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A 55-year-old woman complained of a subcutaneous mass in her left buttock. MR images revealed an ill-defined soft tissue mass that crossed the fascia of the gluteus maximus muscle. Some surrounding edema was noted. The lesion showed some contrast uptake after administration of Gd-DTPA. An excisional biopsy revealed sarcoidosis involving both the muscle and subcutaneous tissue across the fascia, mimicking a sarcoma.
Magnetic resonance (MR) imaging has emerged as an important noninvasive diagnostic imaging technique for assessment of foot pathology. This modality, owing to its multiplanar imaging capability and inherent superiority in contrast, has been shown to be more accurate and sensitive for detection of plantar fascia pathology than any other imaging method. One of the most important and recognizable causes of heel pain is plantar fasciitis. With the exception of plantar fasciitis, there has been little emphasis on imaging other conditions that affect this important structure. The objective of this review is to demonstrate, from a perspective of MR imaging, the many different pathologic conditions that affect the plantar fascia. Included in this review will be a discussion of normal anatomy as well as entities such as acute plantar fasciitis, chronic plantar fasciitis, traumatic rupture, normal post-surgical changes, pathologic post-fasciotomy conditions, infection, and fibromatosis.
OBJECTIVE: To assess the plantar aponeurosis origin (plantar fascia) using high-resolution ultrasound. DESIGN: The sonographic appearance of the plantar fascia in asymptomatic volunteers was compared with the appearance in: (1) clinical idiopathic plantar fasciitis, (2) inflammatory arthropathy without clinically active plantar fasciitis and (3) Achilles tendon or ankle ligament injury. Patients. There were 48 asymptomatic volunteers (96 heels), 190 patients with idiopathic plantar fasciitis (297 heels), 35 with rheumatoid factor negative spondyloarthropathy (70 heels), 17 with rheumatoid arthritis (34 heels), 62 with clinical Achilles tendinitis (93 heels) and 17 with instability secondary to previous ankle ligament injury (17 heels). RESULTS: Compared with the asymptomatic volunteers, the symptomatic plantar aponeurosis demonstrated significant thickening in patients with clinically unilateral (P<0.001) and bilateral (P<0.001) idiopathic plantar fasciitis as well as in patients with spondyloarthropathy (P<0.001). However, the plantar aponeurosis on the asymptomatic side in patients with unilateral idiopathic plantar fasciitis (P<0.2), rheumatoid arthritis (P<0.2) and ankle injury (P<0.1) demonstrated no significant thickening. In patients with idiopathic plantar fasciitis, abnormal plantar aponeurosis echogenicity was seen in 78% and subcalcaneal bone spurs in 24%. Peritendinous edema was present in 5% of all symptomatic heels, subcalcaneal bone erosion in 4% and intratendinous calcification in 3% of heels. Retrocalcaneal bursitis was present in 7% of patients with idiopathic plantar fasciitis, 40% with spondyloarthropathy and 19% with rheumatoid arthritis. CONCLUSION: Ultrasound allows confirmation of the clinical diagnosis in plantar fasciitis and may provide information as to its etiology.
The aim was to study the influence of mesorectal volume, as estimated by magnetic resonance imaging (MRI), that is to be removed during total mesorectal excision (TME), on the accuracy of the first preoperative MRI of rectal cancer compared to histopathology, and its correlation to locoregional prognostic factors. A total of 267 rectal cancer patients from a multinational study (MERCURY or MRI equivalence study) had their mesorectal volume retrospectively estimated by researchers without knowledge of the assessments made by the radiologist or the pathologist. The evaluations made by the pathologist and the radiologist were then compared, including T- and N-staging, assessment of extent of extramural tumor invasion (the largest portion of the tumor beyond the muscularis propria or EMI) and distance to mesorectal fascia; the discrepancies in the results were correlated to the mesorectal volume. T- or N-staging accuracy by MRI and the difference between the EMI as measured by the pathologist and the radiologist were not dependent on individual mesorectal volume. There was no correlation between assessment of involvement of mesorectal fascia or local neighboring organs by MRI and histopathology with mesorectal volume. Mesorectal volume does not affect locoregional prognostic factors or the accuracy of local staging of rectal cancer.
