Unlock Your Hip Flexors

Unlock Your Hip Flexors

Unlock Your Hip Flexors is a program that gives the user a practical, easy-to-follow, natural method of releasing tight hip Flexors. Its aim is to help the user get the desired result within 60 days at 10-15 minutes per day. Naturally, the hip flexors are not meant to be tight. When they become tight, the user needs a way to make them loosen up. Unlock Your Hip Flexor has been programmed in such a way that it will help the user in doing just that. The plan was not created to be a quick fix. In fact, it will take the user close to 60 days to solve this problem and it is hard; yet the easiest as well the only that have been known to successfully help in the loosening of tightened hip flexors. The methods employed in this program are natural ones that have been proven by many specials. The system comes with bonus E-books Unlock Your Tight Hamstrings (The Key To A Healthy Back And Perfect Posture) and The 7-Day Anti-Inflammatory Diet (Automatically Heal Your Body With The Right Foods). There various exercises that can be done at home are recorded in a video format and are so easy that you will only get a difficult one after you have agreed to proceed to the next stage. Read more here...

Unlock Your Hip Flexors Summary


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Author: Mike Westerdal
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Gracilis Muscle Transplant

Pubis Malformation

Made 22-26 , including those by Brandesky and Holschneider 27 in 24 patients, showing definite improvements in 21 Berger et al. 28 , who obtained poor results in 8 patients and Brandesky et al. 29 , who achieved improvement in 8 of 11 patients, but had poor results in myelomeningocele children. In the original method 21 , the gracilis muscle was used as a neurovascular pedicle transplant. The muscle was detached distally and freed from the surrounding tissue up to its proximal one-third, where the neural innervation from the femoral nerve joins the muscle medially. From this point the muscle was transposed to the perineum, where it surrounded the anorectum subcutaneously, then dorsally, and again anteriorly. The tendon of the gracilis muscle was then fixed to the contralateral ischial tuberosity (Fig. 31.9). Holschneider states that to obtain a good functional result, some requirements must be met. First, the gracilis muscle should be long enough so that the muscle belly and not the...

The hip joint and gluteal region

Obturator Internus

The front of the hip joint The front of the hip joint Origins of rectus femoris Iliofemoral ligament Fat pad The hip joint (Figs 46.1, 46.2 and 46.5) Capsule the capsule of the hip joint is attached above to the acetabular margin, including the transverse acetabular ligament. The capsule attaches to the femur anteriorly at the trochanteric line and to the bases of the trochanters. Posteriorly the capsule attaches to the femur at a higher level approximately 1 cm above the trochanteric crest. The capsular fibres are reflected from the lower attachment upwards on the Iliotibial tract Gracilis Synovium the synovial membrane lines the capsule of the hip joint and is reflected back along the femoral neck. It invests the ligamentum teres as a sleeve and attaches to the articular margins. A psoas bursa occurs in 10 of the population. This is an outpouching of synovial membrane through a defect in the anterior capsular wall under the psoas tendon.


Flexes, abducts, and laterally rotates thigh at hip joint, flexes and slightly medially rotates leg at knee joint after flexion Femoral nerve (L2, L3) Insertions of sartorius, gracilis, and semitendinosus fuse on the medial tibia these tendons, called the pes anserinus (goose foot), give medial support to the knee

How To Tell If You Are Lost

It is difficult to get lost in a lateral direction because you will simply run into the subcutaneous tissue lateral to the tensor fascia. It is quite possible, however, to get lost medially and put the femoral nerve at great risk. The key is the sartorius muscle, whose fibers are long and coming off of the iliac spine. It is a discrete muscle in its own fascial sheath that is easy to identify. If you do not see those fibers running from the anterior spine in a distal medial direction, but are seeing fibers only running longitudinally along the leg, then something is wrong. Once you are deep to the sartorius, you will see the longitudinal fibers of the rectus. The rectus muscle is in a discrete sheath, whose medial border protects the psoas tendon. You should see the longitudinal fibers of the rectus and the discrete sheath. If you are deep to the sartorius and you do not see them you are probably too far lateral. If you see fibers coming directly off of the proximal femur, you are...

Structures At Risk

The major structure at risk with this approach is the sciatic nerve. It is imperative that this nerve not be damaged. The nerve is fairly far medial. If the approach to the hip joint is through the external rotators along their insertion into the greater trochanter, then the nerve will be protected by those muscles as they are retracted. The nerve is easy to identify because of the loose tissue around it and because it is large and runs longitudinally, whereas all the other structures in the area run transversely.

