Anatomical characterization of the too-long anterior process of the calcaneum: a computed tomography scan analysis of 69 feet.

Our work aims to identify and measure the morpho-anatomical characteristics of too-long anterior calcaneal process based on computed tomography scans done in patients with a history of pain and who have experienced repeated ankle sprains. The computed tomography scans of 69 feet were reviewed. These scans were used to calculate (1) the calcaneo-navicular distance; (2) the height, length, and width of the too-long anterior calcaneal process; (3) the length of the calcaneum; (4) the angle of the too-long anterior calcaneal process in the sagittal (anterior-superior angle), axial (anterior-medial angle), and frontal plane. Out of 69 feet, forty-nine were pathological (71%) with abnormalities of the too-long anterior calcaneal process, while the rest (29%) had no morphological abnormalities. The calcaneo-navicular distance was found to be <5 mm (mean: 2.8 ± 1.2 mm) in all pathological feet, which also had significantly reduced calcaneo-navicular distance ( P < 0.001) and longer bone portion distal to the calcaneocuboid tangent ( P < 0.001) in comparison to normal feet. In pathological feet, the mean too-long anterior calcaneal process length was 10.7 ± 1.9 mm; the mean anterior-superior angle was 29.6 ° ± 11.6, the mean angle anterior-medial angle was 40.7 ° ± 8.3, the mean angle frontal plane was 74.2 ° ± 14.1. Similar to a cone or a parallelepiped, the too-long anterior calcaneal process has a complex three-dimensional anatomy, with a superior, medial, and anterior direction. Using the measurements obtained, four different too-long anterior calcaneal process morphotypes could be identified: absence of TLACP, triangular shape, rectangular shape, and coalition (level of evidence III).

Interrelations Between the Too-Long Anterior Calcaneal Process, Hind and Mid-tarsal Bone Volumes, Angles and Osteochondral Lesion of the Dome of the Talus: Analysis by Software Slicer of 69 CT Scan of Feet.

Introduction: Although the association between Too-Long Anterior Calcaneal Process (TLACP) and osteochondral lesion of the dome of the talus (OCL) has been hypothesized, no study has investigated the interrelations between TLACP, hind and mid-tarsal volumes and angles and the development of OCL. The main goals of this work are: (1) to measure the volume of the calcaneum, talus, navicular and cuboid in subjects with and without TLACP; (2) to evaluate the angular relationships between talus, calcaneum and navicular in subjects with and without TLACP; (3) to assess whether TLACP has an effect on the volume of OCL. Methods: This is a retrospective study of 69 CT scans of 54 consecutive children aged 11-15 years who had undergone a CT scan due to symptomatology suggestive of TLACP. The 3D Slicer software allowed to calculate the volume of the talus, calcaneum, navicular, cuboid, TLACP and OCL (in cm3). The PACS system was used to perform the angular measurements (in degrees) between talus, calcaneum and navicular in the frontal, axial and sagittal plane. Results: Amid the 69 CT scans, 49 were found to have pathologies related to TLACP (71%, TLACP Group) and 20/69 were normal (29%, Control Group). The mean hind and mid-tarsal bone volumes of the TLACP group were comparable to those of the control group. There were 40 (81.6%) OCLs detected exclusively in pathological feet (TLACP group); 32 lesions were medial (80%), and 8 lesions were lateral (20%). According to Ferkel and Sgaglione CT Staging System, there were 22 (55%) stage 1 lesions, 5 (12.5%) stage 2A, 3 (7.5%) stage 2B and 10 (25%) stage three lesions. Only the angle between the talus and calcaneum in the frontal plane was significantly lower in pathological feet with respect to the control group (p < 0.001). In pathological feet, the talus was supinated, and the calcaneus pronated. Conclusions: TLACP tend to stiffen the foot, modifying its biomechanics and leading to supination of the talus and pronation of the calcaneum. This induces an overpressure at the medial side of the talus where we observed a greater frequency of medial OCL with larger volume than lateral OCL. Level of Evidence: III.

The gracilis and semitendinosus muscles: a morphometric study on 18 specimens with clinical implications.

