Anatomical considerations for nerve transfer in axillary nerve injury.

This study investigated the anatomical details of the axillary and radial nerves in 50 upper limbs from 29 adult formalin-embalmed cadavers, and ten fresh upper limbs. The focus was on understanding the course, division, and ramifications of these nerves to improve treatment of shoulder dysfunction caused by axillary nerve damage. The axillary nerve divided anteriorly and posteriorly before passing the quadrangular space in all specimens, with specific distances to the first ramifications. It was found that the deltoid muscle's clavicular and acromial parts were always innervated by the anterior division of the axillary nerve, whereas the spinous part was variably innervated. The longest and thickest branches of the radial nerve to the triceps muscles were identified, with no statistically significant differences in fiber numbers among triceps branches. The study concludes that nerve transfer to the anterior division of the axillary nerve can restore the deltoid muscle in about 86% of shoulders, and the teres minor muscle can be restored by nerve transfer to the posterior division. The medial head branch and long head branch of radial nerve were identified as the best donor options.

Durability of concrete incorporating organic light-emitting diode (OLED) display waste as cement binder replacement.

The use of supplementary cementitious materials is customary in contemporary concretes. Different industrial by-products and waste materials have been investigated earlier for such applications. In this paper, the use of organic light-emitting diode glass (OLED) display waste as a partial replacement of cement binder in concretes has been explored. Concretes with 10%, 20%, and 30% substitution (by weight) of ordinary Portland cement (OPC) by OLED powder were developed, and the resulting mechanical properties and durability characteristics were evaluated. The results showed that OLED addition leads to strength improvement of up to 8% after 28-day age. Also, the resistance to chloride-ion penetration and sulfate attack improved considerably. The chloride binding capacity for the developed concretes was also investigated. It was demonstrated that the OLED powder incorporation is beneficial in improving the corrosion resistance of the modified concrete. The enhanced mechanical and durability properties of modified concrete point toward the excellent performance of OLED-incorporated concrete for improved service life. Incorporating OLED display waste in concrete as a partial cement replacement can also reduce environmental burden and concrete cost.

Evaluation of a Hydrophobic Coating Agent Based on Cellulose Nanofiber and Alkyl Ketone Dimer.

In this study, we report on the development and testing of hydrophobic coatings using cellulose fibers. The developed hydrophobic coating agent secured hydrophobic performance over 120°. In addition, a pencil hardness test, rapid chloride ion penetration test, and carbonation test were conducted, and it was confirmed that concrete durability could be improved. We believe that this study will promote the research and development of hydrophobic coatings in the future.

Numerical Modeling of Chloride Transport in Concrete under Cyclic Exposure to Chloride.

Concrete structures under cyclic exposure to chlorides entail a higher risk of embedded steel corrosion along with accelerated ionic ingress from the environment. This study proposes a coupled transport model considering moisture and chloride distribution in concrete to investigate the influence of a cyclic exposure condition on chloride penetration. In this model, pore size distribution to quantify the effective pore space for moisture and chloride mobilizations was determined to establish the governing equation for chloride transport through non-saturated concrete. From the simulation results, the rate of chloride penetration increases with decreasing ambient humidity levels due to the enhanced chloride convection. Finally, the coupled transport model was verified by comparing in-situ data, showing reasonable correlations with 0.83 and 0.93 of determinant coefficients for 22 and 44 years of exposure, respectively, while those obtained from LIFE 365 were much lower.

Clinical Anatomy of the Puboprostatic Ligament for the Safe Guidance for the Prostate Surgery.

OBJECTIVE: To provide the anatomy of the puboprostatic ligament and related structures to save urogenital competence after prostatectomy. MATERIALS AND METHODS: Pelvic areas of 31 adult cadavers were dissected to figure out the shape, number, and location of the puboprostatic ligaments. RESULTS: The puboprostatic ligament was the most important support structure between the pubic bone and prostate gland. Puboprostatic ligaments were bilaterally single (61.3%), bilaterally double (19.4%), or mixed (19.4%). Ligaments were mostly I-shaped (53.8%). If ligaments had extra attachment to or from the arcuate line, the ligaments were λ-shaped (36.3%), or Y-shaped (8.8%). In one case, the ligament had a central fusion with an irregular shape. I-shaped puboprostatic ligaments were observed more frequently in specimens with double ligaments, while λ-shaped puboprostatic ligaments were observed more frequently in the cases with single ligaments. The average distance between both puboprostatic ligaments was 8.1 mm at the pubic site and 14.2 mm at the prostate site. The distance was narrower when the specimen had double puboprostatic ligaments on both sides. The neurovascular bundle ran beneath the puboprostatic ligament. If the ligament was the λ-shaped type, the neurovascular bundle frequently pierced the lateral band of the ligament. CONCLUSION: Puboprostatic ligaments hold and stabilize the prostate against the pubic bone. It is believed that a pelvis with bilateral, double puboprostatic ligaments would have advantages in urogenital competence. The morphologic data of the shape, multiplicity, and location of the PPLs would help to make a plan to approach the prostate.

