Z. Asli Aktan Ikiz

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.

A cadaver study on preserving peroneal nerves during ankle arthroscopy.

Background: Ankle arthroscopy is an important diagnostic and therapeutic procedure, but neurovascular injury remains a disadvantage. By understanding the anatomy of the superficial peroneal nerve (SPN) and deep peroneal nerve (DPN) the risk of nerve injury can be minimized. Methods: Thirty-four lower limbs from 17 cadavers were dissected to find the safest anatomical points easily during arthroscopy. Results: There was a single branch of the SPN in eight of 34 specimens (23.5%); type 1), two branches in 18 (52.9%; type 2), three branches in six (17.7%; type 3) and four branches in two specimens (5.9%; type 5) at the level of the talocrural (TC) joint. The closest SPN branch to lateral border of the TC joint was 14 ± 8.4 mm. There was no branch of the SPN or DPN medial to the extensor hallucis longus tendon in any specimen. The DPN bifurcation was 6.5 mm proximal to the TC joint in a single specimen (2.9%) and 14.5 ± 5.5 mm distal to TC joint in 26 specimens (76.5%). In four specimens (11.8%), the DPN bifurcation was at the same level with the TC joint. In three specimens (8.8%), there was no bifurcation of the DPN. Conclusions: From this study the anatomic landmarks defining the medial midline portal are safely away from the SPN and DPN and their respective branches. Clinical studies are needed to define its safety during ankle arthroscopy. Clinical Relevance: This study proves that the medial midline portal is the best portal for the anterior arthroscopic procedures.

Branching patterns of the popliteal artery and its clinical importance

PurposeThe aim of this study was to evaluate the popliteal artery branching patterns and related measurements.MethodsA cadaveric study in forty lower limbs was performed to improve the understanding of anatomy of the popliteal artery and its main branches.ResultsNormal branching of the popliteal artery was present in 36 specimens (90%). High origin of the anterior tibial artery was seen in two specimens (5%). The bifurcation was at the level of proximal border of popliteus, but the posterior tibial artery originated directly from the popliteal artery in one specimen (2.5%). Trifurcation pattern with no trunk was observed in one specimen (2.5%).ConclusionsWe believe that a review of the anatomic characteristics of the popliteal artery and its branches will be beneficial for the surgical approaches and the choice of suitable arterial graft sites.

The variations of the sensory branches of the superficial peroneal nerve course and its clinical importance

Background: Although the sensory branches of the superficial peroneal nerve (SPN) have different anatomical variations that are of clinical importance, little is known about their anatomic courses, branching patterns, or relationships to palpable osseous landmarks. 1,3 A detailed knowledge is necessary for surgical exposures about the foot and ankle, arthroscopic procedures, ankle block anesthesia, and SPN block for leg venography. Methods: Thirty lower cadaver limbs were dissected to assess the anatomic properties and the variations of the sensory branches of the SPN. Results: Three distinct branch patterns were determined. In Type 1 (63.3%), the nerve penetrated the crural fascia 80.15 ± 17.80 mm proximal to the intermalleolar line and then divided into the intermediate dorsal cutaneous nerve (IDCN) and the medial dorsal cutaneous nerve (MDCN) (classic type). In Type 2 (26.7%), the IDCN and MDCN arose independently from the SPN. In Type 3 (10%), the SPN penetrated the crural fascia 101.14 ± 70.27 mm proximal to the intermalleolar line as a single branch. This single branch had a similar course to the MDCN. Measurements in this study were obtained from palpable bony reference landmarks. Conclusion: Detailed knowledge about the SPN, IDCN, and the MDCN may decrease the damage to these nerves during operative procedures near the foot and ankle.

Anatomic variations of popliteal artery that may be a reason for entrapment

PurposeThe aim of this study was to demonstrate some anatomic variations of popliteal artery and its surrounding structures that may be important especially for popliteal artery entrapment (PAE) syndrome.MethodsA cadaveric study in 46 lower limbs was performed to improve the understanding of anatomy of the popliteal artery and its relations with surrounding structures.ResultsThe popliteal artery was lateral to the popliteal vein in four specimens (8.7%) and deep to popliteal vein in three specimens (6.5%). An aberrant accessory head of gastrocnemius was present in three specimens (6.5%). The popliteal artery and vein were tethered at the adductor magnus hiatus very tightly in one specimen (2.2%). An aberrant medial arterial course around normal medial head of gastrocnemius muscle was seen in one specimen (2.2%).ConclusionsVarious anomalous anatomic relationships between muscle and arteries in the popliteal fossa results in arterial compression. We believe that a review of the anatomic variations of the popliteal artery and its surrounding structures will be beneficial for the surgical approaches in PAE.

