Adjacent Soft Tissue Structures Research Articles

Computed tomographic features of suspected arterial pseudoaneurysm in the head and neck of four dogs.

Computed tomography is a valuable diagnostic technique in the clinical work-up of dogs with oropharyngeal trauma and bleeding. Traumatic extravasation can manifest as a pseudoaneurysm. A pseudoaneurysm is an extraluminal accumulation of blood that is contained by the adventitia layer or neighboring tissues. The purpose of this retrospective, multicenter, observational case series study was to describe the CT features in dogs with presumed oropharyngeal arterial pseudoaneurysm and its potential association with trauma. Imaging archives were searched for canine patients with head and neck CT studies showing visible extravasation of contrast-enhanced blood contained by soft tissue structures. Medical records of these patients were reviewed for oropharyngeal bleeding or trauma and reported. Four dogs met the inclusion criteria. CT findings included a well-defined, confined area of vascular contrast enhancement adjacent to the common carotid artery or its branches. The mean contrast enhancement in the corresponding artery and pseudoaneurysm lesion was similar, suggesting that these lesions represent active arterial extravasation. Four-dimensional CT was performed in one case and demonstrated contrast medium leaking from an artery and being contained by adjacent soft tissue structures. All dogs had a history and imaging findings consistent with oropharyngeal bleeding and trauma. Arterial pseudoaneurysm should be considered as a differential diagnosis in dogs with oral trauma and CT features of a well-defined, periarterial, strongly contrast-enhancing lesion.

Osteosarcoma of the mandible and its management: A rare case report

Osteosarcoma is a classical malignant bone-forming neoplasm, characterised by osteoid synthesis by malignant osteoblasts. Osteosarcomas have an aggressive clinical course with a high mortality rate, despite their relatively low risk of distant metastases. The jaw bone is the most common site of occurrence in the head and neck region. These neoplasms often show characteristic clinical behaviours, varied radiological appearances, and a wide-ranging histological growth pattern. Early diagnosis and radical surgery, followed by radiotherapy and chemotherapy if required, have been the treatment of choice. This case report emphasises the importance of early diagnosis of this tumour based on clinical features, radiographic examination, and confirmation by histopathology. Confirmation of the final diagnosis of osteosarcoma often requires a histopathological examination of the multiple biopsy specimens. Adjuvant chemotherapy followed by radical surgery resulted in an excellent prognosis in the present case. Considering the rarity of the neoplasm, its fast progression, and its aggressiveness, the present case report would contribute to a better understanding of osteosarcomas involving the jaw bone and the management of the tumour involving the central arch of the mandible with involvement of the adjacent soft tissue structures.

Efficacy of Cervical Thoracic Spine Correction Exercise in Reducing Pain and Improving Neck Posture in People with Cervical Spondylitis

Background: The development of osteophytes and the involvement of adjacent soft tissue structures are the initialindications of degenerative changes in the intervertebral discs in cervical spondylitis. Forward head posture alsohas an effect on the muscles at the head and shoulders, which aggravates postural deformity.Purpose: The purpose is to determine Efficacy of cervical thoracic spine correction exercises in reducing pain andimproving neck posture in people with cervical spondylitis.Methods: This experimental study has been conducted from December 2022 to April 2023. Patients willing toparticipate in the study were screened for inclusion and exclusion criteria. The total number of subjects (30) weretaken from Sai charan physio clinic and they are divided into 15 subjects for the experimental group, they aregiven cervical thoracic spine correction exercises with ultrasound. The control group consisting of 15 subjects,are isometric exercises with ultrasound. NPRS and Neck disability index are used as outcome measures. Thetreatments were given for 5 days per week and continued for 2 weeks.Results: From statistical analysis made with the quantitative data revealed statistically significant differencesbetween the Group A and Group B, with the P value of <0.0001. Thus, the experimental group has higher statisticaldifferences than the conventional group.Conclusion: According to the findings of this study, Cervical thoracic spine correction exercises in the experimentalgroup were found to be more beneficial than isometric exercises in conventional groups in lowering pain andleading to faster recovery in participants with forward neck posture.

