Unlock Your Hip Flexors
On the basis of anatomical and clinical studies on the vascular supply to the gracilis muscle, Williams advocated interruption of distal small arteries to the gracilis muscle 4 weeks before the muscle transposition to enhance the intramuscular anastomosis and prevent necrosis 22 , but this is not considered mandatory by other Authors (like Baeten and Cav-ina) based on their large clinical experience. The patient is placed in a modified Lloyd-Davis position with the dominant leg abducted and extended. The position of the thigh will be changed (adduct-ed) during the muscle wrapping around the anus to favour this manoeuvre. Under systemic antibiotic prophylaxis, after positioning the urinary catheter, the gracilis muscle is isolated by means of 2 or 3 longitudinal incisions on the medial surface of the thigh and the tendon is cut as distally as possible, at the medial shaft of the tibia. Attention should be paid to prevent damage of the main saphenous vein. The main vascular and nerve...
The gracilis muscle is a type 2 muscle (dominant pedicle and several minor pedicles.) It is a thin, flat muscle that lies between the adductor longus and sartorius muscle anteriorly and the semimebranosus posteriorly. The dominant pedicle is the ascending branch of medial circumflex femoral artery and venae comitantes. The length of the pedicle is 6 cm and the diameter of the artery is 1.6 mm. The minor pedicles are one or two branches of the superficial femoral artery and venae comitantes. Their length is 2 cm and the diameter is 0.5 mm.45 Patient position Supine hip and knee flexed, leg abducted. A line is drawn between the pubic tubercle and medial condyle of the femur. Since the muscle is made 2-3 cm posterior to the line, a parallel incision is made 2-3 cm posterior to this line. Identify and preserve the greater saphenous vein (anterior to the incision). Incise the fascia and identify the gracilis muscle medially and posterior to the adductor longus muscle. Divide the muscle...
Comprised of two muscles, the psoas major and iliacus. o Lesser trochanter. A Most important flexor and pre-elevator muscle of the legs medial and lateral rotation of thigh at the hip joint. B C D 3 M. iliacus. o Iliac fossa. i Lesser trochanter. A Flexion, medial and lateral rotation of thigh at the hip joint. I Femoral nerve and lumbar plexus. C 4 M. psoas major. o Bodies and transverse processes of L1-4. i Lesser trochanter. A Flexion, medial and lateral rotation of thigh at the hip joint. I Lumbar plexus. C 6 M. gluteus maximus. o Posterior, external surface of ilium, sacrum, coccyx, sacrotuberous ligament. i Iliotibial tract, gluteal tuberosity, lateral intermuscular septum, linea aspera. A Extension, lateral rotation, abduction and adduction of thigh at the hip joint. I Inferior gluteal nerve. A D E 7 M. gluteus medius. o External surface of ilium. i Greater trochanter. A Abduction, medial and lateral rotation, flexion and extension of thigh at the hip joint. I...
Functional reconstruction of muscle deficits and tendon injuries should be done immediately. Unrecoverable muscle function can be treated with tendon transfer. We favor primary tendon transfer. However, this can also be performed at a later stage of reconstruction. Delayed transfers are generally more difficult, as they have to be performed through a scarred tissue bed, and this requires additional surgical procedures and further delays patient rehabilitation and recovery. When no donor tendons are available for transfer, muscle function can be restored with functional free muscle transfer. The gracilis is the most commonly utilized muscle for functional reconstruction. Again, this can be done either primarily or at a later stage of reconstruction. We again favor primary reconstruction.
Muscle flaps are used when a moderate to large soft tissue defect is present. Although muscle flaps may be harvested with a skin component, we prefer to harvest muscle alone. This is then covered with a nonmeshed split-thickness skin graft. In the arm and elbow, the latissimus dorsi can be used as a one-stage distal pedicle rotational flap. Most other reconstructions are done with a free muscle transfer using the gracilis, rectus abdominis, latissimus dorsi, or serratus anterior. When a functional deficit is present, consideration should be given to using a functional free muscle transfer to provide both functional restoration and soft-tissue coverage. The gracilis is most commonly used for this transfer.
