[Persistent Müllerian ducts syndrome: one case of late hypofertility]

We report the case of a 35-year-old patient with a syndrome of persistent Müllerian ducts (PMDS) of the female type (group A). The diagnosis was made in adulthood during an infertility workup. Clinical examination revealed an empty scrotum, a normal penis and bilateral inguinal cystic masses. The spermogram found azoospermia. Imaging using MRI and tomotensidometry found the presence of an uterus, two fallopian tubes and two inguinal positions of polycystic testes. A surgical management was performed for surgical testicular biopsy. Histological examination then found a cystic formation of multi-celled mesothelial origin, with atrophic testis Sertoli cell involution and without sperm. PMDS is a rare form of pseudo-internal hermaphroditism characterized by the presence in a man of the uterus, fallopian tubes and upper vagina with external male genitalia and virilized characters. About 200 cases are reported in the literature. The diagnosis is often made in children intraoperatively during a cure of testicular ectopia. The karyotype is 46 XY type. The pathogenesis is related to a deficiency of anti-Müllerian hormone (AMH) or tissue resistance to its action by receptor abnormalities. The regression of the Müllerian duct derivatives can give three types of PMDS : masculine type, feminine type and a transverse type. Surgical treatment is difficult but necessary because of the risk of infertility and ectopic testicular degeneration.

[Microsurgical anatomy of perforating branches of anterior communicating artery]

INTRODUCTION

The anterior communicating artery (ACoA) gives perforating branches to the optic chiasma, the hypothalamus and the corpus callosum. Perforating branches are variable (number, direction). Nevertheless, their knowledge is crucial during surgery of this area to spare injuries leading to ischemic post-operative complications.

OBJECTIVE

The objective was to update the anatomical knowledge about perforating branches of the ACoA.

METHODS

The study was led on a series of seven brains taken from human cadavers. An injection of latex neoprene was performed for every case. The region of interest was observed under operating microscope. Were examined: the length of the ACoA, its diameter, its orientation, its configuration and perforating branches (number and areas).

RESULTS

Three cases on five presented with an anatomical variation at the level of the ACoA. The average length of AcoA was 2.1 millimeters (min: 2, max: 2.2). The average diameter of the ACoA was 1.67 mm (min: 1.1, max: 2.1). The average number of perforating branches was 4.2 (min: 2, max: 6). The presence of a median artery of the corpus callosum seemed to correlated with a low number of perforating branches. Branches supplying the optic chiasma seemed to be more numerous.

Risk of sural nerve injury during lateral distal Achilles tendinoscopy: a cadaver study

BACKGROUND

The risk of damage to cutaneous sensory nerves located near portals has been evaluated for both conventional arthroscopy and extra-articular posterior ankle endoscopy. The objective of the anatomic study reported here was to assess the risk of injury to the sural nerve or lateral calcaneal nerve while using the distal lateral portal for the Achilles tendinoscopy procedure described by Vega et al. in 2008.

MATERIALS AND METHODS

We dissected the sural nerve and its branch, the lateral calcaneal nerve, of 13 human cadaver ankles in the prone position. We defined P as the point where the Achilles peritendon was opened during the distal lateral approach used for the study technique. P was adjacent to the lateral edge of the Achilles tendon, 2 cm proximal to the postero-superior edge of the calcaneal tuberosity. T was defined as the attachment site of the most lateral fibres of the Achilles tendon to the postero-superior edge of the calcaneal tuberosity. We evaluated the origin of the lateral calcaneal nerve relative to T and we measured the shortest distances separating P from the sural nerve and lateral calcaneal nerve.

RESULTS

A lateral calcaneal nerve was identified in 10 (77%) ankles and originated a mean of 39.1mm (range, 25.0-65.0mm) proximal to T. P was at a mean distance from the sural nerve of 12.3mm (range, 5.0-18.0mm) and from the lateral calcaneal nerve of 6.8mm (range, 4.0-9.0mm). The median difference between these two distances was statistically significant (P=0.002).

DISCUSSION

While using the distal lateral portal for Achilles tendinoscopy, the lateral calcaneal nerve is at greater risk for injury than is the sural nerve.

LEVEL OF EVIDENCE

Level IV. Anatomic Study.

