Identifying iliotibial band graft length and incision site may minimise the potential risk of harming adjacent structures: A novel approach for surgeon guidance.

PURPOSE: The Iliotibial band (ITB) is a fibrous thickening of the fascia lata originating at the iliac crest and inserting at Gerdy's tubercle on the lateral tibia. The ITB significantly contributes to lateral knee stabilisation. Due to its size, tensile strength and easy access, it is widely used in orthopaedic surgery as an autograft during reconstruction procedures. Although ITB harvesting may result in complications, such as reduced knee extension or hip flexion, no safety margins or guidelines have been proposed for the procedure. Our aim was to determine the maximal safe length of an ITB graft, that is, that does not harm the lateral collateral ligament (LCL), tensor fasciae latae (TFL), gluteus maximus (GM) or adjacent structures, and reduce the complication rate. METHODS: The study included 50 lower limbs of 25 human cadavers, previously fixed in 10% formalin solution. The inclusion criterion was the lack of visible signs of surgical interventions in the study region. Forty lower limbs were included in the study: 16 female (mean age 83.1 ± 3.4 years) and 24 male (mean age 84.2 ± 6.8 years). Dissection was performed with a previously established protocol. Morphometric measurements were then obtained twice by two researchers. RESULTS: The mean femur length was 404.8 mm [female (F) = 397.3 mm, male (M) = 409.9 mm, standard deviation (SD): F = 23.8 mm, M = 24.1 mm]. The mean ITB length was 318.9 mm (F = 309.4 mm, M = 325.2 mm, SD: F = 25.7 mm, M = 33.7 mm). Longer femurs were associated with longer ITB (p < 0.05). The mean distance from the insertion of the GM to the myofascial junction of TFL and ITB was 34.6 mm (F = 34.5 mm, M = 34.6 mm, SD: F = 3.2 mm, M = 3.3 mm). The longer femurs or ITBs demonstrated a greater distance from GM insertion to the myofascial junction of the TFL and ITB (p < 0.05). CONCLUSION: ITB grafts longer than 21 cm may contribute to the greater risk of TFL rupture. Based on simple measurements of the femur length, the surgeon may assess approximate ITB length, and thus assess the length of the maximal graft length. Moreover, to avoid harming the LCL, the incision should be performed 5 cm proximal to the articular surface of the lateral femoral condyle or 13 mm proximal to the lateral femoral epicondyle. Such preparation and preoperative planning may greatly reduce the risk of complications during ITB harvesting, while performing, for instance, the over-the-top technique for anterior cruciate ligament reconstruction in skeletally immature patients. LEVEL OF THE STUDY: Basic I.

The accessory heads of the quadriceps femoris muscle may affect the layering of the quadriceps tendon and potential graft harvest lengths.

PURPOSE: The aim of the study was to assess the quadriceps femoris system for the presence of additional layers. METHODS: One hundred and twenty-eight lower limbs fixed in 10% formalin were examined. RESULTS: Five types of quadriceps tendon layering were found based on the accessory heads of the quadriceps muscle. Type I (55%)-represented by four heads and four layers, and it was something new because standard orthopaedic textbooks described quadriceps tendon as a structure composed of only three layers. Type II (27.4%)-the first four layers were the same as in Type 1, but the accessory tendon of the fifth head of the quadriceps femoris muscle had the deepest attachments. Type III (10.9%)-this type included 6 heads of quadriceps femoris. It consisted of five layers. Type IV (3.1%)-this type included 7 quadriceps femoris heads. This type consisted of only four layers. Type V (3.1%)-this type included 8 heads of the quadriceps femoris heads. This type consist of 5 layers. CONCLUSION: The findings of this study provide a detailed anatomy of the quadriceps tendon including the accessory tendons of the accessory heads of the quadriceps tendon. The accessory heads of the quadriceps femoris muscle contribute to the layering of the quadriceps tendon. The second conclusion of this study is the development of safe distances depending on the types. Not all types are perfect for harvesting-Type IV seems to be the safest type, in turn Type V the most dangerous.