- Course primary afferent neurons have cell bodies in the dorsal root. Their axons ascend ipsilaterally to the nucleus gracilis and nucleus cuneatus of the medulla. From the medulla, the second-order neurons cross the midline and ascend to the contralateral thalamus, where they synapse on third-order neurons. Third-order neurons ascend to the somatosensory cortex, where they synapse on fourth-order neurons.
P The spinal cord exits the skull at the foramen magnum and ends at L1 level, giving rise to 8 cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal pairs of spinal nerves. The lumbar, sacral and coccygeal roots form the cauda equina. Useful to remember during examination C5 shoulder abduction (deltoid) C6 forearm flexion (biceps) C7 forearm extension (triceps) C8 wrist finger flexion T1 finger abduction L2 hip flexion (iliopsoas) L3 knee extension (quadriceps) L4 ankle dorsiflexion (tibialis anterior) S1 ankle plantar flexion (gastrocnemius).
Following the introduction of endoscopic techniques in almost every field of surgery, the application of the techniques in reconstructive microsurgery represents the natural evolution of this trend. Less postoperative pain, smaller scars in the donor area better visualization of the operative field with the magnified video and better hemostasis are only a few of the advantages of this technique. These advantages have been seen in a recent series of patients in which latissimus dorsi harvesting was compared between the endoscopic technique and the traditional technique.53 Successful microvascular transplantation of gracilis muscle harvested with endoscopic guidance are also described in the literature.54,55
9 100 Double gracilis 8 67 Single gracilis 8 64 Double gracilis 2 50 Single gracilis 10 56 Single gracilis 12 75 Double gracilis 10 58 Single gracilis Evaluation of the results of electrostimulated graciloplasty for total anorectal reconstruction after Miles' operation is extremely unreliable because almost all the reports deal with small series of patients, retrospectively analysed with significant variations in the technique used (double vs. single gracilis, nerve vs. muscle stimulation, the use of dif
The concept of what constitutes quality of life (QoL) is controversial (Koller & Lorenz, 2002) and whether it can be meaningfully measured even more so. The following attempt at defining QoL emphasises the difficulties in defining what most people feel they instinctively understand 'Quality of life can be defined as the individual's perception of their position in life, in relation to their goals and to the value-system which they have accepted and incorporated in to their decision-making' (Sartorius, 1993). There is a more limited concept of health-related QoL that is limited to the effects that health or its absence has on life. The World Health Organisation (WHO) has given definitions of and explained how disease can lead to impairment, which leads to disability and which in turn may lead to handicap (WHO, 1980).
In a comparative study of the effects of short-wave, microwave and ultrasonic diathermy for the treatment of hip joints, it has been found that short-wave and microwave heating (at the maximum tolerated dose) gave rise to first-degree burns in skin and subcutaneous tissue without appreciable heating of the hip joint. Ultrasound, however, produced an adequate temperature rise at the bone without skin heating (Lehmann et al. 1959).
Dementia Praecox Or, The Group of Schizophrenias. Translated by Joseph Zinkin. New York International Universities Press, 1957. Original German first published in 1911. A classic book in the field, this provides excellent descriptions of the symptoms and very interesting discussions of possible causal factors. Gottesman, Irving I. Schizophrenia Genesis The Origins ofMadness. New York W. H. Freeman, 1991. An accessible overview for both general and professional readers includes numerous first-person accounts of the experience of schizophrenia from the perspective of patients and family members. Herz, Marvin I., SamuelJ. Keith, andJohn P. Docherty. Psychosocial Treatment of Schizophrenia. New York Elsevier, 1990. This book, volume 4 in the Handbook of Schizophrenia series, examines psychosocial causes of schizophrenia and psychosocial treatment approaches. Discusses early intervention, behavior therapy and supportive living arrangements. Results of long-term outcome...
