Medial Leg Research Articles

Quadriceps weakness due to disc protrusion causing nerve root compression. A case report and literature review

Most common presentation of spinal disc herniation is pain. Next common presentation is pain associated with neurological symptoms [1] . It is relatively unusual to present muscular weakness purely due to disc herniation in the absence of lower back or neuropathic pain and can be a diagnostic challenge. A male patient of 45 presented to his family physician with five days history of weakness in the left quadriceps. There was no pain in the back or leg or any sensory symptoms at this stage. There was no other significant past medical history apart of history of spontaneous disc prolapse when he was 26. (radiating pain to the left leg but no neurological symptoms at that time). Clinical examination revealed motor deficit of 4/5 in the left quadriceps and diminished knee reflex. There was no sensory deficit elicited at this stage. Patient was referred to neurologist (by this time patient had developed sensory deficit at medial lower leg) who arranged nerve conduction studies which revealed L4 radiculopathy. Patient was referred to spinal surgeon who after consultation arranged MRI of the lumbosacral spine which showed disc extrusion at L3-4 level causing root compression of L4 nerve root. Since the patient was active sportsman, it was decided to do discectomy. However, after case discussion in spinal team meeting, (and patient started to feel slight improvement in sensory symptoms after couple of weeks) it was decided to manage conservatively. Patient started physiotherapy for three months and gradually noticed complete resolution of sensory loss after a month and gradual improvement in motor weakness. Patient started light sporting activities after three months of orthopaedic consultation. Patient continued to recover and had complete resolution of motor symptoms within a year. Patient had a follow up MRI after about a year which showed subtle improvement of compression at the same level. Patient was discharged from outpatient follow up. This case illustrates diagnostic dilemma when symptoms are not typical. However, it is proven the ‘common things are common’ again. Conservative management seems to be way forward when neurological symptoms are mild especially in the absence of neuropathic pain, However, it needs to be decided on case-by-case basis

Enlarging verrucous plaque in a Guatemalan male

A 43-year-old man is being evaluated for intractable pain from an enlarging plaque of 10 years' duration on his left knee. He emigrated from Guatemala 6 months ago and previously worked as a farmer and forklift driver. Originally focal, the lesion progressed to encompass the entire knee, medial leg, and distal thigh. Prior treatment with topical triamcinolone provided no benefit in reducing lesion size or symptoms. Physical examination demonstrates a 30 × 40–cm, indurated, verrucous plaque with central scarring, scalloped borders, and overlying white adherent scale (Fig 1).

Anatomical Findings and Short-term Efficacy of Fascial Anatomy-guided Infrapyloric Lymphadenectomy in Laparoscopic Radical Gastrectomy for Gastric Cancer.

The aim was to investigate the anatomical layers of the specific fascia involved in infrapyloric lymphadenectomy in laparoscopic radical gastrectomy for gastric cancer and to analyze the short-term efficacy of an anatomy-guided surgical approach. On the basis of many years of clinical practice in fascial anatomy-guided laparoscopic radical gastrectomy for gastric cancer, we proposed anatomical considerations for infrapyloric lymphadenectomy in this procedure and investigated the anatomy of the mesentery and mesenteric fusion in this region, including the specific starting and ending points and the plane of the operation. We also retrospectively analyzed the clinical data of 265 patients who underwent fascial anatomy-guided infrapyloric lymphadenectomy in laparoscopic radical gastrectomy for gastric cancer from January 2015 to January 2019 and compared the short-term efficacy between the fascial anatomy-guided laparoscopic infrapyloric lymphadenectomy plus mesogastric excision group and the laparoscopic infrapyloric lymphadenectomy group. Extensive mesenteric fusion and folds exist in the infrapyloric region of the stomach, and removal of the medial fold (medial leg) and lateral fold (lateral leg) of the infrapyloric mesogastrium during surgery is easily missed, resulting in incomplete removal of the infrapyloric mesogastrium. Baseline data were comparable between the laparoscopic infrapyloric lymphadenectomy plus mesogastric excision group and the laparoscopic infrapyloric lymphadenectomy group. The mean operative time for infrapyloric lymphadenectomy, the number of positive lymph nodes harvested in the infrapyloric region, and the number of patients with mesenteric metastasis in the infrapyloric region were not significantly different (P>0.05). The number of harvested lymph nodes was higher in the laparoscopic infrapyloric lymphadenectomy plus mesogastric excision group than in the laparoscopic infrapyloric lymphadenectomy group (5.09±3.30 vs. 4.13±2.90, P<0.05), and intraoperative blood loss was lower in the former group than in the latter group (5.89±3.78 vs. 25.21±11.24 mL, P=0.000). Fascial anatomy-guided laparoscopic infrapyloric lymphadenectomy enables systematic and complete removal of the lymph nodes and mesentery of the infrapyloric region with less intraoperative blood loss.