The Trapezius Muscle Flap: A Viable Alternative for Posterior Scalp and Neck Reconstruction.

BACKGROUND: The trapezius muscle flap is not usually the first reconstructive option for skin and soft tissue defects in the posterior neck and scalp due to surgeons' unfamiliarity with the surgical anatomy and developments in free tissue transfer techniques. The goals of this study were to describe the clinical use of trapezius flaps in posterior neck and scalp reconstruction, and to investigate the vascular anatomy of trapezius flaps in Asians in order to obtain information facilitating the safe design and elevation of flaps in which most of the muscle is preserved. METHODS: A retrospective chart review was performed of 10 patients who underwent trapezius muscle flap for posterior neck and scalp defects. We also performed an anatomical study of 16 flaps harvested from 8 preserved Asian adult cadavers and evaluated the main landmarks relevant for trapezius muscle flap. RESULTS: In the anatomical study, the mean vertical height from the inferior angle of the scapula to the point at which the superficial cervical artery penetrated the trapezius was 4.31±2.14 cm. The mean vertical height of the trapezius muscle flap pivot point was 9.53±2.08 cm from the external occipital protuberance. Among the 10 flaps, partial necrosis on the overlaid skin graft occurred in 1 patient and postoperative seroma occurred in another patient. CONCLUSIONS: Vascular variations in the trapezius muscle flap are uncommon in Asians, but when present, such variations appear to have little impact on harvesting the flap or on its circulation. The trapezius muscle flap is a viable alternative for posterior neck and scalp reconstruction.

Multiple muscular variations in the neck, upper extremity, and lower extremity biased toward the left side of a single cadaver.

Although numerous reports have found accessory or supernumerary muscles throughout the human body, multiple appearances of these variations biased toward one side of body are rare. We report a 76-yr-old male cadaver with an accessory head of the biceps brachii and palmaris profundus, and a muscular slip between the biceps femoris and semitendinosus on the left side in addition to a bilateral accessory belly of the digastric muscle. No remarkable nervous, vascular, or visceral variation accompanied these variations. An interruption of normal somitogenesis or myogenesis may be a cause of these variations.

Anatomy of facial and trigeminal nerve branches associated with the corrugator supercilii muscle: microdissection and modified Sihler staining.

BACKGROUND: Deactivation of the corrugator supercilii for the treatment of unintentional glabellar lines requires high selectivity to avoid sensory complications. OBJECTIVE: The aim of this study was to delineate the topographic anatomy of facial and trigeminal nerves in relation to the corrugator supercilii to improve the selectivity and safety of deactivation of the corrugator supercilii muscle. MATERIALS AND METHODS: The number, courses, and attachments of the facial nerve to the corrugator supercilii muscle were investigated by dissection of 27 cadaveric hemifaces. Twelve cadaveric hemiforehead flaps were stained using a modified Sihler method to trace the supraorbital and supratrochlear branches. RESULTS: On average, 1.8 branches of the facial nerve at the zygomatic arch were associated with the corrugator supercilii muscle through 1 (29.3%) or 2 terminal rami (70.7%). The trigeminal nerve gave off 7.7 supraorbital and 5.1 supratrochlear branches emerging from orbit. The majority of the supraorbital branches became intramuscular branches (60.4%), whereas the majority of the supratrochlear branches became superficial branches (67.8%). CONCLUSION: Resection of the muscle may damage the intramuscular trigeminal branches, leading to sensory changes. The course of the facial nerve branches to the corrugator supercilii muscle was much more predictable at their distal part than the proximal part.

Topographical anatomy of the radial nerve and its muscular branches related to surface landmarks.

