Rectus Muscle Function Research Articles

Aberrant regeneration in an international registry of patients with 3rd-nerve palsy.

To describe the patterns of pre-operative aberrant regeneration and motility outcomes reported in an international registry of patients with 3rd-nerve palsy treated with nasal transposition of the split lateral rectus muscle (NTSLR). This cross-sectional study used data from an international, multicentre registry of patients with 3rd-nerve palsy treated with NTSLR. Patients with aberrant regeneration were identified, and patterns of innervation described. Demographics and postoperative success defined as horizontal alignment ≤15 PD were compared based on the presence, and type, of aberrant regeneration using Wilcoxon rank sum and Fisher's exact tests. Aberrant regeneration was reported in 16% (21/129) of patients. Age at diagnosis, sex, and aetiology of palsy were not significantly associated with aberrant regeneration. Abnormal movements were triggered by adduction in 52% (11/21), infraduction in 23% (5/21), and supraduction in 23% (5/21) of cases. Presentation patterns involved rectus muscle innervation in 29% (6/21) and levator muscle innervation in 71% (15/21) of cases. Although patients with aberrant regeneration had similar probability of success in comparison to those without following NTLSR (76% vs. 69%, p = 0.5), those with abnormal innervation of a rectus muscle had a lower success rate than those with abnormal innervation of the levator palpebrae superioris muscle (17% vs. 93%; p = 0.002). Successful treatment of a 3rd nerve palsy with NTSLR was not influenced by aberrant regeneration involving the levator muscle. Alternative surgical interventions should be considered when aberrant regeneration alters rectus muscle function given its adverse impact on motor outcomes with NTSLR.

Limiting the fascia incision length in a DIEP flap: Repercussion on abdominal wall morbidity

The evolution from free muscle-sparing transverse rectus abdominis myocutaneous flap to deep inferior epigastric perforator (DIEP) flap leads to less donor-site morbidity. However, rectus fascia is usually incised longitudinally from perforator(s) to iliac vessels, often exceeding 15 cm when including longitudinal muscle spreading. By using a limited fascia incisional (LFI-) technique, we try to diminish abdominal wall functional decrease. Twenty-seven patients who underwent unilateral breast reconstructions using free DIEP-flap with limited fascia incision between December 2014 and October 2017 were included in the study. Each patient received a periumbilical electromyogram (EMG) preoperatively, at 6 and 14 weeks postoperatively. They were compared with 27 patients having unilateral breast reconstructions using classic free DIEP-flap, performed at the same department between November 2009 and May 2011. In our LFI-technique, one vertical (4 cm) incision is made where the pedicle exits the muscle. A second, oblique (3 cm) incision is made more distally where the pedicle runs into the iliac vessels. After release, the pedicle is tunneled through the incisions, leaving all fascia, and therefore muscle, intact. In the LFI-group small neurogenic changes were noticed in only 26% and 11% of the patients at, respectively, 6 and 14 weeks postoperatively. By contrast, in the control group, postoperative neurogenic deviations remained in 37% of the patients at 14 weeks postoperatively; significant different compared to the LFI-group. This study shows the importance of preserving anterior rectus fascia. Nerve supply and abdominal rectus muscle function are less endangered using small segmental fascia incisions. We believe that our technique diminishes donor-site morbidity significantly and improves the postoperative recovery.

Surgery Versus Non-surgery Interventions on Rectus Abdominis Diastasis With or Without Hernias: a Systematic Review

Rectus abdominis diastasis is a common pathology and an esthetic and symptomatic problem; its reconstruction, either through a surgical strategy, standard vertical plication, or endoscopic surgery with or without mesh or through non-surgical physical training, is under debate. This study further aimed to compare the results of surgery and non-surgery interventions in cases with rectus abdominis diastasis. A systematic literature search of PubMed, Embase, and the Cochrane Library databases from the earliest data available to November 2018 was performed. Studies assessing symptomatic relief, adverse events, or symptomatic recurrence after surgery or a physical training program were included. A modified Downs and Black checklist for randomized and non-randomized studies of healthcare interventions was used to evaluate the methodological quality of the studies. Of 3908 citations, there were 27 studies with a total of 2372 patients finally being included in this study. In the surgery group, there was no patient relapsed after a follow-up of 12 months, while a 40% recurrence rate was reported after a follow-up of 5 years in one study. The adverse events associated with surgery mainly included seroma (5.13%), a sensibility disorder of the abdominal skin (2.26%), and minor scarring (1.56%). There were no adverse events or reports of recurrence in patients with physical training; however, negative effects of improving rectus muscle function were reported in 4 studies (40%). In conclusion, this review found a limited strength of evidence that abdominoplasty and diastasis recti repair were effective at restoring the functions of the rectus muscles and at improving the stability of the abdominal wall and quality of life in the short-term. A moderate strength of evidence was found that strength training has a limited effect, especially for patients suffering from rectus abdominis diastasis combined with a hernia.

