Pectineus Research Articles

Effect of pectineus muscle plane block versus femoral nerve block for postoperative analgesia and early recovery after knee surgery: a randomised controlled trial study protocol

BackgroundFemoral nerve block (FNB) is a prevalent method used for postoperative pain management after knee surgery; however, it decreases the strength of the quadriceps muscle and is not conducive to...

Poster 214: Cross Sectional Area of Hip Muscles Before and After Surgery for Femoroacetabular Impingement

Objectives: Femoroacetabular impingement (FAI) syndrome is a common cause of hip pain and surgery is a treatment option for patients who do not respond to conservative treatment. Previous studies have identified increases in postoperative hip muscle volume and cross-sectional area (CSA) as associated with increases in patient reported outcomes following hip surgery. There has been a lack of literature analyzing the change of hip muscle cross sectional CSA on MRI following arthroscopic hip surgery for FAI and the effect of changes in hip muscle CSA on patient reported outcomes following surgery. The purpose of this study is to analyze the change in hip muscle cross sectional area (CSA) after arthroscopic surgery for FAI syndrome. Methods: This is a single center, single surgeon, retrospective analysis performed between August 2007 and May 2023. All patients who had a pre-operative MRI within 1 year of their date of surgery and at least one postoperative MRI were included in the study. Cross sectional areas were measured by one blinded researcher and results were checked for reliability by a musculoskeletal radiologist. Statistical analysis was completed using SPSS, Version 24 and normally distributed continuous variables between cohorts were compared using the two-sample Student t test. Results: Initially 1390 patients were included in the study but only 95 were found to have a preoperative hip MRI within 1 year of their date of surgery as well as a postoperative MRI. The average age of the cohort was 35.8 ± 15.7, the cohort was 33.7% male and 66.3% female, and had an average BMI of 23.3 ± 8.1. The mean time between surgery and postoperative MRI was 14.8 ± 8.3 months. There was a significant difference between preoperative and postoperative hip muscle CSA for gluteus maximus (4298.6±883.6 mm2 vs. 4384.6±967.6 mm2, p<0.01), gluteus minimus (1037.0±199.2 mm2 vs. 1074.9±202.3 mm2, p<0.001), and pectineus (415.7±121.9 mm2 vs. 426.7±106.3 mm2, p=0.04). There were no other significant differences between preoperative and postoperative hip muscle CSA values between the other muscles analyzed. A linear regression found that an increase in the change in CSA of the gluteus maximus significantly predicted an increase in mHHS at 1 year (β=3.103, p=0.046) when controlling for age, sex, BMI and time from surgery to postoperative MRI. A linear regression found that an increase in the change in cross sectional area of the pectineus significantly predicted an increase in NAHS at 1 year when controlling for age, sex, BMI and time from surgery to post-op MRI (β=0.186, p=0.037). Conclusions: Patients who undergo surgery for FAI have significantly increased gluteus maximus, gluteus minimus and pectineus muscle CSA on post-operative MRIs. Furthermore, increases in both gluteus maximus and pectineus muscle CSA was found to be significantly associated with increases in mHHS and NAHS at 1 year follow up respectively.

History of the hip joint pectineofoveal fold.

Although Josias Weitbrecht described the retinacula of the hip joint in his 1742 Syndesmologia, the anatomist Cesare Amantini of Perugia specifically studied the medial retinacula he referred to as the pectineofoveal fold in a late 19th-century monograph. This particular synovial fold stretches from the lesser trochanter to the osteocartilaginous junction of the femoral head along a virtual line connecting the lesser trochanter and the fovea for the ligament of the head. Although mentioned by some anatomists and radiologists, and despite its possible involvement in specific hip joint pathologies (fractures, impingements), it is surprising that Amantini's pectineofoveal fold remains ignored by most anatomy and clinical anatomy books. This study aims to verify if Cesare Amantini effectively drew attention to this synovial fold for the first time and coined the term "pectineofoveal fold," as well as determine whether most classical textbooks (i.e., published from 1890 to 2017) acknowledge the discovery and include it in the description of the hip joint. A possible evolutionary link between this synovial fold and the ambiens and pectineus muscles exists and should be discussed.