The purpose of this study is to compare primary repair procedure with those that use bio-concordant materials in the treatment of urethrocutaneous fistula. Twenty-five New Zealand rabbits were randomly placed into five groups (primary repair, free graft, allograft fascia lata, alloderm and bovine pericardium repair groups). A single dose of 20 mg/kg of ceftriaxon was applied intramuscularly as a prophylactic dose. Urethrocutaneous fistula was formed on midpenile level. Later, while primary repair was applied in one group, repair with free grafts and with other bio-concordant materials were performed in other groups. Urinary diversion was not used in any of the rabbits. The macroscopic observation was evaluated with urethrography obtained 21 days after the operation and then the rabbits were sacrificed. A total point was obtained by awarding a point to each good parameter in the histopathological evaluation and all the groups were compared. The urethrographic findings and macroscopic examinations were normal in all groups. In histopathological examinations, ranging from the best to worst results, bovine pericardium group (8 points) had a better total score than primary repair group (7 points), allograft fascia lata group (7 points) and alloderm group (7 points). The free graft group had the worst total point (6 points). Bio-concordant materials can be used in urethrocutaneous fistula repair as an alternative to primary repair or to the grafts obtained from body tissues.
BACKGROUND: One criticism of laparoscopic ventral hernia repair (LVH) is that the rectus muscles are not re-approximated to the midline, and the effect of LVH repair on the fascial edges is unclear. Progressive migration of the fascial edges toward the midline has been observed anecdotally, but objective evidence remains limited. The purpose of this study is to observe the effect of LVH repair on the rectus abdominus fascia. METHODS: Patients undergoing LVH repair with defects > 10 cm in horizontal diameter were identified prospectively and enrolled. All were repaired laparoscopically with intraperitoneal placement of mesh (DualMesh, W.L. Gore and Associates) using a standard approach. Radio-opaque clips were placed at the fascial edges intraoperatively to mark the defect, and plain abdominal films were taken postoperatively (Time 1) to establish the initial distance between clips (measured in cm). A subsequent follow-up film was taken (Time 2), and the difference in clip distance per patient was recorded. Results were analyzed using a chi-squared test. RESULTS: Twelve patients qualified for analysis and their results were compared. Mean fascial defect size was 15.1 cm (range 8.3-22.0). With respect to change in clip distance from Times 1 to 2, three events were observed: (1) Diminished (i.e. medialized), (2) Enlarged, or (3) No Change. Ten patients (83%) medialized, one patient enlarged, and one patient showed no change (chi2 (d.f. = 2) 9.17, p < 0.0023). CONCLUSIONS: Medialization of the rectus abdominus fascia occurs in the majority of patients undergoing LVH repair. Causes for this phenomenon are unclear: however eliminating intrabdominal pressure with intraperitoneal mesh placement likely plays a role.
Dupuytren's disease sometimes seems to arise from the tendon of abductor digiti minimi or the fascia overlying it. The normal anatomy of these structures is described and the tendon is shown to be of central importance in the organisation of the digital fascia. In particular, its connections with the superficial transverse palmar ligament, Grayson's ligaments and the digital band are demonstrated.
After complete elongation using the continuous extension technique the palmar fascia of four patients with Dupuytren's contracture was examined by light and electron microscopy and compared with non-elongated samples from 20 patients at the same clinical stage of the disease. Nodules and cords were no longer clinically recognizable after extension. The tissue contained collagen fibrils of uniform diameter (about 50 nm), densely packed in fibres parallel to the stretching force. Fine filaments (presumably proteoglycans) formed a network which was intermingled with and periodically bound to the collagen fibrils. Fibroblasts and myofibroblasts with an high biosynthetic activity and oxytalan-like microfibrils were aligned along the collagen fibres. The results show that in Dupuytren's disease the contracted palmar fascia reacts to external forces with neoformation and reorientation of all tissue components by myofibroblasts.
