Okan Bilge

The anatomic features of the sural nerve with an emphasis on its clinical importance.

Background: The sural nerve is formed by the union of the medial and lateral cutaneous nerves of the leg that originate from the tibial and common peroneal nerves. Operative procedures and traumatic injuries to the popliteal fossa, leg, ankle and foot place the sural nerve and its branches at risk. The aim of this study was to describe the course, variations and some clinically significant relations of the sural nerve. Methods: The sural nerve was dissected in 30 lower limbs (leg-ankle-foot) of 15 cadavers. The specimens were measured, drawn and photographed. Results: In 18 specimens (60%) the sural nerve originated from the union of the medial and lateral cutaneous nerves of the leg in the upper two-thirds of the leg (classic type). The union of the medial and lateral cutaneous branches was in the distal third of the leg in three specimens (10%). The lateral cutaneous nerve was absent in five (16.7%), and the medial cutaneous nerve was absent in 2 (6.7%) specimens. In two specimens (6.7%) the nerves had separate courses. The mean distance between the most prominent part of the lateral malleolus and the sural nerve was 12.76 ± 8.79 mm. The mean distance between the tip of the lateral malleolus and sural nerve was 13.15 ± 6.88 mm. The most common distribution of the sural nerve in the foot was to the lateral side of the fifth toe (60%), followed by the lateral two and a half toes (26.7%). Conclusions: These described variations and measurements should be helpful for planning operative approaches that minimize the risk of sural nerve injury.

The Anatomic Barriers in the Coronary Sinus: Implications for Clinical Procedures

AbstractBackground: Coronary sinus (CS) catheterization is often used in cardiac resynchronization therapy. Failure to enter the CS is the most common reason for LV pacing lead implant failure. Methods: We evaluated the anatomic barriers, Thebesian and Vieussens valves, the CS and its tributaries in 52 adult human cadaver hearts. Results: The average diameter of CS ostiums was 9.47 mm. In 20 of the hearts heavier than 300 g, the average CS os diameter was 10.76 mm, whereas in the remaining hearts was 8.72 mm (p < 0.005). The Thebesian valves were observed in 35(67%) of the hearts. In 39(75%) of the hearts Vieussens valves were observed and noted that 6(11%) of them were qualitatively well developed and 33(63%) diminutive. Twenty cases (38%) had 3 vein branches, 19(37%) had 4 branches, 6(11%) had 5 branches, 6(11%) had 2 branches and 1(2%) had 6 branches between great and middle cardiac veins. The anatomic barriers in coronary sinus i.e., Thebesian and Vieussens valves and their branchings were evaluated and found optimal, suboptimal and worst for catheterization in 33, 15 and 4 Thebesian valves; 40, 8, 4 Vieussens valves, respectively. The coronary sinus tributaries between great and middle cardiac veins were found to be optimal, suboptimal and worst for catheterization in 88, 60 and 38 veins, respectively. Conclusions: Careful evaluation of anatomic barriers is important for treatment success. Thus, knowledge of these functional anatomic features and barriers allows for better utilization of the human coronary sinus for diagnostic and therapeutic purposes.

A morphometric study on the superficial palmar arch of the hand

The vascular anatomy of the hand is a complex and challenging area and has been the subject of many studies. Knowledge of the vascular patterns and diameters of the hand gained more importance with improvements in microsurgical techniques in reconstructive hand surgery. We evaluated 50 hands (26 left, 24 right) of 26 formalin preserved cadavers to determine the superficial palmar arch, its branches and contributing vessels with special attention to the diameters. The symmetry of the types was also evaluated in detail for the first time in the literature. Measurements were made with the help of a digital caliper. The diameters of the ulnar, radial and median arteries were taken at the level of the wrist while the common palmar digital arteries, hypothenar branches and the superficial palmar branch of the radial artery were measured at their origin. Two types of superficial palmar arch were found and defined as complete (43/50 hands) and incomplete arches (7/50 hands). The complete arches were divided into four subgroups and incomplete arches into three subgroups. Most cases were found at the complete AI group (17 hands). Comparison of the arterial diameters showed the ulnar artery was the dominant vessel of the palm. The diameters of the common palmar digital arteries were not different with regard to complete or incomplete arches and between both sides. It looks safe to sacrifice one of the radial or ulnar arteries in some arterial interventions including radial artery cannulation, radial forearm flap and radial or ulnar artery harvesting for bypass grafting if the arch is complete. But we still recommend the noninvasive tests like modified Allen test or Doppler ultrasonography, before performing an invasive arterial intervention. We propose the radiologists to incorporate the median artery into the Doppler dynamic test in particular the existence or the absence of anastomoses between radial and ulnar arteries.

