An Ectopic External Jugular Vein Draining into the Axillary Vein: a Rare Anatomical Variation with Clinical Implications.

OBJECTIVE: The external jugular vein drains a considerable part of the head and neck and constitutes a vessel implicated in various procedures in the cervical region. The aim of this study is to present an uncommon anatomical variation of the external jugular vein, and discuss the clinical implications of its presence. CASE REPORT: We present a rare case of an ectopic external jugular vein terminating into the axillary vein, that we came across during routine dissection of a male cadaver of Greek origin. CONCLUSION: The venous system of the external jugular vein is used during procedures for the treatment of various conditions such as cardiac arrhythmias, hydrocephalus and defects of the head and neck. Hence, encountering the unpredictable course of a variant draining into the axillary vein may complicate these interventions, leading to multiple manipulations and undesirable results. Surgeons should be aware of the alternate anatomy of the venous system of the cervical region, and mindful of the possibility of encountering them.

Trochlea Dysplasia as the Major Anatomic Risk Factors for Patellofemoral Joint Instability: An Infographic as a Visual Learning Tool.

Patellofemoral instability (PFI) is a common condition in children and adolescents, ranging from mild discomfort and mal-tracking to lateral patellar dislocation [1]. A number of anatomical risk factors have been described in the literature, such as trochlear dysplasia, patella alta, excessive tibial tuberosity to trochlear groove (TT-TG) distance, patellar tilt and soft tissue alterations [2]. Among them, TD has been identified as the main anatomical risk factor with the strongest association with PFI [1, 2]. In the study by Dejour et al. [2] radiographically observed TD was identified in 96% of patients with a history of patellofemoral dislocation [1, 2]. Patients with Dejour Type D dysplasia are characterized by a prominent and convex lateral facet with a vertical connection to a hypoplastic medial facet (Figure 1), which provides inadequate tracking of the patella in the trochlea during flexion leading to patella subluxation [2]. Non-operative treatment of lateral patellar dislocation presents a rate of re-dislocation up to 70% within 24 months of the first episode [3]. Sulcus deepening trochleoplasty is indicated for Type B and D dysplasia, in order to improve patella tracking, reduce the rate of re-dislocation and achieve good functional outcomes [2, 4]. Trochlea dysplasia is defined as a shallow or flattened groove with decreased resistance to lateral patellar translation. TD can be assessed on computed tomography (CT) and magnetic resonance imaging (MRI) with the use of overlapping axial images and are able to show perfectly the global shape of the femoral trochlea [2]. The thresholds for identifying trochlear dysplasia are established based on the sulcus angle ≥ 145°, medial/lateral trochlea facet asymmetry < 40%, trochlear depth < 3 mm and lateral trochlear inclination ≤ 11° and therefore it can be used in young adolescents [4, 5]. A deep knowledge of anatomic variations and abnormalities of the patellofemoral joint, which may predispose to PFI, is crucial in order to choose the appropriate treatment for each patient.

A Rare Inflammatory Myofibroblastic Tumor of the Spleen: A Case Report.

BACKGROUND/AIM: Inflammatory myofibroblastic tumors (IMTs) are rare, solid, potentially malignant lesions of uncertain etiology. Histologically, IMTs exhibit a combination of lymphocytes and inflammatory cells within a fibroblastic myxoid layer. The diagnosis of IMTs poses a challenge for various medical specialties, including surgeons, pathologists, and oncologists, due to their non-specific clinical presentation. Furthermore, radiologists face difficulties in interpreting computed tomography (CT) or magnetic resonance imaging (MRI) results, which often yield polymorphic and inconclusive findings. Ultimately, histopathologists play a crucial role in reaching a definitive diagnosis based on the tumor's histological characteristics. They are detected in every system of the human body, most commonly in the lungs. Here, we report an uncommon occurrence of IMT in the spleen of a patient with nonspecific abdominal pain. CASE REPORT: A 56-year-old Caucasian female presented to Konstantopouleio General Hospital of Nea Ionia, Athens, Greece, with abdominal pain and discomfort. The patient had no significant medical history and normal laboratory tests. An abdominal CT revealed a large mass in the spleen. A splenectomy was performed. Histopathological analysis of the tumor revealed IMTS. CONCLUSION: Splenic IMT is a rare benign tumor with moderate malignant potential. It lacks a distinct clinical presentation and is typically identified either incidentally or during the examination of abdominal pain.