[The conflict between obturator nerve and ovary: a cadaveric and radioanatomic study]

The aim of this study was to describe the anatomical relationships between the ovary and the obturator nerve in its intrapelvic portion. Seven embalmed cadavers were dissected; 20 MRIs were then analyzed. The main distance between the lateral pole of the ovary and the obturator nerve was 29 mm. The authors describe various etiologies responsible for obturator neuralgia. An underdiagnosed cause is gonadal hypertrophy.

[Relationships between piriformis muscle and sciatic nerve: radioanatomical study with 104 buttocks]

OBJECTIVE

The relationships between the piriformis muscle and the sciatic nerve are close and may be changing. In some cases, these relationships are the cause of a piriformis syndrome, an under-diagnosed etiology of non discal sciatica. The aim of the study was to explore, by the MRI, the sciatic nerve and the piriformis muscle. MATERIELS AND METHODS: One hundred and four buttocks were explored by MRI for 52 randomly selected patients.

RESULTS

In 59.6% of cases, no variation of the piriformis muscle and sciatic nerve were found. In 26% of cases, the sciatic nerve was divided into the pelvis. In 9.6% of cases, it was divided into the pelvis, the piriformis muscle was bifid and the common peroneal nerve ran between both heads. The piriformis muscle was bifid in 10.6% of cases, hypertrophic in 13.5% of cases and atrophic in 2.9% of cases.

Position of the anterior branch of the axillary nerve in relation to the humeral bone length

Many studies have attempted to define a safety zone for the axillary nerve in lateral approaches to the deltoid, but with varying results. The main objective of our study was to analyze the variations in the position of this nerve, especially in relation to the length of the humerus. Overall, 16 cadaveric shoulders were dissected. The distances between both the anterolateral edge of the acromin (anterior distance) and the lateral edge of the acromion (posterior distance) to the axillary nerve were measured; the length of the humerus was also measured. Correlation analysis was performed between each distance and the length of the humerus. The average anterior and posterior distance were 7.2 cm ± 0.84 cm and 7.9 cm ± 0.92 cm, respectively; the average length of the humerus was 30.7 cm ± 3.2 cm. A significantly high positive correlation was found between the length of the humerus and both anterior distance (P = .94), and posterior distance (P = .92). In shoulder surgery, prior measurement of the length of the humerus could predict the distance between the acromion and the axillary nerve, and determine its position.

The inter-optic course of a unique precommunicating anterior cerebral artery with aberrant origin of an ophthalmic artery: an anatomic case report

BACKGROUND AND IMPORTANCE

Some variations of the cerebral arterial circle of Willis, such as an inter-optic course of the anterior cerebral artery are exceedingly rare. Imaging of very rare anatomical features may be of interest.

CLINICAL PRESENTATION

In a 67-year-old male individual, the unique precommunicating part of the left anterior cerebral artery was found to course between both optic nerves. There was an agenesis of the right precommunicating cerebral artery. This variation was associated with an aberrant origin of the ophthalmic artery, arising from the anterior cerebral artery. The anatomic features, the possible high prevalence of associated aneurysms of the anterior communicating artery complex as well as implications for surgical planning or endovascular treatments are outlined and embryologic considerations are discussed.

CONCLUSION

To the best of our knowledge, this is a very rare illustrated case of an inter-optic course of a unique precommunicating anterior cerebral artery with aberrant origin of an ophthalmic artery.

Mid- to long-term results of revision total knee replacement using press-fit intramedullary stems with cemented femoral and tibial components

This was a retrospective analysis of the medium- to long-term results of 46 TC3 Sigma revision total knee replacements using long uncemented stems in press-fit mode.

Clinical and radiological analysis took place pre-operatively, at two years post-operatively, and at a mean follow-up of 8.5 years (4 to 12). The mean pre-operative International Knee Society (IKS) clinical score was 42 points (0 to 74), improving to 83.7 (52 to 100) by the final follow-up. The mean IKS score for function improved from 34.3 points (0 to 80) to 64.2 (15 to 100) at the final follow-up. At the final follow-up 30 knees (65.2%) had an excellent result, seven (15.2%) a good result, one (2.2%) a medium and eight (17.4%) a poor result. There were two failures, one with anteroposterior instability and one with aseptic loosening.