Morphological variations of the brachial artery and their clinical significance: a systematic review.

PURPOSE: Morphological variations of the brachial artery are quite commonly discovered in routine dissection and have been the subject of many studies. However, there is a need for a clear classification. This work presents morphological variations of the brachial artery, based on numerous case reports and studies created for the appropriate classification and interpretation among surgeons and radiologists. It also discusses the most important clinical aspects of the given varieties. METHODS: The research method is based on the combined interpretation of the researches based on numerous publications concerning both the principles of correctly classifying the described morphological variations of the brachial artery and the resulting clinical implications. This work considers atypical variations such as the presence of the superficial brachial artery, brachoradial artery, accessory brachial artery and absence of the brachial artery. Variations of the brachial artery in relation to the external and internal diameter of the vessel have also been discussed. RESULTS: After conducting a complex analysis of the collected data, the fundamental principles for classifying such variability as superficial brachial artery, brachioradial artery and accessory brachial artery were defined. Additionally, clinical implications resulting from the above like the impact of the superficial brachial artery on the median nerve neuropathy and the positive correlation between the brachioradial artery and increased danger of incorrect transradial catheterization were demonstrated. CONCLUSIONS: The clinical implications of the atypical arterial pattern within the upper limb are crucial during the angiography and surgical procedures so the variations affect the appropriate diagnosis and surgical intervention. Hence, the knowledge about the morphological variations of the brachial artery should be constantly broadened by radiologists and surgeons to improve the accuracy and effectiveness of the treatment process.

Classification of the popliteofibular ligament.

The purpose of this study was to characterize the morphological variations in the distal attachment of the popliteofibular ligament (PFL) and create an accurate classification for use in planning surgical procedures in this area and in evaluating radiological imaging. One hundred and thirty-seven lower limbs of body donors fixed in 10% formalin solution were examined for the presence and course of the PFL. The PFL was present in 88.3% of cases. We propose the following three-fold classification: type I (72.3%), the most common type, characterized by the attachment onto the apex of the head of the fibula, type II (8.7%), characterized by a bifurcation, with the dominant band inserting on the anterior slope of the styloid process of the fibula and the smaller band onto the posterior surface of the styloid process of the fibula and type III (7.3%), characterized by a double PFL: the first PFL (main) originated from the popliteus tendon and inserted onto the anterior slope of the styloid process of the fibula, while the second originated from the musculotendinous junction of the popliteus muscle and inserted on the posterior surface of the styloid process of the fibula. The PFL was characterized by high morphological variation, as reflected in our proposed classification. This variation may present clinical and biomechanical issues for both medical personnel and researchers. Our proposed classification may be valuable for clinicians who evaluate and perform surgical procedures within the knee joint area.

Case report of unusual insertion of the fibularis brevis muscle.

The fibularis brevis and fibularis longus muscles belong to the lateral compartment of the leg. The fibularis brevis is morphologically variable, especially in the number of tendons and place of insertion. Its type of insertion is correlated with the presence of a fibularis digiti quinti, which is also anatomically variable. We present a case study based on dissection of a seventy-three-year-old female cadaver with an unusual insertion of the fibularis brevis muscle. The tendon had three bands inserting into the fifth metatarsal bone. There was a coexisting fibularis digiti quinti, which was fused with the fibularis tertius muscle. Awareness of such anatomical variation could be useful during reconstructive surgery and planning rehabilitation protocols.

Common trunk of the internal thoracic artery, inferior thyroid artery and thyrocervical trunk from the subclavian artery: a rare arterial variant.