Diagnosis of Lymphatic Dysfunction by Evaluation of Lymphatic Degeneration with Lymphatic Ultrasound.

Background: The standard examination for diagnosing lymphedema is lymphoscintigraphy, which has a disadvantage in versatility and radiation exposure. We have reported the usefulness of echography in observing the lymphatic degeneration. The purpose of this study was to investigate the usefulness of lymphatic ultrasound in diagnosing lymphedema. Methods and Results: The study included 14 patients (28 lower limbs) who underwent lymphaticovenous anastomosis for lower limb lymphedema. Preoperative echography with a common 18-MHz linear probe was used to detect lymphatic vessels. We evaluated abnormal expansion or sclerosis of lymphatic vessels in the medial legs, which indicated the presence of lymphedema. We proposed the method "D-CUPS" on how to detect and observe the lymphatic vessels. We then performed indocyanine green (ICG) lymphography to diagnose lymphedema. The results of examination were compared. Stage 1 lymphedema was diagnosed in 9 limbs, Stage 2a in 7, Stage 2b in 8, and Stage 3 in 4. Lymphatic vessel detection was possible in all 28 medial thighs and in 27 medial lower legs. The sensitivity and specificity for diagnosis of lymphedema based on echography of the medial leg were 95.0% and 100.0%, respectively. The accuracy rate was 94.6%. We could detect lymphatic vessels with echography in 39 of 54 areas that failed detection using lymphoscintigraphy or ICG lymphography (72.2%). Conclusion: The location and degeneration of lymphatic vessels in lymphedematous limbs can be evaluated with a commonly used ultrasound device. Although exclusion of comorbidities is still necessary, lymphatic ultrasound has potential for use in diagnosis of lymphedema or lymphatic dysfunction.

Can within-subject comparisons of thermal thresholds be used for diagnostic purposes?

ObjectiveQuantitative thermal testing (QTT) is a psychophysical assessment method of small nerve fibers that relies on reference material to assess function. Normal limits for within-subject comparisons of thermal thresholds are scarce, and their association with age, height and sex is not fully elucidated. The aim of this study was to investigate the normal limits for distal-proximal– and contralateral homologous comparisons of thermal thresholds with QTT, and their association with age, sex or height. MethodsFifty healthy volunteers ages 20–79 participated in the experiment. Cold detection thresholds (CDT), warm detection thresholds (WDT), heat pain thresholds (HPT), and cold pain thresholds (CPT) were measured bilaterally at the thenar eminence, anterior thigh, distal medial leg and foot dorsum. Sample normal limits were calculated as (mean) ± 2 SD. ResultsForty-eight subjects were included in the analysis. CPT was excluded from all analyses due to a large floor-effect. Sample normal limits for side-differences ranged from 1.8 to 7.2 °C for CDT, 2.4–6.8 °C for WDT and 3.2–4.0 °C for HPT, depending on anatomical site. For distal-proximal comparisons, sample normal limits ranged from 4.0 to 8.7 °C for CDT, 6.0–14.0 °C for WDT and 4.2–9.0 °C for HPT, depending on the pairs compared. Age was associated with side-differences for CDT in the thenar eminences (p < 0.001) and distal medial legs (p < 0.002), and with 11 of 18 distal-proximal comparisons (p < 0.01). ConclusionsThe normal limits for distal-proximal- and contralateral homologous thermal thresholds were wide, and thus of limited use in a clinical setting, although the reported values may be somewhat inflated by low sample-size and consequent age-pooling. Age, but not sex or height, was associated with contralateral differences in CDT in the thenar eminences and distal medial legs, and with most distal-proximal differences. SignificanceDue to wide normal limits, we advise caution when utilizing relative comparisons of thermal thresholds for diagnostic purposes.

