Bony structures at the attachment areas of the cruciate ligaments in human knee joints and their clinical significance-studied using the P45 plastination technique / Estructuras óseas en las áreas de inserción de los ligamentos cruzados en las articulaciones de la rodilla humana y su importancia clínica, estudiadas mediante la técnica de plastinación P45

SUMMARY: For treating cruciate ligament injuries, especially for characterizing the mechanics of the tunnel in cruciate ligament reconstruction, correctly understanding the bony information of the attachment area of the cruciate ligaments is significant. We studied 31 knee joints of middle-aged Chinese adults using the P45 sheet plastination technique, focusing on the attachment areas of the cruciate ligaments, especially the bony structures. The trabeculae at the attachment area were distributed radially and extended deep into the medial wall of the lateral condyle of the femur. However, in the anterior part of the intercondylar eminence, the trabeculae of the anterior group were parallelly arranged along the tendinous fibers of the anterior cruciate ligament, while the trabeculae of the posterior group were parallelly arranged along the perpendicular direction of the anterior cruciate ligament fibers. Similarly, at the attachment area of the lateral wall of the medial condyle of the posterior cruciate ligament, the trabeculae extended radially toward the deep medial condyle. Deep in the posterior part of the intercondylar eminence, the trabeculae were arranged longitudinally. In the anterior part of the intercondylar eminence, the trabeculae were parallelly arranged along the perpendicular directions of ligament fibers. The distribution patterns of the trabecular at the attachment areas of the cruciate ligaments at the ends of the femur and tibia were different. This difference should be considered when orthopedic surgeons reconstruct anterior cruciate ligaments.

Para el tratamiento de lesiones de los ligamentos cruzados, especialmente para caracterizar la mecánica del túnel en su reconstrucción, es importante comprender correctamente la información ósea del área de inserción de estos ligamentos. Estudiamos 31 articulaciones de rodilla de individuos chinos, adultos, de mediana edad, utilizando la técnica de plastinación de láminas P45, centrándonos en las áreas de unión de los ligamentos cruzados, especialmente en las estructuras óseas. Las trabéculas en el área de inserción se distribuyeron radialmente y se extendieron profundamente en la pared medial del cóndilo lateral del fémur. Sin embargo, en la parte anterior de la eminencia intercondílea, las trabéculas del grupo anterior estaban dispuestas paralelamente a lo largo de las fibras tendinosas del ligamento cruzado anterior, mientras que las trabéculas del grupo posterior estaban dispuestas paralelamente a lo largo de la dirección perpendicular de las fibras del ligamento cruzado anterior. De manera similar, en el área de inserción en la cara lateral del cóndilo medial del ligamento cruzado posterior, las trabéculas se extendían radialmente y profundas hacia el cóndilo medial. Profundamente en la parte posterior de la eminencia intercondílea, las trabéculas estaban dispuestas longitudinalmente. En la parte anterior de la eminencia intercondílea, las trabéculas estaban dispuestas paralelamente a lo largo de las direcciones perpendiculares de las fibras del ligamento. Los patrones de distribución del tejido óseo trabecular en las áreas de unión de los ligamentos cruzados en los extremos del fémur y la tibia eran diferentes. Estas diferencias deben tenerse en consideración cuando los cirujanos ortopédicos reconstruyen los ligamentos cruzados anteriores.

Ultrasound Measurement of Lateral Patellar Displacement: A Cadaveric Validation Study.

Background: Patellofemoral pain syndrome (PFPS) is one of the most common musculoskeletal complaints seen in outpatient settings. It has been suggested that hip adduction creates loads on the iliotibial band and causes lateral displacement of the patella (patellar tilt), which can lead to uneven patellofemoral joint loading, and hence, cause patellofemoral pain. In previous studies in the literature, ultrasound has been used to measure lateral patellar displacement. However, the method lacks validity data. Purpose/Hypothesis: The aim of this study was to validate the use of ultrasound to measure lateral displacement of the patella, by comparing the position of the patella as measured first by ultrasound, and then by direct measurement. Study Design: Descriptive Laboratory Study. Methods: Nine soft-fixed cadavers were used in this study. The cadavers had been donated for anatomical examination and research under the Human Tissue Act (2004). The distance between the lateral femoral condyle and the lateral edge of the patella were measured by B-mode real-time ultrasound, and then by direct measurement, in two positions, neutral and at 20° hip adduction. Results: The mean difference in the patella-to-lateral femoral condyle distance in the neutral position and at 20° adduction was 0.27 cm (ultrasound), and 0.34 cm (direct measurement), respectively. There were no significant differences between the measurements obtained by US and by direct measurement (Pearson correlation= 0.97, p=0.83). Conclusion: Ultrasound is a valid and reliable method for measuring patellar position relative to the femoral condyle, and the validity data reported here suggest that it can be used with confidence in clinic to assess lateral patellar displacement. Level of Evidence: 3.