24 Subtendinous bursae of sartorius muscle. Bb. subtendineae m. sartorii. Synovial bursae between the sartorius tendon and the tendons of the gracilis and semitendinosus situated below it. E 1 Anserine bursa. B. anserina. Synovial bursa on the tibial collateral ligament below the tendons of the semitendinosus, gracilis and sartorius muscles. It occasionally communicates with the subtendinous bursa of the sartorius. A
This technique has been popularized by J. R. Urbaniak, MD in the USA who was among the first who started its application 1979, mastered the procedure and performed extensive laboratory and clinical research with vast clinical experience on more than 1500 cases. The long term follow up has demonstrated preservation of the hip joint in 85 of the cases operated prior to articular surface collapse. In patients operated after the establishment of collapse in the articular surface the procedure can delay the need for an arthroplasty up to seven years in 70 of the patients.
Holden et al. studied the effect of a spiked bushing (with a 5-mm diameter shaft) on the fixation of fascia lata graft for ACL reconstruction in a goat model. Results showed that at time 0, the spiked bushing was superior to staples. However, by 8 wk the strength of the graft was only 9 of the control value, vs 15 achieved by belt-buckle staple fixation (37). McPherson et al. (39) also used a goat model to examine the effect of a 6-mm polyethylene ligament augmentation device on ACL reconstruction, consisting of a portion of the rectus femoris tendon, prepatellar tissue, and the central one third of the patellar tendon. Tensioning was secured by attaching the ligament with a bushing
Branch passing to the iliacus muscle in the ilac fossa it lies parallel to the pelvis and anastomoses with the deep circumflex iliac artery. C 17 Anterior branch. Ramus anterior. Located on the adductor brevis it anastomoses with the medial circumflex femoral artery. B 18 Posterior branch. Ramus posterior. It is located beneath the adductor brevis. B
Tensor fascia lata, rectus femoris, gluteus medius (anterior), gluteus minimus Tensor fascia lata, rectus femoris, gluteus medius (anterior), gluteus minimus Hamstrings, gracilis, gastrocnemius Tensor fascia lata, rectus femoris, gluteus medius (anterior), gluteus minimus
The concentration of Zn in MS medium is 30 M but amounts added to culture media have often varied widely between 0.1-70 M and experimental results to demonstrate the most appropriate level are limited. When Eriksson (1965) added 15 mg l Na2ZnEDTA.2H2O (40 M Zn2+)to Haplopappus gracilis cell cultures, he obtained a 15 increase in cell dry weight which was thought to be due to the presence of zinc rather than the chelating agent. Zinc was also shown to increase growth of a rice suspension. The highest concentration tested, 520 M, resulted in the fastest rate of growth and it was suggested that zinc had increased auxin activity (see below) (Hossain et al., 1997). Zinc is required for adventitious root formation in Eucalyptus (Schwambach et al., 2005). In cassava, additional zinc promotes somatic embryogenesis and rooting (C.J.J.M Raemakers, pers. commun.). However, very high concentrations of zinc are found to be inhibitory, and the microelement has been noted to prevent root growth at a...
14 M. quadratus femoris. o Ischial tuberosity. i Intertrochanteric crest. A Lateral rotation and adduction of thigh. I Sacral plexus. A D E M. sartorius. o Anterior superior iliac spine. i Medial to tibial tuberosity. A Flexion, abduction, lateral rotation of thigh at the hip joint, flexion and medial rotation of leg at the knee joint. I Femoral nerve. C E M. quadriceps femoris. The muscle group comprising the three vasti muscles and the rec-tus femoris. I Femoral nerve. M. rectus femoris. o Anterior inferior iliac spine straight head and upper margin of acetabulum. reflected head. i Tibial tuberos-ity. A Flexion of thigh at the hip joint, extension of leg at the knee joint. B C E M. vastus lateralis. o Greater trochanter, lateral lip of linea aspera. i Quadriceps tendon. A Extension of leg at the knee joint. B C D M. vastus intermedius. o Anterior surface of femur.i Quadriceps tendon. A Extension of leg at the knee joint. B D M. pectineus. o Pecten pubis. i Pectineal line below the...
