Morphometry of the sural nerve in diabetic neuropathy: a systematic review.

PURPOSE: The aim of this systematic review is to evaluate the usefulness of sural nerve ultrasonography in diagnosing diabetes mellitus (DM) and diabetic polyneuropathy (DPN), the latter of which is a common long-term complication for diabetic patients that frequently involves the sural nerve. METHODOLOGY: A meta-analysis of the cross-sectional areas (CSAs) of sural nerves in healthy individuals and patients with diabetes mellitus based on a total of 32 ultrasonographic-based studies from 2015 to 2023 was performed. Sub-analyses were performed for factors such as geographical location and measurement site. RESULTS: The meta-analysis showed that the mean CSA of the sural nerve was significantly larger in DM patients with DPN only compared to healthy individuals across all regions and when pooled together. An age-dependent increase in the CSA of healthy sural nerves is apparent when comparing the paediatric population with adults. CONCLUSION: Sural nerve ultrasonography can distinguish diabetic adults with DPN from healthy adults based on cross-sectional area measurement. Future studies are needed to clarify the relationships between other parameters, such as body metrics and age, with sural nerve CSAs. Cut-offs for DPN likely need to be specific for different geographical regions.

Ligamentum Teres Lesions Are Associated With Poorer Patient Outcomes in a Large Primary Hip Arthroscopy Cohort of 1,935 Patients.

Purpose: To retrospectively evaluate the prevalence and characteristics of ligamentum teres (LT) lesions identified in a single-surgeon hip arthroscopy cohort and to compare surgical outcomes of those with, and without, identified LT lesions. Methods: Patients who underwent primary hip arthroscopy between 2005 and 2018 in one surgeon's clinic were identified. Those with a history involving extra-articular scoping or any previous surgery on the ipsilateral hip were excluded. Patient-reported outcome measures completed before and after surgery included the Hip Disability and Osteoarthritis Outcome Score, Nonarthritic Hip Score, and 12-item International Hip Outcome Tool. Conversion to hip joint replacement was ascertained through a national register. Results: A total of 1,935 primary hip arthroscopies (from 1,607 different patients) were included in this study. In total, 323 LT lesions were identified. Those with LT lesions were older than those without (40.3 ± 11.3 years compared with 33.9 ± 12.1 years; P < .001), and more frequently female (58.2% vs 41.8%; P = .001). Hips with lesions had a smaller lateral center-edge angle than other hips (33.0 ± 6.8° vs 34.1 ± 6.0°; P = .004). All patient-reported outcome measures improved significantly (P < .001) from pre- to post-surgery for patients with and without LT lesions. However, patients with LT lesions reported less improvement in the 12-item International Hip Outcome Tool (difference -5.60; P = .004) and in Hip Disability and Osteoarthritis Outcome Score symptoms (-4.41; P = .004), sports (-7.81; P < .001), and quality of life subscales (-8.85; P < .001) than those without lesions. Hips with LT lesions also had a 6.2% 2-year rate of subsequent hip replacement (20/323 hips) compared with those without lesions (0.9%; 14/1612 hips; P < .001). Conclusions: In this single-surgeon hip arthroscopy cohort, identification of LT lesions was associated with poorer patient-reported outcomes and increased likelihood of conversion to arthroplasty within 2 years. These findings suggest a poorer prognosis for patients with LT injury compared with those without. Level of Evidence: Level III, retrospective cohort study.

Clinical anatomy through gamification: a learning journey.

AIM: This study describes the developmental process of a series of anatomy games for medical students and analyses student participation and experiences around the gamification process. METHODS: Three diverse anatomy games were developed on the undergraduate medical curriculum. Based on students' playing and simultaneous learning experiences in each game, subsequent game contents were constructively modified. Students from three different universities participated in the study (total cohort=646); their experiences on the different games were documented and compared with each other. RESULTS: Feedback from 219 players showed that the games were fun (95%) and interesting (81%) and assisted their anatomy learning (97%); students' fun, interest and learning improved significantly in the two subsequent games (p<0.001). CONCLUSION: Carefully designed anatomy games create a fun-filled and interesting learning environment for undergraduate medical students. Learning experiences improved when students' feedback was appropriately addressed to constructively modify the subsequent learning resources.

Load-deformation properties of the ligament of the head of femur in situ.