Polyneuropathy Differential diagnosis

Sensory loss, paresthesias, or radiating pain in the medial thigh. Disability in Symptoms walking due to impaired stabilization of the hip joint. The leg is held in an Iatrogenic Hip surgery, fixation of acetabular fracture, intrapelvic surgery Laparoscopic dissection of pelvic nodes, gracilis flap, prostatectomy Hypogastric artery aneursym Metastatic cancer

Postsurgical Infections

Ideally, surgery should be judged in terms of the survival and rehabilitation of the patient, but the drama of the operation tends to overwhelm the mundane details of post-surgical management. In the pre-anesthetic era, the dazzling speed, strength, and daring of the master surgeon were displayed to good advantage in a limited range of operations. The legendary surgeon who amputated a leg at the thigh, along with two fingers of his assistant, and both testes of an observer, represented the epitome of this genre of surgery. Better authenticated heroes of this era were men like William Cheselden (1688-1752) who could perform an operation for bladder stones in less than one minute, and James Syme (1799-1870), who amputated at the hip joint in little more than 60 seconds. Surgeons were as obsessed with setting speed records as modern athletes, but their goal was the reduction of the stress, pain, and shock endured by the patient. In this context, surgical anesthesia might be seen as a...

AbCs of oPErAtiVE tEChniquES

Most arthroscopic spinal procedures are performed when the patient is in a prone position. This positioning becomes more critical when biportal access to the intervertebral disc is utilized. The available bolsters (US Medical, Paoli, PA) are comfortable and well padded. They provide ample room for the rib cage and adequate support for the patient's iliac crest and anterior superior iliac spine, thereby allowing reversal of lumbar lordosis (Fig. 9A), slight flexion of the hip joints, and widening of the dimensions of the foramen, so that the inserted instruments can be passed into the foramen and triangular working zone.

Alphabetical Listing of Muscles

Abductor digit) minimi of foot. 205 of hand, 149 Abductor hallucis, 203 Abductor pollicis brevis, 145 Abductor pollicis longus, 139 Adductor brevis. 182 Adductor hallucis, 209 Adductor longus, 181 Adductor magnus, 183 Adductor pollicis. 148 Anconeus, 118 Auricularis maximus, 164 medius. 165 minimus. 166 Gracilis, 179 lliacus. 157 lliocostalis cervicis, 74 lumborum, 74 thoracis, 74 Iliopsoas, 154 Infraspinatus. 113 Intercostales externi, 82 interni, 83 muscles, 119 muscles of the wrist, 126 flexors of the fingers, 130 extensors of the thumb, 142 muscles of the hip, 167 muscles of the anterior thigh, 174 hamstring muscles. 178 hip flexors and adductors, 184 anterior and lateral leg muscles, 190 muscles of the calf, 194 deep posterior leg muscles, 199 Mylohyoideus. 54 Palmar interossei, 153 Palmaris brevis, 144 longus, 124 Pectineus, 180 Pectoralis major, 98 minor, 99 Peroneus brevis. 201 longus. 200 tertius, 189 Piriformis. 158 Plantar interossei, 212 Plantaris, 193 Platysma, 51...

Abnormalities of the Femoral Head and Neck

Similarly, adequate development of the femoral neck is brought about by the synergetic effect of the musculature inserted at the great and small trochanters. Weakness of the abductor muscles reduces the growth stimulus to the trochanteric growth plate and femoral neck isthmus, while growth at the physeal plate is not affected. This imbalance results in the development of a thin and vertically oriented femoral neck, with coxa valga deformity. In these circumstances, spasticity of the iliopsoas muscle, which is inserted at the lesser trochanter, increases the likelihood of hip subluxation or dislocation (McKibbin 1968).

Differential diagnosis L2L4 radiculopathy

Proximal (intrapelvic) branches go to the psoas major and iliacus muscles, passing through the inguinal ligament. Motor branches go to the pectineus, sartorius and quadriceps muscles. Sensory branches to the medial aspect of the thigh, anterior medial knee, and lower leg (saphenous nerve) (see Fig. 39).

The nerves of the lower limb I

Femoral nerve Nerve to sartorius Tensor fasciae latae To vastus lateralis Psoas To vastus intermedius and rectus femoris Sartorius Intermediate cutaneous nerve of thigh (Skin of front of thigh) Rectus femoris Lacunar ligament Pubic tubercle Pectineus Pubic tubercle To pectineus Pectineus Adductor longus Femoral vein Great saphenous vein Femoral artery Saphenous nerve To vastus medialis Medial cutaneous nerve of thigh (Skin of medial thigh) Gracilis Adductor longus Pectineus Adductor brevis Anterior division Gracilis

The fractured neck of femur Fig 466

If the fracture components are not impacted the usual clinical presentation is that of shortening and external rotation of the affected limb. This occurs as the adductors, hamstrings and rectus femoris pull upwards on the distal fragment whilst piriformis, the gemelli, obturators, gluteus maximus and gravity produce lateral rotation.