The anatomical variations of the extensor tendons to the dorsum of the hand.

To lead a quality life, tendon repair must be performed in a trauma causing damage to the extensor tendon of the hand. The aim of this study is to study the structures that can be used as donor tendons. Fifty‐four dissected adult hands were examined to study the pattern of the extensor tendons on the dorsum of the hand. The most common distribution patterns of the extensor tendons of the fingers were as follows: a single extensor indicis proprius (EIP) tendon which inserted ulnar to the extensor digitorum (ED)‐index; a single ED‐index; a single ED‐middle; a single ED‐ring; an absent ED‐little; a double extensor digiti minimi (EDM), and a single ED‐ring to the little finger. The frequency of the number of tendons is as follows: a single (87.03%) EIP, a single ED‐index (100%), a single (92.6%) ED‐middle, a single (75.9%) ED‐ring, and an absent (68.5%) or a single (24.1%) ED‐little. A double (88.9%) EDM tendons were seen. The thickest type of juncturae tendinum (JT) is found primarily between the ring and little fingers (90%). Suitable excessive tendon and the thickest JT as donor tendon were found in the fourth intermetacarpal space. The present findings, especially the fourth intermetacarpal space, may explain why incisions on the dorsum of the hand should be large and performed with particular care. It is necessary to have a thorough understanding of the arrangements of the multiple extensor muscles and their junctural connections of the hand when tenoplasty or tendon transfer is required. Clin. Anat. 21:652–659, 2008.

The anatomical features and surgical usage of the submental artery

The skin characteristics make the submental region an available flap site for facial and intraoral reconstructions. For this reason, the anatomy of the submental region and the submental artery (SA) has gained in importance recently. The SA branches out from the facial artery at the level of superior edge of the submandibular gland. The SA runs anteromedially below the mandible and superficial to the mylohyoid muscle. It gives off some perforating branches to the overlying platysma and underlying mylohyoid muscle during its course. The terminal branches continue toward the midline, crossing the anterior belly of digastric muscle either superficially or deep, and end at the mental region in general. Some perforating arteries from the terminal branches supply the anterior belly of digastric muscle. This study aimed to describe the anatomical features of the SA and its branches to help in the preparation of submental arterial flaps.

Variations in the origin of the medial and inferior calcaneal nerves

Introduction: Entrapment of the medial heel region nerves is often mentioned as a possible cause of heel pain. Some authors have suggested that the medial and inferior calcaneal nerves may be involved in such heel pain, including plantar fasciitis, heel pain syndrome and fat pad disorders. The aim of this study was to give a detailed description of the medial heel that would determine the variability and pattern of the medial and inferior calcaneal nerves, as well as to relate these findings to the currently used incision line for tarsal tunnel, fixations of fractures with external nailing, medial displacement osteotomy and nerve blocks in podiatric medicine. Materials and methods: The origin, relationship, distribution, variability and innervation of medial and inferior calcaneal nerves were studied with the use of a 3.5 power loupe magnification for dissection of 25 adult male feet of formalin-fixed cadavers. The medial heel was found to be innervated by just one medial calcaneal nerve in 38% of the feet, by two medial calcaneal nerves in 46%, by three medial calcaneal nerves in 12% and by four medial calcaneal nerves in 4%. An origin for a medial calcaneal nerve from the medial plantar nerve was found in 46% of the feet. This nerve most often innervates the skin of the posteromedial arch. Results: In our dissection, the rate of occurrence of the medial and inferior calcaneal nerves in medial heel region was 100%. When compared with the inferior calcaneal nerve, the medial calcaneal nerve was posterior, superior and thicker. The inferior calcaneal nerve supplies deeper structures. In the majority of the cases, inferior calcaneal nerve aroused from the lateral plantar nerve, but it may also arise from the tibial nerve, sometimes in a common origin with the medial calcaneal nerve. Conclusions: Knowledge of fine anatomy of the calcaneal nerves is necessary to ensure safe surgical intervention in the medial heel region.