PURPOSE: In this article, we describe a complex and rare variant of the common trunk arising as a branch of the subclavian artery. This description highlights the clinical relevance of such a variation for medical practice. METHODS: A routine dissection was carried out on an adult 74-year-old female cadaver. After identification and preparation of the common trunk, measurements and photographs were taken. RESULTS: The dissection revealed a common trunk arising from the first part of the left subclavian artery. It divided into the left internal thoracic artery, the inferior thyroid artery, and the thyrocervical trunk. Further on, the branches of the thyrocervical trunk supplied blood to the trapezius muscle, the longus colli muscle and the supraspinatus muscle. CONCLUSION: For the first time, we report the specific appearance of a common trunk from the left subclavian artery that includes the origin of the left internal thoracic artery, inferior thyroid artery, and thyrocervical trunk. Knowledge of the different variations of subclavian branches is essential because of the high frequency with which this region is involved in diagnostic and surgical procedures. LEVEL OF EVIDENCE: II Basic Science Research.

A new variety of chondrocoracoideus muscle, or an additional head of pectoralis major muscle.

The pectoralis major and pectoralis minor muscles are located in the anterior chest wall. This region is characterized by high morphological variability. During dissection an additional muscle was found, originating from the lateral border of the pectoralis major muscle. After fusion it passed into the tendinous part coursing under the insertion of the pectoralis major muscle, then formed a common junction with the short head of the biceps brachii muscle, the distal attachment of which is on the coracoid process. Such an accessory structure could lead to neurovascular compression and cause thoracic outlet syndrome, of which pain is usually the first symptom. This muscle has not been described in the literature so far and for that reason we can name the present case as an unique structure.

Quadriceps or multiceps femoris?-Cadaveric study.

PURPOSE: The quadriceps femoris (QF) consists of four muscles: the rectus femoris; vastus medialis; vastus lateralis, and vastus intermediate. The tendons of all of these parts join together into a single tendon that attaches to the patella. The QF is a powerful extensor of the knee joint that is needed for walking. A growing number of publications have examined the fifth head of the QF muscle. There is no information about the possibility of other heads, and there is no correct classification of their proximal attachments. Further, the frequency of occurrence of additional heads/components of the QF remains unclear. METHODS: One hundred and six lower limbs (34 male and 18 female) fixed in 10% formalin solution were examined. RESULTS: Additional heads of the QF were present in 64.1% of the limbs. Three main types were identified and included subtypes. The most common was Type I (44.1%), which had an independent fifth head. This type was divided into two subtypes (A-B) depending on its location relative to the vastus intermediate. The second most common type was Type II (30.8%), which originated from other muscles: IIA from the vastus lateralis; IIB from the vastus intermediate, and IIC from the gluteus minimus. In addition, Type III (25%) was characterized by multiple heads: IIIA-two heads with a single common tendon; IIIB-two heads with two separate tendons; IIIC-three heads (lateral, intermediate, medial), and IIID-four heads (bifurcated lateral and bifurcated medial). CONCLUSION: The introduction of a new classification based on a proximal attachment is necessary. The presence of the fifth, sixth, seventh, or eighth head varies.

Is ultrasound effective in determining variation of the insertion of the extensor hallucis longus tendon?

BACKGROUND: The extensor hallucis longus (EHL) is located in the anterior compartment of the leg, between the tibialis anterior muscle and extensor digitorum longus. The EHL is characterized by a number of morphological variations, concerning mainly the accessory bands and their insertion. The aim of our research was to evaluate the effectiveness of ultrasound in determining the anatomical variations of the EHL. METHODS: The morphology of the EHL was evaluated by ultrasound (high-frequency linear probe of Samsung RS80 apparatus) in 50 healthy volunteers. The types of EHL morphology were determined according to a threefold classification. RESULTS: Only two types of the threefold anatomical classification were observed: Type I in 76 limbs (76%) and Type IIa in 24 limbs (24%). The accessory bands of the EHL were found in 24% of cases, all of which demonstrated a course that was located medially in relation to the main tendon. CONCLUSION: Ultrasound allows for visualization of the EHL; however, the potential recognition of morphological variance is limited. LEVEL OF EVIDENCE: I - Clinical Research.