Resolution of Vertical Gaze Following a Delayed Presentation of Orbital Floor Fracture With Inferior Rectus Entrapment: The Contributions of Charles E. Iliff and Joseph S. Gruss in Orbital Surgery.

Orbital floor fractures occur commonly as a result of blunt trauma to the face and periorbital region. Orbital floor fractures with a "trapdoor" component allow both herniation and incarceration of contents through a bone defect into the maxillary sinus as the bone rebounds faster than the soft tissue, trapping muscle, fat, and fascia in the fracture site. In children, the fractured floor, which is often hinged on one side, tends to return toward its original anatomical position due to the incomplete nature of the fracture and elasticity of the bone. The entrapment of the inferior rectus muscle itself is considered a true surgical emergency-prolonged entrapment frequently leads to muscle ischemia and necrosis leading to permanent limitation of extraocular motility and difficult to correct diplopia. For this reason, prompt surgical intervention is recommended by most surgeons. In adults, true entrapment of the muscle itself is not as common because the orbital floor is not as elastic and fractures are more complete. We present an adult patient with an isolated orbital floor fracture with clinical and radiologic evidence of true entrapment of the inferior rectus muscle itself. Despite the delayed surgical repair (4 days after the injury), the patient's inferior rectus muscle function returned to near normal with mild upward gaze diplopia. Inferior rectus entrapment in adults may more likely be associated with immobilization of the muscle without total vascular compression/incarceration significant enough to lead to complete ischemic necrosis.

Surgical planning and innervation in pontine gaze palsy with ipsilateral esotropia

To discuss surgical intervention strategies among patients with horizontal gaze palsy with concurrent esotropia. Five consecutive patients with dorsal pontine lesions are presented. Each patient had horizontal gaze palsy with symptomatic diplopia as a consequence of esotropia in primary gaze and an anomalous head turn to attain single binocular vision. Clinical findings in the first 2 patients led us to presume there was complete loss of rectus muscle function from rectus muscle palsy. Based on this assumption, medial rectus recessions with simultaneous partial vertical muscle transposition (VRT) on the ipsilateral eye of the gaze palsy and recession-resection surgery on the contralateral eye were performed, resulting in significant motility limitation. Sequential recession-resection surgery without simultaneous VRT on the 3rd patient created an unexpected motility improvement to the side of gaze palsy, an observation differentiating rectus muscle palsy from paresis. Recession combined with VRT approach in the esotropic eye was abandoned on subsequent patients. Simultaneous recession-resection surgery without VRT in the next 2 patients resulted in alleviation of head postures, resolution of esotropia, and also substantial motility improvements to the ipsilateral hemifield of gaze palsy without limitations in adduction and vertical deviations. Ocular misalignment and abnormal head posture as a result of conjugate gaze palsy can be successfully treated by basic recession-resection surgery, with the advantage of increasing versions to the ipsilateral side of the gaze palsy. Improved motility after surgery presumably represents paresis, not "paralysis," with residual innervation in rectus muscles.

Traumatic oculomotor nerve palsy.

Traumatic oculomotor nerve palsy.

Functional abdominal wall reconstruction improves core physiology and quality-of-life

One of the goals of modern ventral hernia repair (VHR) is restoring the linea alba by returning the rectus muscles to the midline. Although this practice presumably restores native abdominal wall function, improvement of abdominal wall function has never been measured in a scientific fashion. We hypothesized that a dynamometer could be used to demonstrate an improvement in rectus muscle function after open VHR with restoration of the midline, and that this improvement would be associated with a better quality-of-life. Thirteen patients agreed to dynamometric analysis before and 6 months after an open posterior component separation (Rives-Stoppa technique complimented with a transversus abdominis muscle release) and mesh sublay. Analysis done using a dynamometer (Biodex 3, Corp, Shirley, NY) included measurement of peak torque (PT; N*m) and PT per bodyweight (BW; %) generated during abdominal flexion in 5 settings: Isokinetic analysis at 45°/s and 60°/s as well as isometric analysis at 0°, -15°, and +15°. Power (W) was calculated during isokinetic settings. Quality-of-life was measured using our validated HerQles survey at the time of each dynamometric analysis. Thirteen patients (mean age, 54 ± 9 years; mean body mass index, 31 ± 7 kg/m(2)) underwent repair with restoration of the midline using the aforementioned technique. Mean hernia width was 12.5 cm (range, 5-19). Improvements in PT and PT/BW were significant in all 5 settings (P < .05). Improvement in power during isokinetic analyses at 45°/s and 60°/s was also significant (P < .05). All patients reported an improvement in quality-of-life, which was associated positively with each dynamometric parameter. Restoration of the linea alba during VHR is associated with improved abdominal wall functionality. Analysis of rectus muscle function using a dynamometer showed statistical improvement by isokinetic and isometric measurements, all of which were associated with an improvement in quality-of-life.