B-mode ultrasonography and ARFI elastography of articular and peri-articular structures of the hip joint in non-dysplastic and dysplastic dogs as confirmed by radiographic examination

BackgroundCanine hip dysplasia is a common orthopedic disease in veterinary practice. The diagnosis is made by radiographic examinations that evaluate bone alterations associated with hip dysplasia. Although radiographic examination is the gold standard for diagnosis, it does not allow a detailed evaluation of soft tissues such as the joint capsule and periarticular muscles. This study aimed to evaluate the accuracy of B-mode ultrasonography and acoustic radiation force impulse (ARFI) elastography in assessing the joint capsule and periarticular muscles of dogs using the Orthopedic Foundation of Animals (OFA) classification and the distraction index (DI) in the early and late diagnosis of hip dysplasia. This study sought to propose a protocol for the ultrasonographic evaluation of the structures involved in canine hip dysplasia.MethodsRadiographic and ultrasonographic evaluations were performed on 108 hip joints of 54 dogs. Thirty dogs were older than 2 years and 24 were aged between 4 and 10 months.ResultsIt was verified that an increase in pectineus muscle stiffness (cutoff value > 2.77 m/s) by elastography in some dysplastic dogs and an increase in the thickness of the joint capsule (cutoff value > 0.9 mm) in B-mode ultrasonography, were associated with a distraction index > 0.5, with both having a positive correlation. In B-mode ultrasonographic evaluation, the presence of signs of degenerative joint disease, such as irregularities of the cranial edge of the acetabulum and femoral head, were associated with a distraction index > 0.5 in canines, with a specificity of 94%. In adult dogs, the findings of degenerative joint disease on ultrasound were associated with a diseased OFA classification (P < 0.05). Measurement of the joint capsule > 1.10 mm was diagnostic for dysplasia in unhealthy dogs by OFA.ConclusionsARFI elastography has shown that the pectineus muscle may experience changes in stiffness in dysplastic animals. Additionally, changes in joint capsule thickness can be identified in B-mode in young and adult dogs with dysplastic joints, which contributes to the diagnosis of hip dysplasia.

Location of Trigger Points in a Group of Police Working Dogs: A Preliminary Study.

This study examined the percentage and location of trigger points in police working dogs. Twelve dogs housed at a military police kennel were selected through convenience sampling. Only active dogs with no comorbidities or radiographic changes doing 6 hours of intense physical activity per day were included. After orthopedic and neurological examination, dogs were palpated for the detection of trigger points (TPs), carried out by two independent examiners, with criteria of palpations previously standardized. TPs were recorded using an anatomy reference image according to the corresponding anatomical location. The percentage of TPs was highest in the lumbar portion of the longissimus dorsi muscle (42%), followed by the latissimus dorsi, pectineus, quadriceps femoris, and sartorius (33%) muscles. Most TPs were located on the right side of the body. This study's percentage of TPs in police working dogs was higher in spinal and hind limb muscles, especially on the right side. The major criteria for identifying TPs in dogs were the pain responses to palpation and contractile local response. The findings of this study could be used to refine myofascial pain prevention to reduce early retirement due to musculoskeletal pain and draw attention to this kind of problem that can also affect dogs.

Superficial anatomic landmarks can be used to triangulate the location of canine peripheral lymphocentrums: superficial cervical, axillary, and superficial inguinal.

To utilize the geometry of superficial anatomic landmarks to guide incisional location and orientation for peripheral lymphadenectomy, document deep anatomic landmarks for lymphocentrum identification, and develop novel surgical approaches to the superficial cervical, axillary, and superficial inguinal lymphocentrums in dogs. 12 canine cadavers. 2 cadavers were used for a pilot investigation to determine optimal body positioning, select superficial anatomic landmarks for lymphocentrum identification, and evaluate novel surgical approaches to the 3 lymphocentrums. These lymphocentrums were then dissected in 10 additional cadavers using these novel surgical approaches. Measurements of the distances from lymphocentrum to landmark and between landmarks were obtained for each lymphocentrum. Deep anatomic landmarks were recorded for each dissection. The mean and SD were calculated for each measurement and used to develop geometric guidelines for estimating the location of each lymphocentrum for these surgical approaches. Each peripheral lymphocentrum was found in the same location relative to the respective, predetermined, superficial, anatomic boundaries in all cadavers. Briefly, the superficial landmarks to each lymphocentrum were as follows: (1) superficial cervical: wing of atlas, acromion process of scapula, greater tubercle of humerus; (2) axillary: caudal border of transverse head of superficial pectoral muscle, caudal triceps muscle, ventral midline; and (3) superficial inguinal: origin of pectineus muscle, ipsilateral inguinal mammary gland, ventral midline. The proposed superficial and deep surgical landmarks were identified within every cadaver. The previously undescribed surgical approaches were effective for lymphocentrum identification. Anatomic landmarks provided in this study may help reduce surgical time and tissue trauma during peripheral lymphadenectomy in dogs. This study was also the first to describe a surgical approach to the superficial inguinal lymphocentrum and ventral approaches to the superficial cervical and axillary lymphocentrums and provided previously unpublished anatomic landmarks for a lateral approach to the superficial cervical lymphocentrum.