Unusual case report of seven-headed quadriceps femoris muscle.

PURPOSE: We present a case of a seven-headed quadriceps femoris (QF) muscle and a systematic review of the literature concerning this anatomical variation. METHODS: During a routine dissection of the lower limbs of a 72-year old cadaver, a QF with supernumerary heads was identified. Each head of the muscle was photographed and subjected to further measurement. RESULTS: In addition to the four traditional heads of the QF muscle, we found a tensor of the vastus intermedius (TVI) muscle and two additional muscle bellies composed of tendons. Attachments of the TVI tendon and additional tendons were localized on the superior medial border of the patella. CONCLUSION: It is important to be aware of morphological variability of the quadriceps femoris muscle. The described case assists clinicist with avoiding misdiagnoses around the knee.

New classification of the distal attachment of the fibularis brevis - Anatomical variations and potential clinical implications.

BACKGROUND: Although the lateral compartment of the leg is characterized by a high degree of morphological variation, very little information exists on the morphological variability of the fibularis brevis muscle (FBM) and fibularis digiti quinti (FDQ). The main aim of the study was to characterize the morphology of the FBM tendon and its accessory bands, to classify them and to determine the incidence of FDQ. The work attempts to determine the relationship between the types of the insertion of the FBM tendon and the occurrence of FDQ. METHODS: Classical anatomical dissection was performed on 102 lower limbs fixed in 10% formalin solution. The morphology of the insertion of the FBM and of the FDQ was evaluated. RESULTS: The FBM was present in all specimens. Two types of insertion were observed, the most common being Type I (70.6%): a single distal attachment in which the tendon inserts into the tuberosity at the base of the fifth metatarsal bone. The second most common was Type II (29.4%); this group was divided into three subtypes (A-C). The FDQ was present in 17.7% of specimens and always with Type I FBM. CONCLUSION: Both the FBM tendon and FDQ present significant morphological variation. Two main types of the FBM tendon determine the presence of the FDQ. LEVEL OF EVIDENCE: II Basic Science Research.

A cadaveric study of the morphology of the extensor hallucis longus - a proposal for a new classification.

BACKGROUND: Morphological variations of the EHL concern mainly the accessory tendons and the site of their insertion. The aim of our study is to present a new classification of the EHL. METHODS: Classical anatomical dissection was performed on 104 lower limbs (51 right, 53 left, fixed in 10% formalin solution). RESULTS: In the cadavers, three types of morphology (insertion and addidtional band) were observed. Type I, the most common type, was characterized by a single tendon that ends as an extensor hood on the dorsal aspect of the base of the distal phalanx of the big toe (57.7%). Type II was characterized by two distal tendons and was subdivided into three subtypes according to (A-29.9%, B-4.8% and C-5.7%). Type III was characterised by three distal tendons (two cases - 1.9%). CONCLUSION: The EHL presents high morphological variability. Knowledge of particular types of insertion is essential for both clinicians and anatomists.

Variations in terminal branches of the popliteal artery: cadaveric study.

INTRODUCTION: Identifying the branching pattern of the popliteal artery (PA) is a vital step in planning radiological and surgical procedures involving the anterior and posterior tibial and fibular arteries. The aim of this study was to characterize the course and morphology of the terminal branches of the PA. MATERIALS AND METHODS: The anatomical variations in the branching patterns of the anterior and posterior tibial and fibular arteries were examined in 100 lower limbs fixed in a 10% formalin solution. A dissection of the popliteal region of the leg was carried out according to a pre-established protocol, using traditional techniques. Morphometric measurements were then obtained twice by two researchers. RESULTS: In most cases (72%) the PA divides to form the anterior tibial artery (ATA) and a common junction for the posterior tibial and fibular arteries (type I), which further splits into the fibular artery and the posterior tibial artery (PTA). This type was subdivided into two subgroups according to whether the ATA (subgroup a) or the common junction of the posterior tibial and fibular arteries (subgroup b) had the larger diameter. Other identified variations included division of the PA into the ATA and PTA-8% (type II), trifurcation-12% (type III), the division of the PTA into the ATA and FA-8% (type IV), and aplasia of the PTA-8% (type IV). CONCLUSION: Although the typical PA branching type was observed, it can be classified further into two additional sub-types based on the diameter of the ATA and the common junction of the posterior tibial and fibular arteries.