Recent experimental evidence implicates various growth factors in the pathophysiology of Dupuytren's disease. This study describes a technique to produce an in vitro cell culture system from both normal palmar fascia and Dupuytren's fascia. The cells were separately exposed to basic fibroblast growth factor (bFGF), transforming growth factor beta (TGF-beta), and platelet-derived growth factor (PDGF), after which the effects of these growth factors on proliferation rate and collagen production were determined. Basic FGF and PDGF were found to be mitogenic for both cell types, and TGF-beta was a potent stimulator of collagen production for both cell types. There were quantitative and qualitative differences between the cell types, with Dupuytren cells being more metabolically active and more sensitive to the growth factors tested. We present a theoretical model based on previous investigations and incorporating the contribution of growth factors as it relates to the pathophysiology of Dupuytren's disease.
OBJECTIVE: The study was undertaken to further define the anatomy of the arcus tendineus fascia pelvis (ATFP). STUDY DESIGN: Thirty cadavers were dissected to find the average length, SD, and range of the ATFP. Comparisons were made to height and pelvis type. The average distance between the ischial spine and the attachment of the fascia of the rectovaginal septum (RVF) to the ATFP was measured. RESULTS: The average length, SD, and range in centimeters for the ATFP are 9.0, 0.70, and 7 to 10.5, respectively. The length of the ATFP increased with height. No associations could be made regarding pelvis type. The average distance between the ischial spine and the attachment of the RVF to the ATFP is 2.15 cm with a SD and range of 0.21 and 1.75 to 2.5, respectively. CONCLUSION: In this study, an average length for the ATFP is established and the distance between the ischial spine and the attachment of the RVF to the ATFP is redefined.
The use of tensor fasciae latae was first described as a rotation or island flap and evolved into a free flap in the late 1970s. This series of 85 patients undergoing free tensor fasciae latae transfer includes complex head and neck, abdominal wall and lower limb reconstruction. The overall success rate was 93% (79 patients), partial flap loss, 5% (four cases), and flap failure, 2% (two patients). Twelve patients (14%) required unplanned return to theatre for exploration resulting in a 75% salvage rate. We believe this series demonstrates the great versatility of this flap and highlights particular indications for its use.
Using immunofluorescence histochemistry and immunoelectron microscopy on sections through myocardiac tissues of diverse mammalian (human, cow, rat, mouse) and fish species we show that both desmosomal and fascia adhaerens proteins identified by gel electrophoresis and immunoblot occur in the area composita, the by far major type of plaque-bearing junctions of the intercalated disks (IDs) connecting cardiomyocytes. Specifically, we demonstrate that desmoplakin and the other desmosomal proteins occur in these junctions, together with N-cadherin, cadherin-11, alpha- and beta-catenin as well as vinculin, afadin and proteins p120(ctn), ARVCF, p0071, and ZO-1, suggestive of colocalization. We conclude that the predominant type of adhering junction present in IDs is a junction sui generis, termed area composita, that is characterized by an unusually high molecular complexity and an intimate association of molecules of both ensembles, the desmosomal one and the fascia adhaerens category. We discuss possible myocardium-specific, complex-forming interactions between members of the two ensembles and the relevance of our findings for the formation and functioning of the heart and for the understanding of hereditary and other cardiomyopathies. We further propose to use this highly characteristic area composita ensemble of molecules as cardiomyocyte markers for the monitoring of cardiomyogenesis, cardiomyocyte regeneration and possible cardiomyocyte differentiation from mesenchymal stem cells.
OBJECTIVE: To evaluate pathomorphologic changes of the levator ani muscle, endopelvic fascia, and urethra in women with stress urinary incontinence (SUI) by MRI. STUDY DESIGN: Fifty-four women with SUI were examined by MRI (1.5T): body phased-array coil, axial and coronal proton-density-weighted sequences. RESULTS: The urethral sphincter muscle showed a reduced thickness of its posterior portion (37%), an omega shape (13%) or higher signal intensity (50%); its abnormal configuration was associated with an increased signal intensity in 70% (p=0.001). The levator ani muscle comprised an unilateral loss of substance in 30%, a higher signal intensity in 28%, and altered origin in 19%. Central defects of the endopelvic fascia were present in 39% (n=21), lateral defects in 46%. There was a significant association between loss of the symphyseal concavity of the anterior vaginal wall and lateral fascial defects (p=0.001) and levator ani changes (p=0.016). CONCLUSION: MRI yields findings supporting current theories on the pathogenesis of SUI.