A rare femoral heterotopic bone formation in a 14th-19th century female skeleton from Constância (Portugal)

ObjectiveThis paper aims to: (1) document a rare femoral heterotopic ossification (HO), and (2) discuss its aetiology and impact on the individual's locomotion and daily living activities. MaterialsAdult female skeleton (SG.14-SK.7) from the village of Constância (Portugal), and dated from the 14th-19th centuries CE. MethodsThe biological profile and the macroscopic analysis of the bone changes were assessed using standardized methods. ResultsThe macroscopic analysis revealed a large bony mass (8 cm length) located immediately inferior to the small trochanter of the right femur. The lesion exhibited a compact, tubular appearance located at the site of attachment of the pectineus muscle. No signs of bone fracture were observed. ConclusionsThe morphology of the SG.14-SK.7 femoral lesion is compatible with a probable case of myositis ossificans traumatica (MOT), secondary to acute trauma of the pectineus muscle. The underlying trauma episode, such as random accidental and/or occupation-related injury, is unknown. However, it is highly possible that this self-limiting condition significantly impaired the individual's daily life and mobility. SignificanceEvidence of severe acute muscle trauma is a rare finding compared with HO secondary to bone trauma and other minor muscle injuries. Moreover, no cases of MOT affecting the pectineus muscle have been reported in the paleopathological literature to date. LimitationsAlthough unlikely, a case of neurogenic or burn-related HO cannot be completely disregarded. It was not possible to undertake radiography as part of this study. Suggestions for further researchThe use of imaging techniques to complement the paleopathological description is advised.

Can different positions facilitate block application in ultrasound-guided obturator nerve block? A prospective comparative study

&lt;b&gt;Objective&lt;/b&gt;: We aimed to compare the distances of the landmarks to the skin, image quality, and ease of application in the ultrasound-guided obturator nerve block (ONB) in different positions.&lt;br /&gt; &lt;b&gt;Materials and Methods:&lt;/b&gt; 40 volunteers aged between 20-65 years were included in the study. The distances of the landmarks (anterior and posterior branches of the obturator nerve; junction of the abductor longus and abductor brevis muscles with the pectineus muscle) to the skin, which were taken as a reference for the ultrasound-guided obturator block, were measured and compared in 3 different positions (P1=Neutral position; P2=45&lt;sup&gt;o&lt;/sup&gt; Abduction; and P3=Flexed knee) given to the leg. We also evaluated the quality of the ultrasound image and the ease of application in each measurement by assigning a subjective observer score and comparisons were made for three positions.&lt;br /&gt; &lt;b&gt;Results:&lt;/b&gt; While the mean of the distances of the landmarks to the skin were the shortest in P3 and the longest in P1 position, there was no significant difference between the groups (p&amp;gt;0.05).&lt;b&gt; &lt;/b&gt;A statistically significant difference was observed between P1 and P3 in the distance of the junction of the muscles to the skin surface (p&amp;lt;0.05). The highest score for the clarity of ultrasound images and ease of accessing the measurement points was the P3 position (p=0.00). In addition, in our correlation analysis, we found that as the distance of the landmarks to the skin surface decreased, the image clarity and the ease of access to the obturator nerve (score) increased, where p&amp;lt;0.05.&lt;br /&gt; &lt;b&gt;Conclusions&lt;/b&gt;: In ultrasound guided ONB, in P3 position landmarks get closer to the skin, and image clarity and ease of detection for landmarks increases in parallel with this position. As a result, the ultrasound guided ONB can be best done by giving flexed knee position.

