A cadaveric study of the morphology of the extensor hallucis longus - a proposal for a new classification.
ABSTRACT: BACKGROUND:Morphological variations of the EHL concern mainly the accessory tendons and the site of their insertion. The aim of our study is to present a new classification of the EHL. METHODS:Classical anatomical dissection was performed on 104 lower limbs (51 right, 53 left, fixed in 10% formalin solution). RESULTS:In the cadavers, three types of morphology (insertion and addidtional band) were observed. Type I, the most common type, was characterized by a single tendon that ends as an extensor hood on the dorsal aspect of the base of the distal phalanx of the big toe (57.7%). Type II was characterized by two distal tendons and was subdivided into three subtypes according to (A-29.9%, B-4.8% and C-5.7%). Type III was characterised by three distal tendons (two cases - 1.9%). CONCLUSION:The EHL presents high morphological variability. Knowledge of particular types of insertion is essential for both clinicians and anatomists.
Project description:Adhesion of the flexor hallucis longus (FHL) muscle to the distal tibia can occur after distal tibial fracture, distal fibular fracture, low tibial osteotomy, soft-tissue injury at the posterior ankle, subclinical compartment syndrome of the distal deep posterior compartment of the leg, or Volkmann contracture after deep posterior compartment syndrome of the leg. The purpose of this Technical Note is to report the endoscopic approach of FHL muscle adhesiolysis. It is indicated in patients with symptomatic adhesion of the FHL muscle and contraindicated if there is entrapment of the FHL muscle or tendon in the fracture callus or if there is extensive fibrosis and contracture of the FHL muscle as a result of Volkmann contracture after deep posterior compartment syndrome of the leg.
Project description:In the treatment of Gustilo Type 3B open tibial fractures, it is important to perform soft tissue reconstruction and bone reconstruction simultaneously. Gastrocnemius muscle and soleus muscle flaps are generally used as rotational flaps for the tibia. The distal third of the tibia can often not be covered with the gastrocnemius muscle and soleus muscle flaps. Treatment distal to the distal third of the tibia is difficult because fewer flap options are available. In the present report, we describe our experience with a Gustilo Type 3B open tibial fracture treated by gastrocnemius muscle and soleus muscle flaps, along with an additional proximally based flexor hallucis longus flap, which is a rare procedure.The participant was a 17-year-old male who injured his left tibia in a motorcycle traffic accident. Physical examination revealed a wound of 13 cm × 7 cm extending from the medial lower leg to the posterior aspect, with extensive skin loss. There was no nerve or vascular injury. The tibia was exposed, with detachment of the periosteum. The radiograph revealed a tibial shaft fracture. The AO/OTA classification was 42-A3.3, and it was classified as a Gustilo-Anderson Type 3B fracture. Gastrocnemius muscle and soleus muscle flaps were lifted in the area of the soft-tissue defect and then, placed over the tibia. Despite this, the distal portion of the tibia remained uncovered. Therefore, a flexor hallucis longus flap was lifted and placed over the distal portion of the tibia. On day 7 after the injury, the external fixation device was removed and the tibial shaft was fixated with two Ender nails (4.5 mm in diameter). The clinical course was satisfactory, and the skin graft and flap were successful. Bone union was achieved without infection, and the resulting range of motion was normal.For the treatment of Gustilo-Anderson Type 3B open tibial fractures, early treatment of the soft-tissue defect is vital. We surgically treated a Gustilo-Anderson Type 3B open tibial fracture with gastrocnemius muscle and soleus muscle flaps, along with an additional proximally based flexor hallucis longus flap, which is a rare procedure. In the event of a soft-tissue defect in the distal third of the tibia, the use of a proximally based flexor hallucis longus flap is an effective surgical approach.