The ligament of the head of femur (LHF) or ligamentum teres has been reported to tense during hip adduction and also to provide mechanical stability to the joint. LHF injury is more common in females and also in right hip joints compared with left ones. Although this could be due to leg dominance, pelvic size or muscle strength, there is no study that has looked into these differences. This cadaveric biomechanical study aimed to compare potential differences in the mechanical behavior of the LHF between neutral and 20° adducted hip joints, sex, and sides. Tensile tests of the LHF were performed on 25 hip joints (mean age at death of 85.7 ± 7.5 years; 9 females, 4 males; 13 left, 12 right), positioned either neutrally or in adduction. The maximum force required to rupture the ligament, its strain at failure, tensile strength, linear stiffness, and elastic modulus were obtained and statistically compared between analysis groups. The maximum force the LHF could withstand before rupture averaged 57 ± 37 N, strain at failure of 59 ± 33%, tensile strength of 2.9 ± 1.8 MPa, linear stiffness of 5.4 ± 3.5 N/mm, and elastic modulus of 7.2 ± 3.8 MPa. The LHF length at failure was significantly greater in males compared with females (P = 0.02). Irrespective of joint position, there were no statistical differences in the stress-strain properties of the LHF between females and males, or sides. There may be other anatomical, functional, and demographic factors that could render the ligament tissue vulnerable to injury in these groups. Clin. Anat., 33:705-713, 2020. © 2019 Wiley Periodicals, Inc.

Neurovascular structures of the ligament of the head of femur.

The ligament of the head of femur (LHF), or ligamentum teres, is believed to provide blood supply to the head of femur and mechanical stability to the hip joint. But these functions in the adult are often debated. The existence and distribution of neurovascular structures within the ligament are not widely documented. This study examined the blood vessels and nervous tissue within the LHF to determine whether the ligament may have a vascular and proprioceptive function at the hip joint. Histological sections from the LHF from 10 embalmed hips (six female, four male; mean age 80.4 ± 8.7 years) were cut at three levels: the foveal attachment, mid-length and its base where it attaches to the transverse acetabular ligament. Sections were stained with haematoxylin and eosin to study general tissue architecture or with von Willebrand factor and neurofilament to identify blood vessels and nervous tissue, respectively. The proportion of the ligament's cross-sectional area occupied by blood vessels was expressed as a vascularity index (VI). Nerve endings within the ligament were identified and morphologically classified. Comparisons between the VI at the three levels, or between the tissue layers of the ligament, were made using 95% confidence intervals; statistical significance was set P < 0.05. The ligament tissue comprised three distinct layers: a synovial lining with cuboidal cells, a sub-synovial zone formed of loose connective tissue and the ligament proper composed of dense collagen bundles. Patent blood vessels and nerve fibres were present both in the sub-synovial zone and the ligament proper; Pacinian corpuscles and free nerve endings were found scattered only in the sub-synovial zone. The VI of the ligament proper at the fovea was significantly higher than its middle (P = 0.01) and basal levels (P = 0.04); it was also higher than that of the sub-synovial layer (P = 0.04). The LHF has three histologically distinct zones, and blood vessels and nerves are distributed both in the sub-synovial layer and ligament proper. Higher vascularity within the ligament proper at its foveal insertion suggests a possible nutritive role of the LHF to the adult head of femur. The presence of nerves and nerve receptors indicates the ligament is involved in the perception of pain and proprioception, thereby contributing to mechanical stability of the joint.

Clinical Anatomy of the Ligament of the Head of Femur.

The ligament of the head of femur (LHF) has gained clinical attention recently and is reported to contribute to hip stability. This study explores its morphology and morphometry, information that may help inform surgical decision making. Gross anatomical dissections were undertaken on 229 embalmed hips from European (n = 105) and Thai (n = 124) adult cadavers to examine LHF anatomy. Ligament morphometry was statistically compared at different sites, between sexes and sides. The origin of ligamental arteries and absence of the ligament were documented. The LHF was pyramidal or quadrangular in shape. Sub-synovial fibrous bands originated from the transverse acetabular ligament, edges of the acetabular notch, and acetabular floor; less frequently from the hip joint capsule. Distally, the ligament flattened and converged onto the fovea capitis. The ligament was 22.3 ± 4.4 mm long and was significantly wider (P = 0.001) and thicker (P = 0.0003) at the fovea, compared to its mid-zone. Branches of the obturator artery entered the acetabular foramen inferomedially and penetrated the middle third of the LHF. Blood vessels ran within the LHF and appeared to enter the fovea. The ligament was absent in 2.8% of Thai hips and there were no significant sex or side differences in ligament dimensions. The morphology of the LHF is complex. While individual variation was apparent, blood vessels were seen in the distal ligament. Precise information on LHF morphometry and attachment sites will help inform appropriate graft dimensions and choice of fixation sites necessary for ligament reconstruction. Clin. Anat., 2018. © 2018 Wiley Periodicals, Inc. Clin. Anat., 2018. © 2018 Wiley Periodicals, Inc.

