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Posteromedial knee pain is a common clinical problem. It is often accompanied by degenerative changes or tears in the posterior horn of the medial meniscus and/or pain during deep flexion of the knee. In more advanced cases, it is accompanied by the osteophytic formation of a cam lesion that develops gradually in the posterior of the medial condyle of the femur and, with it (or less frequently without it), an osteophytic lesion at the posterior of the tibia (i.e. pincer lesion) occurs. It is believed that resection of the cam lesion may delay the progression of knee osteoarthritis, similarly to repairing the posterior horn of the medial meniscus. In this technical note, we describe a 2-portal technique for resection of cam lesions by posteromedial knee arthroscopy using anatomic landmarks. Using both portals provides better visualization and a better approach.

There are few studies searching for possible perforator flap donor sites on the arm. This study aimed to identify the locations of cutaneous perforators of the arm according to anatomical landmarks.Thirteen Thiel-fixed and latex-filled upper extremities of bodies donated to science were used. The distance between the acromion and medial or lateral epicondyle of the humerus was defined as the Y-axis, and the axis that cut the Y-axis perpendicularly through the epicondyles of the humerus was identified as the X-axis. The Y-axis was then divided into three parts Cutaneous arterial perforators were found using surgical dissection. The locations of the perforators were determined according to the defined lines and regions.On the lateral side, there were 6.00 ± 2.08 perforators per arm, of which 56.4% were septocutaneous and 43.6% muscular. In all extremities, with in the distal 1/3 of the lateral arm, there were 1-4 radial collateral artery-based perforators. The mean distance of these perforators to the Y-axis was 1.16 ± 0.53 cm. On the medial side, there were 5.05 ± 1.44 perforators per arm, which were all septocutaneous perforators. In 85% of the extremities, within the middle 1/3 of the medial arms, there were 1-2 superior ulnar collateral artery-based perforators. The mean distance of these perforators to the Y-axis was 1.53 ± 0.61 cm.There are always perforators from the radial collateral artery with in the distal third of the lateral arm. Within the middle third of the medial arm, it is usually possible to find a perforator from the superior ulnar collateral artery.

Human cadaveric donors are essential for research in the anatomical sciences. However, many research papers in the anatomical sciences often omit a statement regarding the ethical use of the donor cadavers or, as no current standardized versions exist, use language that is extremely varied. To rectify this issue, 22 editors-in-chief of anatomical journals, representing 17 different countries, developed standardized and simplified language that can be used by authors of studies that use human cadaveric tissues. The goal of these editor recommendations is to standardize the writing approach by which the ethical use of cadaveric donors is acknowledged in anatomical studies that use donor human cadavers. Such sections in anatomical papers will help elevate our discipline and promote standardized language use in others non anatomy journals and also other media outlets that use cadaveric tissues.

Research within the anatomical sciences often relies on human cadaveric tissues. Without the good will of these donors who allow us to use their bodies to push forward our anatomical knowledge, most human anatomical research would come to a standstill. However, many research papers omit an acknowledgement to the donor cadavers or, as no current standardized versions exist, use language that is extremely varied. To remedy this problem, 20 editors-in-chiefs from 17 anatomical journals joined together to put together official recommendations that can be used by authors when acknowledging the donor cadavers used in their studies. The goal of these recommendations is to standardize the writing approach by which donors are acknowledged in anatomical studies that use human cadaveric tissues. Such sections in anatomical papers will not only rightfully thank those who made the donation but might also encourage, motivate, and inspire future individuals to make such gifts for the betterment of the anatomical sciences and patient care.

This chapter outlines the microanatomy of nervous structures that form the sacral plexus, including nerve roots found at vertebral levels extending from L4, L5, S1, S2, S3, and S4.

The first issue of this year is dedicated to the memory of Professor Dr. Med. Dr. H.C. Andreas H. Weiglein, former Head of the Institute of Clinical Gross Anatomy at the Medical University Graz, Austria; one of the greatest clinical anatomist many of you are familiar with. It was not only my personal, but all Turkish Anatomists’ sadness to learn the decease of Andreas Weiglein on February 7, 2020 at such a young and productive age. His contributions to Clinical Anatomy and personal supports to development of academic career of many Turkish anatomists, including myself will never be forgotten. He was a good and a sincere friend, a very knowledgeable person and an irreplaceable figure in Anatomy world-wide. He was also one of the honorary members of the Turkish Society of Anatomy and Clinical Anatomy.

The present study was performed to describe the morphologic characteristics of the peroneus tertius (PT) tendon, evaluate the variations in its insertion point, investigate the interconnections with the tendons of the extensor digitorum longus, and discuss whether these insertion differences of the muscle tension might have an effect on fracture formation. The length and width of the PT tendon and the width at its midpoint were measured in 44 lower extremities. The data obtained were compared statistically. The PT was found to occur in 2 types according to the number of tendons: type 1, a single tendon without a slip; and type 2, 2 tendons with a slip. It has been suggested that the PT tendon could contribute to avulsion fractures of the tuberosity of the fifth metatarsal bone. Therefore, to understand the mechanism of Jones fracture, knowledge of the PT tendon would be beneficial to determine the insertion points.

