Medial Intermuscular Septum Research Articles

Revision surgery for recurrent ulnar nerve compression following failed subcutaneous transposition.

Recurrent ulnar nerve compression after primary anterior subcutaneous transposition is relatively rare, and revision surgery is challenging. This study retrospectively evaluated the clinical outcomes of revision anterior subcutaneous transposition for recurrent ulnar nerve compression. Eight patients who underwent revision anterior subcutaneous transposition for recurrent ulnar nerve compression were enrolled in this study. The outcomes were based on preoperative and postoperative symptoms, physical examination findings, and electromyographic evaluation. Ulnar nerve enlargement was preoperatively found in all patients with a mean cross sectional area of 0.15 cm2 (range, 0.14-0.18 cm2). Intraoperative findings showed that recurrent compression occurred in three areas, including the medial intermuscular septum (n = 5), the medial epicondyle (n = 6) and nerve entrance to forearm fascia (n = 1). Post-operation, significant improvements were observed in ring/little finger numbness (from severe to mild, p = 0.031), grip strength (from 48.00% to 80.38% of the intact side, p < 0.001) and McGowan grade (from Grade III to Grade I, p = 0.049). Postoperative electromyography test also showed significant improvement in motor nerve conduction at elbow (velocity, 23.30 ± 9.598 vs. 35.30 ± 9.367, p = 0.012; amplitude, 3.40 ± 3.703 vs. 5.65 ± 2.056, p = 0.007) and sensory nerve conduction at wrist (velocity, 27.04 ± 22.450 vs. 36.45 ± 18.099, p = 0.139; amplitude, 1.44 ± 1.600 vs. 4.00 ± 2.642, p = 0.011). Seven of the eight patients reported satisfaction with the postoperative results. Revision anterior subcutaneous transposition was an effective treatment for recurrent ulnar nerve compression from prior failed procedures.

Ulnar Nerve Decompression With Subcutaneous Transposition

Background: Medial-sided elbow injuries are becoming increasingly common among throwing athletes due to overuse and increased specialization at early ages. High valgus stress and repetitive elbow flexion/extension during throwing not only affects the ligaments and dynamic support of the elbow, but commonly affects the ulnar nerve. Indications: Management of cubital tunnel syndrome is initially rest, therapy, and functional training; however, if conservative measures do not appropriately address the ulnar neuropathy, surgical decompression with subcutaneous transposition is a reliable treatment option. Technique Description: An incision is created over the medial epicondyle. The medial antebrachial cutaneous nerve is identified and protected. The ulnar nerve is identified and tagged with a vessel loop to allow for appropriate handling of the nerve. Decompression of the ulnar nerve begins proximally by spreading the tissues superficial to the ulnar nerve and splitting the fascia overlying it. Then, dissection deep to the nerve is performed. A small strip of the medial intermuscular septum will be used as a sling to hold the nerve securely in the transposed position. This is released proximally and the distal attachment to the medial epicondyle is left in place. Decompression is then continued distally by releasing the superficial fascia over the flexor carpi ulnaris (FCU) and a portion of the deep FCU muscle belly and fascia. The nerve is decompressed circumferentially, while preserving penetrating branches to the FCU as able. Ultimately, the ulnar nerve is decompressed 10 cm proximal and 10 cm distal to the medial epicondyle. The intermuscular septum is then pulled over the nerve, checked for appropriate length, and sutured in place both posterior and anterior to the ulnar nerve. Results: Symptom improvement after decompression and transposition is high (&gt;90%); however, performance outcomes in overhead and throwing athletes is variable, and return to previous or higher level of play ranges from 60% to 90%. Discussion/Conclusion: Ulnar nerve decompression and transposition can reliably address underlying symptoms, but results are mixed for return to sport outcomes in overhead and throwing athletes. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Anterior transposition of the radial nerve to achieve primary suture for its reconstruction: Anatomical feasibility study

IntroductionRadial nerve palsy after humeral shaft fractures is often associated with formation of a neuroma in continuity. The current standard of treatment is neuroma resection and nerve grafting with contentious results. Anterior transposition of the radial nerve may reduce the length of its path, allowing reconstruction by primary suture. The aim of this study was to determine the maximum length of radial nerve defect that can be treated by the anterior transposition to allow primary suture to be performed. MethodsWe use 10 arms from five fresh cadavers. The radial nerve was dissected in the lateral inter-muscular septum and along the anterior aspect of the forearm. The radial nerve was transected at the level of the spiral groove and both stumps were than transposed anterior to the medial inter-muscular septum. The length of tension-free overlap that could be achieved was measured. ResultsThe average length of the overlap at zero degrees of elbow flexion was 10.00 ± 1.84 mm. Theoretically, this will allow a defect of 20 ± 3.69 mm SD to be treated by primary suture. ConclusionOur results suggest that anterior transposition can be used for radial nerve defects up to 2 cm; however, dissection of both stumps proved to be challenging.