A sectional anatomy learning tool for medical students: development and user-usage analytics.

BACKGROUND: A sound knowledge of cross-sectional anatomy is needed to interpret radiological images. Ultrathin E12-plastinated slices serve as good learning resources to begin with, but effective utilisation of these resources are often challenging due to their fragility and lack of adequate laboratory time. To enhance interpretation of E12 slices, and also to promote independent learning, we developed a web-based self learning resource. METHODS: An interactive online sectional anatomy learning tool (SALT) to learn the cross-sectional anatomy of the spinal levels, thorax, abdomen and pelvis was developed using Courselab software. SALT was piloted on third-year medical students learning regional and clinical anatomy of the human body. At the end of the academic year, student participation within the resource was analysed, and the resource usage was compared with the users' academic performance. RESULTS: Each aspect of SALT was accessed 338 times on average, by 51% of the class. The majority medical students accessed the resource after class hours. Continued research usage was observed on weekends and holidays, which peaked during exam periods. SALT usage also had a positive impact on the users' academic performance (p < 0.05). Students also used the resource after exams and during their subsequent years of study. CONCLUSION: SALT promoted independent learning, as well as enhanced students' learning experience and academic performance. Having the benefit of online access, the resource was used almost 24/7, both on and off-campus. Educators should be encouraged to develop and trial their own simple inexpensive online resources tailormade to meet student needs and supplement to the existing traditional teaching techniques.

Clinical anatomy e-cases: a five-year follow-up of learning analytics.

AIM: This article explores the development and user experiences of a supplementary e-learning resource (clinical anatomy e-cases) for medical students, across a five-year teaching period. METHODS: A series of online supplementary e-learning resources (the clinical anatomy e-cases) were developed and introduced to the regional and clinical anatomy module of the medicine course. Usage analytics were collected online from a cohort of third-year medical students and analysed to gain a better understanding of how students utilised these resources. RESULTS: Key results showed that the students used the supplementary learning resource during and outside regular teaching hours that includes a significant access during holidays. Analysis also suggested that the resources were frequently accessed during examination periods and during subsequent clinical study years (fourth or fifth years of medicine course). Increasing interest and positive feedback from students has led to the development of a further series of e-cases. CONCLUSION: Tailor-made e-learning resources promote clinical anatomy learning outside classroom hours and make supplementary learning a 24/7 task.

The morphology and morphometry of the fovea capitis femoris.

BACKGROUND: There is little published information on the anatomy of the fovea capitis femoris (FCF), the distal attachment site of the ligament of the head of femur (LHF). This study investigates the morphology of the FCF on dry bones in an attempt to answer some of the debate around the functional significance of the LHF. METHODS: The morphological and morphometric details of the FCF were analysed on 125 dry isolated femora (n = 125) from the Anatomy Museum, University of Otago, New Zealand. RESULTS: All femora had a single distinct FCF. The proximal half of the foveal floor was rough indicating the attachment of the LHF, while the distal half or receptacle zone, was smooth. The long axis of most FCF (63.2%) was directed posteroinferiorly. The FCF measured 1.77 ± 0.4 cm (SD) in the longitudinal plane and 1.3 ± 0.32 cm (SD) in the transverse plane and occupied 17% of the surface area of the femoral head. The shape of the FCF was oval in 66%, circular in 28%, and triangular in 6%. In 123 of 125 bones, the FCF was located on the posteroinferior quadrant of the femoral head. Multiple vascular foramina were found in the ligament attachment zone in 76% of the bones and a quarter of the samples showed a shallow perifoveal groove (24%) or a deep perifoveal notch (26%) on the dry bones. DISCUSSION: This study shows that the fovea consistently lies posteroinferior to the true centre of the femoral head and is usually oval in shape. Patent vascular foramina clustered within the LHF attachment site suggest that the ligament conveys some blood supply to the femoral head in adults.

Ligament of the head of femur: A comprehensive review of its anatomy, embryology, and potential function.