Morphometry of the internal structures of the graylag goose (Anser anser) heart

As a result of our research, it was found that the heart of the graylag goose Anser anser is a hollow muscular organ weighing 28.950±0.08 g in females (relative 0.73%), 29.091±0.09 (0.69%) in males, with a length: ♀ 51.55±0.07 mm, ♂ 52.66±0.08; it is oval, slightly elongated. Auricular appendices are oval, slightly elongated, in size: the right one with a length ♀14.98±0.05 mm, ♂ 15.57±0.06; with a width ♀ 21.99±0.0 mm, ♂ 22.23±0.05; their wall thickness data are as follows: ♀ 0.47±0.05 mm, ♂ 0.49±0.06; left – ♀ 12.27±0.05 mm, ♂ 12.98±0.06; ♀ 14.89±0.07 mm, ♂ 15.04±0.08; ♀ 0.71±0.03, ♂ 0.78±0.02 mm, respectively; the convex base. The pectineus muscles are located in the walls of the auricular appendices. From the interatrial crest, four to eight pectineal muscles extend, which are connected by smaller muscles, thereby forming a finely looped network. The left ventricle is ♀ 40.97±0.09 mm long, ♂ 41.05±0.08; with a width ♀ 14.89±0.09, ♂ 14.98±0.09; wall thickness ♀ 8.29±0.05, ♂ 8.35±0.07. It contains a tricuspid valve, which has three cusps: septal, caudal, lateral. The right ventricle is ♀ 31.39±0.05 mm long, ♂ 31.49±0.05; with a width ♀ 6.29±0.03, ♂ 6.39±0.05; wall thickness ♀ 2.89±0.03, ♂ 2.91±0.04, has a crescent-shaped atrioventricular opening. The valve length is ♀ 19.17±0.04 mm, ♂ 21.17±0.05 mm.

The anatomy of the obturator nerve and its branches in a South African cadaver sample

PurposeSeveral surgical and clinical procedures are performed in the area of the medial compartment of the thigh. This places the obturator nerve and its branches in potential danger of injury. This study aimed to provide a clear description of the anatomy and course of the obturator nerve and its branches. Methods: One hundred and one formalin-fixed cadavers were dissected just lateral to the lumbar vertebra to describe the origin and course of the obturator nerve, as well as its relation to other anatomical structures. The location of the obturator nerve within the obturator foramen was quantified by measuring the distance from three bony landmarks of the obturator foramen to the nerve. Findings: In 20% of cases the obturator nerve originated from L3 and L4 rather than L2 to L4 in the combined sample. The bifurcation of the nerve occurred intrapelvically in 2% of cases, within the obturator canal in 93% of cases and extrapelvically in 5% of the sample. Regarding the course in the abdomen, the L3 root joined the L4 root more distally after exiting the psoas major muscle. In all cases on the left (n = 97) and 99% on the right, the anterior branch innervated the muscles of the medial thigh, in one case on the right the anterior branch innervated the pectineus muscle. The posterior branch assisted the anterior branch in the innervation adductor brevis in 10% on the left and 11% on the right sides. ConclusionThe results of this study may be used in the pre-operative preparation of surgeons that are to perform surgery in the area of the obturator foramen such as obturator nerve blocks for pain relief of adductor muscle contractions, prevention of adduction of the thigh during transurethral bladder surgery, additional analgesia after knee surgery, chronic hip pain, as well as postoperative analgesia after hamstring harvest for anterior cruciate ligament reconstruction.

248 Rectus flap for repair of Strangulated Obturator Hernia

Abstract Introduction Obturator hernia (OH) is a rare abdominal wall hernia which commonly presents as small bowel obstruction. Surgical options include suture repair or use of autologous tissue or a mesh repair when primary suture repair is not feasible. We describe a case involving the use of the rectus abdominus muscle to repair a large OH. Case report An 81-year-old female presented with three days of abdominal distension and vomiting. A computerised tomography scan confirmed small bowel obstruction due to an obstructed left OH. At laparotomy, a short segment of non-viable distal ileum was reduced from the sac and resected with a primary anastomosis. The obturator defect was not amenable for suture approximation and due to concerns of possible mesh infection, the ipsilateral rectus muscle belly was mobilised from the anterior sheath, routed extra-peritoneally to plug the defect without tension. The muscle was anchored with prolene sutures to the cooper’s ligament, pectineus muscle and the fascia overlying the inner surface of inferior pubic ramus. Four months post-operatively, she has made an excellent recovery with no concerns currently. Conclusions In OH with a large defect precluding primary suture repair, a range of options have been described (use of autogenous peritoneal fold, pectineus muscle, round ligament, ovary, uterine fundus, omental and mesh plugs, and biological mesh). We believe, to plug and cover the defect, rectus muscle flap is a viable option giving a tension free robust repair, especially in patients with gangrenous bowel and local contamination.

