Study of frontal and ethmoid sinus of sinonasal complex along with olfactory fossa: anatomical considerations for endoscopic sinus surgery.

The Functional endoscopic sinus surgery through transnasal approach is a common modality of treatment for disorders of the nasal cavity, paranasal air sinuses as well as cranial cavity. The olfactory fossa (OF) is located along the superior aspect of cribriform plate which varies in shape and depth. This variable measurement of the depth of OF is mostly responsible for greater risk of intracranial infiltration during endoscopic procedures in and around the nasal cavity. The morphology of frontal and ethmoid sinus (ES) vary from simple to complex. This cadaveric study is planned to improve the ability of the otolaryngologist, radiologist to understand the possible morphological variations and plan steps of less invasive "precision surgery" to have a safe and complication free procedures. A total of 37 human head regions were included in the study. For classification of OF, Modified Kero's classification was used. The size, shape and cells of frontal and ES were noted. We found, type II (60.8%) OF was more common followed by type I (29.7%) than type III (9.5%). The shape of frontal sinus was comma shaped (55.4%) followed by oval (18.9%) than irregular (16.2%). Most common two cells type of ES was seen in 50.0% of both anterior and posterior ES. Out of 74 ES, 8.1% of Onodi cells and 14.9% of agger nasi cells were seen.

Neurovascular Structures at Risk During Surgical Access to Trigeminal Ganglion and Meckel's Cave - An Anatomical Study.

Background: It is difficult to approach the Trigeminal Ganglion (TG) and Meckel's cave (MC) during surgeries. Therefore, the exact knowledge of the relationship of surgical landmarks to related anatomical structures is vital to reduce the associated postoperative morbidity. The aim of the present study was to enhance the knowledge of the surgical anatomy of structures that are present in the conduit of all surgical approaches to TG and MC, their distances from surrounding neurovascular structures, and their variations. Material and Methods: The study was carried out on 40 embalmed cadavers (Eight Female) of the anatomy department of a teaching hospital in Central India. Meticulous dissection of cranial fossae was done to locate TG, MC, and related anatomical structures. All distances from TG and MC were measured using an electronic digital calliper. Results: Length, width, and thickness of TG were 15.39 mm, 4.39 mm, and 2.54 mm, respectively. The distance from zygomatic arch, the lateral end of the petrous ridge, arcuate eminence, foramen ovale, and foramen spinosum to MC was 26.10 mm and 37.94 mm, 16.46 mm, 4.54 mm, and 11.23 mm, respectively. The sixth, fourth, and third cranial nerves were 6.26 mm, 4.94 mm, and 2.53 mm from MC, respectively. The MC was 42.72 mm and 33.87 mm anteromedial from posterior and anterior limits of the sigmoid sinus. Conclusion: Findings of the present study will aid surgical planning and decide the approach to TG and MC and avoid surgical complications.

A Cadaveric Study to Define the Variant Patterns of Median Nerve Formation.

The median nerve is one of the important nerves of the upper limb which supplies the muscles of the front of the forearm, muscles of the hand, and skin of the hand. Many works of literature mentioned its formation by the fusion of two roots, the medial root from the medial cord and the lateral root from the lateral cord. But multiple variations in the median nerve formation have clinical importance from surgical and anesthetic points of view. For the study purpose, we dissected 68 axillae of 34 formalin-fixed cadavers. Out of 68 axillae, two (2.9%) showed median nerve formation by a single root, 19 (27.9%) showed median nerve formation by three roots, and three (4.4%) showed median nerve formation by four roots. A normal pattern of median nerve formation by fusion of two roots was seen in 44 (64.7%) axilla. The knowledge of variant patterns of median nerve formation will be helpful to surgeons and anesthetists while performing surgical or anesthetic procedures in the axilla to avoid any injury to the median nerve.

A Cadaveric Study to Define Morphology and Morphometry of Human Knee Menisci in the Region of Central India.

Introduction The medial and lateral menisci of the knee joint are the functional unit that helps to increase the depth of articular surfaces on the head of a tibia for the reception of femoral condyles. Menisci are important for the distribution of load and thus help to reduce stress on the knee joint. The anatomical knowledge of morphology and morphometry of menisci is vital while performing surgeries in cases of meniscal injury. The study aimed to define the variational anatomy of the menisci of the knee joint. Material and Methods Ninety-six cadaveric knees of 48 cadavers were included in the study. Different shapes of both; lateral and medial menisci were recorded. The peripheral lengths and inner lengths of the menisci were measured with the nonelastic cotton thread. Menisci were divided into three parts; anterior, middle, and posterior. The maximum width and thickness of each part of the menisci were measured and documented. Distance between the medial and lateral meniscus in each knee was measured at the anterior and posterior ends. The most anterior and the most posterior part of each meniscus was determined and the distance between these parts of each meniscus was measured and recorded as the distance between two horns. Results Four morphological types of menisci were found; in medial menisci, the most common was crescent­shaped (53%), and in lateral menisci, the most common shape was c­shape (62.5%). The average peripheral length of the medial menisci was 92.0 mm and the lateral menisci was 96.08 mm while the average inner length of the medial and lateral meniscus was 56.19 mm and 58.92 mm respectively. The anterior third of the medial as well as lateral meniscus was thinnest while the posterior third was thickest. The width of the medial menisci was less at the anterior end and was more at the posterior ends while the width of the lateral meniscus was almost the same at the anterior, middle, and posterior ends. Conclusion The findings of the present study will be helpful for surgeons while planning and performing surgical procedures and for anatomists during routine teaching.