Rough double line on the posterior aspect of the femur for attachment of two vasti muscles and the short head of the biceps. Insertion of the adductors, gluteus maximus, and pectineus muscles. B 16 Pectineal line. Linea pectinea. Bony ridge extending downward from the lesser trochanter, nearly reaching the linea aspera. Gives attachment to the pectineus muscle. B
Electrostimulation can be started 2-4 weeks after the operation, when the perineal wounds have healed and the gracilis tendon is firmly sealed to the ischiat-ic bone. The electrical parameters can be programmed by a portable tele-neuroprogrammer (N-vision MEDTRONIC) according to two different protocols 25 . Table 1. Outcome after total anorectal reconstruction with dynamic (electrostimulated) gracilis neo-sphincter
16 Medial intermuscular septum of thigh. Septum intermusculare femoris mediale. Stout connective tissue layer extending from the fascia lata to the medial lip of the linea aspera between the vastus medialis, sartorius and adductor muscles. 20 Muscular lacuna. Lacuna musculorum. Compartment for passage of the iliopsoas muscle and the femoral and lateral femoral cutaneous nerves between the ilium, inguinal ligament and iliopectineal arch. E 23 Femoral triangle. Trigonum femorale. Triangle between the sartorius and adductor longus muscles and the inguinal ligament. D
Medial part of posterior funiculus coming from the lower half of the body. 15 Nucleus gracilis. Nucleus of fasciculus gracilis medial to cuneate nucleus. D 17 Cuneate nucleus. Nucleus cuneatus. Nucleus of fasciculus cuneatus lateral to the nucleus gracilis. D 20 Decussation of medial lemniscus. Decussatio lemniscorum medialium (d. sensoria). Formed by fibers of nuclei gracilis ans cuneatus, second order neurons of posterior funiculus. C D
Approximately 20 yr ago, the first reports on arthroscopic treatment of cruciate ligaments were published. The first known arthroscopically-assisted anterior cruciate ligament reconstruction was performed by Dandy in 1980 (28). He used a carbon-fiber artificial ligament, which was supplemented by an extra-articular lateral augmentation. During the last two decades, a rapid evolution of new methods has made cruciate ligament repair a well-defined science. Today, almost all cruciate ligament reconstructions are arthroscopically assisted using minimally invasive methods to minimize the surgical morbidity. The most common method is likely the use of a free central-third patellar tendon graft, which has been used for almost 20 yr, producing predictably good results. However, during the last 5-7 yr, use of hamstring tendons (semitendinosus gracilis) has gained popularity. However, it must be kept in mind that there are several unanswered questions concerning the optimal treatment of...
Surgery begins with the mobilisation of the left colon and sigmoid. The peritoneum over the lateral part of the descending colon and sigmoid colon has to be divided along the line of attachment of the peritoneum to the sigmoid colon mesentery. It can be best achieved by using electrocautery or sharp dissection with scissors. Careful preparation allows us to enter the avascular, alveolar space of the left iliac area with its structures left urethra crossing iliac common artery and vein as well as iliopsoas muscle. At this point the descending colon and sigmoid can be gently mobilised and colonic vessels separated from the urethra. Identification of the left urethra is one of the crucial points of the operation because it can be easily injured while the operation advances. The incision of the peritoneum has to be extended downward to reach the posterolateral aspect of the left side of the pelvis. On the right side the division of the peritoneum has to be carried out over aorta and right...
The greatest experience in the field was gained by Cavina et al. 9 who, in the mid-1980s, reawakened surgeons' interest in this operation and markedly modified the surgical technique. He first introduced the concept of temporary external muscle electros-timulation with the aim of preventing muscle atrophy and used both gracilis muscles, the first as a pub-orectalis sling, the other as a neo-anal sphincter. But the excellent results reported by Cavina did not overcome the scepticism of general surgeons about this operation and no other surgeons outside Italy repeated Cavina's experience for many years. The gracilis muscle is, in fact, unable to function as an anal sphincter because it cannot sustain prolonged contraction without developing fatigue and, if not stimulated for a long time, it becomes atrophic. A strong push towards wider and more reliable application of a dynamic neo-anal sphincter using the gracilis muscle in total anorectal reconstruction came from the outstanding works...