Morphological variability of the palmaris longus muscle in human fetuses.

PURPOSE: The palmaris longus (PL) muscle is characterized by high-morphological variability. It is clinically important as it is routinely harvested for the reconstruction of other tendons. The study characterizes the morphology of the PL in human fetuses and creates a new classification based on its variations that would relate to the spectrum of morphological variability in adults. METHODS: Eighty spontaneously aborted human foetuses (44 male, 36 female, 160 upper limbs), aged 18-38 weeks of gestation, were examined. RESULTS: The palmaris longus muscle was present in 62.5% of fetuses. The absence was bilateral in 26.25%, and unilateral in 22.5%. Nine types of palmaris longus muscles were identified based on the morphology of its insertion (Types I-IX). All types originated on the medial epicondyle of the humerus. The most common type was Type I, which was characterized by insertion to the palmar aponeurosis (52%). The rarest types were Type VII and Type IX (1% each). Type VII was characterized by partial doubling of the muscle belly, which then turned into two separate tendons that inserted together into the palmar aponeurosis. Type IX was characterized by fusion with the flexor carpi ulnaris muscle. CONCLUSION: Our findings concerning morphological variability of the PL in fetuses present a new perspective on the understanding nature of the morphological variation of the PL muscle in adults. LIST OF EVIDENCE: Basic Science Study.

The morphological variability of the pelvic girdle muscles: a potential trap during ultrasound.

BACKGROUND: The muscles present in the pelvic girdle compartment demonstrate clinically significant anatomical variation regarding both their site of attachment and additions, such as accessory heads, muscles or tendinous slips. Many of those variations might be considered potential traps during ultrasound examination that may result in misdiagnosis. The aim of this study was to raise awareness of such possibility. MATERIALS AND METHODS: A comprehensive search for morphological variations was performed in PubMed and NIH. Relevant papers were listed and citation tracking was accomplished. RESULTS: Although several anatomical variations of pelvic girdle muscles have been presented, few studies have examined their relevance in ultrasound imaging. CONCLUSIONS: The morphological variability of the pelvic girdle muscles does not vary from such incidence in other regions of the human body; however further ultrasound studies are needed of the numerous morphological variants that can be found in this region.

Anatomic Variations of the Calcaneofibular Ligament.

BACKGROUND: The lateral ankle joint comprises the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL). The purpose of this study was to propose a classification of CFL morphology. METHODS: The material comprised 120 paired lower limbs from human cadavers (30 male, 30 female), mean age 62.3 years. The morphology was carefully assessed, and morphometric measurements were performed. RESULTS: A 4-part method for anatomic classification can be suggested based on our study. Type 1 (48.3%), the most common type, was characterized by a bandlike morphology. Type 2 (9.2%) was characterized by a Y-shaped band, and type 3 (21.7%) by a V-shaped band. Type 4 (20.8%) was characterized by the presence of 2 or 3 bands. Type 2 and 4 were divided into further subtypes based on origin footprint. CONCLUSION: The aim of our study was to describe variations of calcaneofibular ligament. Our proposed 4-part classification may be of value in clinical practice in future recognition of CFL injuries and in its repair or reconstruction. CLINICAL RELEVANCE: The anatomy of the CFL plays an important role in stability of the ankle. Greater recognition of anatomical variation may help improve reconstructive options for patients with chronic lateral ankle instability.

