Costoclavicular ligament as a novel cause of venous thoracic outlet syndrome: from anatomic study to clinical application.

PURPOSE: Venous thoracic outlet syndrome (VTOS) is a compressive disorder of subclavian vein (SCV); we aimed to investigate the role of costoclavicular ligament (CCL) in the pathogenesis of VTOS. METHODS: A cadaver study was carried out to investigate the presence and morphology of CCL in thoracic outlet regions, as well as its relationship with the SCV. Six formalin-fixed adult cadavers were included, generating 12 dissections of costoclavicular regions (two sides per cadaver). Once CCL was identified, observation and measurement were made of its morphology and dimensions, and its relationship with SCV was studied. To take a step further, a clinical VTOS case was reported to prove the anatomical findings. RESULTS: Two out of twelve costoclavicular regions (2/12, 16.7%) were found to possess CCLs. Both ligaments were located in the left side of two male cadavers and were closely attached to the lateral aspect of sternoclavicular joint capsules. The lateral fibers of the ligament proceed in a superolateral-to-inferomedial manner, while the medial fibers proceed more vertically. Both ligaments were tightly adherent to the SCV, causing significant compression on the vein. In the clinical case, multiple bunches of CCLs were found to compress the SCV tightly intraoperatively. After removing the ligaments, the patient's symptom kept relief during a follow-up period of 2 years. CONCLUSION: Our study demonstrated that CCL could be a novel cause of VTOS by severe compression of SCV. Patients diagnosed with this etiology could get less invasive surgical treatment by simply removing the ligament.

Long-term Outcomes Following Vickers Ligament Release and Growth Modulation for the Treatment of Madelung Deformity.

BACKGROUND: Madelung deformity arises from a partial distal radial growth disturbance in combination with an abnormal hypertrophic ligament spanning the volar radius and carpus, termed, the Vickers ligament. The purpose of this study is to report long-term clinical and radiographic outcomes following Vickers ligament release and distal radial physiolysis in a population of skeletally immature patients with symptomatic Madelung deformity. METHODS: Medical records were retrospectively reviewed of patients with Madelung deformity surgically treated between 1994 and 2005. All eligible patients who underwent a Vickers ligament release and distal radial physiolysis were contacted and invited to return to the clinic for follow-up. RESULTS: Six patients (8 wrists) with Madelung deformity underwent Vickers ligament release and distal radial physiolysis. All were white females with a mean age at initial presentation of 11.4 years (10 to 12.8 y). Mean age at the time of initial surgery was 12.0 years (10.0 to 14.5 y). The median follow-up time was 10.6 years (5.8 to 21.9 y) and the average age at last follow-up was 23.1 years (17.5 to 32.2 y). Pain alone or in combination with concerns for deformity was the chief complaint in 6 of 8 of the wrists. At 1 year of clinical follow-up, 7 of 8 wrists were reported to be pain-free, and 6 of the 8 were noted to be completely pain-free at last follow-up. Motion in flexion, extension, pronation, supination, radial, or ulnar deviation was similar between the preoperative status and long-term follow-up. The average preoperative ulnar tilt was 35.1 degrees (SD: 8.5 degrees), average preoperative lunate subsidence was 1.9 degrees (SD: 1.8 degrees), and average preoperative palmar carpal displacement was 21.9 degrees (SD: 2.9 degrees). At the final follow-up, there was a large progression in lunate subsidence, but minimal change in ulnar tilt and palmar carpal displacement. At last clinical follow-up, 2 of the 6 patients had undergone a subsequent procedure including 1 radial dome osteotomy and 1 ulnar shortening osteotomy. CONCLUSION: In the skeletally immature patient population with Madelung deformity with growth potential remaining, distal radial physiolysis and Vickers ligament release is associated with relief of pain, preservation of motion, and, a reasonable rate of reoperation. TYPE OF STUDY: This was a therapeutic study. LEVEL OF EVIDENCE: Level II.

A variant in OLFML3 is associated with pectinate ligament abnormality and primary closed-angle glaucoma in Border Collies from the United Kingdom.