The TC3 revision knee system, when used with press-fit for long intramedullary stems and cemented femoral and tibial components, in both septic and aseptic revisions, results in a satisfactory clinical and radiological outcome, and has a good medium- to long-term survival rate.

Microsurgical anatomy of the anterior commissure: correlations with diffusion tensor imaging fiber tracking and clinical relevance

BACKGROUND

Detailed anatomy of the anterior commissure is unknown in the literature.

OBJECTIVE

To describe the anterior commissure with the use of a fiber dissection technique by focusing on the morphology (length and breadth of the 2 portions), the course, and the relations with neighboring fasciculi, particularly in the temporal stem.

METHODS

We dissected 8 previously frozen, formalin-fixed human brains under the operating microscope using the fiber dissection described by Klingler. Lateral, inferior, and medial approaches were made.

RESULTS

The anterior olfactive limb of the anterior commissure was sometimes absent during dissection. The cross-sectional 3-dimensional magnetic resonance rendering images showed that fibers of the anterior commissure curved laterally within the basal forebrain. The tip of the temporal limb of the anterior commissure was intermingled with other fasciculi in various directions to form a dense 3-dimensional network.

CONCLUSION

Functional anatomy and comparative anatomy are described. The anterior commissure can be involved in various pathologies such as diffuse axonal injury, schizophrenia, and cerebral tumoral dissemination.

Relationship of the lumbar lordosis angle to the abdominal aortic bifurcation and inferior vena cava confluence levels

The objective of this study is to determine the relationship of the variations of the lumbar lordosis angle (LLA) to the aortic bifurcation level and inferior vena cava (IVC) confluence level using CT angiography. A retrospective study was conducted using the data available on abdominopelvic CT angiography scans. The LLA, the level and angle of bifurcation of the aorta, the level and angle of confluence of the IVC were identified using multiplanar and 3D reconstruction. Linear regression models were fitted to the data. We interpreted 181 scans for 181 individuals having a mean age of 55 years (18-89). The most common site of aortic bifurcation was at L4-L5 disc space (34.8%) and that of vena confluence was at the upper of L5 (29.3%). The mean LLA was 34.65° (13°-77°). The mean aortic bifurcation angle was 47.43° (17°-100°) and the mean IVC confluence angle was 71.86° (30°-120°). The positions of the aortic bifurcation and venous confluence levels showed a proximal shift with an increasing LLA P < 0.001. This study showed that the level of bifurcation of the aorta and the level of confluence of the IVC may vary with the variations of the LLA.

The article critique as a problem-based teaching method for medical students early in their training: a French example using anatomy

In France, "article critique" became a particular teaching method in the second part of the medical curriculum. It approaches a reading exercise of scientific medical papers similar to that of journal club. It could be compared to reviewing a paper as performed by reviewers of a scientific journal. We studied the relevancy of that teaching method for the youngest medical students. Our questions were about the understanding and the analyzing ability of a scientific paper while students have just learned basic medical sciences as anatomy. We have included 54 "article critique" written by voluntary students in second and third years of medical cursus. All of the IMRaD structure items (introduction, materials and methods, results and discussion) were analyzed using a qualitative scale for understanding as for analyzing ability. For understanding, 89-96% was good or fair and for the analyzing ability, 93-100% was good or fair. The anatomical papers were better understood than therapeutic or paraclinical studies, but without statistical difference, except for the introduction chapter. Results for analyzing ability were various according to the subject of the papers. This teaching method could be compared to a self-learning method, but also to a problem-based learning method. For the youngest students, the lack of medical knowledge aroused the curiosity. Their enthusiasm to learn new medical subjects remained full. The authors would insist on the requirement of rigorous lessons about evidence-based medicine and IMRaD structure and on a necessary companionship of the students by the teachers.

Microsurgical anatomy of distal medial striate artery (recurrent artery of Heubner)

INTRODUCTION

In literature, many controversies exist about courses and terminology of the distal medial striate artery (DMSA) or recurrent artery first described by Heubner near 1872. The purpose of this study was to define the accurate anatomy of this artery, to help the practitioners during surgery of the anterior cerebral-anterior communicating arteries (ACA-ACoA) complex.

MATERIALS AND METHODS

20 cranial bases were examined using magnification of the surgical microscope. One half for which the internal carotid arteries and internal jugular veins were dissected, cannulated and perfused with colored silicon on fresh cadavers; the other half only with arterial injection of formalin-fixed normal adult human brains.

