Manuel Llusa

The axillopectoral muscle (of Langer) report of three cases

Abstract The axillopectoral muscle, usually called Langer’s axillary arch instead of Langer’s arm arch, is a supernumerary muscle and is the principal anatomic variation of the axilla. Three cases of the muscle were observed originating from latissimus dorsi crossing over the axillary neurovascular bundle and inserting deep to the insertion of pectoralis major or into the coracoid process. Clinicians should be aware of its existence as it can give rise to different pathologies. It should be recognised and excised to expose the axillary artery and vein in patients with trauma and to perform axillary lymphadenectomy or axillary bypass. It should be considered in the differential diagnosis of axillary masses or in a history of intermittent axillary vein obstruction. If the muscle causes problems its excision should be curative.

Subclavius posticus muscle: supernumerary muscle as a potential cause for thoracic outlet syndrome.

During routine dissection a subclavius posticus muscle was found on the left side of a male cadaver. This muscle arose from the upper margin of the scapula and transverse scapular ligament, inserted in the superior side of the first rib cartilage, and was innervated by a small branch from the suprascapular nerve. The anatomical relationships of the supernumerary muscle with the brachial plexus and the subclavian artery is suggestive of a possible cause of the thoracic outlet syndrome and therefore of clinical significance. Clin. Anat. 14:55–57, 2001.

How to avoid injuries of the superior gluteal nerve.

BACKGROUND Injuries to the superior gluteal nerve are a common complication in hip replacement surgery. They can be avoided with a good anatomical knowledge of the course of the superior gluteal nerve. METHODS We dissected 29 half pelvises of adult cadavers. The distance and the angle from the entry points of branches of the superior gluteal nerve into the deep surface of the gluteus medium and minimus muscles to the midpoint of the superior border of the greater trochanter were measured. RESULTS The dissections revealed that the nerve divided into 2 branches (86.20%) or 3 branches (13.8%). The more caudal branch was responsible for innervation of the tensor fascia latae. CONCLUSIONS A 2-3-cm safe area above the greater trochanter is appropriate to prevent nerve damage.

Arteries of the scrotum: a microvascular study and its application to urethral reconstruction with scrotal flaps

To study scrotal microvascularization and apply the findings to the design of reliable skin flaps for reconstructive surgery of complex urethral or panurethral stenoses.

New surgical approach to advanced Kienböck disease: lunate replacement with pedicled vascularized scaphoid graft and radioscaphoidal partial arthrodesis.

Reconstructive procedures such as proximal row carpectomy or partial arthrodesis have been commonly proposed for advanced Kienböck disease (Lichtmann IIIB to IV). The purpose of this study is to evaluate an alternative surgical technique to advanced Kienböck disease: lunate excision and replacement with pedicled vascularized scaphoid graft and partial radioscaphoidal arthrodesis. The main advantage of the proposed intervention is to preserve mobility while not jeopardizing prime clinical outcomes such as pain. By replacing the devitalized lunate we aim at maintaining midcarpal range of motion, and preventing disease progression with carpal collapse and osteoarthritis of the wrist. Between 2002 and 2008, 13 patients of mean age 41 years (range, 25 to 57 y) were operated using this technique. The surgical act included 3 key steps. First, we excised the lunate, then, filled the generated gap with the rotated scaphoid, using it as a pedicled vascularized autograft. Finally, we performed a partial radioscaphoid arthrodesis. At the final follow-up, none of the intervened patients had pain at rest, and 6 patients could perform nonrestricted daily activities. The average postoperative range of motion in flexion/extension was 70 degrees (range, 55 to 90 degrees), 44% (range, 38% to 54%) of what could be achieved by the contralateral arm, and only 16% (range, 14% to 19%) or 25 degrees (range, 18 to 30 degrees) less than the preoperative range of motion of the same wrist. Grip strength improved by more than 30% (range, 24% to 36%). At an average follow-up of 4 years after surgery, 12 of 13 patients had no radiographic evidence of osteoarthritis or collapse of subchondral bone at the level of the new scaphocapitate joint. At follow-up evaluation, the average DASH score was 14 points (range, 6 to 20). The patients experienced a significant improvement in their functional abilities, achieving good results compared with the conventional techniques. The absence of carpal collapse and good functional results are encouraging.

