Gunther Windisch

The Vascular Anatomy of the Tensor Fasciae Latae Perforator Flap

Background: The purpose of this study was to differentiate between musculocutaneous and septocutaneous perforators of the tensor fasciae latae perforator flap; to evaluate their number, size, and location; and to provide landmarks to facilitate flap dissection. An additional injection study estimated the skin area of the flap. Methods: The anatomical study was performed on 23 fixed and injected cadavers. The perforators of the tensor fasciae latae were identified and classified as septocutaneous or musculocutaneous. Diameter, location, and numbers were measured and the perforators were dissected up to their origin. The injection study was performed on 10 fresh cadavers. On one side, the ascending branch of the lateral circumflex femoral artery was injected with methylene blue; on the other side, the septocutaneous perforators were injected selectively. The size, location, and borders of the stained skin were measured. Results: Forty-five thighs were included in this study. All perforators emerged from the ascending branch of the lateral circumflex artery. The average number of musculocutaneous perforators was 2.3 (range, 0 to 5), the distance from the anterior superior iliac spine was 10.9 cm (range, 4.5 to 16.1 cm), and the diameter was 0.9 mm (range, 0.2 to 2 mm). Four specimens had no musculocutaneous perforator. The average number of septocutaneous perforators was 1.8 (range, 1 to 3), the distance from the anterior superior iliac spine was 10.9 cm (range, 6.2 to 15.7 cm), and the diameter was 1.5 mm (range, 0.5 to 3 mm). Seventy-six percent of the septocutaneous perforators emerged between 8 and 12 cm from the anterior superior iliac spine. The possible pedicle length of a flap based on these vessels is 8.1 cm (range, 6.5 to 10 cm). In the injection study, the average skin area stained with methylene blue was 19.4 × 13.4 cm (range, 10 to 24 cm × 7 to 17 cm) in the ascending branch group. In the perforator group, the average skin area was 19.2 × 13.7 cm (range, 15 to 22 cm × 12 to 16 cm). Conclusions: The authors could show that the number of septocutaneous perforators for the tensor fasciae latae flap is more constant and that their diameter is greater than that of musculocutaneous perforators. The location of these perforators on a line extending from the ilium to the greater trochanter facilitates planning and dissection of a flap.

The Cricothyroid Joint—Functional Aspects With Regard to Different Types of Its Structure

The cricothyroid joint (CTJ) plays a key role in pitch adjustment of the human voice. It allows an external elongation of the vocal fold performed by the cricothyroid muscle with a consecutive stretching and increasing of tension. Phonosurgical methods such as cricothyroid approximation need sophisticated investigations on anatomical and functional principles because of the low satisfaction rates. Fifty cadaveric specimens were analyzed to reveal the morphological and functional anatomy of the CTJ focusing on possible gliding movements in a horizontal and vertical direction. The cartilaginous surfaces of the CTJ were categorized according to Maue and Dickson into three different types (type A: well-defined facet; type B: no definable facet; type C: flat cartilage surface or protuberance) and functional correlations examined. Side different statements and intraindividual differences between male and female specimens were included. Besides from rotational movements, the CTJ allowed horizontal and vertical gliding movements depending on the different types of the cartilaginous surfaces. Especially the difference concerning mobility between type A and the others was highly significant (P<0.001). Two thirds of our specimens showed a similar type in both CTJs, whereas in one third it was asymmetric. In comparison to the possible change of distances between horizontal gliding movements and rotation, rotation caused significant elongation of the vocal folds, which should be proposed in phonosurgical methods for cricothyroid approximation.

Herniation of the mylohyoid muscle.

During ultrasound examinations in patients with dysphagia, deficiencies in the mylohyoid muscle with herniation of the sublingual gland were found, which may be mistaken as soft tissue tumors. Between the years 2001 and 2003, 205 half-heads used in dissection courses were examined to determine the location and contents of these gaps. In 25 of these cadaveric specimens, the hiatus (of variable size) appeared as small fissures between the divided fibers of the mylohyoid. In 18 cases (72%), the sublingual gland slipped through these deficiencies and occurred in the front part of the submandibular triangle. From the inferior surface of the muscle, the submental artery also coursed through the separated muscle fibers. The herniations of 7 specimens (28%) were found without any contents, neither with gland perforation nor with a submental artery. The following study points out the spatial relation of the salivary glands to the floor of the mouth and the clinical significance, and some factors referred to the development of herniations are discussed.