The location of the infraorbital foramen and its variations are important during periorbital, dental, plastic, and oromaxillofacial surgeries. The aim of this study is to document the most practical anatomical soft tissue landmarks for defining the location of infraorbital foramen and infraorbital nerve for effective nerve blockade and to decrease its risk of injury during periorbital surgeries. Forty sides from 20 adult fixed cadavers were used for this study. The position of the infraorbital nerve was determined in reference to the lateral edge of the ala of the nose, medial and lateral palpebral commissures. All these three soft tissue landmarks were then connected to each other forming a triangular shaped region. In 75 % of the cases the infraorbital foramen was located on the line which is connecting the lateral palpebral commissure to the ala of the nose. The closest distance of infraorbital foramen to the inferior orbital margin and to facial midline was also measured. The infraorbital foramen was located outside the previously defined triangular region in 20 % and inside the triangle in 5 %. The closest mean distance between the infraorbital foramen and the infraorbital margin was measured as 8.8 ± 1.0 mm and the distance between the medial wall of the infraorbital foramen and the facial midline was measured as 30.3 ± 2.7 mm. The triangular region and the soft tissue landmarks we offered in this study may facilitate prediction of the locations of the infraorbital foramen thus, the infraorbital nerve.

Few anatomical textbooks offer much information concerning the anatomy and distribution of the phrenic nerve inferior to the diaphragm. The aim of this study was to identify the subdiaphragmatic distribution of the phrenic nerve, the presence of phrenic ganglia, and possible connections to the celiac plexus. One hundred and thirty formalin-fixed adult cadavers were studied. The right phrenic nerve was found inferior to the diaphragm in 98% with 49.1% displaying a right phrenic ganglion. In 22.8% there was an additional smaller ganglion (right accessory phrenic ganglion). The remaining 50.9% had no grossly identifiable right phrenic ganglion. Most (65.5% of specimens) exhibited plexiform communications with the celiac ganglion, aorticorenal ganglion, and suprarenal gland. The left phrenic nerve inferior to the diaphragm was observed in 60% of specimens with 19% containing a left phrenic ganglion. No accessory left phrenic ganglia were observed. The left phrenic ganglion exhibited plexiform communications to several ganglia in 71.4% of specimens. Histologically, the right phrenic and left phrenic ganglia contained large soma concentrated in their peripheries. Both phrenic nerves and ganglia were closely related to the diaphragmatic crura. Surgically, sutures to approximate the crura for repair of hiatal hernias must be placed above the ganglia in order to avoid iatrogenic injuries to the autonomic supply to the diaphragm and abdomen. These findings could also provide a better understanding of the anatomy and distribution of the fibers of that autonomic supply.

Summary Introduction Botulinum toxin injections are previously reported to be a noninvasive alternative method for treating masseteric hypertrophy. However, there is a debate on finding an ideal place for injection. The aim of this study is to document the anatomical landmarks for defining the motor nerve entry points (MNEPs) of the masseteric nerve in the masseter for effective botulinum toxin injections. Materials and methods Twelve sides from six adult fixed cadavers were used for this study. The MNEPs of the masseteric nerve were defined according to standard landmark lines including the orbitomeatal line (OML) and the line (VL), which intersects the mid-distance of the OML to the tip of the angle of the mandible. Results All MNEPs were located 4.4 cm inferior to the OML. In addition, the average anterior distance of the MNEPs to the VL was 1.4 cm and the average posterior distance was 0.6 cm. Conclusion The ideal site of Botox injection into the masseter is a rectangular area: 5 cm inferior to the OML, 1 cm anterior and posterior to the VL, and just above the periosteum. Based on the data of our study, injections to the parotid gland and branches of the facial nerve such as the marginal mandibular and buccal can be avoided. The masseteric nerve can easily be found approximately 1.0–1.5 cm inferior to the zygomatic arch, 1 cm medial to the temporomandibular joint capsule, and 1 cm superior to mandibular notch, which makes its use for facial reanimations more efficient.

An accessory muscle adjacent to the extensor digitorum brevis muscle was encountered between the extensor digitorum brevis muscle and the tendon of the peroneus brevis on the right foot of a 75-year-old male cadaver. This accessory muscle and its tendon is of clinical significance for clinicians performing tendon transfers and other surgical procedures in the region, or when they use EDB as pedicles or free flaps at the ankle area or in other body parts. Keywords: accessory muscle; extensor digitorum brevis; variation

The surgical procedures directed to the orbit are invariably reported to be one of the most challenging procedures of the neurosurgery and it is very important to take measures to protect the ocular nerves. Many researchers have tried to identify safe approaches or safe regions in the orbit but the suggestions and results vary among published studies. The ocular motor nerves are under risk of injury during various approaches to the orbit. Simple but careful attention to potential variations in the origin and anatomical course of the ocular nerves and their relationships to the orbit may help to define "safe zones" during various approaches, thus, help to enhance clinical outcomes. The objective of this review, therefore, is to discuss the surgical anatomy of the orbit with special emphasis on oculomotor, trochlear, and abducens nerves and further emphasize their relationships with a surgical point of view during various approaches directed to the orbit. Anat Rec, 302:568-574, 2019. © 2018 Wiley Periodicals, Inc.