Supernumerary breast on the thigh of a woman

1 Indamadar AC, Palit A, Athanikar SB, Sampagavi VV, Deshmukh NS Periocular ecthyma gangrenosum in a diabetic patient. Br J Dermatol 2003; 148 : 821. 2 Song WK, Kim YC, Park HJ, Park HJ, Cinn YW Ecthyma gangrenosum without bacteraemia in a leukaemic patient. Clin Exp Dermatol 2001; 26 : 395–397. 3 Reich HL, Williams Fadeyi D, Naik NS, Honig PJ, Yan AC Nonpseudomonal ecthyma gangrenosum. J Am Acad Dermatol 2004; 50 : S114–S117. 4 Kim HL, Kovacs MS. Diclofenac associated thrombocytopenia and neutropenia. Ann Pharmacother 1995; 29 : 713–715. 5 Jick H, Derby LE. Garcia-Rodriguez LA, Jick SS, Dean AD Nonsteroidal antiiinflammatory drugs and certain rare, serious adverse events: a cohort study. Pharmacotherapy 1993; 13 : 212–217. 6 Greene S, Su W, Muller S. Ecthyma gangrenosum: report of clinical, histopathologic, and bacteriologic aspects of eight cases. J Am Acad Dermatol 1984; 11 : 781–787.

Applied Anatomy and Surgical Approaches to the Elbow

Knowledge of the anatomy and surgical approaches is crucial to develop a surgical strategy while minimizing complications. The most widely used approaches of the elbow will be reviewed with an emphasis on how to extend the approaches if so needed and according to which exposures are best used for the most common elbow pathologies. Key aspects of neurovascular relationships are discussed to protect them during elbow surgery.

The Pathophysiology of the Osteoarthritis of the Thumb Joint Stability and Role of the Main Carpometacarpal Ligaments

Introduction: More than 16 ligaments around the joint have been described by Bettinger et al. (1999); four ligaments and the joint capsule are the main stabilizers of the trapeziometacarpal (TM) joint. These ligaments are the dorsoradial (DRL), intermetacarpal (IML), anterior oblique (AOL), and posterior oblique ligaments (POL). The importance of each of these ligaments in the stability of the TM joint is debatable. The purpose of the study was (1) to describe the anatomy and dimension of the thumb carpometacarpal (CMC) joint ligaments, (2) to assess the ligament lesions and the degree of subluxation of the CMC joint, and (3) to measure cartilage thickness in the trapezium and metacarpal and pattern of chondromalacia and osteoarthritis (OA). We investigated the role that these ligament ruptures play in the pathophysiology of the OA. Methods: Twenty-five fresh-frozen cadaver hands were dissected of all soft tissue to expose the joint capsule and ligaments of the TM joint. There were 14 male and 11 female with mean age of 67 years (range, 51-94 years). The dissection was performed under ×4.5 loupe magnification. We showed the main ligaments and also the ligament ruptures in IML, AOL or beak ligament, dorsal oblique ligament (DOL), and DRL. We described the location of the ligament tears and whether these ruptures were partial or total. The ligament ruptures and the metacarpal translation associated with these ruptures were measured (mm). Cartilage thickness in the trapezium and metacarpal of specimens was assessed. We described the degree of degenerative changes using the stanging protocol to describe visual degeneration by Koff et al. (2003). We investigated the relationship between the ligament ruptures and the area of chondromalacia and OA. Statistical analysis of data was performed with the chi-square test, and the level of significance was P < .05. Results: Seven principal ligaments of the thumb CMC joint were identified using Berger’s principles (200s1). Ligament lesions were found in all 25 specimens. Isolated rupture of the AOL was found in 7 (28%), isolated rupture of the DRL was found in 10 (40%), isolated rupture of the IML was found in 2 (8%). Combined rupture of the AOL and IML was found in 2 (8%) and combined rupture of the DRL and IML in 4 (16%) joints. The mean metacarpal displacement due to isolated rupture of the ligaments was DRL 17 mm (P = .006), AOL 11 mm, POL 0.5 mm, and IML 0.4 mm. We found 2 cases OA stage I, 7 cases OA stage II (1 IIa, 3 lib, and 3 IIc), 9 OA stage III, and 7 OA stage IV. There was a relationship between the presence of a tear in the DRL and the presence of OA in the radial quadrants (P = .032). Conclusion: These observations suggest a translation of metacarpal on trapezium in the production of arthritic lesions and support a hypothesis that pathologic joint instability could be a cause of CMC OA. This study suggests that repairing the DRL during ligament reconstruction of the CMC joint should be considered.

Macroscopic View of the Lumbar Plexus and Sacral Plexus

The motor and sensory innervation of the lower limb depends on the anterior branches of the lumbar and sacral spinal nerves. In the lumbar region, the combination of the anterior rami of spinal nerves L1 to L4 forms the lumbar plexus. Its collateral and terminal nerves are distributed through the lower region of the abdominal wall, external genitalia, anterior region of the thigh, and medial cutaneous territory of the leg and foot.