.6 °;95% CI: -1.33,0.76). A paired samples t-test revealed a non-significant difference (t=-.611; p=.555) in passive hip adduction for the band-septum-dissected condition (18.8 ± 3.9 °) versus the band-septum-intact condition (18.5 °±4.7 °). The lateral intermuscular septum does not appear to have a constraining effect on passive hip adduction in un-embalmed cadavers. Future research should evaluate the constraining effect of other selected tissues and conditions on hip adduction. Furthermore, inflammatory, metabolic, viscoelastic, and sensorimotor control properties within the iliotibial band in response to stretching should be investigated. 3.

Utility of Preoperative Multidetector-Row Computed Tomographic Angiography after Sublingual Nitroglycerin with Three-Dimensional Reconstruction in Planning of the Anterolateral Thigh Flap.

The utility of nitroglycerin is well established in coronary angiography but less so in other surgical fields. In this study, the authors investigated the utility of preoperative computed tomographic angiography after sublingual nitroglycerin followed by three-dimensional visualization for selecting suitable perforators in planning the free anterolateral thigh flap. The authors performed preoperative computed tomographic angiography following sublingual nitroglycerin (after screening for contraindications) in patients for whom reconstructive surgery with the free anterolateral thigh flap was planned. Data were reconstructed three-dimensionally, mapping location and course of source arteries and perforators. Suitable perforators were selected, and flap design was planned. The characteristics of perforators were analyzed statistically. Of 14 patients for whom surgery was planned, two had contraindications to nitroglycerin and underwent computed tomographic angiography alone. Nitroglycerin allowed for the visualization of more peripheral branches. The Hounsfield units at the deep fascia of perforators selected for surgery were significantly higher than for those not selected (p = 0.003). The distance from the intermuscular septum to the selected perforators was significantly shorter than the distance to nonselected perforators (p = 0.017). There were no adverse events, and all flaps survived. Sublingual nitroglycerin before computed tomographic angiography was safe and increased the visibility of perforators, enabling preoperative planning of flap design based on the three-dimensionally-reconstructed image. The authors highly recommend this procedure. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Diagnostic, IV.

Cubital tunnel syndrome in Noonan syndrome secondary to hypoplasia of the humeral trochlea

This report describes the case of a 45-year-old woman with Noonan syndrome who developed cubital tunnel syndrome secondary to hypoplasia of the humeral trochlea. Cubital tunnel syndrome, the second-most common peripheral compression neuropathy, is caused by compression of the ulnar nerve at the elbow. Noonan syndrome, an autosomal dominant multisystem disorder, is characterized by variable cognitive deficit and skeletal, ectodermal and hematologic anomalies. Results show three distinctive anatomical features such as (1) hypoplasia of the humeral trochlea and medial epicondyle, (2) absence of the medial intermuscular septum and (3) lack of Osborn’s ligament.

Evaluation of the Clinical Anatomy of the Most Important Perforator Veins of the Lower Extremities by Dissection and Duplex Ultrasound Scanning

