Prevalence and morphometry of sternal and xiphoid foramen: a meta-analysis on 16,666 subjects.

PURPOSE: Sternal foramen is a perforation of the sternum that can be a source of misdiagnosis during radiographic imaging or life-threatening perforations during bone marrow sampling. The aim of this study was to conduct a meta-analysis on the prevalence, morphometrics, and location of foramen in the sternal body and xiphoid process, describe morphometric features of this phenomenon, and thus verify its clinical importance. Moreover, our secondary outcome was to compare effectiveness of various imaging methods in diagnosis of the sternal or xiphoid foramen. METHODS: A comprehensive search was conducted on major scientific databases to identify studies containing relevant information. Data on foramen's prevalence, location, morphometrics, and accompanying findings were extracted and pooled into a meta-analysis using MetaXL 5.0. RESULTS: Thirty-five studies (n = 16,666 subjects) were included. The overall pooled prevalence of a foramen in the sternal body and/or a xiphoid process was 8.9% (95% CI 6.5-11.7) and it equaled 6.5% (95% CI 5.6-7.6) for sternal body alone and 2.9% (95% CI 0.5-6.9) for the xiphoid process. The foramen was more prevalent in males than in females (12.2% vs. 6.8%). The prevalence of sternal foramen was higher in South American [13.9% (95% CI 11.2-16.9)] and African [13.6% (95% CI 9.7-18.0)] studies compared to North American [6.2% (95% CI 5.0-7.5)] and European populations [8.6% (95% CI 3.1-16.3)]. Mean transverse and vertical diameter of foramen equaled 4.7 mm (95% CI 3.8-5.5), and 5.6 mm (95% CI 4.2-6.9), respectively. CONCLUSION: Our analysis proves that the sternal foramina are structures of significant prevalence and size. Any physician should keep them in mind when performing punctures in this area.

Prevalence of the sternalis muscle in a sample of routinely dissected human cadavers.

PURPOSE: Sternalis muscle is an uncommon muscle head attaching between the sternoclavicular joint superiorly and the costal cartilage near the xiphoid process. METHODS: In this study, 36 cadavers (18 male, 18 female) were obtained through the Anatomical Board of the State of Florida and complete, routine musculoskeletal dissection was performed while adhering to all relevant laws and practices. RESULTS: Two examples of the sternalis muscle belly (5%) were identified, one in a black male and one a white female. The sternalis muscles were bilateral in both cases and each was formed of a single muscle belly. The superior attachments were continuous with the sternal attachment of sternocleidomastoid, and the inferior attachments connected to the costal cartilages. Sternalis did not cross the midline and the T2-T5 anterior intercostal neurovasculature associated closely with the muscle belly. In the female, a well-formed unilateral chondrocoracoideus muscle was apparent with a branch from the medial pectoral nerve closely associated on the deep surface. No other abnormalities in the chest, axilla, or brachial plexus were noted on either cadaver, and the pectoralis major and minor muscles were normally formed and innervated in both cases. CONCLUSION: This study supports other evidence in the literature that indicates the sternalis muscle has an average prevalence in the population of approximately 5%, and it appears across race and sex. Education about this structure is important for radiologists, surgeons, and doctors of physical therapy that may be involved in treatment and post-surgical rehabilitation of this region.

Correlation of Xiphopubic Distance, Body Weight, Height and Body Mass Index with Intravesical and Abdominal Initial Resting Pressures in Urodynamic Testing in the Sitting Position.

OBJECTIVES: To compare the initial resting intravesical pressure (pves ) and abdominal pressure (pabd ) in the sitting position with the typical range of values, to assess the correlation between such pressures and patient xipho-pubic distance, body weight, height and body mass index (BMI), and to estimate if xipho-pubic distance can be a guide to interpret initial resting pressures in urodynamic testing. METHODS: Women with lower urinary tract symptomatology referred for urodynamic testing were consecutively enrolled in a prospective study. Conventional cystometry was done following "good urodynamic practices". The correlation between initial resting pves and pabd and xipho-pubic distance, body weight, height and BMI were studied using simple and multiple linear regression analysis. Statistical significance was defined as P < 0.05. RESULTS: One hundred women aged (mean ± SD) 59.2 ± 13.3 were studied. There was a significant correlation between both pves and pabd , and xipho-pubic distance, body weight and BMI and no correlation with height. Over the multiple analysis, xipho-pubic distance and body weight correlated independently with pves ; body weight correlated independently with pabd . Three patients had pves and/or pabd out of typical range, with BMIs values of 18.48, 18.72 and 35.81 kg/m2 . There was a wide range of difference between xipho-pubic distance and initial resting pressures. CONCLUSIONS: Out of range initial resting pressures occur in underweight (or close to) or severely obese patients. Xipho-pubic distance and body weight correlated independently with pves . Body weight correlated independently with pabd . Xipho-pubic distance cannot be a guide to interpret the initial resting pressures.

