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 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.

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.

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.

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.

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.

Morphological variability of the leg muscles: potential traps on ultrasound that await clinicians.

BACKGROUND: Although muscles and their tendons are not considered the most morphologically variable structures, they still manifest a substantial diversity of variants. The aim of this study is to increase awareness of some of the many possible variants found during ultrasound imaging of one lower limb compartment, the leg, that could potentially mislead clinicians and lead to misdiagnosis. MATERIALS AND METHODS: PubMed was used for a comprehensive literature search for morphological variations. Relevant papers were included, and citation tracking was used to identify further publications. RESULTS: Several morphological variants of muscles of the leg have been described over many years, but this study shows that the occurrence of further variations in ultrasound imaging requires further investigations. CONCLUSIONS: The incidence of additional structures including muscles and tendons during ultrasound examination can cause confusion and lead to misinterpretation of images, misdiagnosis, and the introduction of unnecessary and inappropriate treatments.

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.

Impaction Fractures of the Lateral Femoral Condyle Related to Anterior Cruciate Ligament Injury: A Scoping Review Concerning Diagnosis, Prevalence, Clinical Importance, and Management.

Background: During pivot-shift anterior cruciate ligament (ACL) injury, bone bruises or impaction fractures of the lateral femoral condyle (LFC-IF) may occur due to impaction between the posterior part of the lateral tibial plateau and anterocentral part of the LFC. The purpose of the study was to systematically review the literature concerning the diagnosis, prevalence, clinical importance, and management of LFC-IF occurring during ACL injuries. Methods: Included were studies concerning impaction fractures of the anterocentral part of the LFC occurring during ACL injuries. Studies concerning only bone bruises or cartilage lesions, without subchondral bone impaction, were not included. A search was performed in Medline and Scopus databases, with final search in May 2022. A secondary search was conducted within the bibliographies of included articles and using "Cited In" option. Two authors independently extracted data in three domains: study design, LFC-IF characteristics, and LFC-IF importance and management. Results: A total of 35 studies were included for review with several studies reporting on multiple domains. Summarily, 31 studies were on the diagnosis and prevalence, 19 studies reported on the clinical importance, and 4 studies reported on the management of LFC-IF. Conclusions: A LFC-IF occurs due to the pivot-shift mechanism of ACL injury. Its radiological feature is defined as an impaction of terminal sulcus deeper than 1 mm and is present in up to 52% of patients with a torn ACL. An LFC-IF causes injury to the cartilage, probably leads to its progressive degeneration, and is significantly associated with an increased risk of a lateral meniscus injury. A large LFC-IF might be associated with greater rotational knee instability. Although several techniques of LFC-IF treatment were proposed, none of them has been evaluated on a large cohort of patients to date.

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.

Morphological variability of the pectoralis major muscle in human fetuses.

BACKGROUND: The pectoralis major muscle is located in the anterior chest wall. In most cases, it is divided into clavicular, sternal (sternocostal) and abdominal heads. The aim of this study is to demonstrate and classify the morphological variability of the pectoralis major muscles in human fetuses. MATERIAL AND METHODS: Classical anatomical dissection was performed on 35 human fetuses aged 18-38 weeks of gestation at death were examined. (17 female, and 18 male, 70 sides; fixed in 10% formalin solution). The fetuses were obtained from spontaneous abortion after informed consent of both parents and through deliberate donation to the Medical University anatomy program. Upon dissection, the following morphological features were assessed: the morphology of the pectoralis major, the possible occurrence of accessory heads, the possible absence of some head, and morphometric measurements of each head of the pectoralis major muscle. RESULTS: Five types of morphology (based on number of bellies) were observed in the fetuses. Type I was characterized by a single claviculosternal belly (10% of all samples). Type II comprised the clavicular and sternal heads (37.1%). Type III comprised three clavicular, sternal and abdominal heads (31.4%). Type IV (17.2%) was characterized by four muscle bellies and was divided into four subtypes. Type V (4.3%), was represented by five parts, and was divided into two subtypes. CONCLUSIONS: Due to its embryological development, the PM demonstrates great variability in the numbers of its parts. The most common type was the PM with two bellies, in line with previous studies which also distinguished only clavicular and sternal heads.

A new look at quadriceps tendon - Is it really composed of three layers?

BACKGROUND: The aim of this study was to qualitatively and quantitatively describe the anatomy of the QT including its size, its layers and relationship between layers. METHODS: Sixty lower limbs (15 females and 15 males fixed in 10% formalin were examined. A retrospective analysis of 20 thigh MRI examinations was performed (10 males, and 10 females). RESULTS: In all dissected specimens, the quadriceps femoris was composed of 4 layers: superficial (first layer), middle (second layer), middle-deep (third layer) and deep (fourth layer). The first layer (superficial) was formed by the rectus femoris tendon and fascia. The second layer was composed of tendons of the vastus medialis and superficial part of the vastus lateralis. The third layer was formed by the intermediate part of the vastus lateralis. The fourth layer was composed of the tendon of the vastus intermedius. This type of anatomy was visualized in 4 males and 2 female on MRI scans. CONCLUSION: The findings of this study provide a detailed anatomy of the quadriceps tendon. There were 4 different layers of the QT consistently found in all specimens. The first layer was independent and composed by the rectus femoris tendon, the second was formed by the superficial part of the vastus lateralis and vastus medialis. The third layer was formed by the intermediate part of the vastus lateralis, and the deepest fourth layer was composed of the vastus intermedius. This detailed structural anatomy was also able to be visualized on MRI scans.