Surgical management of popliteal artery entrapment syndrome

IntroductionPopliteal artery entrapment syndrome (PAES) is a rare condition in which the popliteal artery becomes compressed by adjacent soft tissue structures causing progressive claudication. Due to its low incidence, this disorder and its surgical management is poorly described in the literature. This study presents our institutional data surrounding PAES management to further optimize care of this syndrome. MethodsThis retrospective study gathered demographic, surgical, and outcome data of all patients with PAES who underwent surgical decompression at our institution from 2015 to 2022. Patients were identified using CPT and ICD-9/10 codes. Summary statistics were calculated, with Chi-squared and T-test used for subgroup analysis. Results50 surgical patients with PAES were identified. On average, they were young (mean age: 20.7 years), mostly female (78 %), and predominately white (68 %). The vast majority were physically active, with 13 of the 50 patients being runners (26 %). Medically, the cohort was otherwise healthy, with 74 % reporting no comorbidities. Diagnosis was often delayed, with patients on average seeing 4.5 physicians over 2.0 years prior to arriving at our institution for care. In addition to popliteal artery release, the second most performed procedure was fasciotomy (82 %). Postoperatively, there was significant long-term subjective improvement, with 91 % of patients reporting they would repeat the operation and 65 % reporting improved activity. ConclusionPAES is a rare condition affecting the lower limb that requires a nuanced surgical approach. From diagnosis to outcome, we hope to better inform surgeons of PAES so that these patients may receive the highest quality care.

Management strategy for open pelvic fractures: A 11-year single-centre, retrospective observational study

Introduction: Open pelvic fractures are commonly associated with life-threatening, uncontrollable haemorrhages. Although management methods for pelvic injury-associated haemorrhage have been established, the early mortality rate associated with open pelvic fractures remains high. This study aimed to identify predictors of mortality and effective treatment methods for open pelvic fractures. Methods: We defined open pelvic fractures as pelvic fractures with an open wound directly connected to the adjacent soft tissue, genitals, perineum, or anorectal structures, resulting in soft tissue injuries. This study was performed on trauma patients (age ≥15 years) injured by a blunt mechanism between 2011 and 2021 at a single trauma centre. We collected and analysed the data on the Injury Severity Score (ISS), the Revised Trauma Score (RTS), the Trauma and Injury Severity Score (TRISS), length of hospital stay, length of intensive care unit stay, transfusion, preperitoneal pelvic packing (PPP), resuscitative endovascular balloon occlusion of the aorta (REBOA), therapeutic angio-embolisation, laparotomy, faecal diversion, and mortality. ResultsForty-seven patients with blunt open pelvic fractures were included. The median age was 45 years (interquartile range, 27–57 years) and median ISS was 34 (24–43). The most frequently performed treatment methods were laparotomy (53%) and pelvic binder (53%), followed by faecal diversion (40%) and PPP (38%). PPP was the only method performed at a higher rate in the survival group for haemorrhagic control (41% vs. 30%). Haemorrhagic mortality was present in one case that received PPP. The overall mortality was 21%. In the univariate logistic regression analysis, initial systolic blood pressure (SBP), TRISS, RTS, packed red blood cell transfusion for the first 24 h, and base excess showed statistical significance (p<0.05). In the multivariate logistic regression model, initial SBP was identified as an independent risk factor for mortality (odds ratio, 0.943; 95% confidence interval, 0.907–0.980; p = 0.003). ConclusionA low initial SPB may be an independent predictor of mortality in patients with open pelvic fractures. Our findings suggest that PPP might be a feasible method to decrease haemorrhagic mortality from open pelvic fractures, especially for haemodynamically unstable patients with low initial SBP. Further studies are required to validate these clinical findings.