RESULTS

The artery arose principally from A2 segment (58%), always less than 5 mm up to downstream from ACA to ACoA junction. In 59.5% it had a recurrent course anterior to A1 segment. It terminated in one to three stems which entered the medial part of the anterior perforated substance. The DMSA was present as a single vessel in 95% of cases. Its main outer diameter was 0.7 mm and the length had an average of 24 mm.

CONCLUSION

Iatrogenic damage or occlusion leads to a mediobasal striatum infarction with important neurological deficits such as brachiofacial hemiparesis and aphasia. This artery should be routinely identified during clipping of ACoA aneurysm. Special attention in this study was given to atypical posterior course or anatomic variations such as double DMSA on a same side.

[Arteries and veins of the lateral ventricle]

Tumors of the frontal horn of the lateral ventricle (LV) are only supplied by the posteromedial choroidal artery. Tumors of the body of the LV are supplied by the same artery. Tumors of the atrium of the LV with anterior extension are supplied by both posteromedial choroidal and posterolateral arteries. Tumors of the atrium with inferior extension are supplied by both anterior choroidal artery and posterolateral choroidal arteries. Tumors of the inferior horn are only supplied by anterior choroidal artery. The tumoral venous drainage is organized with three main groups of veins: a medial group, a lateral group and a choroidal group.

[Anatomy of the periventricular white matter]

The lateral ventricle (LV) has a deep position within the cerebral hemisphere. The LV is covered by white matter with important functional role in the dominant hemisphere. Lateral wall of the frontal horn is covered by the inferior occipitofrontal fasciculus (IOFF) and its roof by the corpus callosum (CC). The body of the LV has the same cranial relationship and is covered laterally by fibers of internal capsula and arcuate fasciculus; its lower part is in relationship with the body of the fornix. The atrium of the LV is covered by the arcuate fasciculus and its lower part is covered by the IOFF and optic radiations. The inferior horn or temporal horn is covered by optic radiations in depth of middle temporal gyrus (T2). The auditive radiations crossed the optic radiations at the level of the roof of the inferior horn.

Large diameter head metal-on-metal bearings total hip arthroplasty: preliminary results

INTRODUCTION

Although the use of the metal-on-metal bearings has been validated over the long term in total hip arthroplasty (THA) for standard 28 and 32 mm diameters, and over the medium term in resurfacing procedures, the use of larger metal head size in conventional THA has not yet been extensively reported.

HYPOTHESIS

The large-diameter metal-on-metal head is beneficial in terms of implant stability without altering the result in terms of function and bone fixation compared to the standard 28 and 32 mm diameters.

OBJECTIVE

The objective was to test this hypothesis by assessing the short-term clinical and radio graphic results of a metal-on-metal large-diameter heads THA system, using cups from the resurfacing hip concept.

MATERIAL AND METHODS

We conducted a retrospective study on a continuous series of 106 uncemented acetabular cups (Durom) implanted in 102 patients (mean age, 66 years): 93 cases of primary or secondary coxarthrosis, 11 cases of aseptic osteonecrosis, one fracture of the femoral neck, and one case of rheumatoid arthritis of the hip. At 30 months of follow-up,the Harris Hip Score and the Merle d'Aubigné (PMA) score were calculated. The radiological investigation included comparison of the implant head with native head diameters, variations of acetabular center of rotation, inspection for implant migration, and search for a gap or radiolucent line.

RESULTS

The series included two post-traumatic dislocations as well as spontaneously receding tendinitis of the gluteus medius with no further recurrence. The mean Harris Hip Score improved from 49.3 preoperatively to 91.6 at the latest follow-up and the mean PMA score ranged from 12 to 17. The results were excellent for 70 cases, good for 31 cases, fair for three cases, and poor for two cases. In the last five cases, the overall results were undermined by low pain subscore,with no identifiable explanation. Restoration of the original head diameter was verified for 65 hips. No cup migration was observed. Measurement of the acetabular centre of rotation showed a mean lateralization of 1.1mm. Of the 67 immediate postoperative gaps, only two did no disappear at follow-up. Implant head diameter, cup position, and the existence of a gap were not correlated with the clinical results.