How to Differentiate Pronator Syndrome from Carpal Tunnel Syndrome: A Comprehensive Clinical Comparison.

The diagnostic process that allows pronator syndrome to be differentiated reliably from carpal tunnel syndrome remains a challenge for clinicians, as evidenced by the most common cause of pronator syndrome misdiagnosis: carpal tunnel syndrome. Pronator syndrome can be caused by compression of the median nerve as it passes through the anatomical structures of the forearm, while carpal tunnel syndrome refers to one particular topographic area within which compression occurs, the carpal tunnel. The present narrative review is a complex clinical comparison of the two syndromes with their anatomical backgrounds involving topographical relationships, morphology, clinical picture, differential diagnosis, and therapeutic options. It discusses the most frequently used diagnostic techniques and their correct interpretations. Its main goal is to provide an up-to-date picture of the current understanding of the disease processes and their etiologies, to establish an appropriate diagnosis, and introduce relevant treatment benefiting the patient.

A comparative study of the epiligament of the medial collateral and anterior cruciate ligaments in the human knee: Immunohistochemical analysis of CD 34, α-smooth muscle actin and vascular endothelial growth factor in relation to epiligament theory.

BACKGROUND: This study evaluated and compared the expression of VEGF, CD34, and α-SMA in the anterior cruciate ligaments and medial collateral ligaments in healthy human knees in order to enrich the epiligament theory regarding ligament healing after injury. METHODS: Samples from the mid-substance of the anterior cruciate ligament and the medial collateral ligament of 12 fresh knee joints were used. Monoclonal antibodies against CD34, α-SMA, and VEGF were used for immunohistochemical analysis. Photomicrographs were analyzed using the ImageJ software. RESULTS: The epiligament of the anterior cruciate ligament showed slightly higher expression of CD34, α-SMA, and VEGF than the epiligament of the medial collateral ligament. Overall, among the tested markers, α-SMA expression was most pronounced in anterior cruciate ligament epiligament images and CD34 dominated in medial collateral ligament epiligament images. The intensity of DAB staining for CD34, α-SMA, and VEGF was higher in vascular areas of the epiligament than in epiligament connective tissue. CONCLUSIONS: The results illustrate that CD34, α-SMA, and VEGF are expressed in the human epiligament. The differences between the epiligament of the investigated ligaments and the fact that CD34, α-SMA, and VEGF, which are known to have a definite role in ligament healing, are predominantly expressed in the main vascular part of the ligament-epiligament complex enlarge the existing epiligament theory. Future investigations regarding better ligament healing should not overlook the epiligament tissue.

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.

The relationship between additional heads of the quadriceps femoris, the vasti muscles, and the patellar ligament.

INTRODUCTION: The quadriceps femoris consists of four muscles: the rectus femoris, vastus medialis, vastus intermedius, and vastus lateralis. However, the effect of additional quadriceps femoris heads on the vasti muscles and patellar ligaments is unknown. The aims of the present study are to determine the relationship between additional quadriceps femoris heads and the vasti muscles and patellar ligaments and to review the morphology of the vastus lateralis, vastus medialis, and vastus intermedius. MATERIALS AND METHODS: One hundred and six lower limbs (34 male and 19 female cadavers) fixed in 10% formalin were examined. RESULTS: On all lower extremities, the vastus lateralis consisted of superficial, intermediate, and deep layers. The vastus medialis, on the other hand, consisted of only the longus and obliquus layers. The quadriceps head had one or more supplementary heads in 106 dissected limbs from 68 cadavers (64.1%). The distal portion of the patella was wider in lower limbs without supplementary heads than in type IA but narrower than in type IIIA. In general, the distal portion of the patella was narrower in specimens with a supplementary head than in those without (19.03 SD 3.18 mm vs. 20.58 SD 2.95 mm, p = 0.03817). Other patellar ligament dimensions did not differ significantly. CONCLUSION: The quadriceps femoris muscle is characterized by high morphological variability. Occurrence of extra heads is at the level of 64.1%. The vastus lateralis consists of three parts (superficial, intermediate, and deep), and vastus medialis consists of two (longus and oblique).

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.

The novel epiligament theory: differences in healing failure between the medial collateral and anterior cruciate ligaments.

According to current literature, 90% of knee ligament injuries involve the medial collateral ligament or the anterior cruciate ligament. In contrast to the medial collateral ligament, which regenerates relatively well, the anterior cruciate ligament demonstrates compromised healing. In the past, there were numerous studies in animal models that examined the healing process of these ligaments, and different explanations were established. Although the healing of these ligaments has been largely investigated and different theories exist, unanswered questions persist.Therefore, the aim of this article is 1) to review the different historical aspects of healing of the medial collateral ligament and present the theories for healing failure of the anterior cruciate ligament; 2) to examine the novel epiligament theory explaining the medial collateral ligament healing process and failure of anterior cruciate ligament healing; and 3) to discuss why the enveloping tissue microstructure of the aforementioned ligaments needs to be examined in future studies.We believe that knowledge of the novel epiligament theory will lead to a better understanding of the normal healing process for implementing optimal treatments, as well as a more holistic explanation for anterior cruciate ligament healing failure.

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.