PURPOSE: Canine primary closed-angle glaucoma (PCAG) is a complex disease caused by multiple genetic factors. A c.590G>A variant in OLFML3 was recently reported to be a candidate for pectinate ligament abnormality (PLA) and PCAG in the Border Collie. We investigated the association of this variant with PLA and PCAG in Border Collies from the United Kingdom. METHODS: The OLFML3 variant was genotyped in 106 Border Collies comprising 90 with normal eyes (controls) and 16 with PLA (n = 11) and/or PCAG (n = 5) (cases). Genotyping was performed in an additional 103 Border Collies to estimate variant frequency within the population. To investigate the association of the variant with disease in other breeds, genotyping was performed in 337 non-Border Collies with PLA and/or PCAG. RESULTS: Of the 90 controls, 71 were homozygous for the wild-type allele, two were homozygous for the variant, and 17 were heterozygous. Of the 16 cases, three were homozygous for the wild-type allele, 11 were homozygous for the variant, and two were heterozygous. The association of the variant allele with disease was significant (P = 1.1 x 10-9 ). We estimated the frequency of this variant to be 4.4% within the United Kingdom Border Collie population, and it was not identified in clinically affected dogs of any other breed. CONCLUSIONS: This study confirms the association of the OLFML3 variant with PLA and PCAG in Border Collies from the United Kingdom. DNA testing for the variant and selective breeding can reasonably be expected to result in a reduction of PLA and PCAG prevalence in the breed.

An Unusual Bilateral Duplication of the Suprascapular Vein and Its Relation to the Superior Transverse Scapular Ligament Revealed by Anatomage Table.

OBJECTIVE: The aim of our paper is to present a rare variation of the suprascapular vein, its incidence and clinical significance. CASE REPORT: A rare case of a double suprascapular vein was observed in a digitalized human cadaver on Anatomage Table 5.0. The vein divided into two branches, one passing over the transverse scapular ligament, while the other one coursed underneath the ligament, inside the notch. CONCLUSION: This variation has major clinical importance as it is associated with the appearance of Suprascapular nerve entrapment syndrome.

Scleraxis is required for maturation of tissue domains for proper integration of the musculoskeletal system.

Scleraxis (Scx) is a basic helix-loop-helix transcription factor that is expressed persistently in tendons/ligaments, but transiently in entheseal cartilage. In this study, we generated a novel ScxCre knock-in (KI) allele, by in-frame replacement of most of Scx exon 1 with Cre recombinase (Cre), to drive Cre expression using Scx promoter and to inactivate the endogenous Scx. Reflecting the intensity and duration of endogenous expression, Cre-mediated excision occurs in tendinous and ligamentous tissues persistently expressing Scx. Expression of tenomodulin, a marker of mature tenocytes and ligamentocytes, was almost absent in tendons and ligaments of ScxCre/Cre KI mice lacking Scx to indicate defective maturation. In homozygotes, the transiently Scx-expressing entheseal regions such as the rib cage, patella cartilage, and calcaneus were small and defective and cartilaginous tuberosity was missing. Decreased Sox9 expression and phosphorylation of Smad1/5 and Smad3 were also observed in the developing entheseal cartilage, patella, and deltoid tuberosity of ScxCre/Cre KI mice. These results highlighted the functional importance of both transient and persistent expression domains of Scx for proper integration of the musculoskeletal components.

A controlled study on the anatomy of cervical extraforaminal ligaments and three-dimensional fast-imaging employing a steady-state acquisition sequence.

PURPOSE: To evaluate the utility of magnetic resonance three-dimensional fast-imaging employing a steady-state acquisition (MR 3D-FIESTA) sequence to study cervical EFLs using the anatomical results of cadavers as the gold standard. METHODS: Part I: The cervical regions of five embalmed adult cadavers were scanned using the MR 3D-FIESTA sequence. Ligamentous structures in the intervertebral foramina (IVFs) between C4 and T1 in the MRI scans were identified by a radiologist. Part II: After the specimens were scanned, gross and microscopic anatomical studies were conducted on the IVFs between C4 and T1 in the specimens by an anatomist. Part III: Using the anatomical results of the cadavers as the gold standard, the utility of the MR 3D-FIESTA sequence for imaging cervical EFLs was evaluated. Specificity, sensitivity, positive and negative predictive values (PPV and NPV, respectively) and accuracy were calculated. RESULTS: The occurrence rate of transforaminal ligaments (TFLs) in the IVFs between C4 and T1 was 42.5%. The results obtained by the radiologist using the MR 3D-FIESTA sequence to identify TFLs are as follows: specificity 96.2%, sensitivity 76.5%, PPV 92.9%, NPV 86.2%, and accuracy 88.4%. CONCLUSION: MR 3D-FIESTA sequences clearly showed cervical EFLs. In the 3D-FIESTA sequence scans that the radiologist believed to indicate the presence of a cervical TFL, the probability that the TFL existed was approximately 93%. When the radiologist believed that no TFL was present in the 3D-FIESTA sequence scan, the probability that a TFL existed was 14%.