The Effect of Self-Myofascial Release on the Pennation Angle of the Vastus Medialis Oblique and the Vastus Lateralis in Athletic Male Individuals: An Ultrasound Investigation.

Background: Maintenance of patellar stability requires a balance between the vastus medialis oblique (VMO) and the vastus lateralis (VL). The imbalance between these muscles is thought to be implicated in the etiology of patellofemoral pain (PFP). Where there is hypertrophy of the VL in PFP patients, self-myofascial release (SMR) may be utilized for its management. However, there is no current evidence regarding SMR and its effects on VMO and VL architecture. The aim of this study, therefore, was to use ultrasound to gain further understanding of the effects of a program of SMR on the fiber angles of the VMO and VL. Hypothesis: There will be a significant decrease in the pennation angles of the VMO and VL after seven weeks of SMR using a foam roller. Study Design: Cohort Study. Methods: Twenty-five young, athletic, male participants were recruited to use a foam roller, along the full length of both anterior thighs, three times weekly, on three separate days, for seven weeks. Ultrasound was used to determine the initial and final VMO and VL pennation angles on both limbs. One eligible participant was chosen as an intra-rater control and did not partake in the SMR regimen. Results: There was a statistically significant (p < 0.001) decrease in the pennation angles of the VMO and VL after the SMR regime. Mean combined right and left VL angle change was -6.65° (-18% mean change) and the mean combined right and left VMO angle change was -7.65° (-11.5% mean change). A weak negative correlation was found between initial VMO fiber angle and the angle change (Rsquared = -0.21), as well as moderate negative correlation for the VL (Rsquared = -0.51). Conclusion: A program of SMR on the anterior thighs of young, asymptomatic males resulted in changes to the fiber angles of both the VMO and VL. There was a significant decrease in pennation angle after seven weeks of SMR using a foam roller.

The effect of stretching exercises on the fibre angle of the vastus lateralis and vastus medialis oblique: an ultrasound study.

[Purpose] To investigate the effects of a seven-week quadriceps stretching program on the muscle fibre orientation of the vastus medialis oblique and vastus lateralis in the lower limbs by ultrasound imaging. [Participants and Methods] Twenty-seven healthy, physically fit, asymptomatic females and males (age 21.5 ± 1.3, Tegner activity level score ≥4) were recruited. Their initial vastus medialis oblique and vastus lateralis fibre angles were determined using ultrasound. They then undertook a seven-week quadriceps stretching program, 3 sets of stretches to be performed on both lower limbs, 3 times a week on 3 separate days. One volunteer was assigned as an intra-rater control and did not take part in the stretching program. The vastus lateralis and vastus medialis oblique fibre angles were measured again on completion of the exercise regime. [Results] A statistically significant decrease in muscle fibre angle was observed in both the right and left vastus medialis oblique, and the right and left vastus lateralis. [Conclusion] A 7-week stretching program can result in a significant decrease in muscle fibre angle in both the vastus medialis oblique and the vastus lateralis. This can help in understanding the effects of prescribed stretching exercises on athletic patients with PFP.

Standardized statement for the ethical use of human cadaveric tissues in anatomy research papers: Recommendations from Anatomical Journal Editors-in-Chief.

