Prevalence of the additional head of quadriceps femoris in the South Indian population: a cadaveric and radiological study.

Quadriceps femoris is an extensor muscle in the anterior compartment of thigh and is traditionally taught to be composed of four heads. Recently, there is an increased interest in the occurrence of an additional muscle head of quadriceps femoris. But scientific knowledge regarding its incidence is lacking in the South Indian population. This study was done to confirm the presence of the additional head by routine anatomic dissection and radiological imaging techniques. Forty-one formalin fixed human cadaveric lower limbs were dissected and the morphology of the additional head was noted. Retrospective analysis of 88 MRI images of patients was done. The additional muscle head was present in 43.9% of the cadaveric lower limbs and was consistently located between the vastus lateralis and vastus intermedius. It originated from variable portions of the greater trochanter, intertrochanteric line, lateral lip of linea aspera and lateral surface of the shaft of femur and inserted either as a muscle belly or as an aponeurosis into the vastus intermedius (55.6%), vastus lateralis (22.2%) or directly into the base of the patella. It received its vascular supply from branches of the lateral circumflex femoral artery and was innervated by branches from the posterior division of the femoral nerve. In addition, the additional muscle head was identified by MRI and its incidence was reported to be 30.68% for the first time in living subjects. The result of this study provides additional information in understanding the morphology of the quadriceps femoris muscle.

One-Step Lower Leg Reconstruction with Vascularized Functional Vastus Lateralis Muscle Flap in the Treatment of Embryonal Rhabdomyosarcoma for a Six-Month-Old Boy: A Case Report.

Rhabdomyosarcoma (RMS) is a common soft tissue sarcoma in childhood, however, it is very rare in the neonatal period (0.4-2% of cases). This case depicts a boy, who presented with RMS at two weeks of age, but officially diagnosed at the age of three months. MRI and scintigraphy determined a soft tissue tumor in the soleus muscle, while biopsy confirmed embryonal RMS with high mitotic activity (Ki67 (monoclonal antibodies) ~80%). CWS (Cooperative Weichteilsarkom Studiengruppe)-2012 with I2VA (ifosfamide, vincristine, actinomycin) chemotherapy regimen was administered per protocol. Surgical treatment was performed at age of six months and 18 days. The operation consisted of radical tumor resection and total triceps surae with partial fibula resection. Immediate reconstruction of triceps muscle was accomplished using a vascularized functional musculocutaneous vastus lateralis flap. Functional outcome was measured using the Lower Extremity Functional Scale (LEFS) and the Foot and Ankle Outcome Score (FAOS) with the results of 92.5% and 99% respectively.

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.

Structural differences in the diaphragm of patients following controlled vs assisted and spontaneous mechanical ventilation.

PURPOSE: Ventilator-induced diaphragm dysfunction or damage (VIDD) is highly prevalent in patients under mechanical ventilation (MV), but its analysis is limited by the difficulty of obtaining histological samples. In this study we compared diaphragm histological characteristics in Maastricht III (MSIII) and brain-dead (BD) organ donors and in control subjects undergoing thoracic surgery (CTL) after a period of either controlled or spontaneous MV (CMV or SMV). METHODS: In this prospective study, biopsies were obtained from diaphragm and quadriceps. Demographic variables, comorbidities, severity on admission, treatment, and ventilatory variables were evaluated. Immunohistochemical analysis (fiber size and type percentages) and quantification of abnormal fibers (a surrogate of muscle damage) were performed. RESULTS: Muscle samples were obtained from 35 patients. MSIII (n = 16) had more hours on MV (either CMV or SMV) than BD (n = 14) and also spent more hours and a greater percentage of time with diaphragm stimuli (time in assisted and spontaneous modalities). Cross-sectional area (CSA) was significantly reduced in the diaphragm and quadriceps in both groups in comparison with CTL (n = 5). Quadriceps CSA was significantly decreased in MSIII compared to BD but there were no differences in the diaphragm CSA between the two groups. Those MSIII who spent 100 h or more without diaphragm stimuli presented reduced diaphragm CSA without changes in their quadriceps CSA. The proportion of internal nuclei in MSIII diaphragms tended to be higher than in BD diaphragms, and their proportion of lipofuscin deposits tended to be lower, though there were no differences in the quadriceps fiber evaluation. CONCLUSIONS: This study provides the first evidence in humans regarding the effects of different modes of MV (controlled, assisted, and spontaneous) on diaphragm myofiber damage, and shows that diaphragm inactivity during mechanical ventilation is associated with the development of VIDD.