Entrapment of the Subscapular Artery between the Radial Nerve and the Posterior Wall of the Axilla: An Anatomical Variation with Clinical Significance.

OBJECTIVE: The subscapular artery vascularizes a substantial region of the thoracic wall, and the significance of its distribution is well depicted in the diversity of reconstructive procedures that rely on its blood supply. The aim of this study is to present an uncommon anatomical variation of the artery and discuss the clinical implications of its presence. CASE REPORT: This case report depicts a rare variant of compression and the kinking of the subscapular artery by the radial nerve on the posterior wall of the axilla that was encountered during dissection of a male cadaver of Greek origin. CONCLUSION: The use of autologous tissues in the reconstruction of defects and treatment of lymphedema is expanding, so the need to establish safer surgical dissections is also becoming more apparent. The case of entrapment of the subscapular artery by the radial nerve is extremely rare, however, utilizing tissues perfused by this artery for reconstructive purposes could potentially be futile and unsuccessful due to the inadequate blood supply or vessel thrombosis. Hence, the surgeon should adapt the treatment plan according to preoperative findings, as the presence of anatomical variants should always be suspected.

Keystone Flap Type IV in Breast Reconstruction: A Case Report.

OBJECTIVE: The objective of this paper is to present and document a specific case of breast reconstruction using an adapted Type IV Keystone Flap technique, with a droplet-shaped design with a reduced flap ratio, and to identify the qualities of this method. CASE REPORT: A 41-year-old woman, with a history of myocardial infarction and low ejection fraction, underwent a lumpectomy, resulting in a lower medial quadrant deficit in her left breast. After she developed skin and tissue necrosis and infection, implementing the Type IV Keystone Flap effectively addressed the deficit, ensuring sufficient coverage. The flap extended dropwise beneath the deficit, progressing anteriorly towards the upper rectus abdominis, with a ratio of 2.5:1. The flap's novel droplet shape allowed for the utilization of fewer perforators, while ensuring adequate blood supply and tissue coverage, leading to improved perfusion and aesthetic outcome. CONCLUSION: The application of the adapted Type IV Keystone Flap highlights its capacity as a versatile and effective method for breast reconstruction post-lumpectomy. With the advantages of a short learning curve, easy execution, and acceptable risk profile, it offers a valuable alternative for patients who may not be suitable for more complex surgeries. Further research is recommended to confirm its broader applicability and to conduct a comparative analysis with other techniques.

George Sclavunos (1869-1954): Anatomical Insights and His Contribution into the "Magenstrasse of Waldeyer".

The purpose of this article is to present a well-known physician and highlight his contribution into an essential, but neglected anatomical feature. George Sclavunos (1869-1954) was a 20th century Greek physician, whose scientific work was a significant milestone in global medical knowledge. In 1899 he became Professor of Anatomy and Head Director of the Department of Anatomy. In 1906 Sclavunos G. published the first volume of the three volume book "Human Anatomy" (1906-1926), which is characterized by its unparalleled illustrations. For more than a century it was the most important book of medical literature in Greece. In 1926 he became a Full Member of the Academy of Athens and was named Life Partner of the International Anatomical Society. His interests included Anatomy, Physiology, Histology, as well as Osteology and Syndesmology. In his book "Human Anatomy", he described for first time the "Sialine Groove of the Stomach", which was described by Waldeyer-Hartz almost at the same time as the "Magenstrasse", a German word that means "stomach road". It is a ribbon-like path that extends along the lesser curvature of the stomach from the gastric cardia to the antrum and releases the gastric content directly into the small intestine. Its importance is confirmed by its association not only with drug delivery, but also with anti-obesity surgical techniques. The old German term has come back into common medical usage in view of the commonly performed Magenstrasse and Mill procedure, a form of bariatric surgery. CONCLUSION: Sclavunos G. managed to observe an anatomical structure that has remained of great importance until today.