Introduction - literature sources provide significant amount of data on the anatomy of the perforator veins (PVs) of the lower extremities. However, detailed descriptions of the topography of PVs are rare. Methods - 70 amputated lower extremities were subjected to anatomical dissection; 2800 patients (3500 extremities) underwent duplex ultrasound scanning (DUS). Results - There were 4 to 6 PVs on the medial surface of the foot. They directly connected the medial tributary of the medial marginal vein and vv. plantaris medialis and were located along the medial intermuscular septum. There were 2 to 3 PVs on the lateral surface of the foot. They connected the tributary of the lateral marginal vein (which together with the main trunk of the lateral marginal vein formed small saphenous vein) and vv. plantaris lateralis in a direct manner. Topographically PVs passed behind the lateral muscle group of the foot along the lateral intermuscular septum. Moreover, both PVs had tributaries, which drained the subcutaneous tissues of the lateral and medial surfaces of the foot. Presence of the muscular/venous pump of the calf complicates the structure of the PVs, among which are direct, indirect, and mixed PVs. Anatomical dissection has shown that the most constant were PVs located at a distance of 7-10 cm and 11-16cm from the lower edge of the medial ankle. Each PV of the calf (direct or indirect) and the foot was accompanied by an arterial twig, and it was often possible to identify a twig from a nearby nerve. There were 2 PVs in the subfascial area, located by the sides of the artery. PVs in the popliteal region may be referred to as “atypical” due to their rare presence (0.4% according to the DUS and no cases during dissection) in combination with the lack of a typical saphenopopliteal junction. PVs in this area were not supported by the intermuscular septa. 0.34% of the PVs emptied into the popliteal vein at the lateral side, while the small saphenous vein emptied into the great saphenous vein (GSV) at the upper 3rd of the or into the Giacomini vein. Arterial twigs accompanied every PV. DUS has shown the typical localization of the PVs on the thigh: middle third of the thigh where PVs emptied into the femoral vein at the level of the adductor canal, PVs connected GSV and femoral vein in 82.8% cases; lower third of the thigh – PVs emptied into the popliteal vein below the level of the adductor canal, PVs connected GSV and popliteal vein in 73.6% cases. All PVs passed along the medial intermuscular septum and were accompanied by an arterial branch from the femoral artery in all cases. The angle of the confluence of the PVs and the deep veins was approximately 45°, the length of their subfascial course was 5 to 7cm. Such characteristics prevent incompetence of the PVs in patients with varicose disease but create higher risks of introducing a Babcock’s probe into the deep veins in antegrade direction during phlebectomy (0.5% of cases). Conclusion - 1. Perforator veins mostly constitute the neurovascular bundles. 2. Perforator veins are primarily located along the intermuscular septa, which provides a solid support for the perforator vessels due to the rigid fixation of the intermuscular septa to the bones. 3. Presence of a concomitant artery makes it possible to propose an additional mechanism of venous outflow via the perforator vascular bundles - an arterio-venous pump.

Case Report: Median nerve formation; an unusual position in the right upper extremity with clinical relevance

There was no direct relationship between its formation and the axillary artery. Hence, it may be not be readily compromised. The site of MN formation was in proximal relation to the insertion of the coracobrahialis. This is clinically important as it may give a reinforced innervation to the muscle and proprioceptive impulses to medial fibres of the brachialis muscle. Conversely, the MN may be compressed by the tendon of the coracobrahialis, affecting its sympathetic filaments to the brachial artery. Furthermore, when present, it may be severed during reconstructive surgeries around the mid arm as the medial intermuscular septum fades out above the insertion of the coracobrachialis muscle. This report highlights the presence of a significant anatomical variation of the median nerve with regards to its site of formation, roots morphology and distribution, as well as its arterial relations for proper planning of surgeries.Key Words: Median nerve, arterial relations, right upper extremity, Morphology.

Detailed Anatomy of the Lateral Rectus Muscle-Superior Rectus Muscle Band.

Background To elucidate the detailed anatomy of the lateral rectus muscle-superior rectus muscle (LR-SR) band by cadaver eye investigation. Methods In total, 48 eyes of 24 cadavers were observed macroscopically. The lateral rectus muscle (LRM) and superior rectus muscle (SRM) were dissected from their origins to their insertions under the dissecting microscope, and the location, width, length, and tensile strength of the LR-SR bands were measured. Results The LR-SR band is the thick ligament interconnecting LRM pulleys with SRM pulleys. The LR-SR band was covered by the orbital part of the lacrimal gland superiorly, and the intermuscular septum between the LRM and SRM was shown anterior to the LR-SR band. The length of the attachment site between the LR-SR band and the SRM was less at 8.64 ± 1.52 mm (p=0.040), its thickness was thinner at 0.74 ± 0.16 mm (p=0.002), and its tensile strength was weaker at 7.64 ± 1.82 N (p=0.028) compared to the attachment site between the LR-SR band and the LRM. Conclusions This study revealed the detailed anatomy of the LR-SR band and provided helpful information to understand heavy eye syndrome and sagging eye syndrome.

Anteromedial minimally invasive plate osteosynthesis (MIPO) for distal third humeral shaft fractures – Is it possible?: A cadaveric study