DISCUSSION

These results are comparable to 28 mm-diameter metal-on-metal heads in uncemented cups but with improved stability but without demonstrable alteration of the quality of the bone fixation. We found no mechanical or medical cause that could explain the five cases of persistent pain leading to fair or poor results. Long-term follow-up will validate these theoretical advantages in terms of wear and implant survival.

LEVEL OF EVIDENCE

IV. Retrospective series.

Anatomical background of the perforator flap based on the deep branch of the superficial circumflex iliac artery (SCIP Flap): a cadaveric study

BACKGROUND

The groin flap, based on the superficial circumflex iliac artery, was the first successful free flap. However, its popularity was lost essentially due to variable arterial anatomy. Clinical applications of perforator flap based on superficial circumflex iliac artery suggest that a dominant perforator based on his deep branch is enough to supply a large groin flap.

METHODS

Fresh cadaveric dissections were performed and the perforators of Sartorius based on the deep branch of superficial circumflex iliac artery were identified. The dominant perforator was isolated and injected selectively with methylene blue solution.

RESULTS

We performed 20 dissections of superficial circumflex iliac artery and the deep branch. We found a deep branch with 2 perforators penetrating the Sartorius muscle. The diameter of the dominant perforator of the deep branch was 0.85 mm on average and the mean injected skin area was 162 cm(2).

CONCLUSIONS

These findings are in agreement with early clinical suggestion. The dominant musculocutaneous perforator of the deep branch of superficial circumflex iliac artery provides constant and reliable blood supply to ensure a relatively large perforator groin flap.

[Endoscopic anatomy of the terminal portion of the basilar artery and its distal perforating branches]

The aim of this study was to describe and highlight the endoscopic anatomy of the tip of the basilar artery and its perforating branches. Knowledges of the anatomy are crucial for neurosurgeons to avoid pitfalls during endoscopic third ventriculostomy.

Morphometric study of the shoulder and subclavicular innervation by the intermediate and lateral branches of supraclavicular nerves

BACKGROUND

The supraclavicular (intermediate) and supra-acromial (lateral) branches of supraclavicular nerves contribute to the innervation of the thorax, shoulder, and neck. Despite their clinical and surgical interest, they are not often considered for descriptive anatomy. The goal of this work was to clarify the morphometric knowledge of these two branches and to discuss the clinical relevance of the anatomical features.

METHODS

Intermediate and lateral branches of supraclavicular nerves of 14 necks (8 embalmed cadavers) were dissected using magnifying glasses. Macroscopic parameters were measured and nerve relationships were recorded.

RESULTS

In 12 cases, the intermediate and lateral branches arose from a common trunk behind the posterior border of the sternocleidomastoideus muscle, at a mean distance of 96 mm (70-137) from the sternal angle. The intermediate branch divided into two or three secondary rami. Its most internal ramus crossed the middle third of the clavicle and its most external ramus crossed the second lateral quarter of the bone. The distance between the two farthest nerve endings of this branch was at mean of 98 mm (85-125). The mean distance of the most distal nerve ending from the clavicle was 46 mm (30-63). The lateral branch divided into two or three rami in eight cases and did not divide in six cases. Its most anterior rami crossed the trapezius muscle at a mean distance from the clavicular insertion of 17 mm (12-24). In 13 cases, these rami ended posteriorly or at the level of the anterior border of the acromion process and in 12 cases, they ended laterally or at the level of the acromion process with a mean distance 10.4 mm (0-24).

CONCLUSION

In case of deficiency of these nerves, pain or sensitive deficit can occur without motor trouble. The factors of acute or chronic injury are direct compression, nerve stretching, repetitive stresses, and direct wound. Moreover, several neck or shoulder surgical approaches are dangerous for these nerves.

The infra-optic course of the anterior cerebral arteries: an anatomic case report

Although variations of the anterior part of the cerebral arterial circle of Willis are quite well known, though some anomalies are exceedingly rare. In a 61-year-old female individual, on both sides the precommunicating parts of the anterior cerebral artery were found to course inferiorly to the ipsilateral optic nerves. This anomaly was associated with an agenesis of a left posterior communicating artery. The anatomic features, the possible high prevalence of associated aneurysms of the anterior communicating artery complex as well as implications for surgical planning or endovascular treatment are outlined and embryologic considerations and discussed.