The shoulder joint, commonly known as the glenohumeral joint, is very important as it is the joint with the body highest mobile capability. The ability of movement restriction of the passive structures of the joint (joint surfaces and ligaments) is very low. The articular surfaces of the bones which take part in the joint allow a wide range of movement; on one side is the shallow glenoid cavity and on the other side, the wide humeral head. The thin and loose joint capsule, again allows a wide range of movement.

The fibula is known not to involve in transmission of weight but known simply as an ankle stabilizer. However, its main function in stabilizing the ankle remains obscure. Since the fibula has an impact on torsion and rotation of the ankle, its effect on lateral ankle instability should be investigated.Twenty patients with lateral ankle instability (Group 1) and 19 healthy volunteers (Group 2) were included in the study. The tibiofibular and talofibular relationships were evaluated using MRI images. Fibular torsion and rotation angles were calculated using a new method. Range of motion of the ankle joint was investigated while the knee was at flexion (90°) and extension (0°). The comparisons performed between the 2 groups and independent from the groups were statistically evaluated and, the p value of0.05 was considered as statistically significant.A significant difference was found between the two groups for age (p0.05). There were no statistically significant differences between the right and left sides for all measurements in the group 1 and 2 (p0.05). There was a statistically significant difference between the two groups in dorsal flexion when the knee is at flexion (90°) and extension (0°) position. There was also a statistically significant difference between the two groups in plantar flexion which was measured while the knee was at extension (0°) position. No statistically significant difference was found between both groups in terms of fibular torsion and rotation. However, independent from the groups when the patients were divided into 2 groups according to whether the fibula localized posteriorly or not, in patients with posteriorly localized fibula it was demonstrated that the fibular torsion and rotation was increased significantly.We did not detect any relationship between fibular torsion and rotation and ankle instability. However, independent from the groups when the patients were divided into 2 groups according to whether the fibula localized posteriorly or not, we realized that in patients with posteriorly localized fibula, fibular torsion and rotation significantly increased. This finding did not explain the cause of instability. However, it may gain significance with new further studies regarding ankle instability.

The fibular collateral ligament (FCL) is one of the larger ligaments of the knee. The FCL, along with the popliteus tendon, arcuate popliteal ligament, and joint capsule, make up the posterolateral corner of the knee. Recently, there has there been an increased awareness and research on the structures of the posterolateral corner of the knee, particularly the FCL. Studying the detailed structure of the FCL may provide a better understanding that can lead to better diagnosis and treatments following injury. Therefore, this article reviews the FCL, which appears to be the primary restraint to varus rotation but is poorly oriented to resist external rotation of the knee.

Object The object of this investigation was to conduct a morphometric study in cadavers to determine anatomical structures, their relationships, and their morphometry for subaxial cervical spondylectomy. Methods Forty sides of 20 cadavers were used for this study. Dissections were performed in 2 stages (anteriorly and posteriorly). Twenty-one morphometric measurements were performed for both sides of the C3–6 vertebrae. Data were analyzed statistically. Results Morphometry of the laminas, tuberculum posterius, pedicle, corpus, foramen transversarium, and processus costalis were measured. Conclusions Detailed quantitative anatomical knowledge for operations requiring wide dissection and resection, such as cervical spondylectomy, lowers the morbidity rate.

The superior gluteal nerve (SGN) is vulnerable to damage during total hip arthroplasty and various pelvic surgeries. Recently introduced minimally invasive approaches to the hip show promise for less muscle trauma compared to conventional approaches. However, the risk of damaging the SGN has not been well documented for such alternative approaches. Therefore, we aimed to investigate the anatomic course of the SGN and to define anatomical landmarks that may be used by surgeons during minimally invasive approaches to the hip. Twenty-eight gluteal regions from 14 formalin-fixed cadavers were dissected and the course and the distances of the SGN and its branches to the tip of the greater trochanter (GT) were measured. The landmarks for standardizing the course of the SGN included the posterior inferior iliac spine (PIIS), GT, and a line (PIIS-GT) connecting these two points. The exit of the SGN was found to be at the medial one third of the PIIS-GT line and 5.4 cm from the GT. Two branching patterns were noted. The branches of the SGN were distributed lateral to the PIIS-GT line. On the basis of our study, the safe zone for the SGN was smaller than previously reported. Posterior, lateral, or anterolateral minimally invasive approaches to the hip should take into account the point of exit of the SGN and the area of distribution of its branches. A minimally invasive anterolateral approach may particularly compromise branches to the tensor fasciae latae muscle. Localization of the SGN and its branches using the anatomic landmarks defined in this study may decrease surgical morbidity. Clin. Anat. 26:614–620, 2013. © 2012 Wiley Periodicals, Inc.