Mutations of PHOX2B Gene in Patients of Obesity Hypoventilation Syndrome in Central India.

Background Paired-like homeobox 2B (PHOX2B) gene on chromosome 4p12 codes for a transcription factor having a role in the formation of noradrenergic neuronal circuits. Its mutations have been linked to congenital central hypoventilation syndrome (CCHS). The clinical presentation of both, obesity hypoventilation syndrome (OHS) and CCHS in adults (named late-onset central hypoventilation syndrome), is quite similar. Because of this symptomatic similarity, multifactorial causation of OHS, the mutation of PHOX2B gene was studied in patients with OHS in this study. Methods A hospital-based cross-sectional study was performed on patients diagnosed with OHS. The deoxyribonucleic acid was extracted from 2 mL of venous blood and was further amplified, specific to exon 3. The amplified products were cast and run in 2% agarose gel and then subjected to Sanger sequencing. Results Thirty patients of OHS (21 male; 9 female) were enrolled in the present study, average age being 51.7 years. The Sanger sequencing of the samples revealed no apparent areas of deletions and no apparent mutations. Conclusion Primers for exon 3 were used for amplification in thermocycler, as exon 3 is the most frequently mutated exon for PHOX2B gene, as per existing literature. The entire gene needs to be studied for mutations and the sample size needs to be increased.

Morphologic Features of the Distal Femur and Proximal Tibia: A Cross-Sectional Study.

Background The asymmetric medial and lateral condyles of the distal femur and proximal tibia have a direct influence on the biomechanics of knee joint and prostheses design. This study aimed to determine the morphologic data, that is., anteroposterior (AP) and mediolateral (ML) widths, and the radius of curvature (ROC) of the geometric arcs of the distal femur and proximal tibia. Methods One hundred and seventeen adult dry bones (57 femurs and 60 tibias) were studied. Aspect ratios (AP/ML) were calculated. The AP and ML widths were measured using digital Vernier Caliper with a measuring range of 0-150 mm, resolution of 0.01 mm, and accuracy ± 0.02 mm. The geometric arcs of femoral and tibial condyles were divided into three parts namely anterior 1/3rd, distal (femur) or middle (tibia) 1/3rd and posterior 1/3rd and were estimated in the sagittal plane for the femur and transverse plane for tibia using the ROC gauges. Results For the femur, the mean AP length for medial and lateral condyles was 55.62 mm and 57.93 mm, respectively, while the mean ML width was 73.45 mm. For the tibia, the mean AP length for medial condyle (MC) and lateral condyle (LC) was 47.74 mm and 43.46 mm, respectively. The mean aspect ratios for the distal femur and proximal tibia were 1.26 and 1.45, respectively. The mean aspect ratios for MC and LC of the femur were 0.50 and 0.52, respectively, whereas, for tibia, they were 0.61 and 0.71, respectively. The mean ROC for femoral MC - 20.77 mm, 31.42 mm, and 19.68 mm and for LC - 21.48 mm, 64.40 mm and 19.06 mm for the anterior, distal and posterior arcs, respectively. The mean ROC for tibial MC - 22.42 mm, 22.49 mm and 19.94 mm, and LC - 19.92 mm, 21.79 mm and 20.95 mm for the anterior, middle and posterior arcs, respectively. Conclusions The morphologic data accumulated in this study for both the distal femur as well as the proximal tibia would provide guidelines and help the manufacturers of joint prostheses to address the potential for compromised implant fit and re-design and make available 'anatomic' knee prostheses appropriate for the local population which would not only improve function but also prolong the longevity of the prostheses.

Correlation Between the Thickness of Anterolateral Ligament and Lateral Collateral Ligament of the Knee.

Background Persistent anterolateral rotatory instability (ALRI) following the anterior cruciate ligament (ACL) reconstruction has led to a renewed interest in defining the role of anterolateral complex (ALC) of the knee. Methods We explored the anterolateral corner of 34 cadaveric knees to define the anterolateral ligament (ALL) in all its dimensions and measured the thickness of lateral collateral ligament (LCL) at the lateral meniscus level (tLCL) in ALL-intact and ALL-deficient knees. Results ALL was present in 27/34 (79%) of the knees. We found complete ALL in 13 cadavers bilaterally. ALL was absent bilaterally in three cadavers; it was present on one side and absent contralaterally in one cadaver. In ALL-intact knees, the average tLCL was 2.05 mm, whereas, in ALL-deficient knees, it was 2.57 mm. This difference in tLCL was statistically significant. Conclusions Our study adds new data to the recent voluminous research on ALL. We have examined the correlation between the thickness of ALL and LCL and documented alterations in the thickness of LCL in ALL-intact knees. These findings would help in designing reconstructive procedures for the combined ACL injury with ALRI.

