Popliteal Region Research Articles

Evaluation of an Axial Pattern Flap Based on the Cranial Cutaneous Branch of the Saphenous Artery: A Cadaveric Perfusion Study.

To confirm the anatomic location of the cranial cutaneous branch of the saphenous artery (CCSA), delineate the angiosome of the CCSA, and provide guidelines for clinical use of an axial pattern flap based on the CCSA. Anatomic study. Greyhound cadavers (n=10). Shortly after euthanasia, the CCSA was identified and isolated in each hindlimb. Methylene blue and radiographic perfusion studies were performed. The skin was freed from the thigh for photographic and radiographic images. The dimensions of the skin area suitable for use as an axial pattern flap were related to anatomical landmarks. Mock surgical elevation and transposition of the flap in 2 dogs allowed assessment of flap mobility and ease of donor site closure for clinical use. The CCSA was reliably identified in all dogs branching from the saphenous artery as it became superficial to the sartorius muscle, immediately distal to the caudal cutaneous branch and proximal to the genicular branches. Genicular branches were variably paired or singular. Perfusion studies defined the CCSA angiosome as the area cranial to the saphenous artery and caudal to the cranial border of the thigh, extending proximally from the level of the medial tibial condyle to two-thirds of the distance to the inguinal ring. An axial pattern flap based on the CCSA could be expected to cover skin defects of the cranial aspect of the distal thigh and stifle, the popliteal region caudal to the stifle, and the proximal medial crus.

Surgical anatomy of medial open-wedge high tibial osteotomy: crucial steps and pitfalls.

To give an overview of the basic knowledge of the functional surgical anatomy of the proximal lower leg and the popliteal region relevant to medial high tibial osteotomy (HTO) as key anatomical structures in spatial relation to the popliteal region and the proximal tibiofibular joint are usually not directly visible and thus escape a direct inspection. The surgical anatomy of the human proximal lower leg and its relevance for HTO are illustrated with a special emphasis on the individual steps of the operation involving creation of the osteotomy planes and plate fixation. The posteriorly located popliteal neurovascular bundle, but also lateral structures such as the peroneal nerve, the head of the fibula and the lateral collateral ligament must be protected from the instruments used for osteotomy. Neither positioning the knee joint in flexion, nor the posterior thin muscle layer of the popliteal muscle offers adequate protection of the popliteal neurovascular bundle when performing the osteotomy. Tactile feedback through a loss-of-resistance when the opposite cortex is perforated is only possible when sawing and drilling is performed in a pounding fashion. Kirschner wires with a proximal thread, therefore, always need to be introduced under fluoroscopic control. Due to anatomy of the tibial head, the tibial slope may increase inadvertently. Enhanced surgical knowledge of anatomical structures that are at a potential risk during the different steps of osteotomy or plate fixation will help to avoid possible injuries. Expert opinion, Level V.

Bioelectrical Impedance Analysis at Popliteal Regions of Human Body using BIMS

Bioelectrical impedance (BI) at popliteal regions was measured using a bioelectrical impedance measurement system (BIMS), which employs the multi-frequency and the two-electrode method. Experiments were performed as follows. First, a constant AC current of 800 μA was applied to the popliteal regions (left and right) and the BI was measured at eight different frequencies from 10 to 500 kHz. When the applied frequency greater than 50 kHz was applied to human’s popliteal regions, the BI was decreased significantly. Logarithmic plot of impedance vs. frequency indicated two different mechanisms in the impedance phenomena before and after 50 kHz. Second, the relationship between resistance and reactance was obtained with respect to the applied frequency using BI (resistance and reactance) acquired from the popliteal regions. The phase angle (PA) was found to be strongly dependent on frequency. At 50 kHz, the PA at the right popliteal region was 7.8o slightly larger than 7.6o at the left popliteal region. Third, BI values of extracellular fluid (ECF)and intracellular fluid (ICF) were calculated using BIMS. At 10 kHz, the BI values of ECF at the left and right popliteal regions were 1664.14 Ω and 1614.08 Ω, respectively. The BI values of ECF and ICF decreased sharply in the frequency range of 10 to 50 kHz, and gradually decreased up to 500 kHz. Logarithmic plot of BI vs. frequency shows that the BI of ICF decreased noticeably at high frequency above 300 kHz because of a large decrease in the capacitance of the cell membrane.