OBJECTIVE: There is paucity of information regarding the specific anatomy and clinical significance of ossified ligaments near the foramen ovale (e.g., pterygospinous and pterygoalar ligaments). The present study was undertaken to define this anatomy in more detail and to review the literature regarding these anatomic variations. METHODS: One hundred fifty-four adult human dry skulls were analyzed for the presence of ossified ligaments of pterygospinous (ligament of Civinini) and pterygoalar (ligament of Hyrtl). Measurements were made of these bony structures and observations made of their relationships to the inferior aspect of the foramen ovale and neighboring structures. RESULTS: Two ossifications each (2.6%) of the ligaments of Civinini and Hyrtl were found. One of each of these (1.3%) was completely ossified, thereby resulting in 2 complete foramina (i.e., 1 foramen of Civinini and 1 foramen of Hyrtl). A significant correlation was found between the left and right sides, with either complete or incomplete ossification of these ligaments being found on left sides (75%) (incomplete Civinini on right side and all others on left side). The complete foramen of Civinini was found to have an area of 16.7 mm 2 , and the complete foramen of Hyrtl was found to have an area of 9.42 mm 2 . CONCLUSION: Such anomalous bony obstructions could interfere with transcutaneous needle placement into the foramen ovale or distort anatomic relationships during approaches to the cranial base.

We hypothesized that a correlation may exist between the length of the upper limb and the length of the cubital tunnel, which transmits the ulnar nerve from the arm to the forearm. If true, this association might aid in predicting individuals at greater risk of developing ulnar nerve compression at this site. A total of 46 cadaveric upper limbs were dissected. The lengths of the upper limb and cubital tunnel were measured and analysis made of any correlation between these two distances. The average length of the cubital tunnel was found to be 2.7 cm (range 1.2–4.7 cm, SD 0.82), and the average length of the upper limb was 62.5 cm (range 51–72 cm, SD 4.33). No significant difference was found with either length of the tunnel between left and right sides or among genders. Neither the ratio of upper limb length to length of the cubital tunnel between genders nor the ratio between left and right sides was found to have a positive correlation. These data suggest that the cubital tunnel length maintains similar proportion to upper limb length among genders and sides and that a correlation between these two distances does not exist.

The axillary nerve is invariably reported to be one of the most commonly injured nerves during surgical procedures of the shoulder, and the importance of protecting it cannot be overemphasized. Many researchers have tried to identify safe regions, but the results vary among published studies. The axillary nerve may also be injured during acute trauma to the shoulder or by chronic repeated trauma as has been described in the quadrilateral space syndrome. The nerve injury may occur together with shoulder dislocation and rotator cuff tear, thus comprising the so-called "unhappy triad" of the shoulder joint. Simple attention to potential variations in the origin and course of the axillary nerve and its relationship to the shoulder capsule and having a precise knowledge of "safe zones" during operations can enhance clinical outcomes. The objective of this review, therefore, is to discuss the surgical anatomy of the axillary nerve and further emphasize the clinical importance of the its injury following shoulder trauma.

The percutaneous repair of the calcaneal tendon (CT) places the sural nerve (SN) at high risk for injury up to 60%. The aim of our study, therefore, was to explore and describe the course of SN in relation to the CT and to provide an anatomical description of the area in which the SN resides in order to assist surgeons in avoiding iatrogenic injury during surgical procedures in the leg. Forty-four lower extremities of 22 adult cadavers were dissected and the course of the sural nerve investigated. The CT was divided into ten horizontal equal fractions. The widths of CT, and horizontal distances of the SN and small saphenous vein (SSV) to a vertical line connecting the midpoints of these fractions were measured. All the measurements were obtained using a computer-assisted image analysis system. In 95.5% of the specimens the sural nerve was medial to the lateral border of the CT proximally and was intersecting with the lateral border of the CT at the 55% of the mid-tendon line. The SN divided into its terminal branches at a mean of 90% of the mid-tendon line. Based on our results, the course of the sural nerve is quite variable and seems to have the highest risk of injury at its proximal portion. The sutures placed on the CT distal to the 55% of the mid-tendon line may decrease iatrogenic nerve injury.

Many authors have questioned the gross anatomy of the septal papillary muscle of the conus known as the papillary muscle complex (PMC) during the past century. An anatomical investigation was conducted to identify the morphology and the topography of the PMC. Our study involved 200 formalin fixed adult human hearts. The PMC was present in 82% of the hearts, while in the remaining 18% of specimens, it was replaced by tendinous chords. The PMC was connected with the septal (59.7%), anterior (20.7%), or both septal and anterior leaflets (19.5%) with single (29.8%) or multiple chordae tendinae (70.1%). The PMC was also found to be present as a single papilla (51.8%), double papilla (32.9%) or triple papilla (15.2%). In addition to the PMC, we observed accessory single septal papillary muscles 42 specimens, double septal papillary muscles 32 specimens and triple septal papillary muscles 26 specimens. In the right ventricular inflow tract, the location of the PMC was consistently found to be in a position below the junction of the anterior and septal leaflets of the tricuspid valve. In the right ventricular outflow tract, we were able to identify 73 specimens in which the PMC was located at the junction formed superiorly by the inferior border of the subpulmonary infundibulum and inferiorly by the superior-lateral border of the septal band, extending into the region of the subpulmonary infundibulum. In the remaining 27%, the PMC was located primarily at the area occupied by the superiolateral border of the septal band without extending to the subpulmonary infundibulum. The present study describes the topography of the PMC according to its surrounding anatomical structures such as the tricuspid valve, subpulmonary infundibulum and septal band of the right ventricle. This anatomical data could have important clinical significance for cardiac surgeons operating in this area.