Understanding of the anatomy of the radial nerve and its branches is vital to the treatment of humeral fracture or the restoration of upper extremity function. In this study, we dissected 40 upper extremities from adult cadavers to locate the course of the radial nerve and the origins and insertions of the branches of the radial nerve using surface landmarks. The radial nerve reached and left the radial groove and pierced the lateral intermuscular septum, at the levels of 46.7, 60.5, and 66.8% from the acromion to the transepicondylar line, respectively. Branches to the long head of the triceps brachii originated in the axilla, and branches to the medial and lateral heads originated in the axilla or in the arm. The muscular attachments to the long, medial, and lateral heads were on average 34.0 mm proximal, 16.4 mm distal, and 19.3 mm proximal to the level of inferior end of the deltoid muscle, respectively. The radial nerve innervated 65.0% of the brachialis muscles. Branches to the brachioradialis and those to the extensor carpi radialis longus arose from the radial nerve above the transepicondylar line. Branches to the extensor carpi radialis brevis usually arose from the deep branch of radial nerve (67.5%); however, in some cases, branches to the extensor carpi radialis brevis arose from either the radial nerve (20.0%) or the superficial branch of the radial nerve (12.5%). Using these data, the course of the radial nerve can be estimated by observing the surface of the arm.

Development of a type II diabetic mellitus animal model using Micropig®.

Diabetes, which has shown an explosive increase in terms of its incidence, is regarded as a serious disease that must be overcome for the sake of human life. Among animal models used for testing of drug efficacy, the mini-pig model has shown a rapid upload due to its many similarities with human, particularly concerning the pharmacokinetics of compounds after subcutaneous administration, the structure and function of the gastrointestinal tract, the morphology of the pancreas, and overall metabolic status. Based on these various advantages, we sought to develop an animal model of type II diabetic mellitus using the Micro-pig, which differs from other miniature pigs. We used six male Micro-pigs for induction of a moderate insulin deficient model with nicotinamide (NIA)/streptozotocin (STZ) treatment and three animals for control. For evaluation of incidence of type II diabetes, we measured blood glucose level, and performed oral glucose tolerance test and immunohistochemistry on pancreatic tissue using insulin antibody. Compared to control animals, all animals treated with NIA/STZ showed high levels of glucose and low levels of insulin. In addition, we observed the partially destroyed beta cell population from tissue of the pancreas in treated animals. Based on these results, we report that the Micro-pig model developed in this study can be used for testing of the efficacy of therapeutic agents for treatment of Type 2 diabetic mellitus.

Novel findings of the anatomy and variations of the axillary vein and its tributaries.

The anatomy and variations of the axillary vein has significant implications in various invasive procedures such as venous access, axillary block, arteriovenous fistula creation, axillary node dissection, breast augmentation, and other surgical procedures involving the axilla. To clarify the anatomy of the axillary vein and its tributaries, 40 cadaveric upper extremities were examined after dissection and were classified into several types according to the courses and terminations of brachial veins. The brachial veins ended separately (Type A; 72.5%) or made a common brachial vein (Type B; 27.5%) to enter the basilic vein or the axillary vein. The basilic vein was absent in 5.0% of the specimens. Duplication of the axillary vein was observed in 17.5% of the specimens and the lateral venous channel running along the lateral wall of the axilla was observed in 40.0% of the specimens. The most common drainage vein of the deep brachial vein was the lateral brachial vein (67.5%). The anterior circumflex humeral vein also emptied into the lateral brachial vein in 67.5% of the specimens. The posterior circumflex humeral vein crossed posterior side of the brachial plexus to join either the axillary vein (45.0%) or subscapular vein (42.5%). Perforation of the lateral root of median nerve by a lateral brachial vein, a common brachial vein, or a venous channel was observed in 15.0% of the specimens. Other venous variations accompanying the variations of the axillary artery or the brachial artery are described herein. The clinical importance of these findings is described in the discussion.

Topographical anatomy of the suprascapular nerve and vessels at the suprascapular notch.

Suprascapular nerve entrapment caused by the superior transverse scapular ligament (STSL) causes pain, and limitation of motion in the shoulder. To relieve these symptoms, suprascapular nerve decompression is performed through the resection of STSL. To describe and classify the topographic anatomy of the suprascapular notch, 103 cadaveric shoulders were dissected. The mean length and width of STSLs were 11.2 and 3.4 mm, respectively. The bony bridges replacing STSL in four shoulders were 8.2 mm long and 3.5 mm wide on average. The suprascapular nerve always ran through the notch under the STSL. All shoulders had a single suprascapular artery, while multiple suprascapular veins appeared in 21.3%. The arrangement of the suprascapular vessels was classified into three types: in Type I (59.4%), all suprascapular vessels ran over the STSL; in Type II (29.7%), the vessels ran over and under the STSL simultaneously; in Type III (10.9%), all vessels ran under the STSL. In 48.9% of cadavers, these types were bilaterally matched. The omohyoid muscle originated distantly from the STSL in 38.0%, was adjacent to it in 44.0%, and was partially over the STSL in 18.0%. The number of suprascapular vessels running under the STSL was positively correlated with the size of the STSL and the middle diameter of the suprascapular notch. Age was inversely correlated with the length of STSL. The STSL was wider in males than in females. This study provides details of the structural variations in the region of the suprascapular notch.