IntroductionThe purpose of this study was to evaluate the feasibility of the anteromedial minimally invasive plate osteosynthesis (MIPO) approach for distal third humeral shaft fractures and identify neurovascular structures at risk with this approach. MethodsTwenty cadaveric arms were fixed with 12-hole precontoured narrow locking compression plates (LCP) with the anteromedial approach using MIPO technique. The proximal approach was done between the biceps and deltoid muscle directly to the bone. The distal approach involved elevating the brachialis from medial intermuscular septum. The plate was inserted beneath the brachialis tunnel from distal to proximal. Three locking screws were fixed at each end through incisions and the rest of screws were inserted percutaneously. The arms were then dissected to identify damage to or direct contact between the screws and brachial artery (BA), median nerve (MN), musculocutaneous nerve (MCN), and radial nerve (RN). The distances from the screws to structures at risk, humeral length, and length of three distal screws in mediolateral (ML) direction were measured. ResultsThe average humeral length was 28.97 cm. The average danger zone for the BA and MN were 20.47%–62.66% of the humeral length from the lateral epicondyle, and 20.47%-75.02% for the MCN. The ulnar nerve was not endangered by this approach as it lies posteromedially to the humerus. The danger zone for the RN averaged 27.07%–43.74%, and the most dangerous screw that either penetrated or touched the nerve was at the fifth hole, which lay at 33.14% of the humeral length. The average length of three distal screws in ML direction were 41.4, 25.0 and 22.5 mm. ConclusionsThe anteromedial MIPO approach can be performed through the internervous plane beneath the brachialis muscle without exposing any nerves or causing any muscle splitting with a 12-hole plate. Both proximal and distal screw insertion must be done with direct exposure. Insertion of percutaneous screws in the middle part of the plate between the two incisions is not possible. This approach could be an alternative for extra-articular distal third humeral shaft fractures which provides less invasive surgical dissection, allows the use of longer distal screws, and achieves better cosmesis.

Spontaneous Orbital Hemorrhage Related to the Extraocular Muscles

The authors present the largest series of patients to date of spontaneous hemorrhage in relation to extraocular muscles (EOMs). Observational retrospective case series. Institutional review board approval was obtained. Eighteen patients with a mean age of 71 years presented with 20 episodes of spontaneous orbital hemorrhage closely related to an EOM. Most patients woke with unilateral proptosis, pain, and diplopia. Vision was impaired in 25%. Imaging identified a characteristic well-circumscribed hematoma arising within the muscle sheath or intermuscular septum. Three episodes required surgical drainage. All patients had good recovery of vision. The authors describe a distinct clinical entity of idiopathic hemorrhages related to EOMs. No patient had an underlying vascular malformation or other lesion. The authors demonstrate that a proportion of these patients have vascular risk factors, namely, hypertension, hyperlipidemia, and antiplatelet use. This study suggests that inferior rectus is the most commonly affected EOM and shows that it is the muscle sheath or intermuscular septum of inferior rectus that is involved, rather than the muscle belly. Most patients can be managed conservatively with good visual outcomes. However, there were 3 exceptional cases that required surgical intervention. The findings that spontaneous orbital hemorrhages related to EOMs have certain predisposing factors, a characteristic radiological appearance, and a typically benign course will be helpful for clinicians in the management of this condition.

Ulnar Nerve Innervation to Triceps: A Cadaveric Study and a Technical Note on Partial Triceps to Biceps Transfer.

Background:The loss of elbow flexion is a routinely encountered problem in clinical practice. There is no literature on ulnar nerve innervation to triceps in addition to the radial nerve which is dual nerve innervation to triceps in the Indian population. We intend to study the incidence of ulnar nerve innervation to the medial head of triceps in Indian population and also the clinical feasibility of transfer of long and medial head of triceps tendon to biceps around the medial aspect of humerus.Materials and Methods:A cross-sectional study was conducted using 32 fresh-frozen skeletally mature cadavers of Indian origin. The possible contribution of the ulnar nerve to medial head of triceps in addition to the radial nerve was recorded. The arm length, the distance where the ulnar nerve pierces the medial intermuscular septum from medial epicondyle; the distance of the ulnar nerve fascicle from the medial epicondyle was also measured.Results:The incidence of ulnar nerve innervation to the medial head of triceps was 43.8%. Mean arm length was 29.13 cm. Mean distance where the ulnar nerve pierced the medial intermuscular septum from medial epicondyle was 9.93 cm. Mean distance of the ulnar nerve branch to the triceps from medial epicondyle was 8.01 cm.Conclusion:This study reveals the presence of dual nerve innervation to triceps in 43.8% of the Indian population. The clinical implication would be to look for the possible contribution of the ulnar nerve fascicle to the medial head of triceps, which will help us to include the medial head along with the long head of triceps while performing partial triceps-to-biceps tendon transfer, and the other use would be as a donor fascicle when performing a nerve transfer.