Body composition profile of young inline speed skaters

The aim of this work was to determine the body composition profile of children and young roller skaters. 516 athletes (361 males and 155 females) between the ages of 5 and 21 years old, who belong to official clubs in Colombia and Venezuela, were evaluated longitudinally. The anthropometric variables were taken according to ISAK, using the Holtain© caliper for the skin folds (triceps, anterior thigh and medial leg) and the Sanny© tape for the perimeters (relaxed arm, medial thigh and leg). The treatment for the estimation of the percentage of body fat (%F) and muscle mass (%MM) was performed under the protocol of the GREC and processed by means of SPSS 24.0. The results point to the existence of significant differences (p&lt;0.05) between sexes for %F and %MM. For the development of the profile the methodology of smoothed curves was used with the application of the software LMS Chart Maker© and to generate cut points for the percentiles 3, 10, 75, 90 and 97. It is concluded, that the classification for the proposed body composition, without trying to be a unique norm to establish the typification of the status of the body composition of a skater, allows to distinguish and to categorize with rigor and objecti-vity, the characteristics of the body composition of the skaters independently of the age and competitive level. This work is recommended as a starting point for future studies in larger populations with established probability sampling and ethnicity.

Clinical Presentations of Lumbar Disc Degeneration and Lumbosacral Nerve Lesions.

Lumbar disc degeneration is defined as the wear and tear of lumbar intervertebral disc, and it is mainly occurring at L3-L4 and L4-S1 vertebrae. Lumbar disc degeneration may lead to disc bulging, osteophytes, loss of disc space, and compression and irritation of the adjacent nerve root. Clinical presentations associated with lumbar disc degeneration and lumbosacral nerve lesion are discogenic pain, radical pain, muscular weakness, and cutaneous. Discogenic pain is usually felt in the lumbar region, or sometimes, it may feel in the buttocks, down to the upper thighs, and it is typically presented with sudden forced flexion and/or rotational moment. Radical pain, muscular weakness, and sensory defects associated with lumbosacral nerve lesions are distributed on lower extremities, the buttock, lower abdomen, and groin region. A lumbosacral plexus lesion presents different symptoms in the territories of the lumbar and sacral nerves. Patients with lumbar plexus lesion clinically present with weakness of hip flexion, knee extension, thigh adduction, and sensory loss in the lower abdomen, inguinal region, and over the entire medial, lateral, and anterior surfaces of the thigh and the medial lower leg, while sacral plexus lesion presents clinical symptoms at nerve fibers destined for the sciatic nerve, common peroneal nerve, and pudendal nerve. Weakness of ankle inversion, plantar flexion, and foot drop are the main clinical manifestations of the sacral plexus lesion area. Numbness and decreased sensation are also present along the anterolateral calf and dorsum of the foot. On examination, foot eversion is usually stronger than foot dorsiflexion. The patients may also present with pain and difficulty of bowel movements, sexual dysfunction assessments, and loss of cutaneous sensation in the areas of the anal canal, anus, labia major, labia minor, clitoris, penis, and scrotum.

Leg Injury—ATV Accident

HISTORY: A 16-year-old female presented with a 2 week history of right knee and lower leg pain following an ATV accident. Outside radiographs of the right tibia-fibula, femur, and right foot were reported as normal. She had noted worsening knee pain as well as tingling in her 2nd-5th toes. She was using crutches and non-weight bearing (WB) at presentation. PHYSICAL EXAMINATION: Exam revealed 3/5 muscle strength with great toe flexion/extension, 3/5 strength with ankle dorsiflexion, and 4/5 strength with plantar flexion, inversion, and eversion. Decreased sensation noted in the right 1st web space as well as the lateral, medial, and posterior lower leg. Tinel’s sign postive at fibular head. Lateral proximal tibia and lateral knee joint line tender to palpation. 4/5 strength with painful flexion/extension of knee, but range of motion (ROM) intact. She had 2+ posterior tibialis and dorsalis pedis pulses. DIFFERENTIAL DIAGNOSIS: 1) Proximal Lateral Tibia bony stress injury 2) Peroneal Neuropathy 3) Intra-articular knee derangement TEST AND RESULTS: Due to examination, a knee MRI was obtained as was an EMG/Nerve Conduction Study (NCS) to assess the peroneal nerve. MR Knee revealed a non-depressed subchondral fractures of anterior lateral tibial plateau and femoral condyle. Semimembranosus tendon partial tear near tibial insertion. Grade 1 MCL injury. The EMG/NCS reveaed a mild, acute-subacute, peroneal neuropathy. FINAL WORKING DIAGNOSIS: Non-displaced fractures of lateral tibial plateau and lateral femoral condyle with peroneal neuropraxia. TREATMENT AND OUTCOMES: 1) Initial visit- Ankle Foot Orthosis (AFO) and hinge knee brace provided while MRI and EMG/NCS pending. Remained non-WB with crutches. 2) After MRI and EMG/NCS 1 week later- began home passive and active assisted ROM exercises at home. Continued AFO and crutches when not at home. 3) 4 weeks after first evaluation- began toe-touch WB with progression to partial WB as tolerated and also began PT with right knee/ankle stretching and strengthening. Continued to wear AFO to allow for peroneal nerve healing as she progressed to WB as tolerated. 4) 3 months post injury- AFO removed for activities of daily living but advised against exertional impact activity while completing PT.