Elite Distance Runners and Breastfeeding.

BACKGROUND: Elite female distance runners lack guidelines regarding breastfeeding while training at a high intensity. OBJECTIVES: The purpose of this research was to understand how elite female distance runners manage breastfeeding. METHODS: Semistructured interviews were conducted with 14 women who had had at least one pregnancy within the past 5 years and had achieved a minimum of the USA Track and Field 2012 Olympic Trials "B" entry standard for running for the marathon or equivalent performance for 1,500 m or longer. RESULTS: Using thematic analysis, we identified the following themes: breastfeeding as a barrier to training and competition, limited access to relevant breastfeeding information, and concerns for the baby's health. Our findings show that despite the considerable barriers with which these women contend, they breastfed at higher rates and for longer duration than members of the general public. CONCLUSION: Based on our findings, we argue that elite female distance runners' experiences of breastfeeding would be enhanced if more research were conducted on breastfeeding practices while training and competing at an elite level.

Classification and techniques of en bloc venous reconstruction for pancreaticoduodenectomy.

BACKGROUND: Surgical resection is the only cure for hepato-pancreato-biliary (HPB) malignancy. In the era of multidisciplinary approaches and neoadjuvant therapies for locally advanced, borderline resectable tumors, the feasibility and efficacy of en bloc vascular resection has been validated across multiple studies. However, the variability of venous anatomy within the perihepatic and peri-portal regions necessitates familiarity with alternative resection and reconstruction techniques appropriate to the specific region of tumor invasion. METHODS: To organize these paradigms, the venous system has been divided into five zones: 1) hepatic hilum; 2) hepatoduodenal ligament; 3) portal vein/splenic vein confluence, which is further subdivided into right (3a) and left (3b); 4) infra-confluence; and 5) splenic vein. RESULTS: This study systematically analyzes the anatomic considerations and clinical scenarios specific to each zone to organize the necessary preparative maneuvers, surgical procedures, and vascular reconstruction techniques to achieve an R0 resection. The anatomic and tumor-specific factors which deem a specimen unresectable are also explored. Surgical videos demonstrating these techniques are presented. DISCUSSION: Preparation and familiarity with venous reconstruction maneuvers is essential for an oncologically effective operation, and can be safely achieved by utilizing this logical anatomic and procedural framework.

Rare complications of a low lying median arcuate coeliac ligament.

Pancreaticoduodenal artery aneurysm is a rare complication of coeliac artery stenosis secondary to a low lying median arcuate coeliac ligament. This article reports the case of a 69-year old man who presented with left arm and leg weakness, clinically in keeping with right hemisphere stroke. Initial CT brain scan was within normal limits. The patient did not receive thrombolysis as he was outside the time window. 3 hours later the patient experienced sudden onset epigastric pain and acute shock. CT aorta abdominal was diagnostic of a ruptured inferior pancreaticoduodenal artery aneurysm. Repeat CT brain the following day showed subacute infarction within the right frontal lobe. Embolisation of the aneurysm was successfully performed. It is well documented that ischaemic stroke can cause acute hypertension. This acute hypertension probably contributed to the rupture of the pancreaticoduodenal artery aneurysm. The patient was well on discharge and remains well 2 months on.

Concave impressio ligamenti costoclavicularis ("rhomboid fossa") and its prevalence and relevance to clinical practice.