Assessment of Articular Disc with MRI in Patients with Disc Displacement of Temporo-Mandibular Joint – MRI the Game Changer

Background: The temporomandibular joint (TMJ) is considered a complex joint. Temporomandibular disorders (TMDs) are a common cause of musculoskeletal pain. At least one TMD symptom is seen in 33% of the population and 3.6% to 7.0% of the population shows significant severity warranting treatment. Magnetic resonance imaging (MRI) is better for the evaluation of disc and adjacent soft-tissue structures compared to cone beam computed tomography. MRI allows articular disc assessment in open and closed mouth positions. MRI has 95% accuracy in the assessment of disc disorders and 93% accuracy for osseous changes. Materials and Methods: A cross-sectional study was performed with a sample size of 21 patients as per inclusion and exclusion criteria. MRI findings were noted and compared with clinical findings. Results: As per our study, the most common age group is between 20 and 35 years. Of 42 TMJ, 41 joints show disc displacement changes and one TMJ was normal. Disc displacement with reduction is less than disc displacement without reduction. Left TMJ is more affected as disc displacement without reduction, as compared to the right side. Two TMJ were with posterior DD. Four TMJ shows anteromedial and 4 TMJ shows anterolateral DD. Six joints have a subluxation. Conclusion: In our study, we found that MRI in TMDs is more reliable and accurate for the diagnosis of DD.

The H Laminectomy: Technical Description and Clinical Experience From the First 85 Patients.

Over the years, lumbar laminectomy has been widely employed by spinal surgeons for many purposes throughout the spinal canal. The Misonix BoneScalpel relies on ultrasonic energy and allows the surgeon to make precise osteotomies while protecting collateral or adjacent soft tissue structures. Amplification of electric impulses allows the blade in the BoneScalpel to oscillate at very high frequencies, which thus allow it to cut bone with immense amounts of heat, which are then tempered with copious irrigation to prevent overheating. The purpose of this study is to outline and detail an innovative technique while providing insight into the technique's clinical application in a variety of spine surgeries. Data were retrospectively collected from medical charts and surgical reports from February 2018 to July 2021 for each surgery in which the ultrasonic scalpel was used to perform the H laminectomy. Baseline demographic information was recorded, including age, gender, laminectomy indication, and the number of levels of laminectomy. A total of 85 patients (64 women, 21 men) were included in this study. The mean age of the patients was 63.7 years. Of those patients, 42.4% underwent H laminectomy for degenerative stenosis without instrumentation, 31.8% for degenerative stenosis with instrumentation, 9.4% for traumatic injuries, and 7.1% for revision surgery with instrumentation. Approximately 55% of patients underwent laminectomy of 2 or more levels, while the rest underwent single-level laminectomy. No patients had a dural tear or cerebrospinal fluid (CSF) leak as a result of the BoneScalpel. The H laminectomy is another safe and effective way to perform a lumbar laminectomy. The technique has not been previously reported in the literature. No patients experienced a dural tear or CSF leak from the BoneScalpel using the H laminectomy technique. This technique affords the surgeon enhanced control of the dura-ligamentum interface. Even if the surgeon is not very experienced with the BoneScalpel, this technique provides an inherent safety mechanism with constant visualization/tactile feedback of the tip of the instrument and osteotome.