Human left atrial appendage anatomy and overview to its clinical significance

OBJECTIVE The left atrial appendage (LAA) is an important anatomic region since it is a source of thromboembolism in patients with atrial fibrillation. Although this anatomic and clinical relation it has received little attention until recent years. METHODS This descriptive laboratory study was performed in 56 hearts of adult formalin fixed cadavers. The morphological characteristics of LAA were recorded. The distances between the orifices of left superior pulmonary veins (LSPV), circumflex artery, left anterior descending (LAD) artery, mitral valve and LAA were also measured in this study. RESULTS The morphological appearance of the LAA was classified into two different ways. There were two types according to the first classification: slender like a crooked finger (in 73.2%) and stump-like (in 26.8%). The lobe number of LAA was two in 64.3% specimens and three in 35.7%. The types of LAA were Cactus (24%), Chicken Wing (12%), Windsock (38%) and Cauliflower (26%) according to the second classification. The LAA orifice was oval-shaped in 37.5% and round-shaped in 62.5%. The bridge on the orifice was determined in one specimen. The longest diameter of LAA orifice was 16.5±4 mm. The presence of accessory left atrial appendage was observed in one specimen. The distance between LAA orifice and oval fossa was 27.5±5.5 mm. CONCLUSION We highlighted the anatomic features of LAA and LAA orifice. LAA diameters, shape and the relation between neighboring structures in relation to atrial fibrillation and surgical approaches were discussed.

Connection types between the spinal root of the accessory nerve and the posterior roots of the C2–C6 spinal nerves

PurposeThe aim of this study was to demonstrate the connection types and frequency between the accessory nerve and the posterior roots of the C2–C6 cervical nerves.MethodsThe cranial cervical regions of 49 specimens from 27 human cadavers were used for the present study under an operating microscope.ResultsFive different connection types between the accessory nerve and the posterior roots of the cervical nerves were recorded and photographed (types A–F). One of these types was not described previously in literature (type F). All connections between the posterior roots of the C2–C6 spinal nerves and the accessory nerve were at the level of the C2 segment. Type B was the most frequently seen type in our series. One of the rootlets of the cervical posterior root joined the accessory nerve without a connection to the spinal cord in type B.ConclusionsThe clinical importance of these connections is especially noticed during the radical neck dissection as it may lead to the development of the shoulder-arm syndrome.

The distribution of the superficial peroneal nerve on the dorsum of the foot and its clinical importance in flap surgery.

Background: The superficial peroneal nerve (SPN) and its branches are at risk during surgical exposures. Our study aimed to demonstrate the distribution of the SPN on the dorsum of the foot to aid in surgical procedures close to this nerve. Methods: The SPN was dissected in 30 cadaver lower limbs (13 male and two female). Results: The variations in the distribution of the nerve were classified into seven types. Conclusion: A detailed knowledge of the branching patterns of the SPN may help to decrease iatrogenic injury to this nerve.

Anatomic characteristics of left atrium and openings of pulmonary veins.

OBJECTIVE Left atrium (LA) and left atrial pulmonary venous anatomy have clinical importance for atrial fibrillation (AF) and cardiac tumor surgery. A detailed anatomic knowledge of these structures may faciliate clinical evaluations. The aim of this study was to assess LA size and to demonstrate other anatomic features of LA with pulmonary vein openings in normal population. METHODS This descriptive laboratory study was performed in 56 hearts of adult formalin fixed cadavers. The number of pulmonary vein openings into LA was recorded. Different patterns of pulmonary vein openings were described such as common ostium and additional vein. RESULTS The roof of LA was determined as flat (75%), convex (14.3%) or concave (10.7%) in specimens. A roof pouch was present in 8.9% of specimens. The diameter of LA roof, the anteroposterior LA diameter and the LA diameter between septum and lateral wall were recorded. Thin areas on the atrial wall were observed in front of a light source around left atrial appendage orifice. Septal band was found in 7.1% of specimens. Five different patterns of pulmonary vein openings were recorded: The common arrangement, the unilateral common ostium, the unilateral additional vein, the additional vein on both side and the complex type were observed respectively in 41 specimens (73.2%), 10 specimens (17.9%), three specimens (5.4%), one specimen (1.8%) and one specimen (1.8%). CONCLUSION It is expected that the data from present study will be a guide to the clinicians during the surgical approaches or radiologic examinations of LA and pulmonary vein openings into LA.

Connections between the accessory nerve and the posterior root of the first cervical nerve

The aim of this study was to demonstrate the incidence of absence of the posterior root of the first cervical nerve, and the relation between the accessory nerve and the posterior root of the first cervical nerve in Turkish population. Dissections of the accessory nerve and the posterior root of the first cervical nerve were performed in 49 specimens from 27 formalin fixed cadavers (25 male and 2 female). The type of the connections between the accessory nerve and the posterior root of the first cervical nerve was classified into four types. Type III was the most common type in present study (30.6%). There was a connection between the accessory nerve and the posterior root of the first cervical nerve in this type. The connections demonstrated in this study are important in the etiology and surgical treatment of the spasmodic torticollis.