A unique variation of the deep fibular nerve: A case report.

Deep fibular nerve is one of the two terminal branches of the common fibular nerve. The deep fibular nerve can be damaged in procedures related the anterior compartment of the leg such as the application of an external fixator to the leg and operations using intramedullary nailing after tibial fracture. Therefore, it is important to know the anatomy and variations of the deep fibular nerve. An anatomical variation concerning the deep fibular nerve was detected in the right lower extremity of the 65-year-old cadaver we dissected. In this case, it was observed that the deep fibular nerve split into two nerve arms in the distal half of the leg and reunited after continuing 9cm apart to form a loop. This loop formation may increase the iatrogenic damage of the deep fibular nerve as a result of surgery and percutaneous interventions to the anterior leg compartment. We described in this case report a hitherto unobserved finding of the branching pattern of the deep fibular nerve. We think that this unique anatomical variation seen in the right lower extremity of the case of academic interest and will also help orthopedicians in anterior leg compartment surgery.

Avoiding abdominal flank bulge after lumbotomy incision: cadaveric study and ultrasonographic investigation.

OBJECTIVE: The object of this study was to better define the relevant anatomy and innervation of the anterolateral abdominal wall musculature seeking to avoid abdominal wall complication after open donor nephrectomy. We dissected four cadavers and retrospectively assessed donor ultrasonographic imaging of anterolateral abdominal muscle atrophy after donor nephrectomy with a lumbotomy incision. METHODS: Anatomic study was performed on four cadavers using bilateral dissections. The 8th, 9th, 10th, 11th, and 12th (subcostal) intercostal nerves were dissected from the intercostal space to the rectus sheath. With the experience gained from anatomic study, we performed 40 living donor incisions 1.5 to 2 cm medial to the tip of 12th rib, toward the lateral border of the rectus muscle and the umbilicus. Donors were invited to the hospital at 1 year postoperative to examine abdominal wall complications. Ultrasonography (USG) was performed to assess the thickness of the abdominal wall muscles bilaterally to ascertain whether there was atrophy. RESULTS: All distal intercostal nerves ran as multiple mixed segmental nerves, communicating with each other widely within the neurovascular plane. The thick 12th nerve was located at 1.5 to 2 cm medial and under the tip of the 12th rib, running to the suprapubic area. Postoperative USG confirmed that the mean percent thickness of the abdominal muscles of the operative side was not significantly different from the other side (P < .05). CONCLUSION: Most significant intercostal nerve contributions to the anterolateral abdominal wall arise from T12. Damage to the intercostal nerves will be minimal if the lombotomy incision is performed above the safe line between the tip of the 12th rib and the umbilicus.

Coexistence of a Meckel's diverticulum and a urachal remnant.

Meckel's diverticulum, which is a remnant of the omphalomesenteric or vitelline duct, is the most common congenital abnormality of the gastrointestinal system. Urachal abnormalities, resulting from anomalous urogenital development, are not observed frequently and case reports are mainly represented in literature. The presence of these two congenital anomalies together is a very rare pathology. Complications arising from a Meckel's diverticulum or urachal remnant may clinically mimic acute appendicitis and other surgical pathologies. We report on a patient who underwent surgery for acute appendicitis when it was discovered that the symptoms were produced by a perforated Meckel's diverticulitis. In the course of the surgery, a urachal remnant was found to coexist with the diverticulum.

Cubital tunnel release with two limited incisions: a cadaver study.

Cubital tunnel syndrome is the second most common compressive neuropathy in the upper extremity. Treatment of cubital tunnel syndrome consists of releasing the compression on the ulnar nerve with conservative or surgical methods. Nerve decompression is an alternative simple and less invasive procedure. We have proposed a "two limited incisions" technique in order to release the cubital tunnel with two minimal incisions on a cadaveric elbow model. Thirty elbows of 15 formalin-fixed cadavers were studied. The study was performed in two steps. The first step involved a two limited incisions technique. During the second step, dissected anatomic structures were assessed. The cubital retinaculum was opened totally in 27 elbows (91%) and partially in two elbows (7%). The ulnar nerve was injured in one elbow (3%), because of the contracture of the forearm muscles. It was shown that with relaxation of the elements involved, a two limited incisions technique allowed decompression of the ulnar nerve at the elbow to be performed.

Navigation for ankle arthroscopy: anatomical study of the anterolateral portal with reference to the superficial peroneal nerve.

We aimed to navigate the surgeon regarding the localization of the main anatomical structures at the anterior part of the ankle joint, in order to find easily the safest anatomical points with reference to the superficial peroneal nerve (SPN), in particular for anterolateral portal placement in ankle arthroscopy. Sixty-three ankles in 36 fresh cadavers were dissected. In all specimens we examined (1) the distance between the SPN bifurcation and the most distal point of the lateral malleolus; and at the level of ankle joint, (2) the number of SPN, (3) the distance between the medial and intermediate dorsal cutaneous nerves, which are branches of the SPN, (4) the localization of the peroneus tertius (PT) tendon in relation to the lateral malleolus, (5) the width of the extensor digitorum longus (EDL) tendon, (6) the relationship of the PT tendon and (7) the relationship of the extensor hallucis longus (EHL) tendon with the SPN. The results were as follows: (1) In 41 ankles with bifurcation (65%) the average distance was 71.8+/-35.3 mm. (2) There were two SPN branches in 39 (62%), three branches in seven (11%) and one branch in 17 (27%) cases. (3) In 39 ankles with two branches of the SPN, the mean distance was 15.2+/-7.1 mm. (4) The lateral border of the PT tendon was positioned a mean distance of 20.8+/-3.3 mm proximal and 25.2+/-5.8 mm medial to the reference points. (5) The mean width was 10.1+/-2.9 mm. (6) In 42 ankles (67%) the distance between the lateral border of the PT tendon and the SPN was a mean of 6.2+/-6.6 mm, median of 3 mm (range 0-22 mm lateral to the tendon). (7) In 56 cases (89%) a branch of the SPN was found a mean of 6.6+/-4 mm and a median of 6 mm lateral to the EHL tendon, and in seven cases (11%) on the tendon. According to our study, in ankle arthroscopy the risk of the SPN injury is maximal in the 0-3 mm lateral to the PT tendon. To avoid injury to the SPN, the safest placement of the anterolateral portal is 4 mm lateral to the PT tendon.

Hepatomesenteric trunk.

An hepatomesenteric trunk, formed by the common hepatic and superior mesenteric arteries, was found in a 50-year-old male cadaver. The left gastric and splenic arteries arose as a common trunk, the gastrosplenic trunk, from the abdominal aorta; no typical celiac trunk was present. In addition, the hepatomesenteric trunk passed posterior to the portal vein. A knowledge of variations of the common hepatic artery may be important in pancreaticoduodenectomy, as well as during hepatic artery infusion chemotherapy.