Stock Solutions and Buffers

TSP buffer for virus storage 10 mM Tris-HCl, pH 8.0, 8.5 (w v) sucrose, 0.5 (v v) PEG400. Sterilize by filtration (0.2- im Sartorius Minisart RC 15). 9. MTS Cell Titer 96 AQueous reagent powder (Promega Corp., Madison, WI). Add 42 mg MTS powder to 21 mL of DPBS. Adjust to pH 6.0-6.5 with 1 M HCl if necessary. Filter-sterilize (0.2 m Sartorius). Protect from light. Store at -20 C. Stable for up to 6 mo.

Dynamic Graciloplasty

In general, two local muscles are used for intensification of the striated muscle complex, especially the external anal sphincter, the gracilis, and the gluteus muscles. With both muscles, long-term muscle contractions are difficult to maintain due to muscle fatigue. The gracilis muscle, however, is technically much easier to transfer, and most activities of daily living and even sports are still possible. The patients are able to contract the gracilis without contraction of the other adductor mucles of the thigh in a neu-rophysiological adaptation process that takes about 7-9 months and needs intensive cooperation by the child. However, the gracilis muscle is not contracted under resting conditions and can only be used to support voluntary efforts to restain defecation if the patient wishes. Therefore it replaces only the voluntary function of the external anal sphincter, not the resting pressure barrier. Unfortunately many complications with this new technique have also been...

Hans Erik Akerlund 1 Introduction

To understand the function of a biological membrane like that of chloroplast thylakoids, it is important to understand the arrangement of its different protein and lipid components. Preparations that have proven to be particularly suited for such studies are those consisting of membrane vesicles that are turned inside-out. Inside-out vesicles from the thylakoid membrane were first obtained from spinach chloroplasts by a combination of mechanical fragmentation and separation by aqueous two-phase partition (1,2). By the same or very similar procedures, inside-out thylakoid vesicles have now also been obtained from other plant sources such as pea (3), barley (4), mangrove (Avicennia marina) (5), lettuce (6), Euglena gracilis (7), cyanobacteria (8,9) and the photosynthetic bacteria Rhodopseudomonas viridis (10). Because the isolation procedure does not involve the use of detergents, the inside-out thyla-koids have a preserved membrane structure and are ideally suited for...

Complete or Near Complete Transections

Amputee Boating Accident

In addition, there were wounds of the right groin, the scrotum and the right thigh which Boyle described as the most appalling spectacle I had ever seen before in the form of a wound extending from the hip joint to within 4 inches of the knee the neck of the femur was marked by the animal's teeth. It was clear the left forearm transection required formal amputation above the elbow and the right forearm was amputated above the wrist the question of amputating the right leg at the hip was debated but considered too hazardous, and the wound was cleaned and sutured. Boyle concluded All this the heroic boy bore without a murmur After 4 days of slight fever, he steadily recovered, the amputation stumps healing gradually, and on December 25 he walked without a limp and took passage for England.10 Sharks continue to be an agent of accidental amputation as well as death, and indeed a growing factor, as the quotation heading this chapter suggests (Fig. 3.1). A recent victim near Brisbane,...

Radical vulvar surgery

Groin Labia Majora

The major portion of the bulbocavernosus, ischiocavernosus and superficial transverse perineal muscles are included in the radical vulvectomy dissection. The sartorius and adductor longus muscles represent the lateral and medial borders of the groin node dissection. The posterior border is made mostly of the pectineus, with some psoas and iliacus muscles.

Inferior Gluteal Artery

Inferior Mesenteric Circumflex Iliac

6 Adductor longus nerve 7 Adductor brevis nerve 8 Pectineus nerve 10 Sartorius nerve 11 Rectus femoris nerve Femoral nerve injury results in decreased hip flexion and leg extension due to the loss of the iliacus, rectus femoris, vastus lateralis, intermedius and medialis, and sartorius muscle function. Injury to the obturator nerve results in loss of leg adduction and pronation from loss of the adductor brevis, longus and magnus, as well as obturator externus and gracilis muscle innervation. The sciatic nerve is not usually injured during surgical procedures but can be compromised by cervical cancer spread to the lateral pelvic wall, causing significant pain. Pain, secondary to cancer or postoperative, can be controlled in the pelvis by regional anesthetic blockade of the dorsal nerve roots of T10, T11, and T12 to the uterus tubes and ovary, and S2, S3 and S4 to the remaining genital structures (see Chapter 22). One useful relationship is that between the rectus abdominis muscle and...

Table 208 Arterial Supply to the Pelvic Region and Lower Limb continued

Planter Region Blood Supply

In some places, major arteries come close enough to the body surface to be palpated. These places can be used to take a pulse, and they can serve as emergency pressure points where firm pressure can be applied to temporarily reduce arterial bleeding (fig. 20.31a). One of these points is the femoral triangle of the upper medial thigh (fig. 20.31fc, c). This is an important landmark for arterial supply, venous drainage, and innervation of the lower limb. Its boundaries are the sartorius muscle laterally, the inguinal ligament superiorly, and the adductor longus muscle medially. The femoral artery, vein, and nerve run close to the surface at this point.