Clinical Validity Comparison Study of Patients Severity Triage System in the Emergency Department: Modified Emergency Severity Index (mESI) and modified Canadian Triage Acuity System (mCTAS)

PURPOSE: This study was conducted to identify better methods of determining the severity of triage by comparing triage results and clinical outcome of patients categorized by the modified Canadian Triage Acuity Scale (mCTAS) and modified Emergency Severity Index (mESI). METHODS: Subjects enrolled in this study consisted of 1,000 adult patients (age 16 years or older) who visited the emergency room of a university affiliated hospital between September 15, 2011 and September 30, 2011 and were categorized into five levels by mCTAS and mESI. RESULTS: 1) Good confidence was verified based on weighted kappa values of 0.70 between the physicians group and nurses group. 2) Upon evaluation of triage by mESI, the majority of patients were at level 3 among 5, followed by level 4, 2, 1 and 5 in order. The same level orders were shown upon evaluation of triage by mCTAS beside differences in patient numbers. 3) Comparing clinical outcome according to the mCTAS and the mESI revealed similar results in both triage tools, with a higher triage level being associated with a higher admission rate and lower triage level and the discharge rate became higher. CONCLUSION: Triage by mESI showed good agreement among asserters and high agreement between physicians and nurses. Clinical results based on mCTAS and mESI triage showed similar rates of admission to the ward or intensive care unit and rates of discharge. Although these two triage protocols are similar in many aspects, the use of mESI is perceived as a better because mCTAS requires knowledge of various diseases and mESI has a short training period.

Topographical anatomy of the transverse facial artery.

The transverse facial artery (TFA) is found in the lateral face and supplies the parotid gland and duct, facial nerve, facial muscles, and skin. To better understand the cutaneous vascularization of the lateral face and to better characterize the topography and other anatomical features of the TFA, microsurgical dissection was performed in 44 cadavers. The number of TFAs present ranged from one to three, and a single TFA was most common (70.5%). The TFA originated from the superficial temporal artery at or above the level of crossing by the temporofacial trunk of the facial nerve in the parotid gland (57.6%). The TFA divided into superior and inferior trunks in the gland, and continued as emerging branch. The superior emerging branch emerged from the gland superior to the parotid duct and divided into many branches. It supplied the malar area, crossed the parotid duct, terminated as perforator, vasa nervorum, or artery to the parotid duct or muscle. The inferior trunk in 72.5% continued as emerging branch instead of terminating in the gland. TFAs were classified into four types; the most common type was Type A in which the superior and inferior emerging branches and the duct-crossing branch were present. The mean number of perforators to the superficial cutaneous layer was 1.9. Most perforators extended from the superior emerging branches (77.9%). The most common perforating site was below the duct on the anterior third of the masseter muscle. In two cases, the TFA formed an anastomosis with the facial artery.

Intersegmental origin of the axillary artery and accompanying variation in the brachial plexus.

The wide anatomical variation of the brachial plexus and the axillary artery has been thoroughly explored in previous studies. However, there has been little information reported on the variation in the relationship between the brachial plexus and the axillary artery. The principal feature of this relationship is the passage of the axillary artery through the loop of the median nerve, which occurs in normal arteries derived from the seventh intersegmental artery. In this study, we analyzed the abnormal position and course of the axillary artery related to the brachial plexus in 607 axillae of 306 cadavers. We found 12 unusual axillary arteries that did not pass through the median loop. Eleven arteries were determined to be ninth intersegmental arteries and one as the sixth intersegmental artery. All ninth intersegmental arteries ran caudally to the brachial plexus. In six cases of this type, abnormal connections interfering with the normal arterial position were observed in the brachial plexus. In another five cases of this type, the lateral and medial cords merged and the axillary artery passed anteromedial to the plexus. The sixth intersegmental axillary artery pierced the musculocutaneous nerve which is from the unified lateral and medial cords. This study discussed the how the anomalous structure of the brachial plexus could involve the deterioration of the course of the axillary artery.

Variations of the superficial brachial artery in Korean cadavers.

The superficial brachial artery (SBA), a branch of the axillary artery, is one of the most common arterial variations in this area. While it is more vulnerable to accidental arterial injection or injury, it could be useful for the nourishment of a medial arm skin free flap. To analyze the relationship between the SBA of axillary origin and segmental variation of the axillary artery, we dissected 304 arms of Korean cadavers. We found an SBA of axillary origin in 12.2% of cadaveric arms. Unilateral occurrence was detected in 16 cadavers and bilateral in 10. SBAs gave rise to radial and ulnar arteries in the cubital fossa (8.9%), continued in the forearm as the radial artery (2.3%), or ended in the upper arm (1.0%). The SBA ended as ulnar artery was not found in any of the cadavers. The bifurcation of the SBA into the radial and ulnar arteries, presence of an SBA that ends in the upper arm, and the lack of continuation as the ulnar artery are characteristics of SBAs in Korean cadavers.