Management of varicose ulcer using dressing with unprocessed Haridra, Ghruta,Madhu-a case study.

Varicose ulcer are the wound caused due to improper functioning of venous valve. Venous ulcer develop mostly along the medial distal leg can be painful,can bleed &amp; get infected with negative effect on quality of life .When valve gets damaged,it prevents the backflow of the blood, increases local venous pressure &amp;which turns into venous ulcer. After conservative &amp; surgical treatment ,recurrence of venous ulcer is common ranging about 54-78% by the 5th year after wound healing. In Ayurveda varicose vein correlated with Sirajanyadushtyavrana.Acharya Sushruta more scientifically described wound &amp; its management with help of these specific Ayurvedic adjuvant therapies this kind of ulcer may be treated. A 45 yrs male patient diagnosed with varicose ulcer daily dressing done with Unprocessed Haridra,Ghruta&amp; Madhu for 5weeks.The symptom like Pain, Ankle flare, Discharge, Hyperpigmentation,Size of ulcer &amp; Granulation tissue were assessed. Trial showed that unprocessed Haridra,Ghruta,Madhu is effective in the management varicose ulcer. Hence this study conclude Ancient Management is safe, easily available , devoid Complication &amp; Hence better Acceptability.

Sihler's staining of the cutaneous nerves of the leg and its implications for sensory reconstruction.

This study aimed to reveal the entire cutaneous nerve distribution pattern of the leg and provide a morphological basis for sensory reconstruction during skin flap transplantation. Twelve adult cadavers were fixed with formalin, and the whole leg skin with subcutaneous fat was removed close to the muscle surface. The cutaneous nerves were visualized using modified Sihler's staining to reveal the distribution and innervation density of the cutaneous nerves. The saphenous nerve innervated the anterior part, 82.2% of the upper-middle region of the lateral part of the anterolateral leg, and the upper 63.4% of the medial posterior leg. The superficial peroneal nerve innervated 90.1% of the lateral lower one-third of the anterolateral leg. The medial sural cutaneous nerve covered 26.4% of the posterior leg. The lateral sural cutaneous nerve covered 42.3% (approximately 28.6% overlap with the saphenous nerve) of the upper-middle region of the anterolateral and posterolateral leg. The number of branches differed between certain cutaneous nerves in the leg. Communications were observed between the arborizations of the four cutaneous nerves mentioned above. The highest density of primary and secondary nerve branches was observed in the upper one-third of the lateral posterior leg. The upper one-third of the posteromedial leg contained the highest density of intracutaneous nerve branches and highest number of total nerve branches. These results may be used to map sensory regions when designing leg skin flaps for reconstruction surgery to obtain improved sensory recovery.

Physician interpretation of ultrasound in the evaluation of ankle edema.