Free Autogenous Muscle Transplant for Strengthening of the Levator Ani Palmaris Longus Transplant

Gracilis Muscle Transplant

Hakelius 13 and Hakelius et al. 14-16 originally described the procedure in which a graft of muscle (usually the palmaris longus, less commonly the sartorius, or extensor digitorum brevis) is first de-nervated 2 weeks before transplantation and is then The problem with this operation is similar to that of transposition of denervated gracilis muscle described by Holle et al. 19 . Scarring of the pelvic floor prevents reinnervation, and fibrosis of the regenerating muscle graft remains a critical factor for the ingrowing nerve fibers. A further problem is the degree to which the graft is prestretched. On the one hand, it is necessary to prestretch the muscle sufficiently to obtain a better angulation of the anorectal angle and to achieve a compression of the rectum from both

External Abdominal Oblique

Linea Semilunaris

Femoral Nerve Iliacus Muscle Femoral Nerve Iliacus Muscle As the inguinal ligament runs from the anterior superior spine toward the pubic tubercle, it leaves a posterior gap occupied by vessels and nerves that supply the thigh (Fig. 1.8). This gap is divided by the iliopectineal arch, a septum continuous with the iliopsoas fascia and inguinal ligament into vascular (lacuna vasorum) and muscular (lacuna musculorum) compartments. The vascular compartment contains the femoral vein and artery, and the femoral ring, whereas the muscular compartment encloses the femoral nerve and iliopsoas muscle.

Diabetic amyotrophy Bruns Garland syndrome

Diabetic amyotrophy is usually a unilateral (but can be bilateral) proximal plexopathy affecting the hip flexors, femoral nerve, and some adjacent structures. Vasculopathies, metabolic causes, or vasculitic changes have been described. A paper by Dyck (1999) summarizes the characteristic features it typically strikes elderly diabetic individuals between 36 and 76 years (median 65 years). The duration of diabetes has a median of 4.1 years (range 0-36 years), HbA1c has a median value of 7.5 (range 5-12). The CSF protein can be moderately elevated and a mild pleocytosis may occur. All except one patient of this series had type II diabetes. A clinical feature is severe weight loss before the neurologic disease. Pain is the dominant symptom, radiating into the hip or anterior thigh, and weakness and atrophy occur. Hip flexors, gluteal muscles, and quadriceps showed weakness, and adductors can be involved, demonstrating clearly that

General Anatomy of Skeletal Muscles

Antagonistic Muscle Pairs

Parallel muscles are long, straplike muscles of uniform width and parallel fascicles. They can span a great distance and shorten more than other muscle types, but they are weaker than fusiform muscles. Examples include the rectus abdominis of the abdomen, sartorius of the thigh, and zygomaticus major of the face. 4. Pennate9 muscles are feather-shaped. Their fascicles insert obliquely on a tendon that runs the length of the muscle, like the shaft of a feather. There are three types of pennate muscles unipennate, in which all fascicles approach the tendon from one side (for example, the palmar interosseous muscles of the hand and semimembranosus of the thigh) bipennate, in which fascicles approach the tendon from both sides (for example, the rectus femoris of the thigh) and multipennate, shaped like a bunch of feathers with their quills converging on a single point (for example, the deltoid of the shoulder).

Functional Outcome Following Secondary Surgery for ARM

Gracilisplasty has been a common method for secondary sphincter reconstruction. Several reports have shown a clear improvement in fecal continence in the short term 101,102 . The improvement in continence is caused by a somewhat increased resting pressure 101 and significantly increased squeeze pressure. In adults who have had gracilisplasty during childhood, the functional results are not very encouraging 32,83,84 . Fecal continence is no better, and may be worse, than in patients with only a primary reconstruction. The main functional limitation of conventional gracilisplasty is that a skeletal muscle like the gracilis muscle can contract only voluntarily. The initially increased tone of a tight muscle wrap around the anus tends to weaken with time 101 . Recently, electrically stimulated gracilisplasty has been used to improve deficient fecal continence in adult patients with ARM. The patients underwent conventional gracilisplasty followed by implantation of a muscle stimulator 103...

Anatomic considerations

Pyramidalis Muscle

Skin vascularization may be direct or indirect. Direct vessels travel along nerve fibers, between muscles and along fascial planes to enter the skin. Indirect vessels arise from named vessels as perforators of the fascia from the underlying muscle. Free flaps, which require microsurgical anastomoses, depend on the direct vascular supply. Peninsular flaps (e.g. advancement flaps) may have a well-defined blood supply or depend upon intrafascial and suprafascial blood flow through the preserved skin bridge. Island flaps (e.g. gracilis flap) require a well-defined vascular pedicle to support the indirect blood supply to the overlying skin. Certain muscles used for flaps have a single dominant vascular pedicle (e.g. epigastric vessels for the rectus abdominis) or one dominant vascular pedicle with several minor ones (e.g. the medial femoral circumflex or femoral artery for the gracilis muscle) (Figures 1 and 2). It may not therefore be possible to identify a distinct blood supply for the...