Project description:PURPOSE:To investigate the difference between sonographic findings in extensor pollicis longus tendons rupture and other finger tendons rupture in patients sustaining hand and wrist trauma. METHODS:Twenty-four patients who presented with signs and symptoms clinically suspicious for tendon injury and surgically confirmed tendon rupture were included in this study. We analyzed 6 sonographic features: discontinuity of the tendon, pseudomass formation, decreased echogenicity of the tendon, retraction of the ruptured tendon, fluid collection within the tendon sheath, and the motion of the tendon. We compared the sonographic features of ruptured extensor pollicis longus tendons with the other ruptured finger tendons. RESULTS:Discontinuity of the tendon was the most common sonographic findings and retraction of the ruptured tendon was the second most common findings. Fourteen of 16 cases with a dynamic study on sonography showed loss of normal motion of the tendon. Pseudomass formation was the second most common feature in ruptured extensor pollicis longus tendons, in contrast to the other ruptured finger tendons (p < 0.05). CONCLUSION:Using ultrasonography, detection of discontinuity of the tendon, retraction of the ruptured tendon, and limitation of tendon motion could be very helpful for diagnosing a tendon rupture in hand and wrist trauma. Pseudomass formation could be more specific for diagnosing extensor pollicis longus tendon ruptures compared with other finger tendons.
Project description:Loose bodies of the posterior ankle can occur either at the posterior recess of the ankle or subtalar joint or at the posterior ankle extra-articular space. Loose bodies at the extra-articular space can be a result of tenosynovial chondromatosis of the tendons of the posterior ankle, especially the flexor hallucis longus tendon. Endoscopic removal of loose bodies of the posterior ankle extra-articular space is indicated for symptomatic cases that are not improved by conservative treatment. It is contraindicated if there is active infection at the planned portal sites or the surgeon is not familiar with the technique of posterior ankle endoscopy. Systematic assessment of the different parts of the posterior ankle will minimize the risk of loose body retention.
Project description:de Quervain's disease is a commonly encountered problem; its management is multimodal, and often, there is recurrence which is commonly associated with anatomical variation in the first dorsal compartment of the wrist. Our purpose was to find out the anatomical variation of the first dorsal compartment of the wrist in the general population to assess the anatomical basis of de Quervain's disease and its recurrence. In this cadaveric study, 86 wrists in 46 patients were dissected to search out the first dorsal compartment of the wrist and its content tendons, presence of septa in the compartment, and insertion of the tendons. Supernumerary tendons in the first dorsal compartment were seen in 74.41 % of cases. The most commonly found tendon arrangement was two abductor pollicis longus (APL) and one extensor pollicis brevis (EPB). In all cases, there was a fixed insertion of APL to the base of the first metacarpal. Among other sites, the most common site of insertion of APL is the trapezium, which was 56.14 %. Variations of EPB with respect to number, site of insertion, thickness, and bilaterality were also found. The presence of septations was found in 37.20 % of dissected cadaveric wrists. We had found supernumerary tendons or slips in the first dorsal compartment very commonly. The presence of a septum was less frequently found. So, it may be concluded that there is immense anatomical variation present in the first dorsal compartment of the wrist, supernumerary tendons/tendon slips are commonly found, there is a variation of insertions present in the population, septum/aberrant compartment are also present, and bilateral variations are present in the population. These variations may be responsible for recurrence and unilateral affection in de Quervain's disease.
Project description:The main objective of this study is to describe a surgical technique that combines intra- and extra-articular techniques using the semitendinosus, gracilis, and peroneus longus to perform reconstruction of the anterior cruciate ligament and anterolateral ligament. This technique offers a more stable, fast, low-cost, and widely accessible procedure and consists of drilling 3 tunnels—1 femoral and 2 tibial tunnels—in which the grafts are fixed with interference screws. The fact that the peroneus longus graft is long and thick allows for robust reconstruction of the aforementioned ligaments. Technique Video Video 1 First, the peroneus longus graft is removed. A single longitudinal incision of approximately 3 cm is made in the posterolateral region of the fibula over the peroneus longus tendon. Both peroneal tendons are then brought together in the most distal region of the incision using single sutures. After the tendons are unified with sutures, the peroneus longus tendon is incised with the aid of a tenotome and removed to its proximal insertion, up to approximately 5 cm from the fibular head, avoiding any injury to the fibular nerve. The hamstring grafts are folded to form a single quadruple graft. Subsequently, the peroneus longus tendon graft is incorporated into the hamstring grafts without folding, forming a quintuple graft in the most distal region and a single, more proximal graft comprising the remainder of the length of the peroneus tendon. Anterior cruciate ligament reconstruction is performed through anatomic positioning to create the femoral and tibial tunnels. With the aid of radioscopy, the distance halfway between the Gerdy tubercle and the anterior eminence of the fibular head is found at approximately 1.5 cm from the articular surface. The skin is marked using a surgical pen before the procedure begins. At this point, a guidewire is passed through the tibia in the anterior direction, and a bone tunnel is constructed under radioscopic visualization. The single portion of the graft is passed freely through the tibial and femoral tunnels until the quintuple graft portion occupies both tunnels. An interference screw is then fixed to the femur.