Pigmented Papules and Patches of the Folds: A Case Series of Lcihen Planus Pigmentosus Inversus with Review of the Literature

We report nine cases of Lichen Planus Pigmentosus (LPP) inversus in Caucasian patients. They were 5 women and 4 men aged from 29 to 77 years with violaceous hyper pigmented ovalar or annular macules and patches mostly located at axillary folds but also groin, submammary folds, popliteal and genital regions. Histological examinations showed a band-like lymphocytic infiltrate in the upper dermis and melanophages in the papillary dermis. LPP inversus is a rare variant of LPP appearing in non-sun exposed areas. In contrast to LPP which occurs almost exclusively in dark skinned individuals, a comprehensive review of the literature revealed that about half of the cases reported of LPP inversus affects fair skinned individuals including Caucasian patients.

Features of pathological changes of fibro-cartilaginous tissue knee in patients with Baker cyst

Using magnetic resonance imaging (MRI) to evaluate the characteristics of pathological changes of fibro-cartilage of the knee in patients with Baker cyst, to assess the compliance of degrees of damage stages of osteoarthritis on a scale of Kellgren–Lawrence (K–L), and compare the results with the data of other researchers. This study included patients (38–82 years) with a cyst Baker accidentally detected during ultrasound veins of the lower extremities. The subjects underwent a single knee MRI. MRI was made in three dimensions using 3D gradient-echo protocol. Independent radiologist evaluated the presence and severity of chondral defect osteophytosis, damage to the menisci and ligaments, intraosseous edema and subchondral cysts. The osteoarthritis stage of the knee were identified by X-ray performed in a standing position in the standard two projections, with K–L scale. In this study, the results of a survey of 20 people, whose average age was 57.2 years. According to the radiological scale of K–L two patients were assigned to the stage 0 degree, 5 people to stage 1, 2, 4 each, and 3 – to stage 3. Synovitis of various severity was detected in 85% of the studies. Nineteen visualized the patellar cartilage damage, the condyles of the femur and tibia are most commonly affects the joint area. Among the most commonly injured ligament anterior cruciate ligament was determined – 9 (45%) patients in the same amount of detected intramedullary edema condyles femur and tibia. Eighteen subjects had at least one anomaly meniscus detectable by MRI, while in 11 (55%) persons were deviations, at least two or more regions of the knee examined. Our results suggest that not all visualized on MRI degenerative damage to intra fibro-cartilaginous tissue correlate positively with the stages of osteoarthritis of the knee, identified by standard radiographs and may not significantly affect the onset and progression of synovial cyst of the popliteal region.

Systemic Mastocytosis- A Case Report

Mastocytosis is a rare heterogenous disease characterized by the presence of excessive number of mast cells in various organs mainly in skin and bone marrow. .The incidence was 1 in 1,000 to 8,000 patients. It can follow a benign or indolent course, or it may be associated with life threatening symptoms. We report a rare case of 2 month old female child presented with hyperpigmented macular rash all over the body and few nodular lesions in popliteal and inguinal regions. The skin biopsy and bone marrow examination revealed numerous mast cells which stained metachromatically with giemsa and toluidine blue stain and showed positivity with cd 117. Based on these findings a diagnosis of systemic mastocytosis was made.

Injection Sclerotherapy and Ablation

Closure of incompetent superficial veins via endovenous techniques has become the standard of care for treatment of patients with chronic venous insufficiency and symptomatic varicose veins. The safety and efficacy of these procedures have been supported by the peer-reviewed literature, and these procedures have largely replaced the surgical treatments of high ligation and stripping. Three major developments have led to the current endovenous techniques: laser and radiofrequency catheters that deliver thermal energy, tumescent anesthesia, and duplex ultrasonography. This review covers relevant anatomy, pathophysiology, clinical signs and symptoms, diagnostics, treatment, tumescentless therapy, ClariVein (mechanochemical ablation), and the VenaSeal Closure System. Figures show telangiectasias, reticular veins, varicose veins, edema/swelling, hyperpigmentation, venous stasis ulcers, the ClosureFast Catheter, access using the great saphenous vein proximal to the popliteal region, application of tumescent anesthesia, segmental ablation using the ClosureFAST system, the NeverTouch Direct Procedure Kit by AngioDynamics, Varithena foam sclerosant, the ClariVein Occlusion Catheter, and the VenaSeal Sapheon Closure System. Tables list perforating veins of the lower extremity, Clinical, Anatomic, Etiologic, Pathophysiologic classification, and the Venous Clinical Severity Score. This review contains 12 figures, 3 tables, and 103 references

Tuberculosis of the calcaneus in children.