Stripping of the Tendon

The full length of the harvested tendon is usually about 30 cm (Fig. 6.38). The tendon stripper is pushed up the tendon using short strokes. The key is to keep tension on the distal end to prevent the tendon from folding over and being cut off short. There is often resistance at the muscle tendon junction, and the stripper should be rotated to slip it up along the surface of the muscle. This gives extra length. The total length of the tendon is usually 28 to 30cm. If it is shorter, then the physician has the gracilis tendon. The gracilis tendon is harvested in the same fashion.

Osteomyelitis Newborn


Osteomyelitis of the proximal end of the right femur with marked bony changes. Note the marked increase in the size of the hip joint. This again demonstrates that joint swelling may be the first indication of the development of osteomyelitis. The reason for the common involvement of joints in the neonatal period is that sinusoidal vessels, termed transphyseal vessels, connect the two separate circulatory systems seen in the bones of older children (the metaphyseal loops which derive from the diaphyseal nutrient artery and the epiphyseal vessels which course through the epiphyseal cartilage canals). With skeletal maturation the transphyseal vessels obliterate (8 to 18 months) and the epiphyseal and metaphyseal systems become totally separate.

Operative procedure

Virginal Introitus

The gracilis flap The skin is incised anteriorly down to the medial group of muscles. The sartorius muscle is identified and retracted superiorly. The gracilis tendon can now be identified distally, usually through a separate short distal incision, and the tendinous insertion divided (Figure 7). The posterior incision is made down to the muscle, taking care not to undermine perforators from the muscle to the skin or to shear the cutaneous aspect of the flap off the muscle. The flap is then elevated from distal to proximal on the thigh. One or two large perforators to the muscle are ligated distally. The main pedicle is identified entering the proximal third of the gracilis muscle in the space between the adductor longus and adductor magnus muscles (Figure 8), approximately 8-10 cm below the pubic tubercle. Once the pedicle is identified and preserved, the proximal muscle can be dissected and, if necessary, the origin from the pubic symphysis may be divided. The entire myocutaneous...

Discriminative touch joint position vibration

Dorsal Column Tract

The axons enter the spinal cord and turn upward, with no synapse (see Figure 32). Those fibers entering below spinal cord level T6 (sixth thoracic spinal segmental level) form the fasciculus gracilis, the gracile tract those entering above T6, particularly those from the upper limb, form the fasciculus cuneatus, the cuneate tract, which is situated more laterally. These tracts ascend the spinal cord between the two dorsal horns, forming the dorsal column (see Figure 32, Figure 68, and Figure 69). The first synapse in this pathway is found in two nuclei located in the lowermost part of the medulla, in the nuclei gracilis and cuneatus (see Figure 9B, Figure 40, and Figure 67C). Topographical representation, also called somatotopic organization, is maintained in these nuclei, meaning that there are distinct populations of neurons that are activated by areas of the periphery that were stimulated.

Figure 67c lower medulla crosssection

Area Postrema Anatomy Pictures

The tegmentum contains the cranial nerve nuclei, the reticular formation and the other tracts. The nuclei of CN X and CN XII, as well as the descending nucleus and tract of V, are present as before (as in the mid-medullary section, see Figure 67B). The MLF and anterolateral fibers are also in the same position. The solitary tract and nucleus are still found in the same location. The internal arcuate fibers are present at this level these are the fibers from the nuclei gracilis and cuneatus, which cross (decussate) to form the medial lemniscus (see below). These fibers usually obscure visualization of the nucleus ambiguus. Finally, the reticular formation is still present. The dorsal aspect of the medullary tegmentum is occupied by two large nuclei the nucleus cuneatus (cuneate nucleus) laterally, and the nucleus gracilis (gracile nucleus) more medially. These are found on the dorsal aspect of the medulla (see Figure 9B and Figure 40). These nuclei are the synaptic stations of the...

Traumatic Avulsion at the Shoulder and

Admitted to hospital severely shocked, the whole of the right side of his pelvis and much musculature including the psoas and gluteal muscles were missing the urethra was torn across (Fig. 3.5). After resuscitation and surgery he developed various complications but ultimately walked with sticks. The second patient sustained a similar injury but avulsion took place at the hip joint, removing only part of the acetab-ulum and the ischium although the gluteal muscles were avulsed, there was no urethral injury. Wound contamination required a temporary colostomy he left hospital with a lower limb prosthesis after 3 months.

Issues in Hamstring Grafts

Compared this to a 15-mm-wide patellar tendon graft that was 125 the strength of the native ACL. This was widely quoted as a reason to use the patellar tendon graft rather than the hamstring. With the advent of the multiple bundles of hamstrings, this graft now has twice the strength of the native ACL (Fig. 5.7). Sepaga later reported that the semitendi-nosus and gracilis composite graft is equal to an 11-mm patellar tendon graft. Marder and Larson felt that if all the bundles are equally ten-sioned, the double-looped semi-t and gracilis is 250 the strength of the normal ACL. Hamner, however, emphasized that the strength is only additive if the bundles are equally tensioned.