Project description:Extensor mechanism deficiency in the knee may occur due to neglected patellar and quadriceps tendons rupture or may be caused by chronic fractures of the patella. Older patients can tolerate nonunion with impaired function including extension limitation or persistent muscle weakness. In young patients, performing rigid internal fixation with reoperation should be considered when a nonunion occurs. However, delayed and neglected nonunion in patella fractures require performing different surgical procedures. We report two cases, operated for a patella fracture, in whom nonunion occurred and accompanied by patellar migration and retraction of quadriceps tendon because of a fixation failure. We reconstructed the extensor mechanism with peroneus longus tendon autograft and, owing to this method, we achieved excellent functional results during a 2-year follow-up period.
Project description:I. Experimental Design: a. Type of experiment: Time course b. Experimental factors: 3 month old mice subjected to lengthening contractions of the extensor digitorum longus muscle (EDL). Samples of EDL collected at 6 and 72 h and compared to non-treated control. c. How many hybridizations in exp: 9 d. Common reference used for all hyb: no e. Quality control steps: All arrays used from same lot. Triplicate hybridizations performed for each time point. II. Samples used, extracts, preparation and labeling: Animals. Nine male C57BL/6 mice (3-4 mo of age, 27.8 ± 3.3 g body mass, Harlan Sprague-Dawley, Indianapolis, IN). Muscle Injury. The extensor digitorum longus (EDL) muscle of six mice were exposed to lengthening contractions. Mice were anesthetized with 2% avertin (0.015 ml/kg) and supplemental doses were administered if the mouse responded to a toe pinch. Animals were placed on a plexiglass platform that was maintained at 37°C. The distal femur of the right hindlimb was fixed between screws and the foot was taped to the platform. The distal tendons of the EDL were exposed by incision and tied to the lever arm of a servomotor (Aurora Scientific, Richmond Hill ON, Canada) with 4-0 silk suture. Needle electrodes were placed adjacent to the peroneal nerve to stimulate dorsiflexor contraction (Grass Instruments, West Warwick, RI). Maximal isometric force (Po) was determined by stimulating the dorsiflexors maximally at optimum length (Lo) for force development. To induce muscle injury, 75 lengthening contractions were performed at 0.25 Hz for 5 min. For each lengthening contraction, the muscle was stimulated at 150 Hz and stretched 100 ms after the initiation of stimulation. Muscle stretch involved 20 % strain relative to Lo. Force deficit was evaluated 10 min after the 75 contractions and then the incision was closed with 7-0 silk suture. Animals were returned to their cage to recover until the time of sacrifice. Prior to sacrifice by cervical dislocation, animals were anesthetized with avertin and the EDL muscles were excised and flash frozen in liquid nitrogen. Muscles were stored in liquid nitrogen until RNA isolation. RNA Isolation. Total RNA was isolated from EDL muscles from control mice (n=3) and mice sacrificed at 6 h (n=3) and 72 h (n=3) after lengthening contractions according to the modified protocol of Chomzynski et al.. Frozen muscles were added to preweighed tubes containing TriReagent (Sigma-Aldrich, St. Louis, MO). Tissue was homogenized in TriReagent using a Tissue Tearor (Fischer, Pittsburgh, PA) at 30,000 rpm for 1 minute. Homogenates were transferred to sterile, RNAase free microcentrifuge tubes and incubated for 10 min at room temperature. Chloroform (0.2 ml; Sigma-Aldrich, St. Louis, MO) was added and after incubation, the samples were centrifuged for 15 min at 12,000 g and 4°C. Total RNA was precipitated from the aqueous phase by the addition of isopropanol (Sigma-Aldrich), and pelleted by centrifugation. Pellets were washed in ethanol (75 and 95 %) and air dried before resuspension in diethylpyrocarbonate (DEPC) treated water. RNA concentration was determined by optical density at 260 nm. III. Hybridization procedures and parameters: Microarray Hybridization and Analysis. To reduce measurement error, all membranes (Atlas mouse 1.2; Clontech, Palo Alto, CA) were prepared from the same lot. Additionally, each membrane was hybridized only once to avoid errors associated with stripping and multiple hybridizations. In order to minimize individual biological variability, total RNA was pooled from three animals for hybridization of arrays. Three arrays were used for the pooled sample at each time point. First strand cDNA probe generation from total RNA and microarray hybridization were performed according to manufacturer’s instructions (Atlas cDNA Expression Arrays User Manual, Clontech). 