INTRODUCTION: The pes anserinus consists of the sartorius, semitendinosus, and gracilis muscles. They coalesce together with the leg fascia to form the anserine plate. The semitendinosus and gracilis both form the deep layer of this plate and are clinically relevant for ligament reconstruction. The aim of the study is to report a detailed morphometric evaluation of the semitendinosus and gracilis muscles and assess their clinical implications. METHODS: Using a rigorous dissection process on 18 cadaveric hips, measurements of both the semitendinosus and gracilis muscles with bone parameters were conducted. We measured the following: (a) total femur, femoral shaft, and neck lengths, (b) total muscle lengths, and (c) intra-muscular and extra-muscular (free) tendon lengths. Correlation values between bone variables, muscle variables, and in-between muscle variables were computed. RESULTS: The total muscle and the distal intra-muscular tendon length of the St and Gr are correlated with the total femur length. When compared to gracilis, the total muscle and distal intra-muscular tendon lengths of the ST are much better correlated with the total femur length. The free distal tendon length for both muscles did not show a significant correlation with any of the femoral bone lengths. CONCLUSION: The variability of tendon length of the ST/Gr poses a significant challenge to surgeons. This study reports a detailed morphometric evaluation of the ST/Gr hamstring muscle and tendons. It revealed a positive correlation between the femoral length and the ST/Gr graft lengths. This could help orthopedic surgeons in predicting the graft lengths pre-operatively and develop better planning for reconstructive surgeries.

Morphometric analysis of all 24 hip muscles: A cadaveric study of 18 hip specimens with proposal of a new classification of muscles.

PURPOSE: There are few papers investigating the morphometry of hip muscles and reporting either a single muscle or a group of synergistic muscles. With the development of hip joint simulation, hip arthroplasty implants, and gait analysis, a set of biometric data covering all the muscles that act on the hip joint is needed. METHODS: Using a rigorous dissection process on 18 cadaveric hips, measurements of all 24 hip muscles and bone parameters were conducted. We measured the following: (a) total femur, femoral shaft, and neck lengths, (b) total muscle lengths, (c) intra-muscular and extra-muscular (free) tendon lengths, (d) bone angles, (e) muscle pennation, sagittal, and frontal angles, (f) muscle weight, (g) muscle volume, (h) muscle cross-sectional area, and (i) and bending moment. Data on more than 12,000 morphometric or anatomical parameters were collected. Correlation values between bone variables, muscle variables, and in-between muscle variables were computed. Based on their compliance, muscles were classified using the ratio of belly length over the sum of intra-muscular and free tendons. RESULTS: Values of the neck, shaft, and total femur lengths were highly correlated in relation to each other. The long muscles and the pelvitrochanteric muscles were highly correlated with femoral bone lengths. The proximal and distal intra-muscular tendon lengths were correlated to the total muscle length for all long muscles, independently of free tendon (extra-muscular) or muscle belly lengths. A very significant correlation was found between muscle weight variations among specimens. Three groups of muscles were identified based on their compliance. CONCLUSION: This is the first comprehensive anatomical morphometric study which includes all the 24 muscles acting on the hip joint. It generates a unique anatomical dataset comprising all necessary data for musculoskeletal modeling and arthroplasty implants of the hip joint. A new muscle classification was proposed based on compliance where muscles of the same group would exhibit similar compliance and functional anatomy.

Historical anatomy of hepatic segmentation: about 250 livers corrosions by Rapp (1953) and Couinaud (1953) in the Conservatory of Anatomy in Montpellier.

Two "surgeons-anatomists" Rapp in Montpellier and Couinaud in Paris at the same period (1953) given precise anatomy useful for the hepatic surgery and to the tremendous upheavals of radiological investigations. Actually, the fundamental anatomy of liver is classic with 8 segments with autonomous territories having a vascular afferent pedicle and a venous and biliary efferent drainage. These autonomous territories supported the surgical approach of the liver with the possibility of resecting a hepatic territory in a carcinological perspective well saving quite vascularized parenchyma. It will be in the future history about liver morphology to specify the contribution of these two "surgeons-anatomists". Actually it will be possible to look in the "Conservatory of Anatomy" in Montpellier these original livers corrosions.