Anatomic Risk Factors for Patellofemoral Joint Instability: An Infographic as a Visual Learning Tool.

Patellofemoral instability is a complex pathology with multiple risk factors, which affects mostly young females and may avert them from both activities of daily living and sports participation. Risk factors for instability include patella alta, trochlea dysplasia, abnormal lateral patellar tilt, and increased tibial tuberosity-trochlea groove distance. The knowledge of these anatomical abnormalities is the key to identifying the problem and succeeding in treating the patients.

Aberrant accessory abductor digiti minimi manus muscle: a rare anatomical variation.

The hypothenar muscle with the greatest frequency of variations is the abductor digiti minimi manus. Except for morphological variations of this muscle, have also been reported cases of an extra wrist muscle, the accessory abductor digiti minimi manus muscle. This case report presents a rare case of an accessory abductor digiti minimi muscle characterized by an unusual origin from the tendons of the flexor digitorum superficialis. This anatomical variation was identified on a formalin - fixed male cadaver of Greek origin during routine dissection. This anatomical variation, which may result in Guyon's canal syndrome or complicate common wrist and hand surgical procedures such as the carpal tunnel release, should be known to orthopaedic surgeons and hand surgeons in particular.

Carotid Body Tumor in a 26-Year-Old Male Patient Managed With Preoperative Embolization.

Carotid body tumors are rare, highly vascularized neuroendocrine tumors that arise near the bifurcation of the common carotid artery (CCA). Controversy exists in the management of those tumors about whether preoperative embolization facilitates surgical excision and decreases perioperative complication risk. We present the case of a 26-year-old patient with a carotid body tumor manifesting as a painless pulsatile mass in the anterior triangle over the left side of the neck and provide details of the preoperative diagnostic steps. Treatment included preoperative embolization of the tumor followed by surgical excision after 48 hours to safely address this rare pathology, resulting in a favorable outcome for the patient.

Anatomical Variations in the Celiac Trunk: A Short Review.

OBJECTIVE: The objective of the current study was the examination of possible variants of the celiac trunk. METHODS: An advanced review of the literature search was undertaken by means of the PubMed database and Google Scholar, searching for new studies published up to October 2022. Additional articles provided useful information in relation to the aim of this review. Hence, articles that met the inclusion criteria were included in this review and the collected data were organized into a table. RESULTS: The search of the literature retrieved 10 articles that referred to the anatomical variations of the celiac trunk. According to the available literature, the most common anatomical variations are: hepatosplenic trunk where the left gastric artery originates from the abdominal aorta, hepatosplenic trunk, where the left gastric artery originates from the splenic artery, and hepatogastric trunk and splenic artery origin from the superior mesenteric artery. Many other anatomical variations of the celiac trunk may exist, such as tetrafurcation, pentafurcation and hexafurcation, that refer to the division of the celiac trunk into four, five or six branches, respectively, and should be reported as they can affect surgical approaches and the development of the appropriate treatment strategy in patients. CONCLUSION: Every visceral surgeon, interventional radiologist and abdominal imager should be familiar with these variants.

Fracture of the Second Rib: An Indirect Sign of Serious Trauma Like Fracture of the First Rib?