Surgical Implications of Innervation Pattern of the Triceps Muscle: A Cadaveric Study.

The innervation pattern of triceps is complex and not fully comprehended. Anomalous innervations of triceps have been described by various authors. We have attempted to delineate the nerve supply of the triceps and documented the anomalous innervations of its different heads. The brachial plexus and its major branches (in the region of the axilla and arm) and triceps were dissected in 36 embalmed cadaver upper limbs. Long head received one branch from radial nerve in 31 (86%) specimens. Four (11%) specimens received two branches including one that had dual innervation from the radial and axillary nerves, and one (3%) specimen had exclusive innervation from a branch of the axillary nerve. Medial head received two branches arising from the radial nerve in 34 (94%) specimens. One (3%) specimen received three branches from the radial nerve whereas one (3%) had dual supply from the radial and ulnar nerves. Lateral head received multiple branches exclusively from the radial nerve, ranging from 2 to 5, in all (100%) specimens. Knowledge of the variations in innervation of the triceps would not only help the surgeon to avoid inadvertent injury to any of the nerve branches but also offers new options for nerve and free functional muscle transfers.

Study of fingerprint patterns to evaluate the role of dermatoglyphics in early detection of bronchial asthma.

BACKGROUND: Dermatoglyphics and bronchial asthma (BA) are both influenced by genetic factors. Hence, we assessed the diagnostic potential of correlation between fingerprint pattern and BA. MATERIALS AND METHODS: The study was carried out in out-patient Department of Pulmonary Medicine of All India Institute of Medical Sciences Bhopal. It included 36 patients of BA and 50 nonasthmatic individuals as controls. The following parameters were studied and analyzed: (a) Whorls, (b) arches, (c) radial loops, (d) ulnar loops, (e) the absolute finger ridge count (AFRC), (f) total finger ridge count (TFRC). RESULTS: A significant decrease in the mean value of the arches and increase in the mean value of the ulnar loops were observed in BA patients compared to the control group. The mean values of TFRC, AFRC, and whorls were similar in both groups. CONCLUSION: Evaluation of dermatoglyphic patterns may be useful in identifying patients prone to developing BA.

Risk of nerve injury during arthroscopy portal placement in the elbow joint: A cadaveric study.

BACKGROUND: Elbow arthroscopy has become a routine procedure now. However, placing portals is fraught with dangers of injuring the neurovascular structures around elbow. There are not enough data documenting the same amongst the Indians. We aimed to determine the relative distances of nerves around the elbow to the arthroscopy portals and risk of injury in different positions of the elbow. MATERIALS AND METHODS: Six standard elbow arthroscopy portals were established in 12 cadaveric upper limbs after joint distension. Then using standard dissection techniques all the nerves around the elbow were exposed, and their distances from relevant portals were measured using digital vernier caliper in 90° elbow flexion and 0° extension. Descriptive statistical analysis was used for describing distance of the nerves from relevant portal. Wilcoxon-signed rank test and Friedman's test were used for comparison. RESULTS: There was no major nerve injury at all the portals studied in both positions of the elbow. The total incidence of cutaneous nerve injury was 8.3% (12/144); medial cutaneous nerve of forearm 10/48 and posterior cutaneous nerve of forearm 2/24. No significant changes were observed in the distance of a nerve to an individual portal at 90° flexion or 0° extension position of the elbow. CONCLUSION: This study demonstrates the risk of injury to different nerves at the standard portals of elbow arthroscopy. In practice, the actual incidence of nerve injury may still be lower. We conclude that elbow arthroscopy is a safe procedure when all precautions as described are duly followed.

An Anatomical Study to Demonstrate the Proximity of Kirschner Wires to Structures at Risk in Percutaneous Pinning of Distal Radius Fractures.

Distal radius fractures are often treated using percutaneous Kirschner wires (K-wires). The sensory nerves in this area, extensor tendons, radial artery and cephalic vein are at risk of injury in this procedure. We undertook a cadaveric investigation to identify probability of damage to these 'at risk' structures by measuring their distances in relation to standard K-wire sites. Nine upper limbs from six formalin-preserved cadavers were studied. Four K-wires were placed percutaneously simulating fixation of a distal radius fracture. Careful dissection was done preserving the original position of neurovascular and tendinous structures. Distances to relevant soft-tissue structures from each K-wire were measured using an electronic digital caliper. Distance of superficial nerves from radial styloid and Lister's tubercle was measured to determine their 'safe distance' from these fixed landmarks. None of the superficial nerves were injured by a K-wire. Cephalic vein had been pierced on 4 occasions (4/18) and extensor tendons on 3 occasions (3/18). Wilcoxon signed-rank test was used to compare distance of the superficial nerves from radial styloid and Lister tubercle, and the latter was found to be the safer option. This study highlights the inherent danger in percutaneous K-wire fixation of wrist fractures. Limited size of the area, where K-wires can be positioned, and anatomic variations of neurovascular structures pose obstacles in developing guidelines for reducing risk of injury. We advocate use of mini-open approach and guiding devices to avert complications of inadvertent impalement and damage to these structures.