A perineal colostomy with a dynamic neo-anal sphincter using the gracilis muscle has been demonstrated to be a feasible option for selected groups of patients who are strongly motivated to dispense with abdominal colostomy, but these patients should be fully informed and aware that, apart from the possible complications, a perineal colostomy is not a new normal anus and total anorectal reconstruction cannot reproduce a fully normal anorectal function. Not only may continence be incomplete, but rectal sensation is usually lost and defecation may also be troublesome and require daily enemas.
There seems, at least in some plants, to be an interaction between iodine and light. Eriksson (1965) left KI out of his modification of MS medium, finding that it was toxic to Haplopappus gracilis cells cultured in darkness shoot production in Vitis shoot cultures kept in blue light was reduced when iodine was present in the medium (Chee, 1986), but the growth of roots on rooted shoots was increased. Chee thought that these results supported the hypothesis that iodine enhanced the destruction and or the lateral transport of IAA auxin. This seems to be inconsistent with the suggestion that I- acts mainly as a reducing agent.
Access to the front pelvic girdle, ilium, iliosacral joint and hip joint (Pfannenstiel, modified Stoppa, ilioinguinal, anterolateral, Judet, Smith-Peterson) for operating Dorsal access to the sacrum, hip joint, iliosacral joint for 4 fractures, misalignment and posttraumatic lesions in the area of the sacrum, iliosacral joint and hip joint 4 tumours, gluteal compartment syndrome 4 exposure of the sacral nerve and the sciatic nerve
Cobalamin analogues are corrinoids, which may be cobamides (which contain substitutions in the place of ribose, e.g. adeno-side) or cobinamides (which have no nucleotide at all). The analogues are relatively inert for the microbiological assay organisms Euglena gracilis and Lactobacillus leichmannii. In competitive binding assays that use HC but not pure IF as the binding protein, cobalamin analogues lead to falsely high serum cobalamin levels. HC may carry analogues to the liver for excretion in the bile. It is unclear whether they are inert or inhibit cobalamin-dependent reactions. The proportion of analogues derived from diet, gut bacteria or endogenous breakdown of cobalamins is unknown. They are present in fetal blood and tissues.
If the therapist wants to facilitate rolling from the supine into the prone position, the first part of the activity is a concentric action of the flexor chain (trunk flexors, neck flexors and hip flexors) (see O Fig. 11.2 a, b). When the patient rolls from the mid-position (see O Fig. 11.3 b) into the prone position, we see an eccentric activity of the extensor chain (trunk extensors, neck extensors and hip extensors). To facilitate this eccentric activity we should move our hands to the ischial tuberosity and posterior on the top of the shoulder to resist the extensor chain. We ask the patient to let us push him forward, but slowly.
The patient is positioned supine and the entire lower extremity is prepped so that the hip can be adducted, abducted and rotated during elevation. The initial incision for elevation of the flap may be made along the anterior, posterior or distal border of the flap. After the distal incision, identify the fascia lata below the skin. The TFL muscle can be identified after the dissection advances more proximally. Extend the anterior and posterior incision from below upward toward the anterior superior iliac spine and the border of the iliac crest. Identify the terminal branches of the lateral circumflex femoral artery 10 cm below the anterior superior iliac spine and continue to dissect deep to the rectus femoris to develop a long vascular pedicle.
The patient typically complains of severe pain in the hip and upper leg though there may also be knee, lower leg or back pain is unable to weight bear or move the hip joint and may have numbness or Anterior dislocation The femoral head is dislocated anteriorly and usually remains lateral to the obturator externus muscle or lies under the iliopsoas muscle in contact with the superior pubic ramus.
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