Incision of the flexor retinaculum of the foot fails to relieve symptoms of tarsal tunnel syndrome due to presence of a variant flexor digitorum accessorius longus (FDAL) muscle

Tarsal tunnel syndrome (TTS), or posterior tibial neuralgia, is a neuropathy associated with compressive entrapment of the tibial nerve as it travels deep to the flexor retinaculum of the foot, or within the tarsal tunnel. A patient with TTS often presents with paresthesia and numbness within the foot radiating to the big toe and first three toes, but these symptoms can also radiate proximally into the leg as far as the knee joint. Pain, burning, tingling, and electrical sensations extend over the plantar surface of the foot and the heel. Inflammation and swelling can result leading to compression of the tibial nerve. These symptoms are exacerbated with activity or when a physician applies pressure to, or taps upon, the compressed tibial nerve, which is called a positive Tinel's sign. Surgical incision the flexor retinaculum of the foot usually relieves these TTS signs/symptoms because it creates additional space for the impinged tibial nerve in this compressive entrapment neuropathy.A 44‐year‐old competitive male athlete, who was diagnosed with TTS, failed to gain relief from the signs and symptoms of this neuropathy after incision of the flexor retinaculum of the foot. Subsequent MRI review revealed a large variant muscle in the posterior compartment of the distal affected leg, which was later identified as a flexor digitorum accessorius longus (FDAL). This variant muscle arose from the investing fascia of the flexor digitorum longus muscle medially, the transverse intermuscular septum posteriorly, the investing fascia of the flexor hallucis longus muscle medially. This FDAL also extended as far proximally as the middle of leg, and more specifically, the lower border of the gastrocnemius muscle. Though difficult to discern on the MRI, the FDAL appeared to attach to the tibia medially and fibula laterally. Throughout its course, the FDAL muscle was located immediately posterior and impinged upon the tibial nerve. Moreover, this FDAL followed its documented course distally in that it was located posterior to the medial malleolus and entered the tarsal tunnel (deep to the flexor retinaculum), where it continued to act as a space occupying lesion. Finally, the FDAL inserted onto the intersection of the flexor digitorum longus tendon and the quadratus plantae muscle in the second muscular layer of the sole of the foot.To regain the quality of his once active lifestyle, it was necessary for this patient to undergo an addition surgery, using an open approach, in which this FDAL muscle was excised from its proximal attachment to just below the normal location of the flexor retinaculum of the foot. With the prevalence of the FDAL reported in 2–12% of cadaveric studies, this case emphasizes the importance of MRI review before tarsal tunnel surgery is performed and the importance of identifying variant leg muscles that may be causing the compressive entrapment neuropathy of the tibial nerve.Support or Funding InformationWVU Initiation to Research Opportunities (INTRO) Program; NASA WV Space Grant Consortium [NNX10AK62H].This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Ultrasound-guided decompression surgery of the distal tarsal tunnel: a novel technique for the distal tarsal tunnel syndrome\u2014part\xa0III

BackgroundThe aim of this study was to provide a safe ultrasound-guided minimally invasive surgical approach for a distal tarsal tunnel release concerning nerve entrapments.Methods and resultsThe study was carried out on ten fresh-frozen feet. All of them have been examined by high-resolution ultrasound at the distal tarsal tunnel. The surgical approach has been marked throughout the course of the medial intermuscular septum (MIS, the lateral fascia of the abductor hallucis muscle). After the previous steps, nerve decompression was carried out through a MIS release through a 2.5 mm (± 0.5 mm) surgical portal. As a result, an effective release of the MIS has been obtained in all fresh-frozen feet.ConclusionThe results of our anatomic study indicate that this novel ultrasound-guided minimally invasive surgical approach for the release of the MIS might be an effective, safe and quick decompression technique treating selected patients with a distal tarsal tunnel syndrome.

Septocutaneous perforator mapping and clinical applications of the medial arm flap