Morphologic classification and innervation patterns of the pectineus muscle.

The purpose of this study was to identify the frequency of pectineal hiatus and of pectineus innervations, including femoral, obturator, and/or accessory obturator nerves. Also, this study sought to detailed intramuscular nervous distributions, with a particular focus on the relationship of nerves in multi-innervated pectineus. One hundred (49 right and 51 left) thighs from 52 cadavers (25 men and 27 women) were dissected. The morphology and innervations of the pectineus were investigated. Modified Sihler's whole-mount nerve-staining method was employed for visualization of the intramuscular nerve-distribution patterns of the pectineus. Variation of the pectineus forming a hiatus was identified in 18% of the specimens. The femoral innervations to the pectineus were identified in all specimens. Additional innervation either by the obturator or the accessory obturator branch to the pectineus was identified in 10% or 2% of specimens, respectively. No case of triple innervation to the pectineus was observed. In cases of dually innervated pectineus, two nerves formed a communication system inside the muscle. Among the three nerves supplying the pectineus, the femoral nerve branched more than the other two nerves and covered the greatest area in the muscle. The pectineal hiatus appears to be a common variation. The femoral nerve branch in a dually innervated pectineus is the dominant nerve component that supplies the muscle when considering frequency, branching pattern, and area, even though cooperation between two nerve components is implied. This study serves to advance the existing anatomical knowledge about the pectineus muscle, which is of clinical value.

Improvement of analgesic efficacy for total hip arthroplasty by a modified ultrasound\u2010guided supra\u2010inguinal fascia iliaca compartment block

BackgroundFascia iliaca compartment block (FICB) is an anterior approach to the lumbar plexus block and provides the effective adjunctive analgesia for total hip arthroplasty (THA).MethodsAs a case series study, 28 patients (≥ 65 years old) with THA were received a modified in-plane ultrasound-guided supra-inguinal (S-FICB) as an analgesic adjunct to evaluate the analgesic effectiveness and the local anesthetic diffusion with magnetic resonance imaging (MRI). A combination of propofol and sufentanil was administered to conduct target-controlled infusion.ResultsThe pain scores were 1 (0–4), 2 (1–5), 3 (1–6) and 3 (1–6) at 4, 8, 12, and 24 h. The cumulative opioids were 8 (8–12), 18 (16–32), 28 (24–54) and 66 (48–104) mg of i.v. morphine equivalents at 4, 8, 12, and 24 h. The patient-controlled analgesia (PCA) times were 0 (0–1), 1 (0–2), 2 (0–5) and 5 (3–8) at 4, 8, 12, and 24 h. In lateral, anterior and medial part of thigh, the sensory blockade in 28 patients was 23 (82 %), 21 (75 %) and 19 (68 %) at 5 min; 28 (100 %) at 10 and 20 min. Motor blockade of femoral nerve (FN) and obturator nerve (ON) was present in 13 (46 %) and 3 (11 %) patients at 5 min, 24 (86 %) and 9 (32 %) at 10 min, 26 (93 %) and 11 (39 %) at 20 min. Injectate permeated to the FN and extended superiorly over the surface of iliac muscle (IM) and pectineus muscle (PM) in all patients.ConclusionsThe modified S-FICB has provided an effective postoperative analgesic adjunct after THA with the satisfactory blockade of femoral (FN), obturator (ON) and sciatic (SN) nerves, especially for ON, when compared with the existing techniques.