Sternal foramina: incidence in Greek population, anatomy and clinical considerations.

PURPOSE: Sternal foramina represent developmental defects in the sternum, which occur due to incomplete fusion of the sternal ossification centers. Sternal foramina have been correlated with several clinical implications and constitute a subject of interest for the forensic practice. The aim of this study is to define their incidence in Greek population. METHODS: The presence of midline foramen was studied in 60 dried, adult sterna derived from the Anatomy Department of Medical School of Aristotle University of Thessaloniki. Measurements were made with a 0.01-mm accuracy caliber and photographic documentation was obtained. Additionally, computed tomography scanning of the sterna was performed. RESULTS: Sternal foramina were found in 11 subjects, resulting in an incidence of 18.3% over the total population. In 27.3% of the subjects with sternal foramen, a single sternal foramen was observed in the body of the sternum, while in 45.5% of the sterna presenting sternal foramina, multiple xiphoidal foramina were noticed. In two specimens, association of xiphoidal foramina with sternal cleft was documented. CONCLUSION: Sternal foramina are variant quite common in the population, with distinct imaging pattern and awareness of their existence is important for the physician.

Where should the normal position of the umbilicus be in the neonate?

INTRODUCTION: The aim of this study was to determine the normal position of the umbilicus so as to offer a guide to improve cosmetic results after the repair of congenital abdominal wall defects. MATERIALS AND METHODS: The position of the umbilical center was determined in 187 neonates with respect to the xiphoid process, the center of the umbilicus and the pubis. The distance between the xiphoid process and the center of the umbilicus (XU), between the pubis and the center of the umbilicus (PU) and from the xiphoid process to the pubis (XP) were measured while the babies lay in a supine position. The PU:XU ratio was calculated based on these measurements. RESULTS: Mean XP was 11.93±1.40 cm, mean XU was 7.41±1.08 cm and mean PU was 4.52±0.70 (mean±SD). The PU:XU ratio was calculated as 0.61±0.12 (ratio±SD). CONCLUSION: We suggest that the PU:XU ratio should be 0.61 offering an ideal localization in umbilical reconstruction.

Estudio de la anatomía quirúrgica del ángulo xifoideo / Study of the surgical anatomy of the xiphoid angle’s

Fundamento: una de las operaciones más laboriosas y complejas son las practicadas en el hiatus esofágico, para el tratamiento de la úlcera péptica y otras enfermedades, dada su localización anatómica y la necesidad de utilizar varios ayudantes en un campo quirúrgico reducido. Objetivo: definir las características anatómicas del ángulo xifoideo que permita diseñar un retractor quirúrgico a utilizar en esta región. Método: se realizó un estudio descriptivo y prospectivo, el universo se constituyó por doscientos dieciocho trabajadores del Hospital Universitario Manuel Ascunce Domenech de Camagüey, se escogió una muestra al azar de cien adultos. Se analizaron las variables biotipo, edad, sexo, peso, talla, medidas del ángulo xifoideo y ancho del apéndice xifoides. Resultados: el promedio de edad fue de 35,5 años; el peso promedio 64,8kg; la talla media fue 1,64m; el ángulo xifoideo 86,8º promedio; el ancho del apéndice xifoideo fue 1,82cm como promedio. Conclusiones: el ancho promedio del apéndice xifoides fue de 1,82cm.