Congenital Aplasia of the Patella and the Distal Third of the Quadriceps Mechanism: A Case Report.

CASE: Congenital aplasia or hypoplasia of the patella by itself is a rare condition; to our knowledge, it has been associated with aplasia of the quadriceps mechanism only 3 times in the literature. We describe a 5-year-old boy who had bilateral fixed flexion deformity of the knee as well as bilateral hypoplasia of the patella and quadriceps mechanism; he never had been able to stand upright and walk. We present the clinical and radiographic features, the surgical details, and the successful outcome after treatment. CONCLUSION: Corrective femoral osteotomies with soft-tissue reconstruction to provide active knee extension provided a satisfactory outcome. At the last follow-up, the child was walking without support and had good active knee extension.

Efecto de la fatiga en el ratio isquiotibiales: cuádriceps. Revisión sistemática / The influence of fatigue in hamstrings:quadriceps ratio. A systematic review

Las lesiones deportivas conforman la principal causa por la que el proceso de entrenamiento se ve interrumpido total o parcialmente. Entre los diferentes tipos de lesión que pueden darse en cualquier disciplina deportiva, las lesiones musculares, y más especialmente las que se producen en la musculatura isquiotibial, son las más recurrentes. En este sentido, uno de los indicadores más fiables para cuantificar la descompensación muscular que produce esta lesión es el ratio isquiotibiales: cuádriceps, del cual se diferencian dos tipos: ratio convencional y ratio funcional. El objetivo de esta revisión fue buscar en la literatura científica cómo afecta la fatiga a los valores de ambos ratios que indican el riesgo de sufrir una lesión muscular. Se realizó una búsqueda electrónica en diferentes bases de datos, y un total de trece artículos publicados hasta el 19 de Mayo de 2015 fueron incluidos en el análisis bajo las palabras clave «Hamstrings», "Quadriceps", "Isokinetic", "Peak torque" y "Fatigue". Los estudios analizados revelaron un importante descenso en los valores de ambos ratios, en especial del funcional, tras la realización de diferentes protocolos de fatiga, sobretodo en aquellos que eran más específicos. Este descenso de los valores del ratio se traduce en un mayor riesgo de sufrir una lesión muscular. Además, el descenso en ambos ratios se producía por una disminución en los valores de fuerza de los isquiotibiales, especialmente durante su fase excéntrica. Por tanto, los resultados obtenidos sugieren la implantación de estrategias de prevención enfocadas al retraso de la aparición de la fatiga, especialmente en la musculatura isquiotibial, y en el fortalecimiento de la misma durante la fase excéntrica del movimiento

Sport injuries are considered the main cause of cessation of training process, either completely or partially. Among the different types of injuries that may be produced in any sport disciplines, muscular injuries, and more specifically hamstring injuries, are the most common. For that matter the best indicator for evaluating the muscular risk of this kind of injury produced by a muscular imbalance is the hamstrings: quadriceps ratio, of which two types can be distinguished: functional ratio and conventional ratio. The aim of this study was to search in scientific literature how the fatigue presents an influence in the values of both conventional and functional hamstrings:quadriceps ratio as an injury risk indicator. An electronic search of different databases was carried out and a total of thirteen studies publicated until 19th May 2015 were included in this review. The following keywords were employed: «Hamstrings», «quadriceps», «Isokinetic», “Peak torque» and «Fatigue». Analysed studies showed a significant decrease of both ratios values, but especially functional ratio, after the fatigue protocols application. Besides, a greater decrease of both ratios were noticed when protocols were more specific. This fact means a greatest risk of muscular injury. In addition, the fall in both ratios levels were produced by a decrease in hamstings strength values, in particular during the eccentric phase of movement. Hence, our results suggest that it would be important to develop an injury prevention strategy focused on delay fatigue, specially in hamstrings, as much as possible and improve hamstrings strength during the eccentric phase of movement