To review 10 children with calcaneal tuberculosis in terms of presentation, healing, and functional outcome. Medical records of 7 boys and 3 girls aged 7 to 12 (mean, 9.8) years who presented with calcaneal tuberculosis were reviewed. The erythrocyte sedimentation rate of all patients was elevated. All patients presented with pain and swelling around the lateral malleolus and a 'heal-up' sign; 7 of them presented with an additional discharging sinus. Three patients had palpable lymph nodes in the right inguinal or left popliteal region. Symptoms had lasted for one month to 1.5 years. Two patients had healed tuberculosis in the lungs; 8 patients had no pulmonary involvement. Seven patients had a single lytic lesion in the calcaneal body (n=1), tuberosity (n=3), and extension to anterior process (n=3). Three patients had multiple lytic lesions in the calcaneum; one of them had bilateral involvement who had lesions in the phalanges, lumbar spine, and ulna. Two patients had subtalar joint involvement. The mean follow-up period was 17 (range, 8-60) months. The erythrocyte sedimentation rate returned to normal after 3 months in 7 patients and after >6 months in 3 patients. The subtalar range of movement was normal in all except for 2 patients. One patient developed subtalar ankylosis. Sinuses healed in a mean of 10 (range, 2-16) weeks. No patient had pain on level walking after treatment. At 3 months, remineralisation of bone was evident in all patients. Sclerosis of cavity margins and sequestra resorption was noted from 6 to 9 months. No patient experienced recurrence. The 'heel up' sign was common in children with calcaneal tuberculosis in this endemic region. The central granuloma-type presentation was the most common. Pathological fractures and involvement of the subtalar joint were not common. Subtalar joint involvement was a poor prognostic factor.

Advantages of superficial femoral vein grafts for carotid artery reconstruction following carotid artery resection in the treatment of head and neck cancer

Conclusion: Reconstruction of the carotid artery using the superficial femoral vein (SFV) is very effective due to the ease in harvesting the vessel and its optimal size and length for carotid artery replacement. Objectives: To evaluate the effectiveness of carotid artery reconstruction using the SFV. Methods: Ten patients with malignant tumors involving the carotid artery underwent carotid artery resection followed by reconstruction with the SFV. The SFV between the deep femoral vein and branches to the great saphenous vein and deep femoral vein at the popliteal region was used as a reconstructive vessel. Results: The mean length and diameter of the grafted SFVs were 13.9 cm and 11.2 mm, respectively. The mean time for acquisition of SFV was 18 min. Ultrasonography measurements indicated that the mean lumen diameter of the common carotid artery was 8.37 mm. None of the patients experienced any permanent neurologic complications. The 2-year and 5-year overall survival rates were 60% and 40%, respectively. En bloc resection of the cancer and involved carotid artery followed by reconstruction with the SFV provides effective locoregional control. Our results indicated no postoperative vascular graft thrombosis and no donor site complications.

A Different Reason of Painful Popliteal Region: Atypically Localized Tibial Osteochondroma (Case Report)

A Different Reason of Painful Popliteal Region: Atypically Localized Tibial Osteochondroma (Case Report)

Socket Interface Pressure and Amputee Reported Outcomes for Comfortable and Uncomfortable Conditions of Patellar Tendon Bearing Socket: A Pilot Study

The objectives of the current study were to compare intra-socket pressure differences between comfortable and uncomfortable socket conditions, and the usefulness of subject perception of satisfaction, activity limitations, and socket comfort in distinguishing between these two socket conditions. Five unilateral trans-tibial amputees took part in the study. They answered the Socket Comfort Score (SCS) and Trinity Amputation and Prosthetic Experience Scale (TAPES) questionnaires before the interface pressure (in standing and walking) was measured for the uncomfortable socket condition at five regions of the residual limb. Participants were then provided with a comfortable socket and wore it for two weeks. Participants who were satisfied with the socket fit after two weeks repeated the SCS and TAPES questionnaires and interface pressure measurements. The differences between the test results of the two conditions were not statistically significant, except for the interface pressure at the popliteal region during the early stance phase, TAPES socket fit subscale, and the SCS. Due to large variability of the data and the lack of statistical significance, no firm conclusion can be made on the possible relationship between the interface pressure values and the patient-reported outcomes of the two socket conditions. A larger sample size and longer acclimation period are required to locate significant differences.