Anatomy of thoracic splanchnic nerves for surgical resection.

Thoracic splanchnic nerves conduct pain sensation from the abdominal organs around the celiac ganglion. Splanchnicectomy is the procedure used mainly for the control of intractable visceral pain. Forty-six human posterior thoracic walls were dissected. The formation pattern, course, and incidence of communication of the thoracic splanchnic nerves were investigated. The greater splanchnic nerves (GSNs) were formed by nerve branches from the T4-T11 thoracic sympathetic ganglia and the most common type was formed by T5-T9 (21.7%). The uppermost branches originated from T4-T9 while the lowermost branches emanated from the T7-T11. Two to seven ganglia contributed to the GSNs. In 54.3% of the specimens, at least one ganglion in the GSN-tributary ganglionic array did not branch to the GSN. The lesser splanchnic nerves (LSNs) were formed by the nerve branches of the T8-T12 thoracic sympathetic ganglia and the most common type was formed by T10 and T11 (32.6%). One to five ganglia were involved in the LSNs. The least splanchnic nerves (lSNs) were composed of branches from the T10-L1 thoracic sympathetic ganglia and the most common type was composed of nerve branches from T11 and T12 or from T12 only (each 30.4%). One to three ganglia were involved in the lSNs. In 54.3% of the specimens, interconnection between the GSNs and the LSNs existed, bringing the possible bypass around the transection of the GSNs. The splanchnic nerves that appear in textbooks occurred in a minority of our specimens. We provided expanded anatomical data for splanchnicectomy in this report.

Bilateral thoracoscopic splanchnicectomy with sympathectomy for managing abdominal pain in cancer patients.

BACKGROUND: Simple interruption of splanchnic nerve can lead to incomplete transection of nerve fibers responsible for cancer-derived abdominal visceral because lots of neural communications exist. METHODS: From December 1999 to June 2005, a total of 21 cancer patients underwent bilateral thoracoscopic segmental resection of splanchnic nerve with sympathectomy for intractable abdominal pain based on the anatomic observation of 26 embalmed Korean cadaveric specimens in Yonsei University Medical Center, Seoul, Korea. All patients were preoperatively asked to rate the extent of their current pain by using the numeric rating scale (NRS), where 0 indicated no pain and 10 indicated intractable pain. The effectiveness of this thoracoscopic procedure was assessed based on the NRS reevaluated after surgery. RESULTS: NRS score was significantly reduced after thoracoscopic surgery (1.71 +/- 1.10 versus 8.52 +/- 1.08, paired t test, P < .0001). Sixteen patients (76.2%) could tolerate pain without or with reduced dose of analgesics. No mortality and morbidity were found in this study. CONCLUSION: This bilateral thoracoscopic splanchnicectomy with sympathectomy is safe, easy, and effective method in managing cancer-derived visceral abdominal pain.

Surgical anatomy of the middle turbinate.

Clinicians have encountered many variations of the middle turbinate. Previous descriptions of the middle turbinate were only focused on its size and shape and lacked surgical implications associated with endoscopic sinus surgery. Therefore, the aim of this study was to examine the surgical anatomy of the middle turbinate in hemisected cadaveric heads. The middle turbinates from 101 hemisections of adult Korean cadaveric heads were measured using digital calipers and a protractor. The middle turbinates were then classified according to their shape. The mean distance between the anterior attachment of the middle turbinate and the anterior attachment of the superior turbinate was 18.5 mm. The posterior end of the middle turbinate extended more posteriorly than that of the inferior turbinate in 40% of the cases, while in 26.3% of the cases, the posterior end of the inferior turbinate extended more posteriorly than that of the middle turbinate. The middle turbinate was classified into three types according to the shape of its anterior border. In type 1, the anterior border of the middle turbinate ran directly posteroinferiorly from its attachment to the conchal plate, and was observed in 45.3% of the cases. In type 2, the anterior border of the middle turbinate initially coursed inferiorly from the conchal plate and then turned in a posteroinferior direction. This type was observed in 44.2% of the cases. Type 3 involved 10.5% of the cases where the anterior border bulged anteriorly before it coursed posteroinferiorly. The information provided in this report should assist surgeons when performing partial middle turbinectomies.