Electroestimulación neuromuscular intradiálisis, fuerza muscular, capacidad funcional y composición corporal / Intradialysis neuromuscular electro stimulation muscle strength, functional capacity and body composition

Introducción: La capacidad funcional disminuida y la importante atrofia muscular caracterizan a los pacientes en hemodiálisis (HD). El ejercicio físico intradiálisis y recientemente la electroestimulación neuromuscular (EMS), representan dos serias opciones terapéuticas para mejorar esta deteriorada condición física. Actualmente, no existen estudios publicados sobre el papel de la EMS y la composición corporal en los pacientes en HD. Objetivo: Analizar que efecto produce un programa de EMS sobre la fuerza muscular, capacidad funcional, parámetros nutricionales y composición corporal en nuestros pacientes en HD. Material y Métodos: Estudio unicéntrico, prospectivo de 12 semanas de duración. Los pacientes incluidos realizaron un programa adaptativo de EMS en ambos cuádriceps intradiálisis mediante el dispositivo Compex R Theta 500i. Analizamos: 1.- Parámetros nutricionales (Albumina, pre albúmina, triglicéridos, colesterol total y fracciones, ferritina y Proteína C reactiva). 2.- Datos musculares: Composición muscular cuadriceps, Fuerza extensión máxima cuádriceps (FEMQ) y handgrip (HG) brazo dominante. 3.- Test funcionales: “Sit to stand to sit” (STS10) y “six- minutes walking test” (6MWT). 4.- Composición corporal mediante biompedancia electrica (BIA). Resultados: 13 pacientes incluidos: (69.2% hombres). Edad media: 65.7 años y 33.9 meses en HD. I.Charlson medio 9.1. La principal etiología de la ERC fue la DM ( 38.5%). Al final del estudio se observó una mejoría en (*p<0.05): FEMQ* ( 11.7±7.1 vs 13.4±7.4 Kg), STS10 (39.3±15.5 vs 35.8±13.7 seg), 6MWT* (9.9%, 293.2 vs 325.2 m). En relación a la composición corporal, se observó únicamente un aumento significativo del área muscular (AMQ*: 128.6 ± 30.2 vs 144.6 ± 22.4 cm2) y una disminución del área grasa (AGQ*: 76.5 ± 26.9 vs 62.1 ± 20.1 cm2) a nivel quadricipital, sin cambios en el resto de datos analizados (% grasa abdominal, peso graso, peso magro, agua corporal total). No se objetivaron cambios relevantes en los parámetros nutricionales y de adecuación dialítica. Conclusiones: 1.- La electroestimulación neuromuscular intradialísis mejoró la fuerza muscular, la capacidad funcional y la composición muscular del cuadriceps de nuestros pacientes en HD. 2.- Nuestros resultados remarcan el carácter local de la electroes-timulación neuromuscular, dada la ausencia de cambios relevantes en el resto de los parámetros nutricionales y datos corporales analizados. 3.- No obstante, son necesarios futuros estudios mejor diseñados, de cara a discernir si la electroestimulación neuromuscular podría ser una nueva alternativa terapéutica para evitar la atrofia muscular y el deterioro progresivo de la condición física de éstos pacientes (AU)