PURPOSE: The incidence of fossa rhomboidea (RF) and its relevance to clinical practice were retrospectively studied in 1,017 cases of patients who endured clavicle fractures. The aim of the study was to determine the frequency of different types of insertion areas of costoclavicular ligament (LCC) in our group, as well as gender distribution. Furthermore, we wanted to investigate whether the RF represents a weakened part of clavicle where the fracture occurred. Several of our findings in our control group were quite interesting and worth mentioning. MATERIALS AND METHODS: 1,017 roentgenograms were analyzed from 1,027 clavicle fractures of patients from 2 to 90 years of age who were treated between 2007 and 2011. RESULTS: Using the Allman classification system, 79% of the examined clavicle fractures were identified as type 1, 18.4% as type 2, and 2.6% as type 3. Statistical analysis did not demonstrate a difference in fractures of the clavicle between the right and the left side (47, 53%, respectively; p = 0.0570). There was a statistically significant difference in the incidence of fractures between the genders (males 71%, females 29 %; p < 0.0001). The results for the insertion attachment area were as follows for the given percent of cases: flat (75.2%); concave (21.1%); convex (3.7%). Those 21.1% of concave insertions represent RF. 5.3% of RF cases were between 2 to 10 mm in depth. One of the patients with RF had a deepend insertion of the LCC on the superior surface of the first rib analogous to RF. The bilateral RF was asymmetrical in its appearance. One of the patients suffered from LCC enthesopathy. The difference of the distribution of RF throughout the genders was 10.5% in females and 89.5% in males, marking a difference that is statistically significant (p < 0.0001). Only in 0.3%, the fracture line occurred in RF, which did not prove the RF to be a weakened point of the fracture (p < 0.0001). CONCLUSIONS: RF represents a variety of LCC insertion that is predominantly found in male patients, which can be used in the determination of gender in forensic analysis. RF is not a weak point for fracture formation. Enthesopathy of the LCC together with RF can lead to suspicion concerning the osteolytic process. Biopsy of RF should be avoided. Insertion of LCC similar to RF can be exceptionally found on the first rib.

Relationship between midgut malrotation and anatomy of the hepatoduodenal ligament: a rare anatomical variation in a deceased donor.

INTRODUCTION: Anatomical variations around the hepatoduodenal ligament greatly influence surgical procedures and the difficulty of operations. Here, we report the case of a deceased donor with midgut malrotation (MgM) and anatomical variation. We also present an anatomical comparison between MgM and normal cases. CASE REPORT: The donor, a male in his 60s, was diagnosed with MgM based on preoperative computed tomography. Intraoperatively, the liver graft was harvested from the proper hepatic artery (PHA), but its length was too short for reconstruction. Therefore, the hepatic artery was reconstructed at both the left and right hepatic arteries. METHODS: The length of the proper hepatic artery (l-PHA) and main trunk of the portal vein (l-PV) was compared between MgM and control groups (n = 9) using computed tomography. The ratio of PHA (r-PHA) and PV (r-PV), which was calculated as the l-PHA or l-PV divided by the patient's height, was also compared. RESULTS: The r-PV was 1.3% in the MgM group and 1.6% in the control group (P = .09). The r-PHA was 0.23% in the MgM group and 0.92% in the control group (P < .01). Thus, the PHA was significantly shorter in the MgM group. Additionally, anatomical variations of the hepatic artery were confirmed in four cases. CONCLUSION: Preoperative radiological evaluation is not always adequate for identifying anatomical abnormalities in deceased donors. MgM is a rare but important anomaly because of the possibility of associated anatomical variations of the hepatic artery.

Wandering spleen torsion causing acute abdominal pain in a child: case report and review of literature.

Wandering spleen is a rare occurrence where the spleen normal fixation to the abdominal wall is lost and thus allowed to change in position. We report a case of a child who presented with acute abdominal pain secondary to a wandering spleen complicated by torsion of its vascular pedicle. The diagnosis was promptly made using computed tomography and managed with splenectomy.

Principais osteotomias para o tratamento da ruptura do ligamento cruzado cranial em cães - revisão de literatura / Main osteotomies for treating rupture of the cranial cruciate ligament in dogs - a literature review / Principales osteotomías para el tratamiento de ruptura del ligamento cruzado craneal en perros - revisíon de literatura

A ruptura do ligamento cruzado cranial é a principal causa de claudicação do membro pélvico em cães. A causa da ruptura é multifatorial como processo degenerativo, inflamatório e traumático. Acomete principalmente cães de grande porte, não havendo predisposição sexual. O principal sinal clínico é a claudicação. Os testes de compressão tibial e de gaveta são realizados para o diagnóstico, associados à anamnese. As radiografias são importantes para avaliação do platô tibial e o diagnóstico de doença articular degenerativa. Muitas técnicas cirúrgicas podem ser utilizadas para o tratamento. Atualmente as osteotomias são as mais aceitas, devido a conformação anatômica do joelho canino. O objetivo desse trabalho é descrever as principais osteotomias para o tratamento da ruptura do ligamento cruzado cranial em cães, relacionando as indicações e complicações de cada técnica. Conclui-se que existem várias técnicas de osteotomias para o tratamento da ruptura do ligamento cruzado cranial, cada uma com suas indicações e complicações. Sendo de grande importância a medida do ângulo do platô tibial para a escolha da técnica a ser utilizada...