The functional significance of the ligament of the head of femur (LHF), or ligamentum teres has often been debated. Having gained recent attention in clinical practice, it is suggested to partly provide some mechanical stability to the hip joint. However, the anatomy of this ligament is not well studied. This paper systematically reviews the anatomy of the LHF with the aim of exploring our current understanding of this structure and identifying any gaps in knowledge regarding its morphology and function. A systematic search of Medline, Embase, ProQuest, Web of Science, and Scopus databases was undertaken and relevant data extracted, analyzed. A total of 69 references were obtained, that included 53 full text articles, three published abstracts, and 13 textbooks. Many publications related to clinical studies (n = 11) rather than gross anatomy (n = 7), with one report on variation of the LHF. Considerable inconsistency in the naming and description of the LHF morphology was observed. Variable attachment sites were reported except for the acetabular notch, transverse acetabular ligament, and the femoral fovea. Presence and patency of the ligamental arteries supplying the head of the femur and their exact location were variably described and were often incomplete. The LHF is believed to be taught in extreme hip adduction, but there is little evidence to support this. In conclusions, further investigation of the anatomy of the LHF is recommended, particularly to clarify its mechanical role, innervation, and vascular contribution to the developing and adult femur, so to better inform clinical practice.

Inflammation During Gestation Induced Spatial Memory and Learning Deficits: Attenuated by Physical Exercise in Juvenile Rats.

BACKGROUND: Gestational infections induced inflammation (GIII) is a cause of various postnatal neurological deficits in developing countries. Such intra uterine insults could result in persistent learning-memory disabilities. There are no studies elucidating the efficacy of adolescence exercise on spatial learning- memory abilities of young adult rats pre-exposed to inflammatory insult during fetal life. AIMS AND OBJECTIVES: The present study addresses the efficacy of physical (running) exercise during adolescent period in attenuating spatial memory deficits induced by exposure to GIII in rats. MATERIALS AND METHODS: Pregnant Wistar dams were randomly divided into control and lipopolysaccharide (LPS) groups, injected intra peritoneally (i.p) with saline (0.5ml) or lipopolysaccharide (LPS) (0.5mg/kg) on alternate days from gestation day 14 (GD 14) till delivery. After parturition, pups were divided into 3 groups (n=6/group) a) Sham control and LPS group divided into 2 subgroups- b) LPS and c) LPS exercise group. Running exercise was given only to LPS exercise group during postnatal days (PNDs) 30 to 60 (15min/day). Spatial learning and memory performance was assessed by Morris water maze test (MWM), on postnatal day 61 to 67 in all groups. RESULTS: Young rats pre-exposed to GIII and subjected to running exercise through juvenile period displayed significant decrease in latency to reach escape platform and spent significant duration in target quadrant in MWM test, compared to age matched LPS group. Results of the current study demonstrated that exercise through juvenile/adolescent period effectively mitigates gestational inflammation-induced cognitive deficits in young adult rats. CONCLUSION: Inflammation during gestation impairs offspring's spatial memory and learning abilities. Whereas, early postnatal physical exercise attenuates, to higher extent, cognitive impairment resulted from exposure to LPS induced inflammation during intrauterine growth period.

The intrinsic arterial vascularity and morphology of the median nerve within the carpal tunnel: a microscopic study.

Carpal tunnel syndrome (CTS) is the commonest peripheral nerve entrapment neuropathy and is more prevalent in females for reasons that are not fully understood. The aim of this study was to investigate the intrinsic arterial supply of the median nerve in the region of the carpal tunnel to determine if there are significant individual variations. The median nerve was excised intact from 34 cadaver hands (7 male, 13 female; 18 right, 16 left; age 66-100 years) and sectioned at three levels: 1 cm proximal to the transverse carpal ligament; at the entrance to the carpal tunnel; and 1 cm distal to the latter site. Photomicrographs of histological sections were analyzed using ImageJ and the following recorded: the shape and cross-sectional area (CSA) of the nerve and the total CSA of small arteries/arterioles (>80 µm(2)) within the nerve. The proportion of the nerve's CSA occupied by arteries/arterioles was expressed as a ratio to compare vascularity at the three levels. There were no significant differences between hands or levels in males, but in right hands from female cadavers there was a statistically significant reduction in the intrinsic arterial vascularity of the median nerve at the entrance to the carpal tunnel as compared to proximal and distal levels and left hands (p < 0.05). Gender-based differences in the intrinsic arterial supply of the median nerve could be a factor predisposing to CTS.