Surgical Results of Consecutive Exotropia

To determine the success rates of different surgical procedures and the risk factors of surgical failure among patients with consecutive exotropia. Forty patients with exotropia were observed at least 6 weeks after their esotropia surgery. Surgical planning was based on the medial rectus muscle function. Lateral rectus weakening in patients with normal medial rectus function, medial rectus strengthening for patients with limited medial rectus function (-1 to -3), and combined procedure occurred when the correction of each type of surgery was less than the amount of deviation. Postoperatively, patients were divided into success (8 prism diopters [PD] or less) or failure (8 PD or greater) groups. The follow-up period was at least 3 months. The mean preoperative exotropia was 29 ± 13 PD, which was reduced to 7 ± 7 PD postoperatively (P < .001). Successful results were achieved in 31 patients (77.5%), 17 (81%) in lateral rectus weakening, 10 (83%) in medial rectus strengthening, and 4 (57%) in the combined procedure group. More preoperative exodeviation was observed in the failure group compared to the success group (P = .015).The mean dose response was 2.27 ± 0.92 PD/mm in the lateral rectus weakening, 4.25 ± 2.27 PD/mm in the medial rectus strengthening, and 2.31 ± 0.66 PD/mm in the combined procedure groups. If the choice of surgical planning is based on medial rectus function and the amount of exodeviation, satisfactory alignment would be achieved in the majority of patients with consecutive exotropia. The preoperative amount of exodeviation was the only risk factor of surgical failure in the study.

Rectus muscle function after recovery in cases of severe trauma

Rectus muscle function after recovery in cases of severe trauma

A Systematic Review of Abdominal Wall Function Following Abdominal Flaps for Postmastectomy Breast Reconstruction

Perforator flap breast reconstruction potentially offers patients greater postoperative abdominal strength compared with traditional TRAM techniques. Our purpose was to perform a systemic review of the published literature regarding abdominal wall function following breast reconstruction and compare outcomes between pedicle TRAM, free TRAM, and perforator flap procedures. We used the MEDLINE, EMBASE, CINAHL, the Cochrane Network, and HAPI databases from January 1966 through November 1, 2007 to identify potentially relevant studies. Inclusion criteria included studies that evaluated subjective or objective functional abdominal outcomes for postmastectomy patients receiving either pedicle TRAM, free TRAM, or deep inferior epigastric perforator (DIEP) flaps. All study designs were included in the review-prospective studies, cross-sectional studies, and retrospective case series. Our search yielded 20 studies on abdominal wall function after autogenous tissue breast reconstruction. Objective measures of abdominal wall function using isometric dynamometry revealed that pedicle TRAM patients experienced up to a 23% deficit, whereas free TRAM patients experienced up to an 18% deficit in trunk flexion. For trunk extension, pedicle TRAM patients experienced up to a 14% deficit, whereas free TRAM patients experienced minimal to no deficits. However, none of the comparative studies of pedicle and free TRAM procedures found significant differences in abdominal wall function between the 2 groups. Studies that compared free TRAM to DIEP flaps found significantly higher flexion abilities in the DIEP groups, with one study reporting an advantage in measures of extension for DIEP flaps. Functional deficits assessed by physiotherapy measures revealed that patients with pedicle TRAM reconstructions experienced the greatest deficit in rectus and oblique muscle function (up to 53%). Free TRAM groups experienced minimal deficit in rectus muscle function, whereas DIEP flaps returned to baseline for both rectus and oblique muscle function. Subjective measures of abdominal wall function were similar across unipedicle TRAM, free TRAM, and DIEP flap procedures. Patients with bilateral pedicle TRAM reconstruction suffered up to a 40% deficit in trunk flexion and up to a 9% deficit in trunk extension. Patients with bilateral pedicle or free TRAM reconstruction also experienced a significant decrease in the ability to perform sit-ups and a significant decrease in activities of daily living, recreational, and laborious activities. With the exception of those who had bipedicled TRAM or bilateral free TRAM procedures, most women reported return to their preoperative function without a decrease in their ability to perform activities of daily living. Although some studies report an objective advantage of DIEP flaps, this does not appear to translate to detriments in the performance of activities of daily living. However, the current data have limitations in study design and generalizability. A multicenter, longitudinal study is needed to assess objective and subjective outcomes in patients with pedicle TRAM, free TRAM, and perforator flaps using standardized and validated measures.