Background: The first 3 ribs are anatomically well-protected, shielded by the large thoracic muscles, the shoulder girdle, and the arm. A significant force is required to fracture these ribs; thus, such fractures suggest a high-energy trauma and are associated with injuries to vital organs of the thorax, such as the aorta, the heart, the lungs and the great vessels. Methods: A retrospective analysis was conducted over a 10-year period at a single hospital. The study assessed patients with fractures of the second rib, including their concurrent injuries and the overall severity of their trauma. Results: Among the 76 patients included in the study, the average age was 47.35 years, 81.5% were men, and 19.5% were women. Thirteen patients (17.1%) survived their injuries. The most common causes of injury were road traffic accidents (63%) and pedestrian injuries (22%). The patients who did not survive sustained injuries to an average of 5 additional organs, while survivors had injuries to an average of 2.07 additional organs. Left rib fractures were the most frequently observed (46%). The most serious concurrent injuries reported were to the aorta (5.26%), heart (10.52%), lung (52.36%), head (57.89%), liver (30.2%), spleen (26.31%), and kidney (17.1%). Conclusion: As indicators of serious injury to vital endothoracic organs, isolated fractures of the second rib should be considered equal to first rib fractures in clinical importance.

The history of esophageal surgery.

BACKGROUND: Esophageal surgery has always been considered extremely demanding, given the surgical experience and skills required, due to the anatomic location of the esophagus as well as the impact of such extensive operations on patients' homeostasis. The intention of the present study is to review all historical time points of esophageal surgery, from its inception to the modern era of minimally invasive esophageal surgery. METHODS: The first clear description of esophageal surgery is dated back to 1738, in an attempt to remove a foreign body from the thoracic esophagus. However, the high morbidity and mortality rates of esophageal surgical operations led to the invention and application of less invasive surgical procedures. RESULTS: Esophageal surgery has evolved from extensive surgical operations to minimally invasive esophagectomies, aiming exclusively to reduce perioperative morbidity and mortality, while maintaining surgical effectiveness. Despite the fact that benign esophageal pathologies were the main stimulus for this evolution, minimally invasive esophageal surgery is now applied even in patients with esophageal cancer, with outcomes comparable to those of traditional surgical approaches. CONCLUSION: It would be interesting to see how all these new surgical techniques may evolve, altering further the current status of esophageal surgery in the future.

Clinical Considerations of First Extensor Wrist Compartment (FEWC) Variants and De Quervain's Disease: A Review Study.

The first extensor wrist compartment (FEWC) displays significant variants. This review highlights all possible variants that may be associated with the occurrence and pathophysiology of de Quervain's tenosynovitis. A thorough search of PubMed and MEDLINE databases, following the PRISMA guidelines, was conducted from 2002 to 2022 to evaluate all FEWC variants, including the following: 1) the presence of an inter-tendinous septum, 2) the number of tendinous slips of the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB) muscles, 3) their distal insertions and 4) the presence of a bony ridge within the FEWC. A total of 3878 wrists (1277 cadaveric and 1296 de Quervain patients) were included. Of the 1234 cadavers, a total of 701 (56.8%) were males and 533 (43.2%) were females. Regarding the 883 patients, 178 (20.2%) of them were males and 705 (79.8%) were females. An inter-tendinous septum was identified in 42.9% (47% of the patients' wrists compared to 39.3% of the cadaveric wrists, p<0.0001). Cadaveric wrists presented two or more slips for the APL in a significantly higher percentage (92.5%, p < 0.0001) compared to de Quervain patients' wrists (74.5%). Regarding the EPB muscle, de Quervain patients' wrists had a single slip in 93% (p=0.0007) and two or more slips in 3.6%, compared to cadaveric wrists (a single slip in 87%, and two or more slips in 11%, p< 0.0001). A bony ridge over the radial styloid process was recorded in 58.9% of the cadaveric wrists compared to 17.8% of the patients' wrists (p < 0.0001). Remarkable diversity concerning the structures within the FEWC was reported. The presence of an inter-tendinous septum dividing the FEWC and a single EPB muscle slip is more likely to be found in patients with de Quervain's disease.

The Coronoid Anatomical Variation of the Masseter Muscle: A Case Report.