FNAC Diagnosis of Soft Tissue Tumour (Proliferative Fascitis and Proliferative Myositis ): A Case Report

Nodular fascitis is a benign fibroblastic tumour characterized by rapid growth and most of the time requires its differentiation from other tumorous lesions. Here is a case of 45 year old male who presented with a soft tissue swelling in the popliteal region. On FNAC, a differential diagnosis of proliferative myositis and proliferative fasciitis was given. Histopathological examination gave a diagnosis of nodular fascitis. Hence cytology helps to give a definite diagnosis and aid in the surgical management of soft tissue tumors.

Case report: Non-small-cell lung carcinoma presenting as a foot swelling.

Sir, Acrometastases are defined as malignant secondary lesions of the bones located in the hands and/or feet. Acrometastases are very rare and are generally late manifestations of occult cancer and associated with a poor prognosis. In literature, only few cases of acrometastases due to occult lung cancer have been reported.[1] We report a case of acrometastasis to the left foot from an occult lung cancer. A 55-year-old female patient presented with complains of pain and swelling in the left foot of two-month duration. Magnetic Resonance Imaging (MRI) of the left foot showed erosion of the cortex of the second metatarsal with marrow edema and associated soft tissue abnormality noted just anterior to the eroded cortex [Figure 1]. Biopsy from the second metatarsal bone was suggestive of metastatic deposit and tumor cells were positive for cytokeratin 7 (CK-7), Epithelial membrane antigen (EMA), Thyroid transcription factor-1 (TTF-1), and NAPSIN, suggestive of Non-Small Cell Lung Cancer, Adenocarcinoma (NSCLC) [Figure 2].Figure 1: MRI of left foot showed erosion of the cortex of the second metatarsal with marrow edema and associated soft tissue abnormality noted just anterior to the eroded cortexFigure 2: (a) H & E section showing tumor cells arranged in nests and glandular pattern. Tumor cells were positive for, (b) CK-7, (c) TTF-1, and (d) NAPSINOn careful history taking, she was a 15-pack-a-year smoker. The whole body positron emission tomography (PET) computed tomography (CT) showed a left lung lower lobe, hypermetabolic, soft tissue mass and subcarinal and left hilar lymphnodes [Figure 3a]. A hypermetabolic soft-tissue mass in the left base of the second metatarsal, with enlarged lymphnodes, was seen in the proximal left external iliac, left obturator, left inguinofemoral, and popliteal regions [Figure 3b]. The epidermal growth factor receptor (EGFR) mutation was not detected in the biopsy specimen.Figure 3: (a) PET CT showed a hypermetabolic soft tissue mass seen in the left foot with destruction of the underlying base of the second metatarsal, (b) Left lung lower lobe showed a peripheral lobulated hypermetabolic soft tissue massThe patient was started on external beam radiation therapy (EBRT) to the left foot, followed by systemic chemotherapy with Pemetrexed- and Cisplatin-based palliative chemotherapy. Post two courses of chemotherapy she had a dramatic response to the treatment with a decrease in pain in the left foot. Bone metastasis is a common occurrence in patients with advanced carcinomas, particularly in those with lung, breast, and prostate cancer. However, metastases distal to the knee are very rare and metastases to the bones of the foot are even rarer. Metastases to bone develop in 30% of all patients with cancer, with only 0.007 to 0.3% having acrometastasis.[1] The most common sources of acrometastasis are colorectal, renal, and lung carcinomas (50%), with the bladder, uterus, and breast responsible for 25% of the metastases to the foot.[2] Acrometastases are rarely the initial presentation of metastatic carcinoma. In a series by Healey et al., they were seen as the initial manifestation of an occult malignancy in four (14%) of the 29 patients.[3] Acrometastasis are often initially mistaken for more benign processes, such as infection, trauma, inflammatory arthritis, osteomyelitis or gout. Persistent symptoms, unresponsiveness to conservative therapy or prior history of malignancy should prompt the physician to consider metastases, when evaluating a patient. Given the bleak prognosis of digital acrometastatic lung cancer, treatment is largely palliative. Amputation and chemotherapy have been used, but recent literature suggests that localized radiotherapy can successfully relieve the pain and return the function to the affected foot.[4] There may also be a targeted role for bone-remodeling and pharmacotherapies, such as, bisphosfonates or denosumab, which have demonstrated utility in treating other bony metastases.[5] Treatment is directed toward the relief of symptoms and restoration of functional capacity.