The medial arm flap has a long history but remains underused despite providing multiple advantages. We reviewed our experience with using the medial arm flap to clarify the distribution of septocutaneous perforators and its relationship with pedicled flap design. This retrospective study included 36 consecutive patients who underwent reconstructive surgery with a medial arm flap (42 arms). Septocutaneous perforator mapping was conducted using a refined coordinate system originating at the medial epicondyle, with the y-axis running to the axillary apex. At least three perforators were identified along the medial intermuscular septum of the arm, located densely at 88 ± 8%, 49 ± 9%, and 20 ± 6% of the distance between the medial epicondyle and axillary apex (i.e., arm length), with a prevalence of 95.2%, 100%, and 85.7%, respectively. All arms had at least one medium- or large-sized perforator, and 90.5% of arms had at least two such perforators. Twenty-nine flaps were transferred as pedicled distant flaps for head and neck reconstruction or hand reconstruction, while the remaining 13 were transferred as perforator-based propeller flaps for axillary, elbow, or chest wall reconstruction. Thirty-six flaps underwent pre-transfer expansion. The average flap size was 157.9 ± 64.5cm2 (range: 40-330cm2). All flaps were successful, except for one perforator-based flap, which was replaced due to partial loss. Donor site morbidity was minimal. Given its rich septocutaneous perforator distribution, the medial arm flap can be harvested reliably with versatile design and minimal donor site morbidity, thus deserving more attention in reconstructive surgery.

Rotational Malalignment of the Knee Extensor Mechanism: Defining Rotation of the Quadriceps and Its Role in the Spectrum of Patellofemoral Joint Instability.

Background:Osseous rotational malalignment of the lower limb is widely accepted as a factor contributing to patellofemoral instability, particularly in pediatric patients. Patellar instability occurs when the lateral force vector generated by the quadriceps exceeds the restraints provided by osseous and soft-tissue anatomy. The anatomy and activation of the quadriceps are responsible for the force applied across the patellofemoral joint, which has previously been measured using the quadriceps (Q)-angle. To our knowledge, the contribution of the quadriceps anatomy in generating a force vector in the axial plane has not previously been assessed. The primary aim of this study was to introduce the quadriceps torsion angle, a measure of quadriceps rotational alignment in the juvenile population. The secondary aims of this study were to determine the inter-assessor and intra-assessor reliability of the quadriceps torsion angle in the juvenile population and to investigate whether a large quadriceps torsion angle is a classifier of patellar dislocator group membership in a mixed cohort of patellar dislocators and typically developing controls.Methods:Participants between the ages of 8 and 19 years were recruited as either controls or recurrent patellar dislocators. A total of 58 knees in both groups were assessed from magnetic resonance imaging scans of the entire lower limbs. Axial cuts midway between the superior aspect of the femoral head and the articular surface of the medial femoral condyle were used to calculate the proximal reference for the quadriceps torsion angle. The quadriceps torsion angle was defined as the angle between the line connecting the anterior aspect of the sartorius and the junction of the anterior and posterior compartments at the lateral intermuscular septum and the posterior condylar axis line. Inter-assessor reliability was calculated using the intraclass correlation coefficient. The relationship between the quadriceps torsion angle and the femoral torsion was assessed in the entire cohort. These values were compared between the control group and the dislocator group to determine if the raw values or an interplay between the 2 factors played a role in the pathoanatomy of recurrent patellofemoral dislocation.Results:The quadriceps torsion angle was a reproducible assessment in both inter-assessor and intra-assessor reliability analyses. A moderate positive correlation (r = 0.624; p < 0.01) was found between the femoral torsion and the quadriceps torsion angle. Although the quadriceps torsion angle was a fair classifier of patellar dislocation group membership, femoral torsion was not.Conclusions:This study has quantified the rotational alignment of the extensor mechanism using the quadriceps torsion angle. The measurement is shown to be reliable and reproducible and a fair classifier of patellofemoral instability.Clinical Relevance:This article introduces an objective measure of soft-tissue rotational malalignment in the pathogenesis of recurrent patellar dislocation.

Alternative Design for Anterolateral Thigh Multi-Paddled Flaps: The 3-5 System.

BackgroundThe design and harvest of the anterolateral thigh (ALT) multi-paddled flap is a critical step in reconstructive surgeries. However, limited perforator distribution patterns of traditional design methods have gradually emerged in clinical practice. The aim of this study was to investigate the effect of a new technique (the 3–5 system) on ALT multi-paddled flap design.Material/MethodsA total of 151 ALT flaps were harvested from 149 patients over a 26-month period. Among them, 100 ALT flaps were examined preoperatively using a handheld Doppler device to localize vascular perforators.ResultsBy detecting perforator penetration points through the vastus lateral muscle (VLM) or the intermuscular septum and perforator entry points to the deep fascia, precise ALT flap perforator distribution patterns were found. Meanwhile, a 3–5 system was developed to design ALT flaps based on these findings. The remaining 51 ALT flaps from 49 patients during a 9-month period did not require the use of preoperative handheld Doppler. In addition, preoperative handheld Doppler and intraoperative findings demonstrated that all ALT flap penetration points through the VLM or intermuscular septum and the perforator entry point in the deep fascia were closely related based on 3 longitudinal lines and 5 horizontal lines.ConclusionsALT flaps were successfully harvested using a 3–5 system without the need for preoperative handheld Doppler analysis. Moreover, the 3–5 system is a simple and practical approach for preoperative ALT multi-paddled flap design.