The aim of this study was to assess inter‑ and intra‑observer agreement of detection and grading of oedema measured by vascular physicians using ultrasonography. In this observational study, three investigators read 113 videos of ultrasonography of the medial lower leg of 77 patients using a 15-18 MHz linear probe and reported whether oedema was present or not and, if present, to what extent. The videos were selected by the coordinator and sent every two months for a period of six months to the three investigators. Intra‑ and interobserver agreements were calculated using the Fleiss Kappa coefficient, reported with their 95% confidence interval and interpreted using the Landis and Koch values. Inter-observer agreement as to whether oedema was present or not was 0.88 (0.77-0.98), 0.96 (0.89-1.0) and 0.91 (0.80-1.0) for the first, second and third readings, respectively. The concordance was considered to be "excellent." Inter-observer agreement as to the severity of oedema was 0.52 (0.38-0.65), 0.53 (0.39-0.66) and 0.61 (0.47-0.75) for the first, second and third readings, respectively. The concordance was "moderate". Intra-observer reliability for the diagnosis of oedema was only 0.89 (0.70-1.0), 0.93 (0.75-1.0) and 0.92 (0.74-1.0) for the first, second and third reader, respectively, which was "excellent". The inter-observer agreement interpreting ultrasound videos using standard probes was excellent. Only moderate agreement in grading the severity of the edema using our arbitrary criteria was shown.

PD21-03 EFFICACY OF A COIN-SIZED TIBIAL NEUROSTIMULATOR FOR URGENCY URINARY INCONTINENCE

INTRODUCTION AND OBJECTIVE: Existing options for refractory overactive bladder (OAB) treatment lack appeal to most patients given invasiveness or delivery of therapy, or require significant patient compliance and burden on the provider. A novel, subcutaneously implanted tibial neurostimulator (eCoin) has the potential to address such drawbacks while providing a significant clinical benefit. Presented are interim results from the eCoin-2 pivotal trial, a prospective, multi-center single-arm study evaluating the safety and efficacy of eCoin in treating urgency urinary incontinence (UUI) after 24 weeks. METHODS: At 15 U.S. sites, 133 subjects were implanted with eCoin in the medial lower leg during an office procedure under local anesthesia. We included men and women ages 18-80 with at least one daily UUI episode on a 3-day voiding diary. Subjects were washed off OAB medications prior to baseline. The leadless, primary battery-powered eCoin device is slightly larger than a U.S. nickel and delivers automated therapy every 3-4 days for 30 minutes. The primary efficacy variable is the proportion of subjects achieving ≥50% improvement in UUI episodes (responder rate) after 48 weeks of therapy. Secondary outcomes included 3-day voiding diary data and patient reported outcomes. Paired t-tests were used to compare continuous variables between baseline and 24 weeks with differences reported with 95% confidence intervals. RESULTS: At baseline in all subjects, average age (SD) was 64 (11), BMI was 30.4 (8.8), daily UUI episodes was 4.2 (3.1), and the OABq-SF symptom bother score was 65.7 (20.0). 98.5% of subjects were female. The average procedure time was 20.8 minutes. There was one related serious adverse event, a localized infection resolved by device explant. In 113 subjects available at 24 weeks, all measures showed statistically significant improvement: UUI leaks were reduced by -2.7 (p<0.001, 95%CI (-3.2,-2.1)) and the symptom bother score was improved by 32.6 (p<0.001, 95%CI (-37.6, -27.6)). The responder rate was 70.8%, and 77.8% of patients reported feeling at least better on the PGI-I. In patients with ≥10 daily voids at baseline (n=58), frequency improved by -1.9 (p<0.001, (-2.6, -1.1)) from 12.7 mean voids. CONCLUSIONS: The interim data demonstrates that eCoin is safe and effective in treating UUI, delivering meaningful symptom improvement with minimal invasiveness. The eCoin procedure also appears to have a short learning curve and is an easy to perform office-based procedure. Source of Funding: Research was funded by Valencia Technologies.

Pedicled bridge transplantation for soft tissue defects at the contrallateral leg with medial leg skin flap and medial hemi-soleus muscle flap

