Burcu Erçakmak

Association between frontal sinus development and persistent metopic suture.

BACKGROUND Frontal sinuses are 2 irregular cavities, placed between 2 lamina of frontal bone. Expansion continues during childhood and reaches full size after puberty. Persistent metopic suture is one of the factors that are related to abnormal frontal sinus development. In this study, we want to discuss about the coexistence of persistent metopic suture and abnormal frontal sinus development using radiological techniques. MATERIALS AND METHODS In this retrospectively planned study, images of 631 patients were examined, 217 (34.4%) of them were men and 414 (65.6%) of them were women. Brain computed tomography and magnetic resonance images were retrieved from the electronic archive for analysis. RESULTS In this study, frontal sinus development is categorised as right side atrophy, left side atrophy, bilateral atrophy and bilaterally developed sinuses. The presence of metopic suture was accepted as persistent metopic suture. Frontal sinus atrophy was found in 22.7% and persistent metopic sutures were found in 9.7% of overall. CONCLUSIONS In this study, no significant results were detected that were relatedto the frontal sinus agenesis or dismorphism associated with persistent metopicsuture. We conclude that, although publications propounding metopism thatleads to abnormal frontal sinus development are present in the literature, noreasonable explanation has been mentioned in these articles; and we believe thatthese findings are all incidental.

Soft spot: the important zone at the standard posterior portal of shoulder arthroscopy

Background/aim: The localization of the standard posterior portal of shoulder arthroscopy and landmarks mentioned in the literature are unclear. The purpose of this prospective cadaveric study was to determine the localization of the standard posterior portal and its distance to the neural structures. Materials and methods: One fresh frozen and 10 formalin-fixed adult cadaveric shoulders were dissected. In the beach chair position, a 5-mm trocar was placed anteroposteriorly from the superior edge of the subscapularis muscle, superior to the tip of the coracoid process and tangent to the glenoid. The relevant distances of the posterior exit point were measured. Results: In all specimens, the exit point was a triangular fibrous area, between the posterior and lateral parts of the deltoid. Medial and inferior distances of the trocar to the posterolateral tip of the acromion were 1.88 ± 0.53 cm and 1.35 ± 0.34 cm and distances to the axillary and suprascapular nerves were 4.54 ± 1.08 cm and 2.54 ± 0.85 cm, respectively. Conclusion: The most important finding of this study was the superficial localization of the soft spot between the posterior and lateral parts of deltoid.

Association of Medial Meniscus Extrusion With the Prominence of a Fascicular Capsulofemoral Band Subjacent to the Deep Medial Collateral Ligament

OBJECTIVE The objective of our study was to test our hypothesis that a transverse oblique fascicular anteromedial capsulofemoral band partially subjacent to the deep medial collateral ligament (MCL) is more prominent in knees with medial meniscal extrusion. MATERIALS AND METHODS We retrospectively analyzed all knee MRI examinations from a 6-month period for the presence and dimensions of the anteromedial capsulofemoral band on coronal proton-density fat-saturated images and also for medial meniscus extrusion, which was defined as extrusion of 3 mm or greater. Edemalike signal intensity within or in the vicinity of the anteromedial capsulofemoral band, partial or complete tears of the MCL, a history of MCL surgery, or a neoplastic mass lesion violating the medial supporting structures were exclusion criteria. We reviewed procedural videos of patients who subsequently underwent knee arthroscopy. MRI of a cadaveric knee was performed and was followed by dissection and histologic examination. RESULTS MRI examinations of 346 knees of 312 patients met the inclusion criteria; of these knees, 50 had medial meniscus extrusion. The anteromedial capsulofemoral band was discernible on MRI in all knees except five (98.6%), and it was visible in six of the arthroscopy videos of 17 knees. The anteromedial capsulofemoral band was thicker on MRI of patients with medial meniscus extrusion (p < 0.0001). The anteromedial capsulofemoral band was identified on MRI and at dissection of the cadaveric knee, and histologic examination revealed that the anteromedial capsulofemoral band was a capsuloligamentous structure. CONCLUSION A transverse oblique anteromedial capsulofemoral band subjacent to the deep MCL is thicker in knees with medial meniscus extrusion.

Revisiting the relationship between the submandibular duct, lingual nerve and hypoglossal nerve

BACKGROUND The aim of the study was to evaluate the relations between submandibular duct, lingual nerve and hypoglossal nerve for making a reassessment of this area in fresh frozen specimens. Also, the distance between the angle of the mandible and the vertical line drawn from the point where submandibular duct crossed lingual nerve to the base of the mandible was measured to determine a new landmark for neck surgeons. MATERIALS AND METHODS Fourteen fresh frozen head and neck specimens were dissected and evaluated. A marginal mandibular incision was made from the mastoid process to the chin. RESULTS In 8 cases, lingual nerve was crossing the submandibular duct superiorly; in 5 cases, lingual nerve was crossing the duct infero-medially and in 1 case it was parallel to the duct. In 1 case, lingual nerve subdivided into anterior and posterior branches. In 2 cases, 2 parallel submandibular ducts were found and the lingual nerve was crossing the upper duct from superior. In 1 case, lingual nerve was crossing the duct infero-medially and then it was subdividing into branches superior to mylohyoid. In 12 cases, the course of hypoglossal nerve was classical. In 1 case, hypoglossal nerve crossed the submandibular duct medially and coursed parallel to the tendon of posterior belly of digastric. And in another case, hypoglossal nerve crossed the inferior branch of submandibular duct medially. The other structures in this area were as usual. CONCLUSIONS The main factor for reducing nerve damage during surgery is the understanding of the anatomy of this area.