Specific sites of atherosclerotic processes due to hemodynamic changes and resultant stress, including how these normal anatomical structures become problematic in certain individuals, have yet to be acknowledged. One of these areas of the cardiovascular system occurs at the sinutubular junction (SJ), causing altercation in an otherwise normal flow status. The anatomy of the SJ was examined in 100 adult human hearts during the gross anatomy course at St George's University, during the years 2006-2007. All hearts were examined in situ, using a General Electric model 3200S ultrasound machine with a 5 MHz linear probe. The aforementioned cadavers were also examined using a Stryker laparoscopic unit. Serial transverse histological sections were made through the SJ perpendicular to its axis, and stained with eosin-hematoxylin, van Gieson, Masson trichrome, and Orcein methods. In addition, an immunohistochemical analysis was performed for the detection of positive smooth muscle cells stained areas. During gross and endoscopic examination we were able to identify the SJ in all adult heart specimens. Neonatal and fetal hearts did not exhibit any gross evident SJ; however, a SJ was evident histologically. Ultrasonographically we were able to identify the SJ in all adult heart specimens examined, and a sinutubular ridge in 62%. A significant association was present between the thickness of the ridge and the age of the specimens. The SJ was found to exhibit atherosclerotic changes and plaque formation in an age-related manner. In older subjects, the SJ was marked with local calcification and hemorrhages. In contrast, the SJ of neonatal hearts appeared to have intimal thickening with focal fragmentation and absent or duplicate internal elastic lamina. Intuitively speaking, the presence of a sinutubular ridge, an inevitable fate in humans based on the results of this study, provides an irreversible atherosclerotic process as there is no evidence that the promoting ridge regresses. This is an alarming situation in those individuals who will eventually develop cardiovascular risk factors, whether through inevitable genetic manifestations or by means of exogenous environmental causes.

The position of the inferior gluteal nerve (IGN) makes it vulnerable to iatrogenic injury during posterior and posterolateral approaches to the hip. Although the posterior approach has been reported to be the most frequently used technique, it is most likely to be associated with damage to the IGN. As there is scant information in the literature regarding the course and the anatomic relationships of the IGN, we aimed to investigate the anatomic course of the IGN and define the anatomical landmarks that can be used by surgeons during posterior approaches to the hip. Thirty-six gluteal regions from adult fixed cadavers were used for this study. A triangular-shaped anatomic area that contains the IGN was defined. This geometric area was formed by connecting the following points: posterior inferior iliac spine (PIIS) (apex), ischial tuberosity (IT) and greater trochanter (GT). This triangle can further be divided into two, the upper triangle being the "danger zone" since it contains the IGN and its branches. The closest mean distance between the point of IGN origin and the PIIS, IT and the GT was 3.2, 4.8 and 5.4 cm, respectively. In all specimens, the nerve entered the deep surface of the gluteus maximus approximately 5.4 cm from the apex of the GT and approached the GT as close as 0.8 cm, on average. Based on our study, dividing the gluteus maximus with standard techniques may damage the IGN. Posterior minimally invasive approaches to the hip should take into account the point of entry of the IGN into the gluteus maximus. Localization of the IGN by using the anatomic triangle defined in this study may decrease surgical morbidity.

Reports place the frequency of axillary nerve injury at 6% for all brachial plexus injuries, emphasizing the importance of an accurate anatomic description of this nerve within the deltoid in order to reduce iatrogenic injury. The aim of the present study was to explore the anatomic variations of the axillary nerve within the deltoid muscle. Fifty human cadavers were dissected, resulting in 100 nerve specimens. The anterior and posterior branches of the axillary nerve were identified and their length measured from their point of origin (split from the axillary nerve) to their termination in the deltoid muscle. In 65% of cases, the axillary nerve split into two branches (anterior and posterior) within the quadrangular space, and in the remaining 35% split within the deltoid muscle. The posterior branch of the deltoid muscle irrespectively of origin gave off a branch to the teres minor and the superior lateral brachial cutaneous nerve in 100% of cases. The branch to the posterior part of the deltoid muscle was present in 90% of cases, and the branch to the middle part of the deltoid was present in 38% of cases. The anterior branch of the deltoid muscle provided a branch to the joint capsule, a branch to the anterior part of the deltoid muscle and the middle part of the deltoid in 100% of cases. In 18% of the cases, the anterior branch of the axillary nerve provided a branch to the posterior part of the deltoid muscle. The middle part of the deltoid muscle received dual innervation in 38% of cases and the posterior part of the deltoid muscle in 8% of the cases.