A previously unknown variant of the calcaneofibular ligament.

The lateral ankle joint is composed of three ligaments: the anterior talofibular ligament (ATFL), posterior talofibular ligament (PTFL) and calcaneofibular ligament (CFL). The ATFL and CFL demonstrate morphological variation, especially regarding their shape and number of bands. During standard anatomical dissection, an unusual type of triple CFL was observed: the CFL was composed of two bands originating on the lateral malleolus, and the presence of a lateral talocalcaneal ligament (LTC) originating on the talus bone. The insertion point of each band was located on the calcaneal bone. An understanding of these anatomical patterns provides a clearer view of ankle joint biomechanics, and improved the planning and performance of surgical treatment.

Accessory part of the deltoid muscle.

The shoulder and arm region has numerous morphological variations. The deltoid muscle usually consists of three parts: anterior, middle and posterior. This case report describes a very rare deltoid muscle variant, an addition to the spinal part that is attached proximally at the infraspinatus fascia and the spine of the scapula. The distal attachment transforms directly into the brachialis muscle. Additional parts can affect the biomechanics and function of the joints significantly.

The morphological variability of the piriformis muscle.

BACKGROUND: The aim of the study is to create several classifications of the piriformis muscle (PM): proximal and distal attachments, potential fusions, and the relationship with the sciatic nerve. It is the first comprehensive anatomical examination of this subject. MATERIALS AND METHODS: One hundred and twenty-four lower limbs from 62 cadavers, fixed in 10% formalin, were examined. RESULTS: The piriformis muscle was present in 120 limbs (96.8% of cases). Four types of proximal attachment were described (I-IV). The most common type was Type I, in which the proximal attachment was at the anterior surface of the sacrum, between S2 and S4 (52 lower limbs; 43.3%). The rarest type was Type IV, in which the proximal attachment was at the gluteal surface of the ilium near the margin of the greater sciatic notch and from the gluteus medius (12 cases; 10%). Three types of distal attachment were distinguished. The most common was Type 1, a single tendon. This type comprised two subtypes: A and B (105 lower limbs; 87.5%). The other two types accounted for 12.5% of the total. Fusions were noted between the piriformis muscle and adjacent muscles in 31.7%. Four patterns were observed in which the sciatic nerve ran against the piriformis muscle. The most common variation in the relationship was the common fibular nerve exiting superior to the piriformis muscle and the tibial nerve passing inferior to it (10 cases; 8.3%). CONCLUSIONS: The piriformis muscle is highly morphologically variable in both its proximal and distal attachments and its relationship with the sciatic nerve. There are four types of proximal attachment and three types of distal attachment. The piriformis muscle shows numerous fusions with its adjacent muscles: gluteus medius or minimus or superior gemellus. A new (fourth) type of relationship was demonstrated between the piriformis muscle and sciatic nerve. The piriformis muscle was absent in four cases.

The quadratus femoris muscle anatomy: Do we know everything?

INTRODUCTION: The purpose of this study was to characterize the morphological variations in the quadratus femoris muscle (QF) and to create an anatomical classification that could be used in the planning of surgical procedures in this area, radiological imaging, and rehabilitation. MATERIALS AND METHODS: Ninety-two lower limbs from 46 cadavers, fixed in 10 % formalin solution, were examined. RESULTS: The QF muscle was present in all specimens. According to morphology, the QF muscle was classified into three types. The most common type was Type I, characterized by one muscular belly (78.3 %), while the second most common type was Type II, characterized by two bellies, was observed in 17.4 % of cases. The rarest type was Type III. It was characterized by three bellies and was found in 4.3 % of the cases. CONCLUSIONS: The current classification system on quadratus femoris morphological variability is novel. Morphological variants may contribute to clinical issues, such as the ischiofemoral impingement syndrome, that could arise from type I quadratus femoris. Hence, the current study may be applicated to planning surgical procedures, imaging, and rehabilitation.