Objective To evaluate the pedicled bridge transplantation with medial leg skin flap and medial hemi-soleus muscle flap for the treatment of soft tissue defects at the contrallateral leg. Methods Between January of 2012 and January of 2016, 8 patients with soft tissue defects at the leg were treated at Department of Orthopedic Surgery, Hand and Foot Surgery Hospital of Lanzhou. They were 5 men and 3 women, aged from 19 to 50 years (mean, 35 years). All of them were treated by bridge transplantation with medial leg skin flap and medial hemi-soleus muscle flap pedicled with posterior tibial artery. The size of the defects ranged from 10 cm×9 cm to 13 cm×8 cm. The immediate coverage of the muscle flaps and vessel pedicle was repaired by a meshed split-thickness skin graft. The donor site was closed directly. The therapeutic efficacy was assessed at the final follow-up according to the criteria by Iowa for tibial fractures. Results All the skin flaps and muscle flaps survived without any vascular crisis. One case developed necrosis of small skin graft at the distal muscle flap which spontaneously healed after dressing change for 2 weeks. Their follow-up ranged from 2.5 to 4.5 years (mean, 3.8 years). A good contour was confirmed at the recipient area. By the Iowa criteria at the final follow-up, 3 cases were excellent, 4 good and one fair. Conclusion Pedicled bridge transplantation with medial leg skin flap and medial hemi-soleus muscle flap is a good treatment for soft tissue defects at the contrallateral leg which has only one major blood vessel, reducing damage to the donor site. Key words: Leg injuries; Soft tissue injuries; Surgical Flaps; Muscle flap

The repair of the defects of two fingertips with free tibial pedicle double flaps of the second toe

Objective To explore the surgical method and clinical efficacy of two free flaps pedicled with the tibial proper toe artery of the second toe for repair of the defects of two fingertips. Methods From November 2014 to September 2018, five patients with the defects of two fingertips were treated with one pedicle double flaps of the tibial side of the second toe in emergency. The proper artery of the tibial side of the second toe was used as the vascular pedicle. The blood circulation of the two flaps and the injured finger was reconstructed. The donor site was replanted with full thickness skin graft of the medial leg. Results All the 10 finger flaps survived uneventfully. The donor and recipient wounds achieved primary healing without vascular crisis. The postoperative follow-up ranged from 6 to 24 months with an average of 12 months. The appearance, sensation and function of the free flaps recovered well. No second operation was needed to thin the flaps. There were no obvious scar hyperplasia and contracture in the donor site, no abrasion resistance and pain. Conclusion The application of two free flaps from the tibial side of the second toe to repair fingertip defect of two fingers can cover the defect wound, ensure the appearance, sensation and function of the finger, reduce the number of donor sites and damage. It is an ideal repair method. Key words: Finger injuries; Surgical flaps; The second toe; One pedicle and double flaps

Резистентна артеріальна гіпертензія в пацієнта з феохромоцитомою/парагангліомою

Представлено клінічний випадок феохромоцитоми в поєднанні з парагангліомою в пацієнта із резистентною артеріальною гіпертензією (АГ). Феохромоцитома/парагангліома є катехоламінопродукувальною пухлиною з адреномедулярних хромафінних клітин наднирникових залоз або симпатичних і парасимпатичних гангліїв. Перебіг захворювання залежить від характеру та кількості катехоламінів, які виділяє пухлина, а також від того, наскільки стійким чи спорадичним є їх вивільнення в плазму крові. Тому спостерігається стійке підвищення артеріального тиску (АТ), або АГ має пароксизмальний (кризовий) перебіг. Особливістю представленого клінічного випадку є відсутність деяких характерних діагностичних критеріїв. Попри нормальний вміст катехоламінів у добовій сечі, відсутність змін наднирників при ультразвуковому обстеженні, проводився цілеспрямований пошук вторинних причин підвищення АТ. Клінічними виявами феохромоцитоми, окрім підвищеного АТ, були головний біль і серцебиття. Привертала увагу суттєва втрата маси тіла пацієнтом за останні 1,5 року, що обумовлено підвищеним метаболізмом на тлі активації симпатоадреналової системи. При виконанні дуплексного сканування брахіоцефальних артерій у ділянці біфуркації обох загальних сонних артерій виявлено утворення овальної форми з чіткими рівними контурами, що дало підстави запідозрити нетипове розташування феохромоцитоми. Виконано мультиспіральну комп’ютерну томографію з контрастуванням: черевної порожнини, наднирників, нирок та ниркових артерій. У ході дослідження в тілі медіальної ніжки правого наднирника виявлено округле гіперваскулярне утворення з чіткими рівними контурами. Для уточнення діагнозу в пацієнта було вивчено вміст адреналіну і норадреналіну в плазмі крові. Підвищення норадреналіну більш ніж у 4 рази вказувало на наявність катехоламінпродукувальної пухлини. Таким чином, підтверджено діагноз феохромоцитоми правого наднирника і виявлено каротидні парагангліоми шиї. Пацієнту виконана лапароскопічна адреналектомія справа, а також видалення каротидних парагангліом шиї. Дози антигіпертензивних препаратів були суттєво зменшені, АТ знизився до рівня 130–140/80–90 мм рт. ст. Цей клінічний випадок ілюструє необхідність акцентувати увагу лікарів на ймовірності наявності цієї патології за відсутності характерних лабораторно-інструментальних відхилень, що потребує наполегливого пошуку причин АГ.