Object The intradural contributions of the C-4 nerve rootlets have not been previously evaluated for their connections to the brachial plexus. The authors undertook a cadaveric study to evaluate the C-4 contributions to the upper trunk of the brachial plexus. Methods The posterior cervical triangles from 60 adult cadavers were dissected. All specimens that were found to have extradural C-4 contributions to the upper trunk of the brachial plexus were excluded from further study. In specimens found to have no extradural C-4 contributions to the brachial plexus a C1–T1 laminectomy was performed. Observations were made of any neural communications between adjacent spinal rootlets, specifically between C-4 and C-5. Results Nine (15%) of the 60 sides were found to have extradural C-4 contributions to the upper trunk of the brachial plexus. These sides were excluded from further study. No specimen was found to have a postfixed brachial plexus. Of the remaining 51 sides, 11 (21.6%) were found to have intradural neural connections between C-4 and C-5 dorsal rootlets and 1 (1.96%) had a connection between the ventral roots of C-4 and C-5. Communications between these 2 adjacent dorsal cervical cord levels were of 3 types. Type I was a vertical communication between the more horizontally traveling dorsal roots. Type II was a forked communication between adjacent C-4 and C-5 dorsal rootlets. The Type III designation was applied to connections between ventral rootlets. Although communications were slightly more frequent on left sides, this did not reach statistical significance. Conclusions In ~ 20% of normally composed brachial plexuses (those with extradural contributions from only C5–T1) we found intradural C4–5 neural connections. Such variations may lead to misinterpretation of spinal levels in pathological conditions of the spinal axis and should be considered in surgical procedures of this region, such as rhizotomy.

Nerve injury is a common complication during anterior shoulder surgery. The purpose of the study was to evaluate the musculocutaneous nerve (MN) anatomically and to clarify the relationship of the MN to the glenoid labrum and coracoid process in different arm positions. The study was carried out on 40 shoulders of 20 adult cadavers fixed in 10% formaldehyde. The minimum distance of the MN at the entrance point of the nerve into the coracobrachialis to the anteromedial aspect of the coracoid tip and the distance between the MN and the top, middle, and inferior points of the glenoid labrum were measured. All measurements were performed with a digital caliper while the arm was in a neutral position, 45 degrees and 90 degrees of abduction, 90 degrees of abduction-internal rotation and 90 degrees of abduction-external rotation to evaluate whether arm position effects the results statistically or not. The results demonstrated that the position of the arm significantly changes the distance between the coracoid process (CP) and the MN or its cord. The change in distance between the glenoid labrum and the MN or its cord was also statistically significant. The distance between the CP and MN was greatest when the arm was abducted to 45 degrees (mean 3.4 cm) and least when the arm was positioned to 90 degrees of abduction-internal rotation (mean 2.0 cm). While the distance between the MN and the coracoid process was least at 90 degrees of abduction and internal rotation, the distance between the MN and glenoid labrum was lest with 90 degrees of abduction and external rotation. The distance between the glenoid labrum and MN was greatest with 45 degrees of abduction. The results of this study might be of use in avoiding the MN especially during Bristlow operations and certain rotator cuff procedures. Transferring the coracoid process during Bristow operations or placing arthroscopic portals when the arm is abducted to 45 degrees appears to be the safest position in terms of MN injury. Based on our results, when the arm needs to be abducted to 90 degrees during operation, externally rotating it may decrease the tension on the brachial plexus thus increasing the distance between the MN and the portals or retractors.

COSTANZO VAROLIO (CONSTANTIUS Varolius) (1543-1575) was born in Bologna and died in Rome. This professor of anatomy and papal physician was the first to examine the brain from its base up, in contrast with previous dissections of this organ performed from the top down. Varolio was the first to describe many structures, including the pons, which is still known today as the pons Varolli. Varolio was a pupil to the well-known anatomist Aranzio, who was in turn a pupil of Vesalius. Our current understanding of the nervous system is based on the early anatomic descriptions and depictions by such individuals as Varolio.

Left ventricular false tendons (LFTs) have been extensively described and recognized by gross anatomic studies. However, there is very little information available regarding right ventricular false tendons (RFTs). The aim of our study, therefore, was to explore and delineate the morphology, topography and morphometry of the RFTs, and provide a comprehensive picture of their anatomy across a broad range of specimens. We identified 35/100 heart specimens containing right ventricular RFTs and classified them into five types. In Type I (21, 47.7%) the RFTs, was located between the ventricular septum and the anterior papillary muscle; in Type II (11, 22.9%) between ventricular septum and the posterior papillary muscle; in Type III (7, 14.5%) between the anterior leaflet of the tricuspid valve and the right ventricular free wall; in Type IV (5, 10.4%) between the posterior papillary muscle and the ventricular free wall; and lastly, in Type V (4, 8.3%) between the anterior papillary muscle and ventricular free wall. The mean length of the RFTs was 18 +/- 7 mm with a mean diameter of 1.4 +/- 05 mm. Histologic examination with Masson trichrome and PAS revealed that 20 (41.6%) of the 48 RFTs carried conduction tissue fibers. The presence of conduction tissue fibers within the RFTs was limited to Types I, III, and IV. In Types II and V the RFTs resembled fibrous structures in contrast with Type I, II and IV, which were composed more of muscular fibers, including conduction tissue fibers. RFTs containing conduction tissue fibers were identified, which may implicate them in the appearance of arrhythmias.