The teaching of anatomy in Montpellier University during VIII centuries (1220-2020).

Since 1220 in Montpellier the human cadaver dissection had been used for the teaching of anatomy. In the first time the anatomy was based on animal knowledge. Vesalius student in Montpellier then in Italy, written the first book on human anatomy. Among teachers some of them made discoveries such as Pecquet on cisterna chyli, Vieussens on brain and hearth. Wax anatomy was used for teaching and Laumonier and B. Delmas presented some very nice pieces. Progressively a lot of anatomical preparations were exposed in a conservatory with 2330 human cadavers' dissections obtained during a lot of examinations. Anatomy and pathology were developed by Delpech about growing of bones with laws. In 1953 two anatomist surgeons, Rapp and Couinaud, described the segmentation of the liver with using techniques of corrosion. In the conservatory 250 corrosions of the livers are exposed, this is certainly the most numerous in the world and it represents a huge basis for surgery and liver transplantation. Since 1900 the teaching of anatomy continued with blackboard lectures and Human cadavers dissections. Therefore, a new approach of anatomy with computer is going to be used in the future.

Thoracic cage volume and dimension assessment by optoelectronic molding in normal children and adolescents during growth.

PURPOSE: The thoracic spine, the chondral and osseous ribs, and the sternum together make up the thoracic cage. These elements are strictly correlated, although their growth is not synchronous. The purpose of this study is to provide a comprehensive data set of thoracic dimensions and non-invasive volumetric assessment in a large cohort of males and females from early childhood to young adult age. METHODS: In all, 622 healthy individuals (406 girls, 216 boys) aged 6-18 years were consecutively enrolled between 2006 and 2016. All had to be healthy with no history of spinal deformity, or any lung, cardiovascular, systemic or neuromuscular disease. The optical ORTEN system for trunk surface data acquisition was used to calculate thoracic cage volume (V) and perimeter (Pe), anterior-posterior depth (AP) and transverse diameter (TD), AP/TD ratio, sternal length (St), and T1-T12 distance (Tle) in all patients. RESULTS: The overall average age was 11.1 ± 2.5 years (4-18) for girls and 11.0 ± 3.1 years (4-18) for boys. Average growth parameters were: standing height 146.2 ± 14.6 cm (103-172) for girls and 146.4 ± 20.0 cm (94-192) for boys, sitting height 75.4 ± 8.6 cm (61-91) for girls and 75.5 ± 10.3 cm (60-99) for boys, weight 37.6 ± 10.4 kg (16-65) for girls and 38.3 ± 14.3 kg (13.7-104) for boys, BMI 16.7 ± 3.7 (18.5-26) for girls and 17.0 ± 3.3 (18.7-34.3) for boys. At age 6-8 years: V was 52.5% of its final size in girls and 44.9% in boys; Pe was 80.2% its final length in girls and 76.8% in boys; St reached 68% of its final size in girls and 66.9% in boys; Tle reached 73.3% of its final length in girls and 71.2% in boys. At skeletal maturity, thoracic cage volume in boys was 19.4% greater than in girls (p < 0.05). AP/TD ratio remained < 1 in all age groups and did not differ between genders (p > 0.05). CONCLUSION: Growth of the thoracic cage is shown to be a gradual process that is more linear than previously reported. Only small increases in annual growth rates were observed during the pubertal growth spurt. The most important events characterizing thoracic cage development occurred during the first few years of postnatal growth. The circular cross-section of the very young child's thorax reached adult-like proportions together with its ovoid shape before age 6 years.

Postoperative CT-scan 3D reconstruction of the calcaneus following lateral calcaneal lengthening osteotomy for flatfoot deformity in children. Is the surgical procedure potentially associated with subtalar joint damage?