The cranial cruciate ligament is the main cause of lameness in the pelvic limb in dogs. Rupture causes are multifactorial, such as degenerative, inflammatory and traumatic processes. It mainly affects large dogs with no gender predisposition. The main clinical sign is lameness. Tibial compression and tray tests are performed for diagnosis, together with anamnesis. Radiographs are also important for assessing the tibial plateau and the diagnosis of degenerative joint disease. Many surgical techniques can be used for treatment. Osteotomies are currently the most accepted ones, due to the anatomical conformation of the canine knee. The aim of this paper is to describe the main osteotomy for treating cranial cruciate ligament rupture in dogs, stating the indications and complications of each technique. It can be concluded that there are several osteotomy techniques for the treatment of cranial cruciate ligament, each of them with their own indications and complications. It is, therefore, very important to measure the tibial plateau angle for the correct choice of techniques...

La ruptura del ligamento cruzado craneal es la principal causa de claudicación del miembro pélvico en perros. La causa de la ruptura es multifactorial como proceso degenerativo, inflamatorio y traumático. Afecta principalmente perros grandes, no ocurriendo predisposición sexual. La principal señal clínica es la claudicación. Las pruebas de compresión tibial y la bandeja tibial se llevan a cabo para el diagnóstico, asociados a la anamnesis. Las radiografías son importantes para evaluación de la meseta tibial y el diagnóstico de la enfermedad degenerativa de las articulaciones. Muchas técnicas quirúrgicas pueden ser utilizadas para el tratamiento. Actualmente las osteotomías son las más aceptadas, debido la conformación anatómica de la rodilla canina. El objetivo de esta investigación ha sido describir las principales osteotomías para el tratamiento de la rotura del ligamento cruzado craneal en perros, relacionando las indicaciones y complicaciones de cada técnica. Se concluye que hay varias técnicas de osteotomías para el tratamiento de la ruptura del ligamento cruzado craneal, cada uno con sus indicaciones y complicaciones. Es de gran importancia la medida del ángulo de la meseta tibial para la elección de la técnica a ser utilizada...

Median arcuate ligament syndrome in the pediatric population.

OBJECTIVES: Median arcuate ligament syndrome (MALS) is a vascular compression syndrome with symptoms that overlap chronic functional abdominal pain (CFAP). We report our experience treating MALS in a pediatric cohort previously diagnosed with CFAP. PATIENTS AND METHODS: We prospectively evaluated 46 pediatric (<21years of age) patients diagnosed with MALS at a tertiary care referral center from 2008 to 2012. All patients had previously been diagnosed with CFAP. Patients were evaluated for celiac artery compression by duplex ultrasound and diagnosis was confirmed by computed tomography. Quality of life (QOL) was determined by pre- and postsurgical administration of PedsQL™ questionnaire. The patients underwent laparoscopic release of the median arcuate ligament overlying the celiac artery which included surgical neurolysis. We examined the hemodynamic changes in parameters of the celiac artery and perioperative QOL outcomes to determine correlation. RESULTS: All patients had studies suggestive of MALS on duplex and computed tomography; 91% (n=42) positive for MALS were females. All patients underwent a technically satisfactory laparoscopic surgical release resulting in a significant improvement in blood flow through the celiac artery. There were no deaths and a total of 9 complications, 8 requiring a secondary procedure; 33 patients were administered QOL surveys. 18 patients completed the survey with 15 (83%) patients reporting overall improvement in the QOL. Overall, 31/46 patients (67%) reported improvement of symptoms since the time of surgery. CONCLUSIONS: MALS was found to be more common in pediatric females than males. Laparoscopic release of the celiac artery can be performed safely in the pediatric population. Surgical release of the artery and resultant neurolysis resulted in significant improvement in the blood flow, symptoms, and overall QOL in this cohort. The overall improvement in QOL outcome measures after surgery leads us to conclude that MALS might be earlier diagnosed and possibly treated in patients with CFAP. We recommend a multidisciplinary team approach to care for these complex patients.