Muscles Acting on the Hip and Femur

Most muscles that act on the femur (table 10.17) originate on the os coxae. The two principal anterior muscles are the iliacus, which fills most of the broad iliac fossa of the pelvis, and the psoas major, a thick, rounded muscle that originates mainly on the lumbar vertebrae. Collectively, they are called the iliopsoas (ILL-ee-oh-SO-us) (fig. 10.30). They converge on a single tendon that inserts on the femur and flexes the hip joint for example, when you bend forward at the waist, swing the leg forward in walking, or raise the thigh in a marching stance. On the lateral and posterior sides of the hip are the tensor fasciae latae and three gluteal muscles the gluteus maximus, gluteus medius, and gluteus minimus (figs. 10.31 and 10.34). The gluteus maximus is the largest muscle of this group and forms most of the mass of the buttocks. It is an extensor of the hip joint that produces the backswing of the leg in walking and provides most of the lift when you climb stairs. It generates the...

Iliohypogastric Nerve

The iliohypogastric nerve courses posterior to the psoas major and exits through its lateral border posterior to the kidney and anterior to the quadratus lumborum and the iliacus muscles. Near the iliac crest, it pierces and provides innervation to the transverse abdominis and internal abdominal oblique muscles, and splits into lateral and anterior branches. The lateral branch distributes cutaneous branches to the gluteal region, while the anterior branch pierces the internal and external oblique

ADVAntAgES of ArthroSCoPiC AnD EnDoSCoPiC DiSC Surg Ery

During arthroscopic or endoscopic spinal surgery, the paraspinal muscles, namely the erector spinalis, sacrospinalis, quadratus lumbrorum, and psoas major, are not severed, stripped, or retracted. A small soft-tissue dilator with a 4.9-mm outer diameter (od) has a tendency to separate the muscle fibers and descend toward the annulus at the index level. This reduces the postoperative morbidity and eliminates potential denervation and muscle injury (17-20). The derangement of the muscle fibers and massive scar formation may be readily observed in postoperative MRI studies of patients who have been exposed to traditional open spinal surgery (Fig. 7).

Group C Sequelae of Constipation

It is extremely important to recognize this group of patients. Some may be wrongly diagnosed as suffering from true fecal incontinence and some have even undergone reoperations such as gracilis muscle or artificial sphincters, which can actually make the patient worse. This problem should be suspected when one sees a patient who was born with a benign malformation, who underwent a technically correct operation, but who was not treated correctly for constipation.

Patients with Pacemakers or Metal Implants

The examiner must also be aware of the presence of any metal implants when applying the neutral electrode. Again, the distance between the neutral electrode and the active electrode ( location of the endoscope tip or poly-pectomy) must be smaller than that between the active electrode and any metal implant. Artificial hip joints are particularly relevant for colonoscopy.


Breast Anatomy Retromammary Space

Traditional anatomic dissections show that the glandular tissue consists of 15 to 20 lobes or segments containing ducts that branch and subdivide into smaller ducts as they extend into the deeper glandular tissue. The end units of the smallest ducts are composed of milk-forming lobules that drain radially through the ducts toward the nipple. Each lobe has its own segmental duct into which all the ducts from that lobe drain. There are wide lactiferous sinuses in the subareolar region each of these receives the drainage from one or more segmental ducts. Each lactiferous duct then narrows as it passes through the nipple. This narrowed duct in the nipple is called a collecting duct. Sartorius (1986) has demonstrated that the nipple contains only five to seven collecting ducts.


This approach has a slightly higher dislocation rate following prosthetic implant in the hip joint than does an anterior approach. There is also some risk of damage to the sciatic nerve, which is not the case with the anterior approach. Also, in children, there is risk to the blood supply to the femoral epiphysis, which largely comes through the capsule. The most critical blood vessels come in at the pos-terosuperior corner of the capsule. For this reason, the posterior approaches to the hip are generally avoided in children with an open growth plate at the hip.


The contents of Table 1 show that lesions in the coxae were a common finding in hyperekplexic calves. They include deep linear contusions in the cranial portion of the acetabular fossa, and erosions of the corresponding articular surface of the head of the femur. Some erosions were so deep that the hyperemic subendochondral bone was exposed. Fragments of bone were encapsulated in close proximity to fractures of the femoral neck. Investigators also frequently observed hemorrhage and fibrosis in the joint capsule and surrounding tissue (Harper et al., 1986a). The severity of the hip joint lesions is evident on the X-ray images depicted in the video. No other pathology has been associated with ICM.

