Use of the Vertical Profunda Artery Perforator Flap to Capture the Dominant Perforator: A Cadaver Dissection and Imaging Study

Introduction While the originally described transverse profunda artery perforator (tPAP) flap is designed to capture the first profunda perforator, our group hypothesized the dominant perforator may not always be captured in this configuration. This study maps the location of dominant profunda perforators using imaging and cadaveric dissections to determine the probability of capturing dominant perforators with the transverse flap design versus the vertical PAP (vPAP) variant. Methods Fifty preoperative magnetic resonance angiogram or computed tomographic angiogram scans (100 total extremities) were examined from autologous breast reconstruction patients between 2015 and 2019. Profunda perforator characteristics that were examined included the distance from the pubic tubercle to the infragluteal fold (IGF), the distance of the perforators from the IGF, distance posterior to the gracilis, the diameter of the perforator at fascial exit, and total number of perforators present. Profunda perforator dissection was performed in 18 cadaveric extremities. Analysis included mean distance from pubic tubercle, distance posterior to the gracilis, diameter at fascial exit, and total number of perforators. Results In imaging analysis, the mean distance from the IGF to the fascial exit of all dominant perforators was 7.04 cm. The mean diameter of the dominant perforator at the fascial exit was 2.61 mm. Twenty-six thighs (26%) demonstrated dominant perforators that exited the fascia greater than 8 cm below the IGF. In cadaver dissections, the mean distance from the pubic tubercle to the fascial exit of all the dominant perforators was 10.17 cm. Nine cadaver specimens (50%) demonstrated perforators that exited the fascia greater than 8 cm below the estimated IGF. Conclusion The dominant perforator can often be missed in the traditional tPAP design. The vPAP incorporates multiple perforators with a long pedicle, excellent vessel diameter, and favorable donor-site.

Reconstruction of Bony Defects after Tumor Resection with 3D-Printed Anatomically Conforming Pelvic Prostheses through a Novel Treatment Strategy

There has been an increasing interest and enormous applications in three-dimensional (3D) printing technology and its prosthesis, driving many orthopaedic surgeons to solve the difficult problem of bony defects and explore new ways in surgery approach. However, the most urgent problem is without an effective prosthesis and standard treatment strategy. In order to resolve these problems, this study was performed to explore the use of a 3D-printed anatomically conforming pelvic prosthesis for bony defect reconstruction following tumor resection and to describe a detailed treatment flowchart and the selection of a surgical approach. Six patients aged 48-69 years who had undergone pelvic tumor resection underwent reconstruction using 3D-printed anatomically conforming pelvic prostheses according to individualized bony defects between March 2016 and June 2018. According to the Enneking and Dunham classification, two patients with region I+II tumor involvement underwent reconstruction using the pubic tubercle-anterior superior iliac spine approach and the lateral auxiliary approach and one patient with region II+III and three patients with region I+II+III tumor involvement underwent reconstruction using the pubic tubercle-posterior superior iliac spine approach. The diagnoses were chondrosarcoma and massive osteolysis. After a mean follow-up duration of 30.33 ± 9.89 months (range, 18-42), all patients were alive, without evidence of local recurrence or distant metastases. The average blood loss and blood transfusion volumes during surgery were 2500.00 ± 1461.51 ml (range, 1200-5000) and 2220.00 ± 1277.62 m l (range, 800-4080), respectively. During follow-up, the mean visual analogue scale (VAS) score decreased, and the mean Harris hip score increased. There were no signs of hip dislocation, prosthetic loosening, delayed wound healing, or periprosthetic infection. This preliminary study suggests the clinical effectiveness of 3D-printed anatomically conforming pelvic prostheses to reconstruct bony defects and provide anatomical support for pelvic organs. A new surgical approach that can be used to expose and facilitate the installation of 3D-printed prostheses and a new treatment strategy are presented. Further studies with a longer follow-up duration and larger sample size are needed to confirm these encouraging results.