Descriptions of the velum interpositum (VI) are typically brief and lacking detail in most neuroanatomical and neurosurgical texts. As this structure may be involved clinically or encountered surgically, the present study seemed warranted.Twenty-adult (10 male and 10 female) formalin fixed and fresh cadaveric brains underwent a detailed dissection of the VI via an interhemispheric transcollosal approach. Observations were made of the attachment sites and continuation of the VI. Measurements were made of its length and width at its anterior, midportion, and posterior parts.The VI extended laterally over the thalami to become continuous with the choroid plexus of the lateral ventricles. At a point along the thalami where the choroid plexus was found, the VI became "tacked" down and thus continuous with the choroid plexus subependymally. No specimen exhibited a separate choroid plexus of the third ventricle. In each, the choroid plexus of the lateral and third ventricles were the same tissue layer, all arising from the VI. This structure was adherent to but not fused to the deep surface of the fornix. The VI was also not fused to the pineal gland or habenula commissure but simply covered these structures. This membrane was confluent with the pia/arachnoid over the cerebellum and from the inferior surface of the parietal/occipital lobes and extended laterally into the choroid fissure.To our knowledge, the extent of the VI as described herein has not been reported earlier. The supratentorial choroid plexus is simply a vascular extension of the VI. There is no separate choroid plexus of the third ventricle as often described. Clear planes exist between the VI and surrounding structures such as the pineal gland. Such data may be useful to neurosurgeons who operate in this region and to clinicians who interpret imaging in the area of the VI.

Introduction A review of the ancient world finds multiple documentations describing the use of the human calvaria as a drinking implement. Terminology This term, which is frequently and incorrectly called the “calvarium,” has a unique history among multiple cultures of the world. For example, the purported site of Jesus’ crucifixion “Calvary” is derived from this term calvaria. The present report explores the derivation, misuse, and history of the human calvaria.

The presence or absence of a lower esophageal sphincter (LES) has been a matter of debate. The aim of the present study was to revisit the gastro-esophageal region in an attempt to elucidate further the presence or absence of such a structure. The distal part of the esophagus was investigated in 12 fixed and 2 fresh cadavers with the aid of a dissecting microscope. Our findings demonstrated a clear thickening of the circular muscle layer of the gastro-esophageal region in all specimens. The mean length of this muscular thickening was measured to be 3.1 cm. The thickest part of this segment was at its midsection. This midpart had a mean thickness of 5.4 mm. The thickness of the esophagus immediately superior to the sphincter had a mean of 2.7 mm. We believe that the findings of the present study strongly suggest the presence of an internal esophageal sphincter in the distal esophagus. Physiologic experimentation would now be necessary to verify our morphological findings.

Palsy of the external branch of the superior laryngeal nerve (EBSLN) during thyroid surgery is an important complication reported with varying frequency. This study was carried out to investigate the relationship between the EBSLN, the upper part of the thyroid gland and the inferior constrictor muscle of the pharynx (IC), and also to define consistent landmarks for identifying and preserving the EBSLN. Forty neck halves of 20 cadavers were dissected. Measurements were obtained between the crossing point of the EBSLN with the superior thyroid artery (STA) and the upper pole of the thyroid gland, the point where EBSLN penetrates the IC and the inferior thyroid tubercle, and the middle point of the oblique line of the thyroid cartilage, and the EBSLN. In 22.5%, the EBSLN crossed the STA more than 1 cm above the upper pole of the thyroid gland (Type I of Cernea et al. [1992a] Head Neck 14:380-383). In 60%, the EBSLN crossed the STA less than 1 cm above the upper pole of the thyroid gland (Type IIa of Cernea et al. [1992a] Head Neck 14:380-383). In 17.5%, the EBSLN crossed the STA under the upper pole of the thyroid gland (Type IIb of Cernea et al. [1992a], Head Neck 14:380-383). In 22.5%, the full course of the nerve was superficial to the IC (Type 1 of Friedman et al. [2002] Arch Otolaryngol Head Neck Surg 128:296-303). In 67.5%, the nerve penetrated the IC (Type 2 of Friedman et al. [2002] Arch Otolaryngol Head Neck Surg 128:296-303). In 10%, the nerve could not be identified at the lateral side of the IC (Type 3 of Friedman et al. [2002] Arch Otolaryngol Head Neck Surg 128:296-303). In conclusion, it is possible to identify the nerve superficial to the IC in 90% of specimens on average. Knowledge of the relationship between the EBSLN, IC, inferior thyroid tubercle, oblique line of the thyroid cartilage and the sternothyroid muscle will be useful for the surgeon in avoiding unexpected complications.