Traitement des fractures de l’extrémité proximale de l’humérus par clou Télégraph®

PURPOSE OF THE STUDY

Many developments have been devoted to improving osteosynthesis of proximal humeral fractures, but indications remain controversial. Anterograde nailing using a locked self-stabilizing nail is an attractive conception which has provided promising results. The purpose of this study was to assess the early results observed in a series of patients treated with a first-intention Telegraph nail.

MATERIAL AND METHOD

Thirty-four patients were reviewed for a prospective clinical and radiological assessment. Mean follow-up was 13.6 months (range 3-34 months). Mean age at the time of the accident was 68 years (20-90 years). There were 24 women and 10 men: the left shoulder was fractured in 22 patients. All fractures healed within 1 to 4 months. Groups for statistical analysis were determined by type of fracture using the Neer and Duparc classifications. Qualitative functional analysis used the Constant score in comparison with the opposite side. Anatomic analysis of fracture reduction after healing was based on plain x-rays (ap view in neutral rotation) by measuring the angle of inclination of the head in relation to the diaphyseal axis (alphaF). Normal was 45 degrees; reduction was considered adequate for an alphaF angle between 30 degrees and 60 degrees. The lateral view was used to search for posterior or anterior tilt of the humeral head.

RESULTS

Necrosis of the humeral head was observed in four shoulders (11.8%). Three of them after displaced joint fractures. These cases were retained for the analysis. Considering all patients in the study, the raw mean Constant score was 62 points and the age- and sex-weighted score was 82.5%. For two- and three-fragment extra-articular fractures, the mean Constant score was 82.3% (21 shoulders); it was 89% for simple joint fractures (5 shoulders) and 79% for complex joint fractures (8 shoulders). The differential Constant scores, comparing the healthy side with the operated shoulder, showed a difference of 20 points on average (range 0-43 points). 52.9% of patients reviewed displayed mild deficit, 20.6% moderate deficit, and 26.5% major deficit. The mean alphaF angle was 38 degrees (range 0-80 degrees). Reduction was considered good in 18 shoulders with a mean Constant score of 88.7%. Reduction was considered poor in 16 shoulders with a mean Constant score of 75.6%. Four shoulders exhibited posterior tilt of the humeral head, all associated with healing in a valgus position.

DISCUSSION

The Telegraph nail provides reliable fixation for the treatment of extra-articular and simple articular fractures of the proximal humerus. Dislocated fractures are classical indications for arthroplasty, with acceptable results for a only slightly invasive procedure. The risk of osteonecrosis does not necessarily deteriorate shoulder function and secondary revision for insertion of a prosthesis is still possible. The radio-clinical correlations show the importance of reduction quality to obtain a good final clinical result. Among the nine cases of poor outcome, six were related to a misaligned callus with persistent valgus deviation of the head (alpha F<30 degrees ) and in some cases, excessive posterior tilt. The solidity and stability achieved with the Telegraph nail enabled healing in all cases of fracture in this series with immediate postoperative reduction in most. The stability being related to the quality of bone stock, primary arthroplasty remains an important indication when it appears that a solid osteosynthesis cannot be achieved.

Radiological study of the knee joint line position measured from the fibular head and proximal tibial landmarks

Restoring the joint line level is one of the surgical challenges during revision of total knee arthroplasty. The position of the tibial surface is commonly estimated by its distance to the apex of fibular head, but no study evaluating this distance accurately has been published yet. The purpose of this work was to study the distance between the knee joint line and the apex of the fibular head and the proximal tibia, particularly the tibial tuberosity. Variability with clinical data and relations with other local measurements have been evaluated on knee radiographs (an antero-posterior view, a medio-lateral view and an anteroposterior full length view) of 100 subjects (125 knees). Results showed no correlation between the joint line-fibular head apex distance and any clinical data of the patients, or any other performed measurements. Relations between tibial measurements and the sexe or the height of the subjects were noted. Besides, the review of the 25 bilateral cases did not show statistically significant side difference but the descriptive analysis showed too large discrepancies for the joint line-fibular head apex distance to be used as a landmark. We conclude that the fibular head apex cannot be used as a morphologic landmark to determine the knee joint line position. Its interest in clinical and surgical practice must be discussed.