BACKGROUND: Several anatomical studies have shown that the articular facets of the calcaneus can present with different anatomy. This study assessed the 3D anatomy of lateral calcaneal lengthening (LCL) osteotomy in relation to the anterior and middle facet of the calcaneus in a group of skeletally immature patients treated for symptomatic flatfoot deformity. METHODS: During the study period, 14 consecutive patients (10 males, 4 females) presenting symptomatic flatfoot (20 feet) with different aetiologies underwent LCL osteotomy and CT scan with 3D reconstruction of the operated feet. Anatomy of articular factes of the calcaneus were graded according to Bunning & Barnett's classification. In order to assess clinical and functional outcome, all patients were evaluated according to Yoo et al.'s, Mosca's and AOFAS clinical criteria before surgery and at last follow-up visit. RESULTS: Despite proving difficult to assess (10 out of 20 feet), dimensions of bone and joint structures revealed significant anatomical variations. In particular, working to Bunning & Barnett's classification, anatomy of the articular facet varied significantly among patients, and in Bunning & Barnett type-B1 or B2 the LCL osteotomy necessarily violates the articular surface of the anterior and middle facet of the calcaneus due to the fact that the two facets are fused together (single articular surface). CONCLUSIONS: These biometric notions allow a better understanding of the impact on articular facets of the calcaneus of the osteotomy procedure suggested by Evans and Mosca. We anticipate that the findings reported here should lead to improved techniques for assessing all bone structures of the hindfoot, support logical classifications of the different pathological situations, and ultimately lead to improved treatment strategies.

Clinical and radiological outcome of calcaneal lengthening osteotomy for flatfoot deformity in skeletally immature patients.

BACKGROUND: The purpose of this study was to evaluate the clinical, functional and radiological outcome of calcaneal lengthening osteotomy for the treatment of symptomatic flatfoot deformity in skeletally immature patients. METHODS: A retrospective review was led on 31 prospectively enrolled patients with symptomatic flatfoot. Twenty-seven out of 31 patients met the inclusion criteria, for a total of 38 operated feet. Mean age at time of surgery was 13.3 ± 2.2 years (range 7.8-17). Mean BMI at time of surgery was 19.3 ± 4.9 (range 12.3-32). In order to assess clinical and functional outcome, all patients were evaluated according to Yoo et al., Mosca and AOFAS clinical criteria before surgery and at last follow-up visit. Moreover, all patients underwent anteroposterior and lateral weight-bearing foot radiographs preoperatively, at 3-4-month post-surgery and at last follow-up visit. RESULTS: Average Yoo et al. score was 3.3 ± 1 (range 0-4) preoperatively and improved to 9.8 ± 2.1 (range 3-12) at last follow-up (p < 0.001). Clinical outcome was satisfactory in 34 feet (89%) and unsatisfactory in 4 feet (11%). The same results were observed when Mosca clinical criteria were applied. AOFAS score improved significantly from a preoperative mean value of 49.9 ± 16 (range 23-75) to a postoperative value of 89 ± 15.9 (range 34-100) (p < 0.001). All radiographic parameters improved significantly from mean preoperative to mean 3-4-month postoperative value. Correction was maintained at last follow-up visit. Postoperative radiographs showed calcaneocuboid (C-C) joint subluxation in 29 (76%) feet. Final AP and lateral foot radiographs showed complete bone union and good bone graft remodeling. Furthermore, correct joint alignment was restored in all but two patients (93%). CONCLUSIONS: Calcaneal lengthening osteotomy is not contraindicated in symptomatic flatfoot of different etiologies, except neuromuscular disease-related flatfoot that can affect bone quality and reduce foot flexibility. C-C joint subluxation is frequently observed but has little functional impact as it tends to remodel over time.

Long-term post-operative cognitive decline in the elderly: the effects of anesthesia type, apolipoprotein E genotype, and clinical antecedents.