Human cadaveric donors are essential for research in the anatomical sciences. However, many research papers in the anatomical sciences often omit a statement regarding the ethical use of the donor cadavers or, as no current standardized versions exist, use language that is extremely varied. To rectify this issue, 22 editors-in-chief of anatomical journals, representing 17 different countries, developed standardized and simplified language that can be used by authors of studies that use human cadaveric tissues. The goal of these editor recommendations is to standardize the writing approach by which the ethical use of cadaveric donors is acknowledged in anatomical studies that use donor human cadavers. Such sections in anatomical papers will help elevate our discipline and promote standardized language use in others non anatomy journals and also other media outlets that use cadaveric tissues.

Three-dimensional reconstruction of the orbital retrobulbar vasculature.

PURPOSE: The retrobulbar orbital vasculature is known to be complex and variable between individuals. This study aimed to produce a method to map the retrobulbar vessels, to generate 3D reconstructions, to visualise and to improve our understanding of their complexity. METHODS: Five human orbits donated under the Human Tissue Act (2004) were fixed in formalin, decalcified in 10% formic acid, and dehydrated in acetone at -20°C. Specimens were impregnated with epoxy resin, cured, and cut into 0.3 mm sections. Sections were stained with Gomori's trichrome stain, imaged, and reconstructed using 3D reconstruction software (BioVis3D, version 3.1). RESULTS: The arterial system was reconstructed in all five specimens. The superior ophthalmic vein (SOV) and the central retinal vein (CRV) were reconstructed in four specimens. E12 sheet plastination showed excellent results for histological analysis at a macroscopic level; however, anatomical topology was not entirely preserved on a microscopic level. Gomori's trichrome stain gave excellent results in highlighting axial sections of the arterial walls and their tunics, including finer calibre vessels, thus allowing detailed reconstruction of the arterial vasculature. Miller's stain for elastin showed poor results in differentiating vessels from soft tissue; venous vasculature was poorly identified with both stains. CONCLUSIONS: This study provided a detailed anatomical model of the retrobulbar orbital vascular system, a method that can be used for further studies to form a database relating to the topography of the arterial system. These models may be employed for teaching, and possible surgery planning, for both trainees and ophthalmic surgeons.

Ultrasound investigation into the relationship between hip adduction and the patellofemoral joint.

[Purpose] Patellofemoral pain (PFP) is a common musculoskeletal complaint. It has been suggested that hip adduction creates a load on the iliotibial band and causes lateral displacement of the patella (patella tilt). However, data gathered in a previous study were derived from a small sample of males, while the condition predominantly affects females. We assessed the relationship between hip adduction and patellar position with a larger sample size, including males and females. [Participants and Methods] Forty healthy, asymptomatic females and males (age 21.5 ± 1.3 years) were recruited. Their knees were passively flexed by 20°. Using ultrasound, the distance between the lateral edge of the patella and the lateral condyle of the femur was measured in the neutral position and at 20° adduction. [Results] Hip adduction produced a smaller patella-lateral femoral condyle measurement than in the neutral position. The mean difference in the patella-condyle distance between the neutral position and 20° hip adduction was 0.18 cm. No statistically significant difference was found between the right and left limbs, genders, Tegner scores, or BMI of the study participants. [Conclusion] The results of the study showed that hip adduction causes lateral displacement of the patella. Ultrasound is an effective means of assessing patella tilt.

Anatomical basis of the support of fibula to tibial plateau and its clinical significance.

BACKGROUND: The fibula is only indirectly involved in the composition of the human knee joint and has therefore been neglected in the research on knee osteoarthritis. Nonuniform settlement of the proximal tibia plateau is clinically defined as when the height of the medial tibial plateau is lower than that of the lateral side in medial compartment knee osteoarthritis (KOA). The non-uniform settlement of the proximal tibia plateau may be caused by fibular support on the lateral side. Orthopedic surgeons practice partial fibulectomy based on the clinical manifestation of nonuniform settlement, and this technique has been shown to reduce pain and improve function in patients with medial compartment KOA. However, this hypothesis of the mechanism of nonuniform settlement lacks an anatomical basis. METHODS: The P45 polyester plastination technique was used to prepare sections of the proximal tibiofibular joint to investigate the distribution of the bone trabeculae in the region of the lateral tibial plateau. RESULTS: There was uneven distribution of trabeculae in the lateral condyle of the tibia and the head and neck of the fibula. The fibula and the posterolateral cortex of the shaft of the tibia united to form an arch beam via the tibiofibular joint. Many thick, dense trabeculae were present in a longitudinal direction above the tibiofibular arch. CONCLUSIONS: The fibula supports the lateral tibial plateau, and the trabeculae were concentrated above the tibiofibular arch.