Reliability of Tuffier’s line evaluated on cadaver specimens

The aim was to evaluate the reliability of Tuffier’s line usually used as sole method to identify lumbar spinous process for a correct needle placement. Fifty-eight cadaver specimens were placed in a lateral position and a flexion in the lumbar spine performed to achieve a neutralization of the lumbar lordosis. The iliac crests were palpated and the lumbar spinous process marked on the intercristal line with a pin; all specimens were dissected and the marked spinous process documented. The center of the L4 spinous process was hit in 24 male (41.38%) and 10 female (17.24%) specimens. In only two female specimens (3.45%), the upper vertebra was reached; a pin placed in L3 was not found in male cadavers. The inferior edge of the L4 spinous process was hit in male 4 times (6.90%) and in female cadavers 12 times (20.69%). In the fifth lumbar spinous process, pins were placed five times in female cadavers (8.62%) and in only one male cadaveric specimen (3.72%). In conclusion, the accuracy of the focused lumbar spinous process depends on the right bedding and the orientation of the given landmarks, so Tuffier’s line stays the most important tool for anesthetists if palpation is performed very precisely.

A model for clubfoot based on micro-CT data

The pathological anatomy of idiopathic clubfoot has been investigated for more than 180 years using anatomy, computed tomography (CT), histology and microscopy. Seven idiopathic clubfeet and two normal feet of aborted fetuses were dissected in the present study, with special emphasis on the shape of the cartilage and bones. A three‐dimensional (3D) micro‐CT system, which generates a series of X‐ray attenuation measurements, was used to produce computed reconstructed 3D data sets of each of the separated bones. Based on the micro‐CT data scans a high‐definition 3D colour printing system was used to make a four times enlarged clubfoot model, precisely presenting all the bony malformations. This model reflects the complexity of the anatomy of this disease and is designed to be used in the workshops of orthopaedic surgeons and physiotherapists, for training in new surgical and manipulation techniques.

Computer-assisted 3-dimensional anthropometry of the scaphoid.

Scaphoid fracture fixation using a cannulated headless compression screw and the Matti-Russe procedure for the treatment of scaphoid nonunions are performed routinely. Surgeons performing these procedures need to be familiar with the anatomy of the scaphoid. A literature review reveals relatively few articles on this subject. The goal of this anatomical study was to measure the scaphoid using current technology and to discuss the findings with respect to the current, relevant literature.Computed tomography scans of 30 wrists were performed using a 64-slice SOMATOM Sensation CT system (resolution 0.6 mm) (Siemens Medical Solutions Inc, Malvern, Pennsylvania). Three-dimensional reconstructions from the raw data were generated by MIMICS software (Materialise, Leuven, Belgium). The scaphoid had a mean length of 26.0 mm (range, 22.3-30.7 mm), and men had a significantly longer (P<.001) scaphoid than women (27.861.6 mm vs 24.561.6 mm, respectively). The width and height were measured at 3 different levels for volume calculations, resulting in a mean volume of 3389.5 mm(3). Men had a significantly larger (P<.001) scaphoid volume than women (4057.86740.7 mm(3) vs 2846.56617.5 mm(3), respectively).We found considerable variation in the length and volume of the scaphoid in our cohort. We also demonstrated a clear correlation between scaphoid size and sex. Surgeons performing operative fixation of scaphoid fractures and corticocancellous bone grafting for nonunions need to be familiar with these anatomical variations.

Capsular attachment to the distal radius for extracapsular placement of pins

Abstract The aim of this study was to evaluate the anatomy of the wrist joint capsule on the distal radius. As such the extent of the joint capsule and the limits of attachment in relation to the articular surface were determined. Furthermore, the study also determined whether there was any reflection of the capsule onto the distal radius. Fifty cadaveric specimens, preserved according to Thiel’s method, were assessed. After careful dissection the distance between the chondral line of the carpal articular surface and three defined points on each of the palmar and dorsal aspects of the radius were measured. In none of the specimens was there any variation in the course and extent of the joint capsule. Using external fixators for managing fractures of the distal radius, pins and wires can be placed subchondrally close to the articular capsule. The risk of intraarticular infection, due to pin tract infection in intraarticularly positioned pins, is very low.