Pigmented Villonodular Synovitis Presenting as a Popliteal Cyst.

Introduction:Pigmented villonodular synovitis is an uncommon disease characterized by hyperplastic synovium, large effusions and bone erosions. It commonly mimics other conditions. As a result, the diagnosis may remain elusive, as the classic signs of tenderness and effusion are not specific. Occasionally, PVNS presents as a popliteal cyst, which may divert attention from intra-articular pathology. In this article, we describe a case of pigmented villonodular synovitis that presented with a popliteal cyst as the chief problem.Case Report:A twelve year old boy presented to us with a history of a gradually enlarging mass in the left popliteal fossa since eighteen months. He complained of restriction of terminal knee flexion, but he had no pain. After clinical examination and imaging the mass was interpreted as being either a popliteal cyst or chronic hematoma without ruling out the possibility of soft tissue sarcoma. An open excisional biopsy of the lesion was performed which revealed a reddish-brown cystic-nodular mass communicating with the knee joint. The histology was consistent with that of pigmented villonodular synovitis. We performed an arthroscopic synovectomy 3 weeks later. Abnormal synovium found in all compartments of the knee was removed. Histology from the intra-articular lesion was also consistent with a diagnosis of pigmented villonodular synovitis.Conclusion:A swelling in the popliteal region may be due to various etiologies. The cause should be thoroughly investigated. Along with clinical examination and imaging the tissue must be subjected to histopathological examination. Pigmented villonodular synovitis can rarely present as a popliteal cyst. In such a situation, treatment consists of dealing with intra-articular and extra-articular pathology.

Development of Bioelectric Impedance Measurement System Using Multi-Frequency Applying Method

Abstract In order to measure the segmental impedance of the body, a bioelectrical impedance measurement system (BIMS) using multi-fre-quency applying method and two-electrode method was implemented in this study. The BIMS was composed of constant current source ,automatic gain control, and multi-frequency generation units. Three experiments were performed using the BIMS and a commercialimpedance analyzer (CIA). First, in order to evaluate the performance of the BIMS, four RC circuits connected with a resistor a nd capac-itor in serial and/or parallel were composed. Bioelectrical impedance (BI) was measured by applying multi-frequencies -5, 10, 50, 100,150, 200, 300, 400, and 500 KHz – to each circuit. BI values measured by the BIMS were in good agreement with those obtained bythe CIA for four RC circuits. Second, after measuring BI at each frequency by applying multi-frequency to the left and right forearmand the popliteal region of the body, BI values measured by the BIMS were compared to those acquired by the CIA. Third, when thedistance between electrodes was changed to 1, 3, 5, 7, 9, 11, 13, and 15 cm, BI by the BIMS was also compared to BI from the CIA.In addition, BI of extracellular fluid (ECF) was measured at each frequency ranging from 10 to 500 KHz. BI of intracellular fluid (ICF)was calculated by subtracting BI of ECF measured at 500 kHZ from BI measured at seven frequencies ranging from 50 to 500 KHz.BI of ICF and ECF decreased as the frequency increased. BI of ICF sharply decreased at frequencies above 300 KHz.Keywords: Bioelectrical impedance, Impedance analyzer, Multi-frequency impedance meter, Extracellular fluid, Intracellularfluid

Comment to: Postoperative varicose recurrence at the junctions. A multicentric study of 1056 patients by the Italian Society of Phlebolymphology. Preliminary conclusions by Corcos L, Aloi T, Alonzo U, et al. Acta Phlebol 2014;15:69-78