Duplication of the parotid duct a previously unreported anomaly

Abstract A hitherto unreported duplication of the parotid duct in a 63-year-old man is reported. The ducts were found in the right cheek during cadaver dissection. The surrounding connective tissue of the ducts was removed and a photograph was taken. These two parotid ducts were then removed and fixed in a 10% formalin solution, embedded in paraffin blocks and the sections stained with hematoxylin eosin. The histologic findings showed that both had the normal ductal columnar epithelium. There was only one parotid duct in the left cheek.

Accessory tendon slip arising from the extensor carpi ulnaris and its importance for wrist pain

OBJECTIVE The anatomical variations of the extensor carpi ulnaris (ECU) muscle can cause a functional impairment of the wrist and the little finger. The aim of this study was to determine the number, thickness and type of accessory tendon arising from the ECU. METHODS The presence of an accessory tendinous slip from the ECU muscle was examined in terms of gross appearance, size, shape, thickness, location and distribution in 54 cadaveric forearms. RESULTS The accessory slips arising from the ECU muscle were observed in three specimens (5.6%) (two left, one right). These slips ran to the ulnar side of the extensor digiti minimi tendon, originated from the head of the ECU, and ended on the extensor apparatus of the fifth finger. The mean width of the tendinous slips was 1.4±0.01 mm. CONCLUSION This anatomic variation of the ECU should be considered in diagnostic and surgical procedures involving the dorsum of the hand. Its clinical importance in the treatment of tenosynovitis and subluxation of joints is also stressed.

Oxytocin provides protection against diabetic polyneuropathy in rats.

Abstract Purpose: The aim of the present study is to investigate the protective effects of oxytocin (OT) on diabetic neuropathy (DNP) in rats. Materials and methods: Eighteen rats were used to induce diabetes using single dose streptozotocin (STZ, 60 mg/kg). Diabetic DNP was verified by electromyography (EMG) and motor function test on 21st day following STZ injection. Six rats served as naïve control group and received no drug (n = 6). Following EMG, diabetic rats were randomly divided into three groups and administered with either 1 ml/kg saline or 80 μg/kg OT or 160 μg/kg OT intraperitoneally for four weeks. Then, EMG, motor function test, biochemical analysis (plasma lipid peroxides and glutathione), histological, and immunohistochemical analysis of sciatic nerves (bax, caspase 3, caspase 9, and NGF) were performed. Results: Diabetic rats developed neuropathy, which was apparent from decreased compound muscle action potentials amplitudes and prolonged distal latency in saline-treated rats (p < 0.001) whereas 160 μg/kg OT significantly improved EMG findings. OT treatment significantly lessened the thickening of perineural fibrosis when compared with saline group (p < 0.001). Besides, OT significantly reduced plasma lipid peroxides (p < 0.05) and increased glutathione levels in diabetic rats (p < 0.001). The sciatic nerves of saline-treated rats showed considerable increase in bax, caspase 3 and caspase 8 expressions (p < 0.001) while OT treatment significantly suppressed these apoptosis markers. Also, OT improved NGF expression in diabetic rats compared to saline group. Conclusion: Present results demonstrate that OT appears to alleviate harmful effects of hyperglycemia on peripheral neurons by suppressing inflammation, oxidative stress and apoptotic pathways.

Anatomic Basis for Penis Transplantation: Cadaveric Microdissection of Penile Structures.

AbstractWe present a cadaveric dissection study to investigate the anatomic feasibility of penile transplantation. Seventeen male cadavers were dissected to reveal detailed anatomy of the dorsal neurovascular structures including dorsal arteries, superficial and deep dorsal veins, and dorsal nerves of the penis. Dorsal artery diameters showed a significant decrease from proximal to distal shaft. Dominance was observed in one side. Deep dorsal vein showed a straight course and less decrease in diameter compared to artery. Dorsal nerves showed proximal branching pattern. In a possible penile transplantation, level of harvest should be determined according to the patient and the defect, where a transgender patient will receive a total allograft and a male patient with a proximal penile defect will receive a partial shaft allograft. We designed an algorithm for different levels of penile defect and described the technique for harvest of partial and total penile transplants.