INTRODUCTION: Masseter muscle is considered to consist of two layers: the superficial and the deep parts. However, in the literature a few cases have been reported of a third layer of the masseter muscle, which is called the coronoid part. The aim of this study is to present such a rare case of the coronoid part of the masseter muscle. MATERIAL AND METHODS: In our study, a case report is presented and enhanced by searching the existing literature in PubMed for other similar cases that recorded the coronoid part of the masseter muscle. RESULTS: The coronoid part of the masseter muscle was found in a male cadaver of Greek origin that was dissected in the Department of Anatomy, Medical School Athens, Greece. CONCLUSIONS: Good knowledge of anatomy and variations of the masseter muscle are of paramount importance due to their clinical and functional applications as well as during surgical procedures in this anatomical region.

The Coexistence of an Incomplete Superficial Palmar Arch and a Berrettini Anastomosis: A Case Report.

OBJECTIVE: The aim of this study is to present a relatively rare case of the coexistence of an incomplete superficial palmar arch and a Berrettini anastomosis, identified in a cadaveric specimen, and further discuss the potential clinical implications of such anatomical variations. CASE REPORT: The variation was found in the left hand of a formalin-fixed male cadaver of Greek origin, that was dissected under an operating microscope (×4, ×10 magnification) in our Anatomy Department. In the specimen, we found an incomplete superficial palmar arch, formed only by the superficial branch of the ulnar artery, and a Type 1 Berrettini Anastomosis, originating from the ulnar nerve and joining a branch of the median nerve. CONCLUSION: To avoid iatrogenic damage and permanent loss of sensation, hand surgeons and microsurgeons should be aware of the presence of a BA, and the potential coexistence of this variation with vascular abnormalities in the hand that may complicate surgical procedures.

Cutaneous B-cell Pseudolymphoma: A Rare Case Masquerading a Thoracic Mass in a Fourteen-Year-Old Male Patient.

Cutaneous B-cell pseudolymphoma (CBPL) may appear in the face, chest, or upper limbs, and it can be asymptomatic or in the form of nodules, papules, or masses. In most cases, it is idiopathic. However, some causes that have been identified are trauma, contact dermatitis, injected vaccinations, bacterial infections, tattoo dyes, insect bites, and certain drugs. Since the histology and clinical presentation of cutaneous pseudolymphoma (CPSL) are similar to those of cutaneous lymphomas, the diagnosis is usually based on an incisional or excisional biopsy. In this paper, a 14-year-old male patient with a two-month-old mass in the right lateral thoracic region is taken as a case study. He had neither symptoms, nor a past medical history, nor a family history. He had an insect bite a month ago and was fully vaccinated. However, the mass was some centimeters away from the insect bite. A biopsy was taken. The products of it were two paraffin cubes and two histological slides (H&E). The diagnosis was cutaneous B-cell pseudolymphoma. The total removal of the mass was decided since, in idiopathic cases like this, CBPL is not usually healed with topical and non-invasive treatments. Follow-up examinations were suggested since a further antigenic reaction is possible. If cutaneous B-pseudolymphoma is early diagnosed and treated, it does not cause serious problems. In some cases, it even resolves on its own.

Anatomical Considerations and Plastic Surgery Reconstruction Options of Sacral Chordoma Resection.