Variation of pectineus muscle forming a hiatus

Knowledge of the anatomic variations in the pectineus muscle is important for vascular surgeons to minimize complications following surgical approach to the distal part of the deep femoral artery. During routine dissection of the thigh, variations in the bilateral pectineus muscles were identified in an 82-year-old male cadaver. On both sides, the superficial and deep layers of the pectineus were divided at its distal part, forming a triangular-shaped hiatus between them and the femur shaft. Distally, the tendon of the superficial part intermingled with the tendon of the adductor longus. The tendon of the deep part was inserted into the pectineal line. On the right side, the deep femoral artery and its first perforating artery passed through the hiatus. On the left side, the deep femoral artery pierced the hiatus, and then, the first perforating artery was branched from the deep femoral artery. No reported case has described a pectineal hiatus. The variations observed in this study are an ontogenetic vestige of the two different origins of the pectineus. The insertion of the superficial layer into the adductor longus tendon suggests a close relationship between these muscles during prenatal development. Surgeons should be aware of the variation to minimize injury to the pectineus muscle while approaching the deep femoral artery.

B mode ultrasonography and elastography in the evaluation of the pectineus muscle in dogs with hip dysplasia

The goal of this study was to describe and compare B mode and elastographic characteristics of the pectineus muscle of healthy dogs with dysplastic dogs. Thirty-one dogs (62 limbs) with hip dysplasia and 17 nondysplastic dogs (34 limbs) were evaluated. The hip dysplasia score was defined according to the Fédération Cynologique Internationale. Using B mode, echotexture and echogenicity of different regions of the pectineus muscle were evaluated. By means of ARFI elastography, qualitative (elastogram) and quantitative (shear wave velocity) tissue stiffness was assessed. B mode findings demonstrated a hyperechoic and heterogeneous pattern of the pectineus tissue in dogs with hip dysplasia, with compromised muscular delimitation and loss of its normal sonographic appearance, indicating the disease (P &lt; 0.001). In the elastogram, it was observed that dogs with hip dysplasia showed less deformable pectineus muscle, with red colors (rigid). In quantitative evaluation, the different regions evaluated presented similar shear wave velocities; in dysplastic patients, shear wave velocities were higher compared to nondysplastic animals, with values higher than 2.85 m/s being strong indicators of the disease. Values of shear wave velocity were also influenced by the grade of dysplasia and age of the patients; however, there was no correlation with the depth of the evaluated area or body weight. It was concluded that pectineus muscle in dogs with hip dysplasia presents B mode and elastographic changes when compared to normal animals, demonstrating that these techniques might aid the evaluation of diseased dogs.

Localization of the center of the intramuscular nerve dense region of the medial femoral muscles and the significance for blocking spasticity

PurposeTo identify the body surface position and depth of the center of the intramuscular nerves dense region (CINDR) of the medial femoral muscles. MethodsUtilizing twelve Chinese adult cadavers (six men and six women), with an age range from 35 to 75 (66.5±5.4) years, the body surface curves between the greater trochanter of the femur and the pubic tubercle and lateral femoral epicondyle were designated as horizontal (H) and longitudinal (L) reference lines, respectively. Sihler's staining was performed on one side of the medial femoral muscles to show the intramuscular nerve dense regions, and the contralateral CINDR was labeled with barium sulfate and scanned by computed tomography, and three-dimensional reconstruction was performed. The body surface projection point of CINDR was designated as P. Projection of P in the opposite direction was identified as P′. The intersection of the longitudinal line from P to line H, and that of the horizontal line from P to line L was designated as PH and PL, respectively. The percentage positions of PH and PL on the H and L lines and the depth of the CINDRs were determined under the Syngo system. ResultsThe pectineus, gracilis, adductor longus, and adductor brevis muscles each possess one intramuscular nerve dense region; the adductor magnus muscle has two. The PH was located at 80.32%, 95.67%, 85.64%, 94.92%, 84.48%, and 88.83% of line H, respectively. PL was at 12.76%, 40.68%, 33.26%, 23.39%, 25.57%, and 35.29% of line L, respectively. The depth of CINDRs was at 17.58%, 27.89%, 23.05%, 30.45%, 34.09%, and 29.52% of PP′ line, respectively. These percentage values are all means. No statistical difference was observed neither between the left and right sides nor between the male and female cadavers (P>0.05). ConclusionThese results may help improve the efficiency and efficacy of botulinum toxin A injection in the treatment of medial femoral muscle spasticity.