KORONER ARTER BAYPAS OPERASYONLARINDA OTOLOG VENA SAFENA MAGNA ÇIKARILMASINDA ENDOSKOPİK, TÜNEL VE STANDART YÖNTEMİN KARŞILAŞTIRILMASI

Objective: Autologous vena saphena magna is the most common bypass material used in coronary artery surgery. It is generally prepared with a long medial leg incision, and so healing problems are often observed. In this study, we aimed to compare endoscopic, classical and tunnel techniques in saphen harvesting. Material and Method: Fourty patients, who were selected randomly and retrospectively, were included in the study. Endoscopic saphen harvesting was performed on 10 patients, the tunnel technique was performed on 15 patients and the classical method was performed on 15 patients. Postoperative hospital stay, antibiotics, additional antibiotic requirement, upper leg size, hematoma, open care time, culture antibiogram, incision size, complication site, cost, postoperative complaints, median vena saphena magna harvesting time, vena saphena magna length, closed dressing time, elastic bandage time, drenaige amount, postoperative pain scores (Visual Analogue Scale-VAS) were all factors compared regarding saphen insicion site. Results: In tunnel end endoscopic procedures; insicion length, postoperative pain, major complication rate, incision closure time, the sutur material reqired for closing incisions were lower than the classical technique group. Moreover, the level of patients’ satisfaction was increased due to perfect cosmetic results and ease of early mobilization. Conclusion: Comparing classical saphen harvesting techniques with endoscopic and tunnel methods, it was found that incision problems, length of hospital stay, sutur material amounts, incision closure time, incision length and postoperative pain were detected in lower numbers in endoscopic and tunnel methods. Depending on these factors, the patient’s mobilization time was shortened. According to these results, the superiority of the endoscopic and tunnel methods compared to the classical method should be considered.

Myofascial trigger point: an indicator of acupoint sensitization

The present study is to investigate the characteristic distribution of primary pain points and referred pain areas in patients with knee-joint pain diseases, therefore revealing the correlation between the myofascial trigger point and acupoint sensitization. A total of 483 patients (320 men and 163 women, 36 to 72 years in age) with knee-joint pain recruited from 4 clinical centers were observed from July, 2017 to April, 2019 in the present study. The areas of primary and referred pain in these patients were detected by thumb-pressing and marked on human anatomic atlas. Of the 483 enrolled participants, 336 had lesion sites or tender points around the injured knee joint, and 147 with myofascial pain syndrome showed referred pain spots (zones) in the knee joint area. In 105 patients with patellar tendonitis, epiphysitis of the tibial tubero-sity, or quadriceps tendonitis, the pain area was mainly distributed in the anterior region of the knee. In 76 patients with medial collateral ligament injury, medial meniscal lesion, goose foot bursitis or semimembranosus ending-point inflammation, the pain points mainly occurred in the medial area of the knee. In 127 patients with lateral collateral ligament, lateral meniscus lesion, iliotibial band tendonitis, popliteus or triceps tendinitis, the pain spots were found in the lateral region of the knee. In 28 patients with posterior cruciate ligament injury or popliteal fossa tendonitis, the local pain was found to be at the back of the knee. Referred pain areas were normally detected in the lateral femoral muscles (43 cases), anterior femoral muscles (39 cases), adductor group of femur (26 cases), posterior popliteal fossa muscles group (15 cases), hamstrings (13 cases) and medial leg (11 cases)．. The primary pain areas or spots of the knee injury mainly distribute around the joint, whereas those of each muscle group lesion are often located in their respective skeletal muscle. Most of the referred pain areas often occur in the distal end of skeletal muscle and around the knee joint. Primary myofascial trigger points may be considered to be an indicator of acupoint sensitization.