Introduction Chordomas are slow-growing malignant bone tumors arising from remnant embryonic notochord cells with predilection for the sacrum. They rarely metastasize, and early surgical resection with clear margins is the treatment of choice followed by plastic surgery reconstruction supplemented with adjuvant radiotherapy based on the local treatment protocol or in cases with a contaminated surgical field. Aim The aim of the present study is to present our experience in surgical management of sacral chordomas and propose a surgical reconstruction algorithm considering anatomical parameters after partial or total sacrectomy. Materials and methods  Twenty-seven patients with sacral chordomas were treated in our Orthopaedic Surgery Department between January 1997 and September 2022, and 10 of them had plastic surgery reconstruction. Patients were divided into groups based on the type of sacrectomy, sacrum anatomical vascular or neural variations, partial or total, and the type of soft tissue reconstruction. The postoperative complications and the functional outcomes in each patient were assessed. Results  Bilateral gluteal advancement flaps or gluteal perforator flaps are the first choice in patients with partial sacrectomy, intact gluteal vessels, and without preoperative radiotherapy followed by transpelvic vertical rectus abdominis myocutaneous flap or free flaps in those patients with near total sacrectomy and preoperative radiation therapy. Conclusion  There are four reliable options for patients after sacral chordoma resection: direct closure, bilateral gluteal advancement flaps, transpelvic vertical rectus abdominis myocutaneous flaps, and free flaps. Each time, tumor-free margins and a good reconstructive plan according to the defect and patient characteristics are mandatory.

Perianal Skin Tags Revealing Asymptomatic Crohn's Disease in a 12-Year-Old Child With Growth Impairment: A Case Report.

Pediatric Crohn's disease (CD) is a chronic inflammatory bowel disease considered to impair the growth of children and adolescents. Since CD commonly presents perianal manifestations, general surgeons may play a crucial role in its diagnosis and treatment. Detailed history, along with a thorough clinical examination, is mandatory for the management of CD perianal lesions. However, surgical intervention is only indicated in selected patients since it may lead to poor wound healing and recurrence. The article reports a case of a 12-year-old girl, presenting perianal skin tags and growth impairment as the first signs of asymptomatic CD.

Duplicated inferior vena cava-trifurcated portal vein: a rare anatomical variation encountered during Whipple procedure.

The inferior vena cava (IVC) is the largest single vein in humans. However, during embryogenesis, abnormalities can occur resulting in a duplicated IVC. The portal vein (PV) offers the main blood flood to the liver, forming by the left and right PV. A number of anatomical variations are noticed, underlying the great importance of the pre-operative imaging workup. This case report presents a duplicated IVC and a trifucated PV that were incidentally found in an 82 year-old Caucasian male with pancreatic ductal adenocarcinoma who underwent pancreatoduodenectomy (Whipple procedure). Although some anatomical variations, including the duplication of the IVC and the trifurcation of PV, may be rare to the general population, the suspicion of their existence should always be taken under consideration from surgeons during hepatobiliary or retroperitoneal operations.

Syndromic Craniosynostosis: A Comprehensive Review.

Craniosynostosis is a fetal skull condition that occurs when one or multiple sutures merge prematurely. This leads to limited growth perpendicular to the fused suture, which results in compensatory growth of cranial bones parallel to it. Syndromic craniosynostosis ensues when the cranial deformity is accompanied by respiratory, neurological, cardiac, musculoskeletal, and audio-visual abnormalities. The most common syndromes are Apert, Crouzon, Pfeiffer, Muenke, and Saethre-Chotzen syndromes and craniofrontonasal syndrome. Each of these syndromes has distinct genetic mutations that contribute to their development. Mutations in genes such as FGFR, TWIST, and EFNB1 have been identified as playing a role in the development of these syndromes. Familiarity with the genetic basis of each syndrome is not only essential for identifying them but also advantageous for current pharmacological investigations. Surgical treatment is often necessary for syndromic craniosynostosis to correct the cranial deformities. Advances have been made in surgical techniques for each specific syndrome, but further research is needed to develop personalized approaches that address the unique symptoms and complications of individual patients, particularly those related to neurological and respiratory issues. This group of syndromes included in cranial synostosis presents significant educational and clinical interest due to the wide range of symptoms and the variable course of the disease, especially in the last decades when crucial advances in diagnosis and treatment have been achieved, altering the prognosis as well as the quality of life of these patients. In summary, this article provides a comprehensive overview of syndromic craniosynostosis, including the genetic mutations associated with each syndrome and the surgical treatment options available.