ODP475 Developing suppurative thyroiditis

Abstract Suppurative thyroiditis is rare and associated with significant mortality. A high level of suspicion and aggressive management is needed to reduce the risk of serious outcomes. A 67-year-old male with a medical history including diabetes type 2, cognitive impairment, and ESRD presented with decreased appetite and lethargy for a few days. He presented with fever, tachycardia, and hypertension. There was a non-tender fullness around the anterior neck region. Initial laboratory tests revealed leukocytosis to 24K/uL, lactic acid of 5. 0 mmol/L, ESR 100 mm/hr, CRP 419 ng/dl, and blood culture was positive for gram-positive cocci in clusters for which he was started on iv vancomycin and piperacillin/tazobactam. CT scan on admission showed a probable inflammatory process in the neck originating from the thyroid bed, concerning acute thyroiditis and developing abscess/abscesses vs. very atypical presentation of thyroid cancer. Thyroid ultrasound showed diffuse thyroid enlargement with heterogeneous echogenicity. Repeat CT obtained due to apparent thyroid enlargement with erythema and tenderness on examination and fever on day 7 showed extensive heterogeneous thyroid enlargement with ill-defined margins to the adjacent soft tissue structures. A modified barium swallow revealed severe oropharyngeal dysphagia leading to thyroid fine-needle aspiration of both thyroid lobes by interventional radiology and subsequent urgent incision and drainage (I&amp;D) of the right neck and thyroid biopsy under general anesthesia by ENT. I&amp;D showed purulent drainage from the thyroid. Cultures were positive for MRSA. Surgical pathology reported a necrotic muscle and abscess and fragment of thyroid tissue. Thyroid function tests (TFTs) on admission revealed a TSH 0.31 mcIU/ml (reference: 0.30 - 5. 0 mcIU/ml) and a free T4 of 2.21 ng/dl (reference: 0.76- 1.46 ng/dl) and repeat TFTs with a TSH of 0.30 mcIU/mL, free T4 of 1.87 ng/dL, free T3 of 2.15 pg/ml (reference: 2.18- 3.98 pg/ml), consistent with sick euthyroid syndrome. TPO and TSI were negative. Subsequently, the patient's fever resolved, and the neck swelling improved. He continued IV vancomycin for a month. TFTs six weeks later showed an elevated TSH of 13.10 mcIU/ml and normal free T4 of 1. 03 ng/dl. Conclusion MRSA suppurative thyroiditis is rare, and its diagnosis may be delayed due to its indolent course, especially in immunocompromised patients. Therefore, a high index of clinical suspicion is needed for this endocrine emergency in a patient presenting with fever and neck swelling. While an early FNA of the thyroid is likely to aid in diagnosing thyroid infection, TFTs may be variable and not helpful. Presentation: No date and time listed

Management of splint bone fractures

Owing to their superficial position on the lower limb, close approximation to the suspensory ligament and rather insubstantial nature, it is unsurprising that splint bone fractures are commonly encountered in practice. These fractures can be caused by either external or internal trauma, and can take a number of configurations. Treatment and prognoses differ depending on the location, configuration and age of the fracture, as well as involvement of adjacent soft tissue structures, the third metacarpal or metatarsal bone, or the carpometacarpal or tarsometatarsal joints. However, despite the frequency of splint bone fractures, there is no consensus regarding appropriate treatment. Management consists of conservative or surgical strategies, both of which have distinct advantages and disadvantages. Most reports consist of small case series and clinical experience. This review article presents current information and guidance for managing splint bone fractures.

Pelvic Radiation Disease.

Pelvic radiation is increasingly being used for the neoadjuvant and definitive treatment of pelvic organ malignancy. While this treatment can be highly effective, and may assist in organ sparing, it is also associated with significant toxicity and devastating adverse events that need to be considered. In broad terms, pelvic radiation disease affects both the primary target organ as well as adjacent organs and soft tissue structures, with complications that can be classified and graded according to consensus criteria. The complication grade is often modality, dose, and area dependent. The most common manifestations are proctitis, cystitis, recto-urethral fistula, ureteric stricture, and bone involvement. Toxicity can be misdiagnosed for many years, resulting in significant management delays. Complications can be difficult to prevent and challenging to treat, requiring specialized multi-disciplinary input to achieve the best possible strategy to minimize impact and improve patient quality of life.

Spectrum of magnetic resonance imaging findings in post-COVID-19 patients presenting with rhino-orbito-cerebral mucormycosis in a teaching hospital in Malwa region of Punjab.

Rhino-orbito-cerebral-mucormycosis (ROCM) associated with COVID-19 infection was at its peak during and immediately after the second wave of the pandemic in India during 2021. Many of the risk factors were implicated in the development of this deadly fungal infection, when there was a sudden surge of cases, especially who had a history of COVID-19 infection. The objective of the study was to describe the characteristic magnetic resonance imaging (MRI) findings in invasive mucormycosis and to evaluate the extent and severity of invasive mucormycosis. A retrospective study was carried out for 4 months which included 60 patients who underwent MRI using a Siemens Avanto 1.5 Tesla scanner. During our study, 68 cases were selected based on clinicoradiological features suspected of ROCM. However, 8 patients were excluded on the basis of exclusion criteria as either there was no definitive evidence of COVID infection or were proven to be negative for mucormycosis on microbiological examination. On the basis of the spectrum of MRI findings, post-COVID-19 related ROCM was broadly categorized into three stages. Out of total of 60 patients, the disease was localized to the nasal and paranasal sinus region (Stage I) in 7 patients (11.66%), extending to adjacent extrasinus orofacial soft tissue structures (Stage II) in 36 patients (60%), and intracranial extension of disease (Stage III) was seen in 17 patients (28.33%). In post-COVID-19 patients presenting with clinical features suspected of ROCM, MRI imaging helps in early diagnosis and staging/severity of ROCM, so that timely intervention can be planned to reduce mortality as well as morbidity.