The innominate tubercle of the femur is a consistent surgical landmark and shows no variation between sex and side: An osteological study.

INTRODUCTION: During direct anterior approach hip arthroplasty, the innominate tubercle (IT) of the femur is used as a reference point for femoral neck osteotomy. A recent study found that IT dimensions are unaffected by femoral length, neck-shaft angle, and neck length. This study investigated the position of the tubercle relative to femoral side, sex and femoral neck dimensions. MATERIALS AND METHODS: One hundred and ninety femora (95 pairs, complete with biographical data) from St. Bride's Church, London, were photographed with the apex of the tubercle marked. Using imaging software, axes were superimposed onto the image, allowing the X and Y co-ordinates of the tubercle apex to be derived. Statistical analysis was carried out. RESULTS: The position of the tubercle did not vary significantly and did not correlate with femoral side (p > .05). P values for variation of the X and Y coordinates were 0.351 and 0.996 in left and right femora, respectively. The tubercle position did not vary significantly with sex (p > .05). p Values for variation of the X and Y coordinates were 0.254 and 0.634 in males and females, respectively. There was little variation between tubercle position and femoral neck dimensions: correlation coefficient -0.20 (x coordinate) and -0.12 (y coordinate). CONCLUSIONS: The data showed that the position of the IT did not vary significantly with either sex or side and that, therefore, the tubercle can be considered a reliable surgical landmark during arthroplasty surgery.

Acknowledging the use of human cadaveric tissues in research papers: Recommendations from anatomical journal editors.

Research within the anatomical sciences often relies on human cadaveric tissues. Without the good will of these donors who allow us to use their bodies to push forward our anatomical knowledge, most human anatomical research would come to a standstill. However, many research papers omit an acknowledgement to the donor cadavers or, as no current standardized versions exist, use language that is extremely varied. To remedy this problem, 20 editors-in-chiefs from 17 anatomical journals joined together to put together official recommendations that can be used by authors when acknowledging the donor cadavers used in their studies. The goal of these recommendations is to standardize the writing approach by which donors are acknowledged in anatomical studies that use human cadaveric tissues. Such sections in anatomical papers will not only rightfully thank those who made the donation but might also encourage, motivate, and inspire future individuals to make such gifts for the betterment of the anatomical sciences and patient care.

The International Society for Plastination.

The International Society for Plastination (ISP) was conceived as a means of defining plastination as an area of professional activity and serving as an agency for disseminating information relative to the art and science of plastination. In this paper, we present the purpose of ISP, the Journal of Plastination, the Plastination Index and the different international meetings organised by ISP.

An effective and novel method for teaching applied facial anatomy and related procedural skills to esthetic physicians.

BACKGROUND: An understanding of facial anatomy is crucial for the safe practice of nonsurgical facial esthetic procedures. Contextual learning, aided with instructional design, enhances the trainees' overall learning experience and retention, and makes a positive impact on the performance of procedural skills. The present study aimed to develop a teaching approach based on Bloom's taxonomy involving cognitive, affective, and psychomotor learning domains. MATERIALS AND METHODS: The practicability of Assess & Aware, Demonstrate, Decode, Act & Accomplish, Perform, Teach & Test (ADDAPT), a new approach to teaching applied facial anatomy and procedural skills to esthetic physicians in a large group setting, was evaluated in this study. Study participants were from two cohorts (n=124) who underwent 2 days of applied anatomy training in Singapore. Pre- and post-course multiple choice questions and objective structured practical examination were conducted to measure the effectiveness and applicability of the teaching model. Expert raters, table demonstrators, and participants rated the steps involved in the ADDAPT model on an 11-point Likert scale. RESULTS: Pre- and post-course evaluation mean scores for multiple choice questions were 17.32 (SD ±3.36) and 22.61 (SD ±1.77) and for objective structured practical examination were 24.53 (SD ±4.63) and 43.57 (SD ±5.35), respectively (P<0.001). Inter-rater agreement, expressed as the intraclass correlation coefficient, was 0.91 (95% CI: 0.62-0.98) for expert raters and 0.90 (95% CI: 0.78-0.97) for table demonstrators, which reflects the real strength of sound educational practice. The trainees well accepted the model and found the sessions intellectually stimulating. Trainees' feedback stated that the learning experience was enhanced by the repeated observation and constructive feedback provided by the tutors. CONCLUSION: The ADDAPT model is practical to instruct a large group of trainees in clinical anatomy and procedural skill training. This approach to instructional design may be feasible and transferable to other areas of psychomotor skill training in medical education.