Background: one of the most laborious and complex surgical procedures are those practiced in the hiatus oesophageus, for the treatment of the peptic ulcer and other diseases, given their anatomical localization and the necessity to use several assistants in a reduced surgical field. Objective: to define the anatomical characteristics of xiphoid angle’s that allows designing a surgical retractor to use in this region. Method: a descriptive and prospective study was carried out, the universe was constituted by two-hundred eighteen workers of the University Hospital Manuel Ascunce Domenech of Camagüey, a random sampling of one-hundred adults was chosen. Variables like biotype, age, sex, weight, height, measures of xiphoid angle’s and width of the xiphoid appendix were analyzed. Results: the average age was of 35,5 years; the average weight of 64,8 Kg; the average height was of 1,64m; the average xiphoid angle 86,8º; the width of xiphoid appendix was 1,82cm as average. Conclusions: the width average of xiphoid appendix was 1,82cm.

Variation in surface marking of superior epigastric vessels. A guide to safe laparoscopic port insertion.

This study aimed to map surface markings of the superior epigastric artery, to provide safe landmarks for the placement of trochars in laparoscopic surgery. Seventeen cadavers were dissected and surface anatomy of the superior epigastric artery was defined at two levels: the xiphoid process, and midway between the xiphoid process and umbilicus. Safe sites for insertion of ports were determined in cadavers by dissecting and locating the main trunks of the superior epigastric artery. At the level of the xiphoid process, the distance from the midline ranged from 3.9cm to 4.8cm with a mean of 4.3cm (SD +/- 0.2cm) while midway between the xiphoid process and umbilicus, the distance of the superior epigastric artery from the midline ranged from 4 to 7.5cm, with a mean of 5.7cm (SD +/- 0.7cm). In this area the artery is vulnerable to damage, hence it can be declared as a danger zone.

Technical consideration for subxiphoidal incisional hernia repair.

BACKGROUND: The main principle of incisional hernia repair with mesh augmentation is a wide overlap of at least 5 cm in all directions. This is complicated when cartilaginous or osseous structures border the fascial defect, most notably at the xiphoid after sternotomy or in large proximal incisional hernias. METHOD: We performed an anatomic investigation of this "problematic" area with its different structures and layers that form the retroxiphoidal space. RESULTS AND CONCLUSION: The posterior lamina of the rectus sheath inserts on the posterior side of the xiphoid. This lamina inhibits a sufficient mesh placement. By sharp dissection dorsal the xiphoid process, the posterior lamina of the rectus sheath can be detached. This way the retroxiphoidal space can be opened. Further development of this space can be made by blunt dissection. In some cases, with retroxiphoidal scar formation after sternotomy, a sharp dissection might be necessary. This enables a combined retromuscular-retroxiphoid mesh augmentation repair with a sufficient underlay of at least 5 cm, according to the principles of sublay technique.

El proceso xifoides del esternón mapuche / The xiphoid process of the mapucheïs sternum

El proceso xifoides es la parte más pequeña y variable del esternón. Según los diferentes estudios realizados este puede presentar variadas formas, puede ser ancho y fino, puntiagudo, bífido, perforado, curvado o desviado para un lado y otro. Con el objetivo de determinar las características morfológicas de esta parte del esternón en individuos mapuches estudiamos 50 esternones obtenidos de necropsias de individuos adultos. Los huesos fueron preparados por técnicas tradicionales de maceración de los tejidos blandos. El proceso xifoides se presentó bífido en 42 por ciento de los casos, en forma de paleta en 38 por ciento, ovalados y elipsoides en 10 por ciento y presentó otras formas en 10 por ciento. Sus diámetros máximos en promedio fueron: vertical 38 mm, laterolateral 21,9 mm y anteroposterior 2,3 mm. En relación a su orientación, el proceso xifoides se presentó: sin inclinación en 32 por ciento de los casos, inclinado hacia la izquierda en 24 por ciento, inclinado hacia ventral en 16 por ciento, inclinado hacia derecha en 10 por ciento e inclinado hacia dorsal en 4 por ciento. En el 12 por ciento de los casos presentó forámenes. El en el 58 por ciento de los casos el proceso xifoides se articulaba sólo con la región más posterior de la parte inferior del cuerpo del esternón. Nuestro estudio demuestra la variabilidad morfológica del proceso xifoides confirmando lo observado en otros grupos étnicos