Intramuscular Stress Transmission Between the Muscles of the Ball of the Thumb, and the Latissimus Dorsi Muscle After Tensegrity Massage Application a Pilot study

Introduction: The phenomenon of tensegrity in the muscular system still remains theoretical. Research has been mostly performed in vitro. Unfortunately, analyses of this type are focused on this part of the phenomenon. They do not consider, e.g. the presence of body fluids.Study objective: The aim of the study was in vivo verification regarding the occurrence of tensegrity in a model consisting of the latissimus dorsi muscle (LAT), the medial intermuscular septum, muscles of the anterior forearm and muscles of thenar eminence.Material and methods: The study group was divided into an experimental (n =10) and control group (n=10). The experimental group took part in 1 massage session of the thenar eminence muscles for 5 minutes. The control group spent 5 minutes on a couch in the same position as in the experimental group, receiving no intervention. In both groups, at the beginning and end of the session, LAT was tested with a tensiomyograph and algometer.Results: Statistically significant differences between the groups occurred in pressure pain threshold (p=0.02), contraction time (p=0.01), relaxation time (p=0.01) and LAT sustaining duration (p=0.046). The level of statistical significance was p&lt;0.05.Conclusions: In the tested model, the change in the tension of the distal end of the model influenced the displacement of the muscle at the proximal end of the model in accordance with the tensegrity model.

Possible Points of Ulnar Nerve Entrapment in the Arm and Forearm: An Ultrasound, Anatomical, and Histological Study.

Ulnar nerve entrapment is one of the most common entrapment neuropathies, usually occurring in the cubital tunnel of the elbow and in Guyon's canal of the wrist. However, it can also occur at other anatomical locations. Our aim was to review other possible locations of ulnar nerve entrapment in an ultrasound and anatomical study. Eleven upper limbs from eight adult corpses were ultrasonographically examined and subsequently dissected in a dissection laboratory. Four specific anatomical points were analysed, and any anatomical variations were documented. Moreover, six samples of the nerve were taken for histological analysis. Distinct anatomical relationships were observed during ultrasound and dissection between the ulnar nerve and the medial intermuscular septum, the triceps aponeurosis, Osborne's fascia at the elbow, the arcuate ligament of Osborne and the intermuscular aponeurosis between the flexor carpi ulnaris and the flexor digitorum superficialis muscles. A statistical study showed that these locations are potential areas for ulnar nerve compression. In addition, a fourth head of the triceps brachii muscle was found in some specimens. Results demonstrate that ultrasound is a good tool to investigate ulnar nerve entrapment neuropathy and to identify other anatomical points where the nerve can remain compressed.

Osteomuscular Hydatidosis

Introduction: Muscular hydatid disease is an extremely rare entity. Intramuscular hydatid cysts are usually secondary, resulting from spontaneous spread of the cysts or after operations for hydatid disease in distant regions. Material and methods: A case of multiple muscular hydatid disease is presented, which behaves like a soft tissue tumor that increases in size, with a review of the pertinent literature. Results: MR images showed a mass in the medial intermuscular septum of the thigh, adjacent and anterior to the femoral vascular bundle. Several satellite lesions are also visualized. The extension study shows another lesion between the right lumbar psoas and the paravertebral muscles in the posterior pararenal space. The diagnosis of hydatid disease is established with CNB. The patient underwent surgery in another center for one of the lesions with poor evolution, finally opting for treatment with Abendazole. Conclusion: In geographical regions where hydatid disease is endemic, the hydatid cyst should be included in the differential diagnosis of a cystic mass in the muscle for its correct treatment.

Third head of biceps femoris muscle-a case report

Sometimes variations in biceps femoris may be noticed like an accessory head of biceps femoris. Here during routine cadaveric dissection in the department of anatomy. All India institute of medical sciences, Jodhpur we found a case with an accessory head of biceps femoris in both the lower limbs. The muscle belly is originating from the fibers of long head of biceps femoris and going downward medially to get inserted to the medial condyle of tibia on its medial superior aspect. On the right-side insertion site is like a sheath and on half a way it is merging with medial intermuscular septum of thigh. On the left side insertion is first like a thin sheath and then a thin muscle belly. The muscle belly is thin as compared to the long and short head of the main muscle bellies. On the left side thickness is around 3.7 mm in the upper end and thinner in the lower end while on right side also it is around 3.75 mm. On right side length of muscle belly is around 5 cm and on left side it is around 5.5 cm muscle belly, then becomes a sheath with length around 0.5 mm and then again becomes a muscle belly of around 3.5 cm length. Short head is arising high up on the left side while on right side it is as normal.

Ultrasound-Assisted Precise In Situ Decompression for Cubital Tunnel Syndrome.