In spite of a history and evidence of efficacy, numerous attempts have been made to replace traditional surgery with new techniques in the hypothesis that the surgical trauma and high pressure on the venous wall are responsible for the development of neovascularisation by neoangiogenesis (NN) and, consequently, high postoperative recurrent rates. To verify the anatomical causes of postoperative varices recurrence (VR) at the SFJ and SPJ fourteen centres belonging to the Italian Society of Phlebolymphology collected the requested data from 1056 patients (1081 limbs, 25 bilateral) who were either previously subjected to ligation-interruption of SFJ and/or SPJ (927 between 2001-2010) or treated in the last two years (154 between 2011-2012); 611 limbs (56.5%) were examined by DUS only, 470 limbs (43.4%) were subjected to DUS examination and surgical revision (270 with Li technique). The residual saphenous stump (SS), all residual tributaries with their outflows into the stump or directly into the common femoral or popliteal veins and their anatomical variants were investigated; neovascularisation by neoangiogenesis was investigated, searching for thin and tortuous veins measuring <2 mm in diameter and connected with an SS, with the common femoral vein or with thinner subcutaneous veins. The majority of the SS were found to be combined with residual identified or unidentified tributaries. In many cases, the VR consisted of a complex varicose collateral circulation (CVC). The residual SS (n=711, 65.7%) was the most common finding, followed (by decreased frequency) by the anterior accessory of the GSV (n=298, 27.5%), UT at the SFJ (n=290, 26.8%), superficial iliac circumflex vein (n=127, 11.7%), residual GSV (most likely from a previous duplicity), (n=95, 8.7%), superficial epigastric (n=60, 8.8%) A large number of cases with development of a CVC (n=386, 35.7%) were found in the supra-fascial subcutaneous. The anatomical residuals, which were single or multiple and variously combined, were found in a total of 939 operated junctions. Neovascularisation was suspected or demonstrated in a total of 142/1081 cases (13.1%). The data obtained from the different centres appeared to be scarcely detailed to define the various tributary veins involved in the mechanism of recurrence; nevertheless, it is possible to assess the prevalence of SS connected with residual tributaries as major causes of recurrence in both the SFJ and SPJ. NN was recently described as the most dangerous enemy of surgeons and patients operated on for varicose veins. The word neovascularisation seems more appropriate to indicate the appearance of new vessels produced by the phenomenon of neoangiogenesis and does not appear to be appropriate, as it refers to pre-existing veins that remain under the impulse of the venous reflux and progressively dilate. Histological observations have led to describe neoangiogenesis as a physiologic process, which follows inflammation and mainly represents a constant product of large wounds, haematomas and thrombosis). The same reparative process, leading to the appearance of specific progenitor cells, takes place in every anatomical district and in every kind of tissue, not only in veins. It can be invoked as a cause of VR in a small percentage of cases, and it seems to play a minimal role at the groin and popliteal region of the operated limbs. In many cases in which no residual tributary could be detected, except for small, weak and tortuous veins, the VR was represented by an anatomical anarchic development of the collateral circulation, similar to cavernous haemangioma. The presence of anatomical residuals at the SFJ and SPJ has been always indicated in the past as the main cause of VR; this research confirms that residual saphenous stump and tributaries caused by inadequate surgery appear to be the main cause of VR at the saphenous junction. Recent studies have clearly demonstrated that the only way to prevent VR is still traditional surgery. The only trap is represented by the presence of anatomical variants at the junctions but DUS investigation systematically performed before applying any therapeutic technique can prevent such difficulties.

A novel concept for continuous peripheral nerve blocks. Presentation of a new ultrasound-guided device.