Reliability evaluation of inter-eminence line, Akagi and Dalury lines for intraoperative tibial rotation: An osteology-based study.

BACKGROUND: This large osteology study examined the reliability, reproducibility and correlation between previously described tibial tray rotation alignment lines (including Akagi and Dalury lines). In addition, it described a novel inter-eminence line utilising the tibial plateau inter-condylar eminences as a landmark. METHODS: A total of 214 post-medieval (18-19th centuries) skeletal tibia were examined. The inter/intra-observer variation and correlation between reference lines were measured. RESULTS: Inter-observer reproducibility was excellent and there were no differences between Akagi, Dalury, and inter-eminence lines. Similarly, intra-observer reliability was excellent for Akagi, Dalury, and inter-eminence lines. Qualitative review of tibial inter-condylar eminences suggested that these could be easily identifiable. When taking the medial angle from a medial-lateral reference line, the Akagi line showed a mean of 96.90° (±10.27), inter-eminence line 94.52° (±12.84), and Dalury line 88.06° (±11.75). The angle produced by the Dalury line was significantly different from both the Akagi and inter-eminence lines (P≤0.001). The Akagi line and inter-eminence line showed a strong correlation (r=0.74). The Dalury line showed a weaker correlation with both the Akagi line (r=0.69) and inter-eminence line (r=0.40). CONCLUSION: This study suggested that tibial rotation lines showed excellent intra/inter-observer reliability and reproducibility. The novel and easily drawn inter-eminence line showed strong correlation with the Akagi line and could be used for tibial tray rotational alignment in total knee arthroplasty.

Interprofessional anatomy education in the United Kingdom and Ireland: Perspectives from students and teachers.

There is increasing recognition of multiprofessional learning in anatomy and its role in medical and healthcare professions. This study utilized two components to investigate anatomy interprofessional education (AIPE) in the United Kingdom and Ireland. First, a survey involving qualitative and quantitative components asked Heads of Anatomy to report on their institutions' uptake of AIPE. Second, a series of case studies explored the experiences of students by using evaluation forms and an in-depth analysis of thematic concepts to understand the learners' perspectives on designing and delivering AIPE. Out of the 13 institutions that took part in the survey, eight did not offer an AIPE program. Between the remaining five institutions that deliver AIPE programs, 10 different modules are offered with the majority involving healthcare professions. The AIPE component is rated highly by students. The themes from the case studies highlight how valuable AIPE is from the student perspective both in terms of engaging them in anatomy as well as in the broader skills of teamwork and communication. The case studies also revealed how AIPE can be engaging for groups of students who might not have previously had access to cadaveric anatomy, for example, engineers and archeologists. The results of this study have implications for curriculum design in medicine and healthcare but also for further engagement of professional groups from non-healthcare backgrounds.

Rare Variant of Vastus Medialis Detected in vivo by Ultrasound and Confirmed by High-resolution MRI.

[Purpose] This report describes an unusual incidental finding during ultrasound investigation of the vastus medialis muscle. Volunteers underwent ultrasound scanning as part of an on-going investigation into the architecture of the vastus medialis muscle. [Subjects and Methods] The distal thighs of forty-one subjects were scanned using the Philips iU22 US system. An unusual muscle morphology was detected bilaterally in one subject, who then underwent a 3T Magnetic Resonance Imaging (MRI) scan in order to further investigate the muscle morphology. The subject in question was a 32 year-old female who suffers from recurrent bilateral patellar dislocations. [Results] The MRI scan confirmed the ultrasound findings, and indicated the presence of the vastus medialis in two layers, with the VML continuing deep, separate from the VMO. [Conclusion] Although this rare variant has been been reported in previous cadaveric studies, we believe this to be the first report in the literature of this morphology in vivo. The biomechanical implications of this muscle arrangement are unknown, but it may not be without significance that this individual suffers from recurrent patellar dislocations.