ObjectiveTo explore the effect of locating the ulnar nerve compression sites and guiding the small incision so as to decompress the ulnar nerve in situ on the elbow by high‐frequency ultrasound before operation.MethodsA retrospective analysis was conducted on 56 patients who underwent ultrasound‐assisted in situ decompression for cubital tunnel syndrome from May 2018 to August 2019. The patients' average age was 51.13 ± 7.35 years, mean duration of symptoms was 6.51 ± 1.96 months, and mean postoperative follow‐up was 6.07 ± 0.82 months. Nine patients had Dellon's stage mild, 39 had stage moderate, and eight had stage severe. Ultrasound and electromyography were completed in all patients before operation. The presence of ulnar nerve compressive lesion, the specific location, and the reason and extent of compression were determined by ultrasound. A small incision in situ surgery was given to decompress the ulnar nerve according to the pre‐defined compressive sites.ResultsAll patients underwent in situ decompression. The compression sites around the elbow were as follows: two in the arcade of Struthers, one in the medial intermuscular septum, four in the anconeus epitrochlearis muscle, five beside the cyst of the proximal flexor carpi ulnaris (FCU), and the remaining 44 cases were all from the compression between Osborne's ligament to the two heads of the FCU. The compression localizations diagnosed by ultrasound were confirmed by operations. Preoperative ultrasound confirmed no ulnar nerve subluxation in all cases. The postoperative outcomes were satisfactory. There was no recurrence or aggravation of symptoms in this group of patients according to the modified Bishop scoring system; results showed that 43 cases were excellent, 10 were good, and three were fair.ConclusionsHigh‐frequency ultrasound can accurately and comprehensively evaluate the ulnar nerve compression and the surrounding tissues, thus providing significant guidance for the precise minimally invasive treatment of ulnar nerve compression.

Thoracobrachialis- A Cadaveric Study of a Morphological Variation of Pectoralis Major with a Novel Nomenclature and Classification of the Chondroepitrochlearis Muscle

Background: Anatomical variations are not uncommon in the pectoral region but the chondroepitrochlearis muscle has been of special interest in history owing to its rarity. Chondroepitrochlearis is a muscular slip that arises from the lower ribs, the inferolateral aspect of the pectoralis major, or the aponeurosis of the external oblique muscle and crosses the axilla to insert on the medial intermuscular septum or the medial epicondyle of the humerus. Multiple variants of this muscle exist including chondroepitrochlearis, chondrofascialis, costoepitrochlearis, thoracoepicondylaris, chondrohumeralis, etcetera. The objectives is to article aims to simplify and standardize the reporting of the chondroepitrochlearis muscle by proposing a novel nomenclature and classification. In this paper, we also present and discuss a case of chondroepitrochlearis. Subjects and Methods : A prospective study was conducted from 2012 to 2020 in the Department of Anatomy, ESIC MC and PGIMSR, Rajajinagar, to identify anatomical variations in the pectoral region. Results: During routine dissection of a male cadaver, an unusual slip was found on the right side and was identified as chondroepitrochlearis. Conclusion: Since the reporting of this rare muscle has been increasing in live patients, taking into consideration the variability in the presentation of the same anatomical structure, to avoid confusion, we propose a novel, blanket nomenclature- “Thoracobrachialis”. We also propose a clinically relevant classification that is based on the level of insertion of the muscle and the possible neurovascular structures involved.

A Rare Case of Superficial Brachioradial Artery and Median Nerve Within the Pronator Arch Above the Hueter’s Line—a Case Report

The brachial artery divides at the level of the neck of the radius in the elbow into its terminal branches, the radial, and ulnar arteries. If the brachial artery divides at a higher level, the branches are termed brachioradial and brachioulnar arteries. The brachioradial and brachioulnar arteries usually follow the ordinary course of the radial and ulnar arteries. We report a case of the brachial artery along with median nerve passing through a fibromuscular tunnel formed by the extra head of origin of pronator teres (pronator arch) from the medial intermuscular septum in the arm. Further, we observed a higher division of the brachial artery into brachioradial and brachioulnar arteries. The brachioradial artery followed an unconventionally superficial course in the forearm. We believe such a unique variation will be of interest to cardiologists during cardiac catheterization where the artery is prone to iatrogenic injury due to its course below the fibromuscular pronator arch and a concomitant compression of the median nerve.

Anatomy of the ulnar nerve in the posterior compartment of the upper arm: Relationships with the triceps brachii muscle

The aim of our descriptive anatomical study was to clarify the relationships between the ulnar nerve and the triceps brachii muscle in the posterior compartment of the upper arm. This study involved 30 fresh adult upper limbs. In all specimens, the ulnar nerve crossed from the anterior to posterior compartment in a space formed by the medial intermuscular septum and muscle fibers of the triceps' medial head. This transition zone was located an average of 126mm (115-135mm) proximal to the start of the ulnar groove. In the posterior compartment, the nerve descended vertically, and its anterior side was attached to the posterior side of the septum. Its posterior and lateral sides were covered by muscle fibers from the medial head. Its medial side was always free meaning that the nerve did not penetrate through the medial head. The other heads of the triceps muscle had no direct interactions with the ulnar nerve within this compartment. During its posterior course, the nerve was accompanied by the superior ulnar collateral artery. The ulnar nerve did not give off any branches in the upper arm.

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.

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.

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.

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.

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.

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).