Background: The reduced functional capacity and significant muscle atrophy characterized patients on hemodialysis. Intradialytic exercise and recently neuromuscular electrostimulation (EMS) represent two serious therapeutical options to improve the deteriorated physical condition. Until date, there are no published studies about the role of EMS and body composition in HD patients. Objectives: Analyze the effect a program of EMS on muscle strength, functional capacity, nutritional parameters and body composition in our HD patients. Methods: A 12 weeks single-center, prospective study. Patients included in the study performed an intradialysis EMS adaptive program in both quadriceps using the Compex R Theta 500i device. We analyzed: 1.- Nutritional parameters (albumin, pre-albumin, triglycerides, total cholesterol and fractions, ferritin and C-reactive protein). 2.- Muscular data: Muscular composition, Maximum length quadriceps strength (MLQS) and “hand-grip” (HG) dominant arm. 3.- Functional capacity test: “Sit to stand to sit” (STS10) and “six- minutes walking test” (6MWT). 4.- Body composition. Results: 13 HD patients included: 69.2 % men. Mean age 65.7 years and 33.9 months on HD. A significant (* p < 0,05) improvement was observed in MLQS* (11.7±7.1 vs 13.4±7.4 Kg), STS10* (39.3±15.5 vs 35.8±13.7 seg), 6MWT* (9.9%, 293.2 vs 325.2 m). There was a signi-ficant increase in the quadriceps muscular area (QMA*: 128.6 ± 30.2 vs 144.6 ± 22.4 cm2) and decrease of fat quadricipital area (FQA*: 76.5 ± 26.9 vs 62.1 ± 20.1 cm2). No significant changes were observed in nutritional parameters, body composition (body fat percentage, lean and fat mass, total body water) or dialysis adecuacy data. Conclusions: 1.- Intradialysis quadriceps EMS improved muscle strength, functional capacity and the quadriceps muscle composition in our HD patients. 2.- Our results underline the local aspects on EMS, given the absence of relevant changes on nutritional parameters and body composition. 3.- Future studies are manadatory in order to establish if EMS could be a new alternative to prevent muscle atrophy and the progressive deterioration of the physical condition of these patients (AU)

Congenital total absence of the quadriceps muscle and patella: a case report with computed tomography scan and three-dimensional reconstructions.

In this study, we present three-dimensional computed tomography (CT) scan image findings of a case with congenital total absence of the quadriceps muscle and patella and partial absence of the sartorius muscle, which caused fixed flexion contracture of the knee joint. Physical examination, radiography, three-dimensional CT scan, and chromosome analysis of the patient were done. On physical examination, the knee joint was at 85 degree fixed flexion contracture. Radiographic views demonstrated soft tissue defects around left femur. Chromosome analysis was normal. CT scan showed total absence of the quadriceps femoris muscle and patella. Congenital absence of the extensor mechanism and patella are very rare anomalies. This case differed from other patellar aplasia or dysplasia syndromes with the presence of fixed flexion knee contracture and aplasia of the extensor mechanism.

Progressive limitation of knee flexion secondary to an accessory quinticeps femoris muscle in a child: a case report and literature review.

We describe a symptomatic, progressive restriction of knee flexion due to an accessory quadriceps femoris in a nine-year-old girl. There was no history or findings of post-injection fibrosis, nor any obvious swelling of the affected quadriceps. At arthroscopy no intra-articular pathology was found. An accessory 'quinticeps femoris' was diagnosed by ultrasonography and MRI. Following excision of the muscle and tendon full flexion of the knee was regained and there was no recurrence of the contracture.

Congenital aplasia of the patella and the distal third of the quadriceps mechanism.

Congenital absence of the patella and aplasia of the muscles are very rare anomalies. We describe a 4-year-old boy with bilateral congenital aplasia of the patella and agenesis of the distal third of the quadriceps muscle who was unable to walk owing to the lack of active knee extension. The features of this child differed from all other conditions associated with patellar aplasia. The continuity of the quadriceps mechanism was restored and he began walking normally. This appears to be the first report of the combination of aplasia of the patella and the distal third of the quadriceps that was successfully treated.

Reconstruction of quadriceps tendon with Achilles tendon allograft in older children with congenital dislocation of the knee.

This is a case report of two children with congenital dislocation of the knee. They have been treated surgically with Z-lengthening of the quadriceps tendon and additional reconstruction of the quadriceps tendon with Achilles tendon allograft to fill in the remaining average 6 cm gap of the tendon. The patients were two girls, 6 and 9 years old. One of them had an operative treatment previously with a tendon lengthening procedure and it was failed and the other patient was untreated before. Preoperatively, untreated case was unable to walk. The other patient was limping. None of them was able to flex their knees beyond the neutral extension position. Postoperatively, both patients were able to walk and the knees were reduced to a range of motion of 0 degrees -95 degrees of flexion. The mean follow-up time was 20 months.