Variations of the Anatomy and Bony Landmarks of Deep Circumflex Iliac Artery in a Select Kenyan Population

Background: The deep circumflex iliac artery (DCIA) is a large caliber artery which branches laterally from the external iliac artery (EIA), directly opposite the origin of the inferior epigastric artery (IEA). Population variations have been reported in its origin, length, and branching patterns. These may alter its relationship to palpable surgical landmarks such as the anterior superior iliac spine (ASIS) and the pubic tubercle (PT) which are used to locate the artery preoperatively, thus predisposing it iatrogenic injury. Despite this, there is paucity of data from the Kenyan setting. Study Design: Cross-sectional study design. Objective: To determine the variations of the anatomy and bony landmarks of the Deep circumflex iliac artery in a select Kenyan population. Methods: A total of 104 DCIA from 52 formalin fixed adult cadavers were dissected to expose the DCIA, following which its vessel of origin and distance from the ASIS and PT, relation to the inguinal ligament (IL), length and branching patterns were noted. The average of the measurements were calculated. All data were collected and analyzed using Microsoft Excel 2007 (Microsoft Corporation, Redmond, WA). Representative photos of the vessel and its variations were taken. Results: The DCIA was found to be present and bilaterally symmetrical in all cadavers. In all cases observed, it originated as a lateral branch from the EIA (100%), opposite the IEA and directly behind the IL in 98% of the cases. Its average distance from the ASIS along the IL was 7.28 ± 0.99, while it was 5.91 ± 1.03 from the pubic tubercle to its origin. Its length ranged from 3.7 cm to 9.5 cm, with an average length of 3.86 cm in the right limb and 3.67 cm in the left limb. As regards its branching patterns, in 78% of the cases, it bifurcated into the horizontal and ascending branches, in 6%, it trifurcated and in 4%, it divided into more than 3, exhibiting a fine tree-like branching (arborization). Conclusion: The DCIA in our setting exhibited variations from other settings and an increase in awareness of these variations will probably reduce future iatrogenic lesions of the DCIA and its major branches in Kenya.

Inguinal Region and Hernias

Failure of fusion of the processus vaginalis in childhood can predispose to indirect inguinal hernias. The inferior portion of the EO muscle runs between the ASIS and the pubic tubercle; as it folds underneath itself, it forms the inguinal ligament. A hernia is the protrusion of a hollow viscus through a musculoaponeurotic opening. Groin discomfort and a palpable bulge are common. Hernias should be diagnosed on the basis of signs and symptoms. Symptomatic hernias are repaired with open mesh or laparoscopic approaches. Early postoperative complications include urinary retention (1%-10%), hematoma (1%-2%), and superficial skin infection (about 1%).

Role of low-lying pubic tubercle in the development of inguinal hernia

Background: Hernia is defined as abnormal protrusion of whole or a part of a viscus through the wall that contains it. Among all external abdominal hernias, inguinal hernia is one most commonly encountered. Many factors are responsible for the formation of the inguinal hernia but, what makes a few people more susceptible to this situation is still clearly not proved. The lowness of pubic tubercle is associated with narrow origin of internal oblique muscle from lateral inguinal ligament which fails to protect the deep inguinal ring consequently lead to inguinal hernia.Methods: The study was conducted in Sardar Patel Medical College and attached hospital, Bikaner for duration of 12 months from March 2018 to February 2019. It is a case-control study with 50 cases and 50 control meeting inclusion criteria. In all patients, following parameters SS line, ST line, height, weight was recorded and evaluated.Results: The mean value of ST line in our study group is 7.37±0.182 cm which is significantly greater (p=0.0001) than the controls the mean value being 7.01±0.262 cm. In our study, 98% of cases were having ST line >7.01 cm whereas 66% of controls were ST line under 7.01 cm.Conclusions: Group of people with low lying pubic tubercle are at high risk of developing inguinal hernia.

Large pelvic tubercle in orangutans relates to the adductor longus muscle

Orangutan pelves commonly exhibit a large, projecting tubercle in the iliopubic region, historically assumed to homologous to the pubic tubercle in humans. However, it is not clear whether this tubercle is a unique feature of Pongo, or if it is anatomically homologous with the human pubic tubercle when considered as a soft tissue attachment point. To clarify this issue, we dissected orangutan and other ape cadaveric specimens to evaluate the pelvic brim soft tissues and how they may relate to the tubercle (when present). We additionally conducted a broad osteological survey of pelvic brim morphology across 28 primate genera (n = 294 specimens) to document the presence of the tubercle in primate pelves. Cadaveric dissections revealed that the tubercle is exclusively associated with the proximal attachment of the adductor longus muscle tendon in orangutans. Our osteological survey confirms that the tubercle is both constantly present and very prominent in orangutans. We observed that the tubercle is consistently situated along the pectineal line, lateral to where the pubic tubercle in humans is found, thereby making its structural homology unlikely. The osteological survey documented the tubercle at polymorphic frequencies in all hominoid taxa, though generally less protuberant than observed in Pongo. We argue that this further excludes its possibility of homology with the pubic tubercle, and that it may therefore be more appropriately be considered an adductor longus tubercle. We discuss possible functional and phylogenetic implications for this feature.