Logistical Factors

In the 17th century, major injuries of the upper thigh and hip region remained a problem as amputation at hip joint level was considered a step too far, due to the problem of securing major vessels in the groin. Ravaton reported that, in his experience, all men with gunshot injuries of the thigh with an open femoral fracture, when treated conservatively, eventually died. By contrast, gunshot fractures at other levels often did well if carefully managed. For this group of high thigh injuries with poor prognosis, he recommended amputation by disarticulation at the hip joint as the only possibility of saving life.42 Unfortunately, it does not appear he was able to conduct such an operation, for he reported

Clinical Features

Observations based on matings of obligate heterozygotes in the experimental herd provided evidence of the prenatal expression of the bovine disease. Myoclonic responses to tactile stimulation of the lumbosacral region of a 254-day fetus (normal bovine gestation is 282 days), recovered from a cow euthanazed due to metastasizing squamous cell carcinoma, provided evidence of the prenatal occurrence of myoclonic spasms. This evidence was supported by the existence of chronic tissue reaction adjacent to the fractured femoral head in the hip joint of a stillborn hydranencephaly-affected calf. The calf was rendered decerebrate as a consequence of inadvertent intra-uterine infection towards the end of the first trimester of gestation with the insect-borne Akabane virus. Whole body spasms were observed in a newborn calf when the lumbosacral region of the calf was licked by its dam approximately twenty seconds after birth (see video). In addition, the average gestation length for ICM-affected...

Classic Patient

A number of clinical signs can be used to discern localized peritonitis. Tenderness to percussion over the appendix is more sensitive, more specific, and certainly more kind to the patient being examined than rebound tenderness. The unsolicited complaint of pain in the right lower quadrant with maneuvers such as palpation of the left lower quadrant (Rovsing sign), cough (Dunphy sign), internal rotation of the flexed right thigh (obturator sign), or extension of the right hip (iliopsoas sign) all indicate an inflammatory process in the right lower quadrant.

Lumbar Arteries

The lumbar arteries arise from the abdominal aorta anterior and to the left of the lumbar vertebrae. A fifth pair of lumbar arteries may arise from the middle sacral artery. They run posterior to the sympathetic trunk and the tendinous origins of the psoas major muscle. On the right side they travel posterior to the inferior vena cava but only the upper two pairs of lumbar arteries course posterior to the corresponding crus of the diaphragm. The upper three pairs run anterior, while the lowest course runs posterior, to the quadratus

The diaphragm

Origin From the inner surfaces of the lower six ribs, from the back of the xiphisternum, from the right and left crura which are attached, respectively, to the upper three and the upper two lumbar vertebrae, and from the medial and lateral arcuate ligaments which bridge over the psoas major and quadratus lumborum.

The thigh

Rectus femoris Femoral triangle Inguinal ligament Psoas tendon Pectineus Adductor longus Gracilis Sartorius Psoas major Inguinal ligament Pectineus Adductor longus Adductor longus The thigh is divided into flexor, extensor and adductor compartments. The membranous superficial fascia of the abdominal wall fuses to the fascia lata, the deep fascia of the lower limb, at the skin crease of the hip joint just below the inguinal ligament.

Prosthetic Material

This material along with polytetrafluoroethylene (Goretex or Teflon) or a composite material of the two represents the majority of prosthetic materials used today. The classic use of these materials is either as an inset patch or as reinforcement of a primary tissue repair of myofascia. Placement of these materials can be done extrafascial or above the fascia, extraperitoneal and subfascial, or intraperitoneal. This too continues to be a much-debated topic. Complications of the use of mesh include separation of the mesh from the fascia, contact injury (eg, adherence to other structures, erosion, and fistula formation), and infection. Autogenous tissue is considered by some to be the ideal material to close complex myofascial defects. The source of the tissue can be regional musculofascial flaps most commonly represented by rectus abdominis advancement, which can be achieved using one of several plastic surgery tissue advancement techniques, or the use of distant flaps,...


A prospective study was undertaken to assess the effectiveness of the double-looped semitendinosus and gracilis graft secured with a biodegradable interference fixation screw (BioScrew). To be included, a patient had to meet the following criteria a complete ACL tear, knee instability as manifested by positive Lachman test and positive pivot-shift test, a KT-1000 manual maximum side-to-side difference of greater than 5 mm, and a commitment to return for at least two years of follow-up. Patients were excluded if they had an active infection preoperatively or multiple coincident ligament injuries (PCL, MCL, LCL, posterolateral corner). Previous knee ligament reconstruction was not an exclusionary criterion, and several of the patients included had revision surgery. All patients underwent the same procedure an arthroscope-assisted ACL reconstruction using a double-looped semitendinosus and gracilis autograft from the ipsilateral limb. The graft was secured at the proximal and distal...

Graft Passage

The four-bundle semi-t and gracilis graft is attached to the looped end of the graft passing guide wire and the number 5 Ti-Cron is drawn into the femoral tunnel. The graft is pulled into the tibial tunnel. The knee is hyperflexed, and the BioScrew guide wire is introduced through the low anteromedial portal and into the notch in the femoral tunnel. The guide wire should lie on top of the graft, not pushed into the graft. The wire is shoehorned on top of the graft as it is pulled into the tunnel.