PURPOSE: There is no agreement on the ideal treatment of traumatic radioulnar synostosis, especially the type of interposition material to be used. The purpose of this study is to report our experience with synostosis resection and interposition of tensor fascia lata grafts. METHODS: A chart review was conducted for all patients treated for posttraumatic radioulnar synostosis between 2000 and 2004. Demographic data, mechanism of injury, length of time to synostosis resection, range-of-motion, patient satisfaction, and postoperative complications were analyzed. RESULTS: Thirteen patients were identified for this study. The mean preoperative pronation was 14 degrees and the mean postoperative pronation was 62 degrees. The mean preoperative supination was 4 degrees and the mean postoperative supination was 62 degrees. The mean follow-up time was 30 months. CONCLUSIONS: These results indicate that synostosis resection with tensor fascia lata graft interposition is an effective technique for the treatment of posttraumatic radioulnar synostosis. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.
Options to bridge biceps tendon defects which have been described in the literature include fascia lata, semitendinosus tendon, flexor carpi radialis, Achilles tendon-calcaneus composite allografts and Achilles tendon allografts. In this study, the author reports the use of the upper arm fascia. This option is considered most suitable for patients who require simultaneous pedicled latissimus dorsi flap coverage of concurrent traumatic complex anterior elbow defects.
BACKGROUND AND OBJECTIVE: Patients who require surgery for chronic otitis media with perforation and cholesteatoma frequently provide no residual tympanic membrane that is usable in grafting procedures. A novel technique of total tympanic membrane reconstruction (TTMR) is described that maximizes perforation closure rate in these situations while minimizing mucosalization, incomplete healing, and anterior blunting. The specific aim of this report is to assess the safety and efficacy of TTMR and to compare the results obtained with AlloDerm compared with temporalis fascia as a grafting material. METHODS: The records of 50 patients operated within the years 1999 and the 2004 were reviewed. TTMR with intact canal wall was performed in all cases. Both clinical and audiometric data were analyzed. RESULTS: Overall perforation closure rate was 92%. There was no statistical significance in closure rate when grafting with AlloDerm versus temporalis fascia. A statistically significant shortened healing time was observed with AlloDerm grafting. CONCLUSIONS: TTMR is a highly effective and safe technique.
OBJECTIVES: The technique and outcomes of patients treated with allografts or autografts as pubovaginal sling are compared. METHODS: Fascia lata was included among the tissues harvested from brain-dead patients considered for multiple organ donation. After informed consent, segments of allograft (group A) cadaveric fascia lata autografts (group B) were compared with used for sling operations in 60 women from 37 to 73 years of age (mean 53.4 years), who presented with stress incontinence requiring a pubovaginal sling. RESULTS: At a mean follow-up of 36 months (range = 22 to 44 months), 40% of group A patients were cured and 28% were improved. At a mean follow-up of 33 months (range = 24 to 41) 70% of group B patients were cured and 20% improved (P <.05). There were no adverse outcomes of sling erosion or infection in either group. Placement of allograft sling took an average of 62 minutes while the mean duration of sling placement requiring fascial harvest was 81 minutes (P <.05). The mean duration of hospital stay was shorter in the allograft (1.25 days) than the autograft (2.48 days) group (P <.05). CONCLUSION: Use of allografts was associated with a shorter operative time and duration of hospital stay compared to an autograft, but the 3-year continence rate was lower in the autograft group.
Contrary to the accepted understanding that visibility of the perirenal fascia at urography is a rare finding and when seen is usually associated with renal pathology, a recent report has suggested that it is a fairly common, normal finding. In a retrospective study, 261 unselected intravenous urograms performed over a 3-month period were analysed. The findings indicate a low incidence of perirenal fascia visualisation and, when present, an association with renal pathology.