Existing techniques for placing and maintaining the position of peripheral nerve catheters are associated with variable success rates and frequent secondary failures. These factors may affect the clinical efficacy and usefulness of peripheral nerve catheters. We developed a new concept and prototype for ultrasound-guided in-plane positioning and readjustment of peripheral nerve catheters (patent pending). The integrated catheter-needle prototype comprises three parts: a curved needle, a catheter with clear echogenic markings attached to the needle tail and a detachable hub allowing injection of local anesthetic while advancing the needle in the tissue. The system works like a suture and is introduced through the skin, passes in close relation to the nerve and exits through the skin. This allows in-plane ultrasound guidance throughout the procedure both during initial positioning as well as during later in-plane readjustment of the catheter. We tested the system in the popliteal region of two fresh cadavers in a preliminary proof of concept study. Both initial placement and secondary readjustment were precise, judged by the catheter orifices placed close to the sciatic nerve in the popliteal fossa. Circumferential spread of 3-ml isotonic saline around the sciatic nerve was observed on ultrasound images in both conditions. Preliminary proof of concept of this novel method demonstrates that precise in-plane ultrasound-guided initial placement and secondary in-plane readjustment is possible in fresh cadavers. Future studies should address the clinical efficacy and usefulness of this novel concept.

Open wedge osteotomy of the tibial head. Management of vascular complications

Lesions of the popliteal artery during high tibial osteotomy are rare complications, consequently the majority of publications are case related. The interval between surgery and diagnosis is reported to be as long 3 years; therefore, the current literature probably does not reflect the true incidence of vascular injuries. The case reports published in the literature were further evaluated. The focus was on the normal vascular anatomy of the popliteal region and anatomical deviations that predispose to vascular injury. As the flexion angle of the knee joint is considered to be decisive for vascular injury, this aspect was also an additional focus. For the unlikely event of a vascular injury, recommendations are presented which indicate diagnostic and therapeutic decisions. We analyzed the available literature and present own magnetic resonance imaging (MRI) investigations of the popliteal artery with different angles of flexion in six healthy volunteers. A variation of the origin of the anterior tibial artery with a course between the posterior tibial cortex and the popliteal muscle was found in 6% of all patients and predisposes to an accidental injury during osteotomy. The results in the literature and our own MRI findings suggest that a flexion angle of 90° facilitates anatomical dissection and osteotomy but cannot be regarded as a reliable protection against vascular injury.

Anatomy of sciatic nerve bifurcation in popliteal fossa: a fetal study

Abstract Background: We studied the bifurcation of sciatic nerve into two components which change their position throughout the early period of life. We proposed dimensions that would help reducing failure rates of anesthesia in popliteal fossa region and screening of malignancy related to sciatic nerve. Methods: The back of thigh and popliteal fossa of both sides of 50 fetuses (24 male and 26 female) were dissected. Skin over the gluteal region was dissected upto back of the knee. Sciatic nerve was traced from gluteal region to back of the thigh. The level where common fibular nerve and tibial nerve diverge from sciatic nerve and the diameter of sciatic nerve at various levels were evaluated. Results: In 97.7% (41/42) specimens,the bifurcation was above (5.1-20.86 mm) and in 2.3% (1/42) specimens, it was below (2.37 mm) the lateral condyle of femur. In 66% cases, sciatic nerve splits into two at or within 11 mm proximal to lateral condyle, while in 75% cases within 13mm, and in 100% cases within 21mm proximal to lateral condyle. Conclusion: This study provides quantitative data about the sciatic nerve in the gluteal region and back of the thigh. This data has a significant implication in diagnostic and anesthetic practice.

Acanthosis nigricans chez l’enfant et syndrome de Crouzon

Crouzon syndrome with acanthosis nigricans is a rare form of Crouzon syndrome in which craniosynostosis and facial dysmorphism are associated with acanthosis nigricans. Cutaneous examination of a 9-year-old child presenting bicoronal craniosynostosis revealed acanthosis nigricans of the cervical, axillar, inguinal and popliteal regions which appeared at the age of two. He had a dysmorphic face including a large forehead, hypertelorism, mid-face hypoplasia, prognathism and low-set ears. These clinical anomalies suggested a case of Crouzon syndrome with acanthosis nigricans, which was later confirmed by the finding of a mutation in the FGFR3 gene. Acanthosis nigricans in children is often a cutaneous marker of insulin resistance. However, it may also form part of diverse diseases, notably those of genetic origin. The association of craniosynostosis and acanthosis nigricans allows incrimination of the FGFR3 gene from the outset and diagnosis of Crouzon syndrome with acanthosis nigricans. In the present case, dermatological examination allowed an aetiology of craniosynostosis to be determined.