Cognitive dysfunction in the elderly commonly observed following anesthesia has been attributed to age-related neuronal changes exacerbated by pharmacotoxic effects. However, the extent to which these changes may persist following recovery from surgery is still largely unknown. This study investigates the long-term effects of anesthesia on cognitive functioning after orthopedic surgery in 270 elderly patients over the age of 65 who completed a computerized cognitive battery before and 8 days, 4 and 13 months after surgery. Their performance was compared to those of 310 elderly controls who completed the same neuropsychiatric evaluation at baseline and one-year interval. Multivariate analyses adjusted for socio-demographic variables, depressive symptomatology, vascular pathology as well as baseline cognitive performance. We found early and transient post-operative decline in reaction time and constructional praxis. With regard to long-term changes we observed improvement compared to controls in most verbal tasks (probably due to learning effects). On the other hand, a clear dissociation effect was observed for several areas of visuospatial functioning which persisted up to the 13-month follow-up. This specific pattern of visuospatial deficit was found to be independent of apolipoprotein E genotype and closely resembles what has recently been termed vascular mild cognitive impairment, in turn associated with subtle sub-cortical vascular changes. The observation of only minor differences between persons operated by general and regional anesthesia makes it difficult to attribute these changes directly to the anesthetic agents themselves, suggesting that cognitive dysfunction may be attributable at least in part to peri-operative conditions, notably stress and glucocorticoid exposure.

Anatomy and growth of the fetal soft palate: a cadaveric study to improve its ultrasonographic observation.

OBJECTIVE: To determine the anatomy of the soft and hard palate during fetal growth in order to improve its ultrasonographic prenatal visualization. DESIGN: Anatomic study in human formalin-fixed fetus. METHODS: The heads of 18 second and third trimester fetuses were studied in the median sagittal plan. Measurements of the soft palate, the velopharynx, the root of the tongue, and the oral floor were taken. The hard palate/soft palate angle and the anterior cranial base/soft palate angle were measured. RESULTS: The growth of the hard palate was linear, and the growth of the soft palate was polynomial (second order) during the period studied. The hard palate/soft palate angle was 150.33 degrees +/- 7.62 and 150.20 degrees +/- 6.67 in the second and third trimester, respectively. The anterior position of the soft palate in relation to the anterior cranial base was 48.8 degrees +/- 3.13 in the second trimester and 52.26 degrees +/- 3.31 in the third trimester. Its posterior position was 89.66 degrees +/- 5.51 in the second trimester and 92.97 degrees +/- 4.01 in the third trimester. Throughout the fetal period, the soft palate moved downward relative to the clivus and cervical spine. CONCLUSIONS: Despite the nonlinear growth and downward displacement of the soft palate during fetal life, its position remains stable. These results may be useful to explore the fetal soft palate using 2D and 3D ultrasonography and to improve the prenatal diagnosis of isolated cleft palate.

Three-dimensional analysis of the intrinsic anatomy of the metatarsal bones.

Knowledge of the anatomy of the forefoot is important for understanding its mechanical pathology and developing specific surgical procedures. The aim of this study was to quantify 3-dimensional morphological parameters, which were proposed for the characterization of the metatarsal intrinsic anatomy. Thirty-five metatarsal bones prepared from 7 cadaver specimens were analyzed according to a new 3-dimensional computer-aided (CA) methodology. Manual and CA measurement techniques were compared. The reality of an intrinsic axial torsion of the metatarsals was underlined with mean values between 3.2 degrees and 57.7 degrees. Using the CA method, the reliability was excellent (intraclass correlation coefficient, 0.98) and significantly better than the manual method (P < .1E-12). With specific consideration of the second metatarsal intrinsic morphology, we emphasized its mechanical function. These results reflect the possibilities of CA systems. These data, which were carried out on specific anatomical characteristics of the metatarsal bones, can improve the metatarsalgia surgical procedures.

Neural symmetry and functional asymmetry of the mandible.