Anatomical study for an update comprehension of clubfoot. Part I: Bones and joints

PurposeThe aim of our study was to elucidate the gross anatomical changes of bones and joints in idiopathic clubfeet.MethodsGross dissection was carried out on seven idiopathic clubfeet of fetuses aborted between the 25th and 37th week of gestation and compared to two normal feet (27th and 36th week of gestation). Particular attention was paid to the articular surfaces, shapes and angles of all bones and their skeletal relationships.ResultsThe talar neck–trochlea angle in clubfeet ranged from 37° to 41°, in normal feet from 27° to 33°. In clubfeet the deviation of the neck of the talus relative to the body was between 28° and 43°, in normal feet between 22° and 24°. The posterior joint surface was in an anterolateral position and even flat transversely. The head of the clubfeet tali was turned along a longitudinal axis in the opposite direction compared to the normal ones. Instead of a typically saddle-shaped posterior talar surface of the calcaneus, it was triangular and flat transversely, and a bony stability in the subtalar joint was not achieved. The angle of torsion of the calcaneus showed no significant difference between normal and clubfeet. The anterior surface was flat, medially twisted and orientated upwards.ConclusionsWe presume that the calcaneus is the primary fault, which might be explained by pathologic biomechanical forces during development.

The fourth lumbrical muscle in the hand: a variation of insertion on the fifth finger

Usually the four lumbrical muscles arise from the tendons of flexor digitorum profundus and insert into the extensor expansions on the radial side of the corresponding fingers. This special case showed a very rare variation of a unipennate fourth lumbrical muscle of the right hand; the muscle fibre bundles originated on the radial side of the flexor digitorum profundus and coursed horizontal on its radial side, deep to the palmar aponeurosis and in front of the deep transverse metacarpal ligament over the fifth metacarpophalangeal joint. At the level of this joint, its tendon divided into one radial and one ulnar slips. Both heads surrounded the tendons of the flexor digitorum superficialis and profundus muscles, and found their insertion into the flexor digitorum superficialis tendon, as well as their bony attachment into the proximal and even more into the middle phalanx.

Lipoaugmentation of the Vocal Folds: A Survey on Alternative Donor Sites for Graft Harvesting

Lipoaugmentation is a treatment option for patients suffering from glottic insufficiency. Autologous fat is a nearly ideal material for vocal-fold augmentation from the view of biocompatibility and viscoelasticity, but there is still the problem of high graft resorption. As distribution and biological behavior of fatty tissue is very different in the human body, the aim of the study was to elucidate possible donor sites with respect to the quantity of harvested fat, the surgical accessibility to the region, the donor site morbidity and possibility of aesthetic defects and the quality of harvested tissue. Possible donor sites for harvesting were examined by magnetic resonance imaging in thirty-five patients with special emphasis to the buccal fat pad, the neck, the dorsolateral side of the proximal upper extremity, the subcutaneous layer of the abdominal wall, the superficial trochanteric region, the medial thigh, and the infrapatellar fat pad. Identified regions that failed to be chosen into consideration because of an elaborate surgical approach (superficial axillarys space, ischio-anal fossa, subcutaneous layer of buttock, popliteal fossa) were not taken into consideration. The mean volume of the buccal fat was 3.994 cm(3); the average thickness of the fat at the level of C7 was 1.721 cm, the mean value in the upper extremities was 1.913 cm laterally and 1.275 cm dorsally. The subcutaneous fat of the abdominal wall was divided into a superficial compartment (mean: 1.527 cm) and a deep one (average: 3.545 cm). In the superficial trochanteric region, the mean thickness was 2.536 cm, in the medial thigh 2.127 cm; the mean volume of the infrapatellar fat pad was 20.198 cm(3). All regions of interest showed reproducible and sufficient amounts of harvestable tissue, we found significant intersexual differences in dorsolateral side of the upper arm, subcutaneous layer of the abdominal wall and superficial trochanteric region. When harvesting subcutaneous tissue of the abdominal wall, grafts of the deep layer should be preferred, in the upper extremity the deep, muscle-neighbored parts. An alternative method is the surgically accessible fat of the neck. Solid fat pads could be harvested from the buccal region or the infrapatellar fat.