Différences des insertions musculaires dans le medial stress syndrome de Jambe. Étude in vivo

IntroductionThe medial tibial stress syndrome is one of the most common causes of running-related injuries. The primary study objective was to observe the attachment proportion of flexor digitorum longus and soleus, at the most common location of medial tibial stress syndrome, using ultrasonography, on a large cohort of young males and females to evaluate for gender-based anatomical differences. The secondary objective of this study was to investigate the relationship between the anatomical features and medial tibial stress syndrome. MethodsIn this study, we observed whether or not flexor digitorum longus and/or soleus attached at the middle and distal thirds of the medial margin of the tibia (most common location of medial tibial stress syndrome) using ultrasonography. History of medial tibial stress syndrome was defined by inquiries. ResultsThe chi-square tests showed that the attachment proportion of the soleus in female participants was significantly higher than that observed in male participants. In addition, chi-square testing showed that there were no significant differences between attachment proportion of soleus of legs with history of medial tibial stress syndrome and legs without history of medial tibial stress syndrome, in both male and female participants. ConclusionsThese results suggested that the anatomical features of flexor digitorum longus might be involved in medial tibial stress syndrome development, whereas the anatomical features of the soleus might not be involved in medial tibial stress syndrome development. Level of clinical evidenceIII, cross sectional study.

Differences in muscle attachment proportion within the most common location of medial tibial stress syndrome in vivo

IntroductionThe medial tibial stress syndrome is one of the most common causes of running-related injuries. The primary study objective was to observe the attachment proportion of flexor digitorum longus and soleus, at the most common location of medial tibial stress syndrome, using ultrasonography, on a large cohort of young males and females to evaluate for gender-based anatomical differences. The secondary objective of this study was to investigate the relationship between the anatomical features and medial tibial stress syndrome. MethodsIn this study, we observed whether or not flexor digitorum longus and/or soleus attached at the middle and distal thirds of the medial margin of the tibia (most common location of medial tibial stress syndrome) using ultrasonography. History of medial tibial stress syndrome was defined by inquiries. ResultsThe Chi2 tests showed that the attachment proportion of the soleus in female participants was significantly higher than that observed in male participants. In addition, Chi2 testing showed that there were no significant differences between attachment proportion of soleus of legs with history of medial tibial stress syndrome and legs without history of medial tibial stress syndrome, in both male and female participants. ConclusionsThese results suggested that the anatomical features of flexor digitorum longus might be involved in medial tibial stress syndrome development, whereas the anatomical features of the soleus might not be involved in medial tibial stress syndrome development. Level of evidenceIII, cross-sectional study.

Establishment of experimental model for saphenous artery perforator flap in mini pig

Objective To investigate the anatomy characteristics of saphenous artery(SA) and its perforator vessels in mini pig, and to provide a new perforator flap animal model. Methods Between May, 2018 and August, 2018, 6 7-months-old mini pigs weight 25 kilograms were sacrificed by blooding under general anesthesia. The bilateral external iliac arteries were injected with a mixture of latex-lead oxide mixture and underwent CT-scanning to provide 3-dimensional reconstruction. The origin, diameter, courses and distribution of the SA and perforators of both hind limbs were observed. Results One of the hind limbs was abandoned due to the leakage of perfusion fluid. The other 11 hind limbs were available. The femoral artery passed through the medial femoral muscle and sartorius muscle in the middle of thigh, and run between the medial femoral muscle and gracilis muscle above the knee. Below the knee, it run on the surface of the medial leg muscles. A number of small branches were distributed in the tarsal joint and calcaneus at the medial malleolus, and there were abundant communicating branches with the posterior tibial artery. The average length of SA was (14.86±0.76) mm. The outer diameters of SA at initiative, medial tibial condyle and medial malleolus were(1.73±0.15) mm, (1.50±0.12) mm and (1.30±0.13) mm, respectively. There were a total of 79 perforators which were identified, with a mean of (7.09±1.16) perforators per hind limbs. And the average outer diameter was 0.10-0.78 (0.40±0.13) mm. Conclusion The SA constantly exist with good outer diameter. The number of perforator is abundant. SA can be used as a reliable animal model for studying and training of perforator flap. Key words: Saphenous artery; Perforator flap; Mini pig; Animal model