Morphology of cranial sutures and radiologic evaluation of the variations of intersutural bones

BACKGROUND As far as our literature searches showed us, morphological characteristics of cranium such as sutures, sutural bones and fontanelles had been examined in the skulls in the museums and dry specimens until now. As a modern method, three-dimensional virtual reconstruction of cranial bones by using multidetector computed tomography-computed tomography angiography (MDCT-CTA) can display in vivo morphological characteristics. In our study, we aimed to determine the presence and incidence of these morphological characteristics that can be clinically significant in our population, by using radiologic methods. MATERIALS AND METHODS We examined head and neck regions of 185 patients via MDCT-CTA. We evaluated radiologically detectable variations of the metopic sutures, lambda, bregma, asterion and pterion, which can be very easily confused with fractures. Additionally, the differences between the genders and incidence of coexistence of these variations were evaluated. RESULTS According to our study, the incidence of persistent metopic suture was 8.1% and the incidence of lambda variations was 5.9%. Variations were most commonly encountered on the left asterion, and least commonly on the bregma and left pterion. In the evaluation of the coexistence of the parameters and combinations, the Wormian bones located at the right and left asterions were detected. There were no statistically significant differences between genders. CONCLUSIONS Variations of the sutures and sutural bones can be easily misdiagnosed with the fractures of related bony regions in unconscious patients with multiple traumas. During surgical interventions in these patients, surgeons must take this fact into consideration in order to make differential diagnosis of fractures and intersutural bone variations.

Modified tension band wiring technique for olecranon fractures: where and how should the K-wires be inserted to avoid articular penetration?

OBJECTIVE Articular penetration of K-wires is a possible complication of the modified tension band wiring technique. However, there is no clear information or evidence regarding the entry point or introduction angle for K-wires to avoid this complication. The aim of this experimental study was to evaluate the effect of varying K-wire insertion points and angles on the risk for articular penetration during modified tension band wiring for olecranon fractures. METHODS All anatomical measurements were made on 50 cadaveric ulnas, and all other measurements were performed on exact foam replications of the 50 cadaveric ulnas. Morphometric measurements, including olecranon height and heights of the central, radial and ulnar facets of the semilunar notch, were taken. In the sagittal plane, articular angle and tubercle angle were measured. Two 1.6-mm parallel K-wires were inserted from 0, 5 and 8 mm anterior to the dorsal cortex of the olecranon process at angles of 20° and 30°. K-wire articular penetration was evaluated both visually and radiographically. RESULTS The mean central, radial and ulnar heights of the semilunar notch were 17.3 mm (14.7-20.0), 16.2 mm (12.0-21.0) and 15.8 mm (13.30-20.5), respectively. We observed no articular penetration at the 0-mm level at 20° and 30° (0 mm 20° and 0 mm 30°, respectively) or at 5 mm 20°. At 8 mm 30° wire introduction, more than 64% articular penetration was observed on either facet. The sequence from least to most likely to cause articular penetration was: 0 mm = 5 mm 20° > 5 mm 30° = 8 mm 20° > 8 mm 30°. The radial height of the semilunar notch was negatively correlated to the risk of articular penetration, when the wire was introduced at 8 mm 30°, 8 mm 20° and 5 mm 30° (all p<0.047). There were poor correlations between radiological and direct observational assessments, particularly for 8 mm 20° and 5 mm 30°. The frequency of intra-articular positioning for those observed to be radiologically extra-articular was 4/28 (14.3%) for 8 mm 30°, 4/7 (57.1%) for 8 mm 20° and 5/6 (83.3%) for 5 mm 30°. CONCLUSION When applying the modified tension band wiring technique to prevent articular penetration, K-wires should be inserted in the first 5 mm from dorsal cortex of the olecranon process at a maximum angle of 20°. Moreover, if the wires are required to be inserted more anteriorly because of the anatomical configuration of the fracture, they should be inserted at a shallow angle in the sagittal plane in relation to the proximal cortex of the ulna.

Quantitative analysis of the terminal branches of facial nerve in fresh frozen head and neck specimens

BACKGROUND The first aim of this study was the quantification of nerve fibres found in terminal branches of facial nerve and the second aim was the ultrastructural analysis of these terminal branches in order to observe their ultrastructural differences, if present. In the examination of literature; we could not find any studies related to this subject. MATERIALS AND METHODS Four fresh frozen head and neck specimens were used and the dissections were done bilaterally. Therefore; totally 8 samples were examined. The samples were prepared according to routine transmission electron microscopic tissue preparation technique. The semi-thin sections were examined under light microscope by camera lucida. In every sample, the quantitative analysis was performed in 5 different areas in an area of 0.01 mm2 and statistical analysis was done. Secondly; the ultrastructural appearance of these terminal branches were examined under transmission electron microscope. RESULTS In the quantitative analysis of terminal branches of facial nerve in an area of 0.01 mm2; the least number of nerve fibres were found in temporal branches and the highest number were detected in cervical branches. In transmission electron microscopic examination, no significant difference was found in between these branches. In the statistical analysis; statistically significant differences were obtained in between the temporal and buccal, marginal mandibular, cervical branches; zygomatic and marginal mandibular, cervical branches; buccal and marginal mandibular, cervical branches; marginal mandibular and cervical branches. CONCLUSIONS These numerical data will have an importance during the nerve repair process of terminal branches of facial nerve in various injuries.