Sternal wound debridement and muscle flap reconstruction: functional implications.

The mortality rate for poststernotomy infection, which occurs in as many as 5% of median sternotomy incisions after cardiovascular surgery, was 37.5% until sternal debridement with muscle or omental flap reconstruction became the standard treatment for this postoperative complication and lowered the mortality rate to just more than 5%. There are few reports in the literature of physical functional deficits and long-term outcome resulting from such reconstruction. The authors evaluated two groups of patients who had undergone coronary bypass surgery at least 6 months earlier. One group had no postoperative complications; the other group had developed marked sternal wound infections that required debridement and pectoralis major or rectus abdominis muscle reconstruction. Both groups underwent pectoralis and rectus muscle strength testing, evaluation of pain and ability to perform those activities of daily living that are dependent on pectoral and rectus muscle function, and completed self-assessment questionnaires. Differences between the two groups were significant (p<0.05) with regard to pain and patient satisfaction with appearance and general functional capacity. Pectoral muscle function and strength were significantly different in patients in whom that muscle was transposed. Rectus muscle strength was not affected by the transposition of a single rectus muscle. Physical morbidity and loss of strength seemed to be related directly to loss of sternal stability stemming from marked infection and debridement rather than from loss of the muscles used in reconstruction.

Inferior oblique muscle palsy following maxillectomy for squamous cell carcinoma

The patient is a 64-year-old male who presented for ophthalmologic consultation after a left maxillectomy and radiation therapy for squamous cell cancer. Immediately following the surgery, the patient noticed vertical and horizontal double vision. He then underwent reconstruction of his left inferior orbital rim with a Medpore implant and repair of left lower eyelid retraction. Ocular motility evaluation revealed a left inferior oblique muscle palsy, with sparing of the inferior rectus muscle function.

Deep inferior epigastric perforator flap in breast reconstruction: experience with the first 50 flaps.

Abdominal wall function is a major concern for plastic surgeons performing breast reconstruction with TRAM flaps. The deep inferior epigastric perforator (DIEP) free flap spares the whole rectus abdominis muscle, includes skin and fat only, and therefore, preserves adequate abdominal wall competence. Between January of 1995 and May of 1997, a total of 50 breast reconstructions in 42 patients were performed by using the DIEP flap. Eight patients had bilateral procedures. Five breast reconstructions were immediate and 45 were delayed. All patients were collected prospectively and no patients were excluded from this study. The average age of patients was 47 years (range, 22 to 59 years) and the average weight was 65 kg (range, 51 to 103 kg). Seventy percent of patients had one or more risk factors for TRAM flap reconstruction. The mean postoperative follow-up period was 13 months (range, 3 to 30 months). Twenty consecutive patients (17 single and 3 bilateral DIEP flap breast reconstructions) within this group underwent evaluation of their abdominal wall function preoperatively and then 3 and 6 months postoperatively by using Lacote's muscle grading system. Average flap harvesting time was 120 minutes and average blood loss was 420 cc. Total flap loss and partial necrosis occurred in one (2 percent) and three flaps (6 percent), respectively. Abdominal wound infection occurred in seven patients (17 percent). Unfortunately, one patient died of adult respiratory distress syndrome on the seventh postoperative day. Fat necrosis was found in three flaps (6 percent). Postoperative abdominal wall examination did not reveal any hernia, but bulging was found in two patients (5 percent). All patients were able to resume their daily activities. Abdominal wall function tests in the series of 20 patients showed that all patients had reached or even improved their preoperative level of upper and lower rectus muscle function 6 months after the operation. The external oblique muscles were the most affected by the procedure of flap harvesting, but only two patients (10 percent) were found to have a measurable impairment after 6 months. Patient satisfaction with the reconstructed breast and the donor site was rated high. The free DIEP flap is, therefore, a reliable and valuable method of breast reconstruction. The donor site morbidity was decreased, and the more tedious flap dissection did not affect the overall outcome.

Migration of Solid Silicone Encircling Element Through Four Rectus Muscles

Anterior migration of an encircling element through a rectus muscle is an unusual complication of scleral buckling surgery. We describe two patients with migration of a solid silicone encircling element through the insertions of all four rectus muscles after retinal detachment surgery. Buckle migration was associated with elevated intraocular pressure and glaucomatous optic atrophy. Rectus muscle function was preserved in both patients. Despite transsection of the anterior ciliary blood supply, anterior segment ischemia did not develop.