Using ultrasound to measure the fibre angle of vastus medialis oblique: a cadaveric validation study.

BACKGROUND: The assumption that the vastus medialis oblique (VMO) is involved in medial patellar stabilisation has led to speculation that patellofemoral pain (PF) may be a result of abnormal patellar tracking, due to weakness or difference in fibre orientation of the VMO. Recent studies have reported that the VMO fibre angle, measured in vivo with ultrasound (US), is reduced in patellofemoral pain (PF) patients. However, the validity of US in measuring this parameter was not investigated and this would inevitably cast doubt on whether the US results are comparable to direct measurement. The aim of this study was to validate the use of ultrasound (US) in measuring VMO fibre angle by comparing results obtained both from US and direct measurement. METHODS: The VMO fibre angle was determined in relation to the femoral axis in nine lower limbs from five soft-fixed cadavers, first using US and then by direct measurement. RESULTS: The Pearson correlation coefficient between the two methods was 0.92 (p<0.01) indicating a very strong relationship. The average difference in measurements between the two methods was 0.20. Bland/Altman analysis showed 95% limit of agreement to be between -2.550 and 30, showing minimal discrepancies between results obtained by the two methods. CONCLUSION: In conclusion, the VMO fibre angle values obtained by the US method were proved to be valid and comparable to those obtained from direct measurement. We show, therefore, that US can be used with confidence to measure VMO fibre angles in the cadaver, and, by implication, in clinical practice.

Supraorbital notch and foramen: positional variation and relevance to direct brow lift.

PURPOSE: Forehead paresthesia after brow lift is well-documented with rates as high as 40.7%. The authors describe an anatomical study to identify the variation in position of the supraorbital notch/foramen to define safe limits for deep dissection during this procedure. METHODS: Sixty-six orbits from 23 dry skulls and 9 formalin-fixed cadavers were analyzed photographically using ImageJ software. The cadaveric specimens were dissected using a coronal incision, which allowed the inferior resection of the frontalis muscle and periosteum. The exit point of the supraorbital neurovascular bundle was noted as a foramen or notch. The position of the supraorbital notch or foramen was recorded in relation to the midline as defined by the sagittal suture at the level of the highest point of the supraorbital rim. The distance and angle for each foramen/notch were calculated. RESULTS: Thirty-three percent of orbits had a foramen. The average distance from the midpoint to the foramen was 25.24 mm (standard deviation 3.78 mm) and to the notch was 22.69 mm (22.69 mm). The range of distance between the midpoint and the foramen/notch was 17.62 to 32.35 mm. The average angle between the horizontal meridian and the foramen was 81/57° (standard deviation 4.69°). CONCLUSIONS: A wide variation in anatomy was seen. Greater caution is required when performing deep dissection around the supraorbital notch because of the variation in position of the supraorbital foramen.

Lessons from the past: cribra orbitalia, an orbital roof pathology.

AIMS: To define a computed tomography protocol that may be used in future clinical practice for the reliable detection and analysis of cribra orbitalia. MATERIALS AND METHODS: Two osteological assemblages from the Museum of London were used to select 13 cribratous skulls and 5 non-cribratous skulls. Area of cribra orbitalia was measured using image analysis. Morphology of cribra orbitalia, orbital roof density and the associated optic canal diameter was analysed using computed tomography reconstructions. RESULTS: The presence of cribra orbitalia was associated with changes in the internal diploë layer as well as the cortical bone table. A novel radiological grading system and protocol was developed to identify the pathology. A decrease in the orbital roof density by 210 Hounsfield units and a reduction in the optic canal diameter, up to 1 mm, were found to be associated with the presence of cribra orbitalia. CONCLUSIONS: The occurrence of cribra orbitalia is found to be associated with stenosis of the optic canal, and could explain a proportion of cases ofoptic nerve entrapment. This study provides a guideline for radiologists and oculoplastic surgeons to help detect the presence of cribra orbitalia in suspected patients.