33P labeled cDNA was generated from sample RNA using [33P]-dATP (3000 Ci/mmol; ICN, Costa Mesa, CA) and Maloney murine leukemia virus (MMLV) reverse transcriptase (Clontech). Labeled probes were purified using nucleospin columns (Clontech). Array membranes were prehybridized in Express Hyb containing sheared Salmon testes DNA (Gibco BRL, Rockville, MD) for 30 min at 71°C in rotating hybridization tubes. Radiolabeled probe (3 x 106 cpm) was incubated in denaturing solution (Clontech) for 20 min at 71°C, after which Cot1 DNA/neutralizing solution was added and incubation continued for 10 min. The probe mixture was added to the hybridization tube and incubated with rotation overnight. Following hybridization, membranes were washed four times for 30 min in 2X saturated sodium citrate (SSC) and 1 % sodium dodecyl sulphate (SDS) at 71°C, once for 30 min in 0.1X SSC and 0.5% SDS at 71°C, and once for 5 min in 2X SSC at room temperature. Membranes were removed and immediately wrapped in plastic and exposed to a phosphor storage screen (Molecular Dynamics, Sunnyvale, CA) for four days. IV. Measurement data and specifications: Data Analysis. The membrane image was acquired using a Storm phosporimager (Molecular Dynamics) and Image Quant software. Array images were analyzed using Atlas Image 2.0 (Clontech) software to determine raw intensity levels of expression. Raw intensity data was imported into GeneSpring (Silicon Genetics, Redwood City, CA) expression analysis software. Intensity levels were normalized to the median expressed intensity on each of the arrays and averaged for the three arrays at each time point. Normalized expression levels for control arrays were established as a value of 1 and data from 6 and 72 h were expressed as fold changes relative to control. In order to simplify interpretation of the resulting dataset, a k-means cluster analysis was employed to group genes based on similarities in patterns of expression. To reduce the likelihood of false positives, the data was filtered using a criterion 2 fold change in expression prior to clustering. Miller et al. (61) have calculated that using an array of 10,000 features with a coefficient of variation (CV) of 20 percent, a 2 fold criterion for altered gene expression would result in zero false positives. The mean and median CV (15.8 and 14.3%, respectively) for all arrays in the current study fell within these guidelines for the elimination of false positives.
Project description:Trigger finger is a common well recognized condition and involves the flexor tendons at the A1 pulley in the palm. Triggering of the extensor tendons is a very rare clinical entity. We report a rare case of extensor triggering of little finger caused by constriction of the extensor digiti minimi by a markedly thickened extensor retinaculum (ER) at the wrist, well delineated dynamically by real-time high-resolution ultrasound. The patient underwent release of thickened ER and was asymptomatic immediately.
Project description:The purpose of this case report is to describe the value of musculoskeletal ultrasound (US) in diagnosing both distal intersection syndrome (DIS) and rupture of the extensor pollicis longus (EPL) tendon in the same patient. A 38-year-old female presented for evaluation of a painful bump of unknown etiology on the dorsolateral aspect of her non-dominant wrist. US demonstrated tenosynovitis distal to Lister's tubercle of the EPL and extensor carpi radialis tendon sheaths, consistent with DIS. Immobilization therapy was employed, during which time the patient suffered rupture of the EPL tendon. Follow-up US examination confirmed this additional diagnosis. Characteristic US findings of DIS and EPL tendon rupture were observed. Surgical intervention was required and the patient recovered without complication. Although EPL rupture is relatively common in the literature, DIS is rare. This is the first known case of imaging-proven DIS progressing to EPL tendon rupture. This case underscores the value of US as a widely available, cost effective, and dynamic imaging modality for evaluation of wrist complaints.