RETRACTED: Below-knee amputation following the pectineus muscle plane block and sciatic nerve block

RETRACTED: Below-knee amputation following the pectineus muscle plane block and sciatic nerve block

Twitching of the Pectineus Muscle Under Ultrasound-Guided Complete Obturator Nerve Block at the Inguinal Crease: A Case Report

Introduction: This report showed that clinically significant adductor muscle contraction can be possible even when the anterior and posterior branches of the obturator nerve are completely blocked. Case Presentation: A 66-year-old male patient visited Gil Medical Center, Gachon University College of Medicine, Incheon, South Korea during the year 2016. He underwent transurethral resection of the bladder (TURB) of a bladder tumor under spinal anesthesia and obturator nerve block (ONB). ONB was performed at the right-side inguinal crease by an ultrasound-guided block of the anterior and posterior branches. At the beginning of surgery, he exhibited grade IV obturator reflex; therefore, general anesthesia was applied and the surgery completed. After the effect of neuromuscular blockade had been completely reversed, we confirmed twitching of the pectineus muscle by ultrasound using a nerve stimulator (stimulation current 0.3 mA). Main branches of the right obturator nerve were still completely blocked when we rechecked the previously blocked-site (stimulation current 2 mA). Conclusions: The described case cautions that investigators must be aware more than two branches may pass adjacent to interfascial layers at the inguinal crease level and that a missed obturator nerve branch might result in severe adductor muscle contraction. We report this observation and suggest the possibility of an anatomical variant that requires the need for nerve stimulation and ultrasound for obturator nerve block verification.

The fascial connections of the pectineal ligament.

In clinical settings, the pectineal ligament forms a basic landmark for surgical approaches. However, to date, the detailed fascial topography of this ligament is not well understood. The aim of this study was to describe the morphology of the pectineal ligament including its fascial connections to surrounding structures. The spatial-topographical relations of 10 fresh and embalmed specimens were dissected, stained, slice plastinated, and analyzed macroscopically, and in three cases histological approaches were also used. The pectineal ligament is attached ventrally and superiorly to the pectineus muscle, connected to the inguinal ligament by the lacunar ligament and to the tendinous origin of rectus abdominis muscle and the iliopubic tract. It forms a site of origin for the internal obturator muscle, and throughout its curved course, the ligament attaches to both the fasciae of iliopsoas and the internal obturator muscle. However, dorsally, these fasciae pass free from the bone, while the pectineal ligament itself is adhered to it. The organ fasciae are seen apart from the pectineal ligament and its connections. The pectineal ligament seems to form a connective tissue junction between the anterior and medial compartment of the thigh. This ligament, however, is free to other compartments arisen from the embryonal gut and to the urogenital ridge. These features of the pectineal ligament are important to consider during orthopedic and trauma surgical approaches, in gynecology, hernia and incontinence surgery, and in operations for pelvic floor and neovaginal reconstructions. Clin. Anat. 32:961-969, 2019. © 2019 Wiley Periodicals, Inc.

Successful Management Of Tumor-Induced Osteomalacia with Radiofrequency Ablation: A Case Series.

ABSTRACTTumor‐induced osteomalacia (TIO) is a curable condition when the tumor is correctly located and completely removed. These tumors are, however, small and located in regions that make surgical removal difficult and sometimes risky in some patients. Experience of radiofrequency ablation (RFA) in the management of TIO is limited. We describe 3 patients with TIO who were treated in our hospital with RFA. They had suspected lesions in surgically difficult locations and were subjected to single sessions of RFA. The response was documented in terms of improvement in symptoms, normalization of hypophosphatemia and hyperphosphaturia, and disappearance of uptake on follow‐up Ga68 DOTANOC PET/CT imaging. All 3 patients had a clinical and biochemical profile consistent with TIO. The first patient (patient 1) had an intensely Ga68 DOTANOC avid lesion involving the roof of right acetabulum. The second patient (patient 2) had a Ga68 DOTANOC avid intramuscular lesion in left pectineus muscle and the third patient (patient 3) had a Ga68 DOTANOC avid expansile osteolytic lesion involving the angle and ramus of right mandible. All 3 patients achieved complete biochemical as well as clinical remission with single sessions of RFA. Six months after the procedure, Ga68 DOTANOC imaging revealed the absence of uptake at the previous sites, corroborating with the clinical improvement and normalization of hypophosphatemia and hyperphosphaturia. In conclusion, although surgical resection is the standard of care, RFA can be used successfully for treating patients with TIO. It can be an effective, less invasive, and safe modality of treatment in those patients where resection of the lesion is not possible because of inaccessible anatomical location or comorbidity that prohibits surgery. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.