The aim of this study was to determine whether the dimensions of the distal femur and proximal tibia joint surfaces affect the etiology of knee osteoarthritis (OA). The study comprised the records of 1,324 patients who had been admitted to hospital with knee pain. Anterioposterior (AP) and lateral radiographs of the knee were taken. Using the Kellgren-Lawrence Scale, the patient group comprised Stages 2, 3, and 4 radiographs and the controls comprised Stages 0 and 1 radiographs. Four lengths were measured for each patient in both groups: femur mediolateral (femur ML), tibia mediolateral (tibia ML), femur anteroposterior (femur AP), and tibia anteroposterior (tibia AP). Osteophytes were not included in the measurements in the patient group. All the measurements were repeated by two researchers at two different times. The groups were compared in terms of these measurements and the correlations between them. The mean femur ML length was significantly greater in the patient group than the control group (P = 0.032) and the mean femur AP length was significantly less (P = 0.037). In addition, the difference between the femur ML and AP lengths was significantly high in the patient group (P

The variations in the formation and distribution of the lumbosacral plexus and its branches have been subject of several investigations. The classical definitions and common classifications about the formation and branches of the lumbosacral plexus have been done in late 1800s and early 1900s. The descriptions made in current literature and the defined variations in case reports mainly rely on these early publications. This chapter reviews these early publications and also the recently reported findings on the variations of the lumbar and sacral plexus and their branches.

Surgeons expose the nerves of the lower extremity less frequently than the nerves of the upper extremity. Therefore, the surgical techniques for exposing lower-extremity nerves are often foreign to most surgeons. These procedures are most commonly directed at the femoral and sciatic nerves. Surgeons also apply such procedures to common, superficial, and deep fibular nerves and to the tibial nerve deep to the soleus muscle. With the introduction of new surgical advances, this area is attracting more attention because it relates to preventing the functional impairment of the lower limbs. Over the past few years, surgeons have described numerous new approaches, most of which are based on older approaches modified for a specific surgical procedure. When dealing with these approaches, surgeons should know the anatomical courses of the nerves of the lower limb, as well as their possible variations, in order to provide a safe and successful surgery.

The axillary nerve has long been known to be one of the nerves vulnerable to damage during shoulder arthroscopic and open surgical procedures. The relationship of the axillary nerve to the shoulder capsule and the subscapularis muscle has not been well defined in orthopedic literature. This descriptive anatomical study aimed to present the course and the relations of the axillary nerve with neighboring neurovascular structures and the shoulder capsule and to define anatomical landmarks and regions that can be used practically in anterior surgical approaches to the shoulder region. To investigate the course of the axillary nerve and its relationship with neighboring structures, 30 shoulders of 15 fixed adult cadavers were dissected under the microscope through an anterior approach. A triangle-shaped anatomic area containing the axillary neurovascular bundle was defined. The closest distance between the axillary nerve and the anteromedial aspect of the coracoid tip and the glenoid labrum was measured as 3.7 cm and 1.1 cm on average, respectively. The distance between the anteromedial aspect of the coracoid tip and the point where the nerve passes through the medial edge of the subscapularis was measured as 2.5 cm on average. The results of this study demonstrate the anatomic pattern and the course of the axillary nerve and its relations with the shoulder capsule. Knowing the exact localization of the axillary nerve under the guidance of the defined anatomic triangle may provide a safer surgery.

Few anatomical textbooks offer much information concerning the anatomy and distribution of the phrenic nerve inferior to the diaphragm. The aim of this study was to identify the subdiaphragmatic distribution of the phrenic nerve, the presence of phrenic ganglia, and possible connections to the celiac plexus. One hundred and thirty formalin-fixed adult cadavers were studied. The right phrenic nerve was found inferior to the diaphragm in 98% with 49.1% displaying a right phrenic ganglion. In 22.8% there was an additional smaller ganglion (right accessory phrenic ganglion). The remaining 50.9% had no grossly identifiable right phrenic ganglion. Most (65.5% of specimens) exhibited plexiform communications with the celiac ganglion, aorticorenal ganglion, and suprarenal gland. The left phrenic nerve inferior to the diaphragm was observed in 60% of specimens with 19% containing a left phrenic ganglion. No accessory left phrenic ganglia were observed. The left phrenic ganglion exhibited plexiform communications to several ganglia in 71.4% of specimens. Histologically, the right phrenic and left phrenic ganglia contained large soma concentrated in their peripheries. Both phrenic nerves and ganglia were closely related to the diaphragmatic crura. Surgically, sutures to approximate the crura for repair of hiatal hernias must be placed above the ganglia in order to avoid iatrogenic injuries to the autonomic supply to the diaphragm and abdomen. These findings could also provide a better understanding of the anatomy and distribution of the fibers of that autonomic supply.

Apaydin, Nihal/0000-0002-7680-1766; WOS: 000228764800008 PubMed: 15832352 To understand the lesion of the terminal branches of posterior interosseous nerve (PIN), an anatomic study was carried out. Thirty adult cadaver arms were dissected and the anatomic pattern of the nerve was documented. The distance between the point at which the nerve divides into branches and the distal edge of the supinator were measured, as well as the length of each nerve branch to its muscle-entering sites. The number of branches innervating each muscle was recorded. It was found that the PIN was branching to multiple short branches and a single deep long branch after leaving the supinator muscle with great morphometric and schematic variances. (c) 2005 Wiley-Liss, Inc.