Even in the absence of malformation or skull base asymmetry, the mandible may be physiologically asymmetric and this remains a major challenge in the orthodontic treatment. The mandible is a bone formed by a primary subunit, i.e., the neural part, with different functional secondary subunits, so we suggest that in a normal mandible the asymmetry was caused by the secondary functional subunit and the neural part is nearly symmetric. Eighty-three dry human mandible samples were studied. The measurements of the size of the mandible (corpus, ramus, mandible notch, condylar process, the angle of the mandible) and the neural subunit (the mandibular canal and the position of the mental and mandibular foramina) were measured bilaterally. The left and right sides were compared according to the dental status: 60 dentate and 23 edentulous mandibles. The calculation of the symmetry was based on the paired Student t test, the absolute difference |R-L| and the relative absolute difference |R-L|/|R+L|x100. The mandibular canal and the position of the foramina were symmetric, except for the position of the mandibular foramen in relation to the mandible notch. The symmetry was not modified by the dental status. The total length of the mandible and the length of the ramus were greater on the left side independently from the dental status. The length of the corpus and the mandible angle were symmetric in each group. The mandible notch was always asymmetric and its height was greater in the dentate group. The condylar process was the most asymmetric structure in each group. The primary subunit of the mandible, surrounding the mandibular canal, is a symmetric component of the mandible and is not modified by the dental status. The angle of the mandible between the corpus and ramus is another symmetric parameter that is important for the facial architecture. The ramus and especially the mandibular notch as well as the condylar process are the most asymmetric subunits influenced by the functional matrices.

Organization and microscopic anatomy of the adult human facial nerve: anatomical and histological basis for surgery.

BACKGROUND: Despite the progress in microsurgical repair of the facial nerve, the results remain unpredictable and the structural anatomy of the facial nerve poorly understood. The aim of this study was to show how the connective tissue and the nerve fibers are distributed in a serial cross-section of the facial nerve from its origin to its termination. METHODS: Sixty facial nerves from 30 embalmed adult human cadavers were dissected for micro-anatomic study. The facial nerves were serially sectioned every 2 mm from the apparent origin and were prepared for light microscopy study. The endoneural fascicular arrangement was observed, the number of myelinated fibers was counted, and connective tissue was explored. RESULTS: There was an absence of real fascicular organization of the facial nerve in the pontocerebellar cistern and in the internal acoustic meatus. The real fascicular organization with perineurium and epineurium appeared from the geniculate ganglion. The number of fascicles increased in a proximo-distal way, and their diameter diminished. In the extratemporal part, some nerves had a low number of fascicles (two to six), and others had a high number of fascicles (seven to 15). The number of fascicles changed along the course of the facial nerve, especially in the extratemporal part. CONCLUSIONS: The truly fascicular structure appeared after the geniculate ganglion, and the rate of connective tissue progressed in a proximo-distal way. The high numbers of fascicles and the great structural variability of each facial nerve segment constitute a difficulty in nerve repair.

O fixador externo em triangulaçäo de Bonnel / Bonnel's external triangular fixator

O autor apresenta o desenvolvimento de um projeto tecnólogico de Instrumentaçäo Cirúrgica em Ortopedia e Traumatologia - O Fixador Externo em Triangulaçäo de François Bonnel. Como método de imobilizaçäo e osteossíntese tem demonstrado sua grande aplicaçäo e vantagens na experiência clínica porque é um sistema rígido, simples, fácil de aplicar, leve, capaz de transmitir forças nos três planos do espaço, maleável, capaz de anular forças vindas do foco de fratura, reduzir, imobilizar, permitir fácil acesso ao local da lesäo sem maiores danos para o paciente. Os maus resultados da fixaçäo externa säo devidos a erros técnicos de sua aplicaçäo, indicaçöes, erros de montagem, insuficiências de sistema, complexidade e custo elevado de muitos modelos, o que tem conduzido à improvisaçöes inadequadas. A fixaçäo externa, cremos é método viável de grande utilidade e todo cirurgiäo ortopedista deve conhecê-la e aprender seus princípios e saber usá-los corretamente. A fixaçäo externa em triangulaçäo aproxima-se bastante do fixador externo ideal, razäo de nosso estudo do desenho do protótipo experimental que agora apresentamos como viável para as condiçöes nacionais, pelo seu baixo custo, leveza, fácil manuseio, eficácia biomecânica e reduzido número de componentes (07 componentes ao todo) possibilitando toda sorte de montagens necessárias para seu uso do Aparelho Locomotor