Topographic and anatomical features of the most important perforating veins of the lower extremities

The objectiveof the study is to clarify the topographic and anatomical features of the most common perforating veins of the lower extremities.Material and methods. 70 lower extremities (sectional material) without signs of chronic venous diseases and 1700 patients. Research methods: anatomical dissection and ultrasound examination of the venous system of the lower extremities (duplex ultrasound scanning).Results. 4 to 6 perforants were found on the medial surface of the foot. They directly connected the medial boundary of the vein and vv. plantaris medialis. They are located along the medial intermuscular septum at the subfascial level; have subcutaneous tributaries from the medial surface of the foot at the epifascial level. The most constant localization of perforating veins on the ankle was the distal part of the medial surface of the ankle. On the ana to mic preparations they were the main draining vessels of this area. All perforating veins of the ankle (direct and indirect) and foot are the part of the neurovascular bundle, and at the subfascial level of the perforating veins 2, are located on the sides of the artery, next to the nerve branch. Rare incidence of perforating veins of the popliteal region, combining with the lack of typical saphenopopliteal anastomosis, allows relating them to the atypical PV. Among all of the perforating veins of the thigh, the highest frequency of incidence was in the lower third. These veins connected the great saphenous vein, and the femoral vein in 55.6 %. They passed along the medial intermuscular septum and had a long subfascial course. In all cases there is nearby arterial twig.Conclusion.Perforating veins in different areas of the lower extremities have their features of structure. General is that perforating veins mostly are the neurovascular bundles (vein – artery – nerve).

Lateral rectus muscle recession and the vertical palpebral fissure height: to do or not to do inter-muscular septum dissection?

In this study, we aimed to evaluate changes of vertical palpebral fissure height (VPFH) after unilateral lateral rectus muscle recession. Twenty-five and twenty-six patients who were candidates for lateral rectus muscle recession were assigned into "with" and "without" intermuscular septum dissection study arms. The VPFH was measured at one-day before surgery and in two weeks and three months, postoperatively. Three months after surgery, significant increase of VPFH was observed in both groups (Paired t-test; P=0.005). Also, less widening of VPFH was observed in "with intermuscular septum dissection" group (Change in VPFH in "with intermuscular septum dissection" vs "without intermuscular septum dissection" groups: 0.48 mm vs 1.34 mm; ANCOVA test; P<0.001). However, such results were not observed two weeks post-operatively (Change in VPFH in "with intermuscular septum dissection" vs "without intermuscular septum dissection" groups: -0.28 mm vs 0.28 mm; ANCOVA test; P=0.302). Intermuscular septum dissection is recommended in lateral rectus muscle recession to partially prevent the undesirable increment of VPFH.

The 7 Structures Distal to the Elbow That Are Critical to Successful Anterior Transposition of the Ulnar Nerve.

Background: Ulnar nerve transposition (UNT) surgery is performed for the treatment of cubital tunnel syndrome. Improperly performed UNT can create iatrogenic pain and neuropathy. The aim of this study is to identify anatomical structures distal to the medial epicondyle that should be recognized by all surgeons performing UNT to prevent postoperative neuropathy. Methods: Ten cadaveric specimens were dissected with attention to the ulnar nerve. Intramuscular UNT surgery was simulated in each. Distal to the medial epicondyle, any anatomical structure prohibiting transposition of the ulnar nerve to a straight-line course across the flexor-pronator mass was noted and its distance from the medial epicondyle was measured. Results: Seven structures were found distal to the medial epicondyle whose recognition is critical to ensuring a successful anterior transposition of the ulnar nerve: (1) Branches of the medial antebrachial cutaneous (MABC) nerve; (2) Osborne's fascia; (3) branches from the ulnar nerve to the flexor carpi ulnaris (FCU); (4) crossing vascular branches from the ulnar artery to the FCU; (5) the distal medial intermuscular septum between the FCU and flexor digitorum superficialis (FDS); (6) the combined muscular origins of the flexor-pronator muscles; and (7) the investing fascia of the FDS. Measurements are given for each structure. Conclusions: Poor outcomes and unnecessary revision surgeries for cubital tunnel syndrome can be avoided with intraoperative attention to 7 structures distal to the medial epicondyle. Surgeons should expect to dissect up to 12 cm distal to the medial epicondyle to adequately address these and prevent kinking of the nerve in transposition.