Surgical Technique

The semitendinosus and gracilis tendons are harvested through an oblique anterior-medial incision along the upper border of the pes-anserine tendons. Turning down of the medial corner of the pes anserinus identified the tendons. Both were harvested with a closed-looped tendon stripper. The tendons, which ranged in length from 20 cm to 24 cm, were covered with a moist sponge for later preparation.


Aligetti PB, Bazzi R, Zaccherotti G, De Biase P. Patellar tendon versus doubled semitendinosus and gracilis tendons for anterior cruciate ligament reconstruction. Am J Sports Med 1994 22(2) 211-217. Lipscomb AB, Johnston RK, Snyder RB,Warburton MJ, Gilbert PP. Evaluation of hamstring strength following use of semitendinosus and gracilis tendons to reconstruct the anterior cruciate ligament. Am J Sports Med 1982 10 340-342. Marumo K, Kumagae Y, Tanaka T, et al. Long-term results of anterior cruciate ligament reconstruction using semitendinosus and gracilis tendons with Kennedy ligament augmentation device compared with patellar tendon auto-grafts. J Long-Term Effects Med Implants 2000 10 251-265.


There was renewed interest in the semitendinosus during the mid-1990s. Biomechanical testing on the multiple-bundle semitendinosus and gracilis grafts demonstrated them to be stronger and stiffer than other options. This knowledge combined with improved fixation devices such as the Endo-button gave surgeons more confidence with no-bone, soft tissue grafts. The Endo-button made the procedure endoscopic, thereby eliminating the need for the second incision.

Inguinal Hernia

Laparoscopic procedures in the repair of inguinal hernia have produced an increase in the frequency of debilitating neuropathies, most notably those of the ge-nitofemoral, ilioinguinal, and lateral femoral cutaneous nerves. The highly variable course of the lateral femoral cutaneous nerve and its branches within the pelvis may directly account for this complication 50 . Aszman 51 demonstrated five different types of relationships of the lateral femoral cutaneous nerve to soft tissue and bony structures. Four percent (type A) maintained a course posterior to the anterior superior iliac spine and across the iliac crest 27 (type B) traveled anterior to the anterior superior iliac spine, within the inguinal ligament and superficial to the origin of the sartorius muscle. In 23 (type C) the nerve ran medial to the anterior superior iliac spine within the tendinous origin of the sartorius, and in 26 (type D) the nerve was found deep to the inguinal ligament between the iliopsoas fascia and...

Human Body Diagram

Human Body Major Muscle Groups

There are groups of muscles that act together. The rotator cuff (musculotendinous cuff) muscles stabilize the shoulder joint. These are the supraspinatus, the infraspinatus the teres minor and the subscapularis. The abdominal muscles are the rectus abdominis, the external oblique, the internal oblique, and the transversus abdominis. The quadriceps femoris group are the muscles of the anterior thigh. These are the rectus femoris, the vastus lateralis, the vastus medialis, and the vastus intermedius. The hamstrings are muscles on the posterior thigh and they consist of the biceps femoris, the semitendinosus, and the semimembranosus. There are many more functional groups of muscles but these are a few of the major ones. Answer Key a. Sternocleidomastoid, b. Pectoralis major, c. Deltoid, d. Biceps brachii, e. Rectus abdominis, f. External oblique, g. Sartorius, h. Quadriceps femoris, i. Tibialis anterior

Pudendal Thigh Flap

Gracilis Myocutaneous Flap

McCraw JB, Massey FM, Shanklin KD et al (1976) Vaginal reconstruction with gracilis myocutaneous flaps, Plast Reconstr Surg 58 176-83. 2 Adductor longus muscle 3 Sartorius muscle 4 Great sartorius muscle 6 Gracilis muscle Outline of skin island over proximal two-thirds of gracilis muscle Skin and cutaneous skin island incised and distal gracilis muscle identified near knee Bilateral gracilis myocutaneous flaps sewn together

Genitofemoral Nerve

The genitofemoral nerve (L1, L2) pierces the psoas major and emerges on the anterior surface of that muscle. It descends posterior to the ureter and gonadal vessels, and usually divides anterior to the lower third of the psoas major into femoral and genital branches. In the male, the genital branch enters the deep inguinal ring, innervates the cremasteric muscle, emerging from the superficial inguinal ring to supply the scrotum. In the female it follows a similar course and distributes sensory fibers to the skin of the major labium. The femoral branch passes posterior to the inguinal ligament to provide sensory fibers to the upper middle part of the femoral triangle. Due to the variability of the course of the genitofemoral nerve in the inguinal region, entrapment of the genital branch of this nerve maybe a possible cause of chronic groin pain 17 .

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