No neurovascular damage after creation of an accessory anteromedial portal for arthroscopic reduction and fixation of coronoid fractures.

Arthroscopic reduction and internal fixation for coronoid process fractures has been proposed to overcome limitations of open approaches. Currently, arthroscopy is most frequently used to assist insertion of a retrograde guide wire for a retrograde cannulated screw. The present anatomical study presents an innovative arthroscopic technique to introduce an antegrade guide wire from an accessory anteromedial portal and evaluates its safety and reproducibility. Six fresh-frozen cadaver specimens were obtained and prepared to mimic an arthroscopic setting. The coronoid process was localized and a 0.9mm Kirschner wire was introduced from an accessory anteromedial portal, located 2cm proximal to the standard anteromedial portal. At the end of the procedure, a lateral radiograph was taken to verify the Kirschner wire position and open dissection was conducted to evaluate possible damage to neurovascular structures. The Kirschner wire was drilled without complications in the coronoid process of all six specimens. Damage of the brachial artery, the median nerve, and the ulnar nerve did not occur in any specimen. A corridor between the brachialis muscle, the median intermuscular septum, and the pronator teres could be identified as suitable for the wire passage. This study presents a safe and reproducible technique combining the possibility to introduce a guide wire from the anteromedial part of the coronoid, under direct visual control, with a completely arthroscopic approach. This wire can guide the introduction of a retrograde cannulated screw from the dorsolateral ulna to the tip of the coronoid. This new arthroscopic approach permits to obtain improved visual control over coronoid process fixation, without endangering neurovascular structures.

The Anterolateral Complex of the Knee

Aims and Objectives: The objective of this study was to clarify the layer-by-layer anatomy of the anterolateral complex of the knee. Materials and Methods: Twenty fresh-frozen human cadaveric knees (age range 38 - 56 yrs.) without any history of knee injury or surgery were used for this dissection study. After skin and subcutaneous tissue removal, the ITB was incised in its most anterior part and reflected posteriorly followed by blunt dissection of its deeper layers. Subsequently, an incision was made between the ITB and the short head of the biceps muscle with consecutive evaluation of the insertion site of the biceps tendon and its extensions. Once the deep layers of the ITB were identified, the connections to the lateral intermuscular septum and Kaplan fibers were cut. The superficial ITB was then reflected distally in order to assess the geographical relationship between the superficial and deep ITB as well as the distal anteromedial aspect of the biceps muscle. Finally, the anterolateral capsule was incised to evaluate its connections to the surrounding anatomic structures. Results: The anterolateral aspect of the knee consists of three distinct layers. Superficially, the ITB with its insertion to Gerdy’s tubercle and extensions to the patella (iliopatellar band) was appreciated. Posterior reflection of the superficial ITB revealed a firm distinct connection of Kaplan fibers to the distal femoral metaphysis. The deep layer of the ITB runs from the Kaplan fibers in a distal direction and forms a functional arc. This arc is reinforced by the capsulo-osseous layer of the ITB, which originates from an area distal to the Kaplan fibers, the fascia of the lateral gastrocnemius and plantaris muscles. The distal half of the capsulo-osseous layer merges posteriorly with the fascia of the biceps muscle. The three layers of the ITB become confluent distally. Its insertion spanned from Gerdy’s tubercle to an area just posteriorly, with the capsulo-osseous layer forming the posterior part. The biceps muscle has fascial and aporoneurotical extensions, which insert to the proximal tibia together with the capsulo-osseous layer of the ITB. Layer 3 consists of the anterolateral capsule. In 7/20 (35%) specimens the mid-third capsular ligament was observed as a thickening within, but not separate from the anterolateral capsule. Conclusion: The anterolateral complex of the knee consists of the ITB with its three layers, the functional arc formed by the fibers between the distal femoral metaphysis and Gerdy’s tubercle, and the anterolateral capsule. In 35% of specimens a capsular thickening (mid-third capsular ligament) was identified. Surgeons should consider the complex anatomy of this functional unit, i.e. the anterolateral complex, when considering lateral extra-articular procedures.