Outcome of Open Long Bone Fractures in Dogs Stabilized with Linear External Skeletal Fixator

Background: External skeletal fixator (ESF) has been recommended as biological method to stabilize open fracture as it does not involves the wound site, besides protecting adjacent soft tissue structures. Considering the advantages of ESF, this study was envisaged with an objective to study the outcome of open fractures of radius-ulna and tibia-fibula stabilized with linear ESF in dogs.Methods: This study included 17 dogs suffering from open long bone fractures of radius-ulna and tibia-fibula, divided into three groups; linear ESF type I or II (group I, n=8) and type III (group II, n=3). In group III (n=6), open fractures were initially treated using conservative methods i.e management of open wound till complete healing followed by delayed internal fixation using intramedullary pin or bone plating.Result: Majority of the open fractures of radius-ulna and tibia-fibula were transverse (64.71%), involving distal third diaphysis (47.06%) in heavy weight (54.55%), 1-3 year old (64.71%), non-descript (35.29%), male (88.23%) dogs due to automobile accidents (58.82%). Neutrophilic (81.47±4.45%) leukocytosis (24610±2461.88 per cumm) and elevated levels of alkaline phosphatase and creatine kinase were observed. Staphylococcus spp. was the common isolated bacteria sensitive to Gentamicin, Cefotaxime, Tobramycin, Amikacin and Neomycin. High per cent fractures (83.33%) in group III had acceptable functional outcome as compared to fractures treated with linear ESF (55.55%) in groups I and II. Osteomyelitis due to pin tract infections was the major complication (8/11; 72.7%) recorded in ESF groups (Group I and II) that lead to delayed and/or nonunion. Weight bearing score improved markedly after removal of the ESF frame. In conclusions, immediate fixation of the long bone fracture using linear ESF in the presence of open contaminated / infected wounds leads to unacceptable outcome. Poor animal compliance, pin tract discharge, osteomyelitis, delayed union and nonunion are major complications associated with linear ESF. Conservative management of the open fracture wound using standard treatment for 2-3 weeks till complete wound healing followed by internal fixation with intramedullary pin or bone plate is recommended for open long bone fractures in dogs.

Klippel-Feil Sendromu: Olgu Sunumu

Klippel-Feil syndrome is a condition characterized by fusion of the spine owing to the failure of normal segmentation of the cervical structures. In this case report, we aimed to describe this rare syndrome, show the findings of this syndrome using imaging techniques, and demonstrate its clinical importance. A 41-year-old female patient presented to our faculty hospital with neck pain. Using cervical magnetic resonance imaging, we observed a decreased anteroposterior diameter; fusion between the corpora of the 2nd, 3rd, and 4th cervical spine; and an appearance consistent with fusion between the arches of the same vertebrae in sagittal slices. Cadaver studies and radiology tests were performed to identify the variations and anomalies of the cervical spine. Although computed tomography scanning is more frequently performed for the purpose of evaluating spine, magnetic resonance imaging may be performed to evaluate the adjacent soft tissue structures and the symptoms associated with vertebral pathologies. These imaging modalities are necessary and beneficial for anatomists, radiologists, neurosurgeons, and orthopedists so that they may evaluate the findings, coexisting anomalies, and risk factors of Klippel-Feil syndrome in order to reach appropriate diagnosis, follow-up, and treatment.

Anatomic Structures at Risk during Posterior to Anterior Percutaneous Screw Fixation of Posterior Malleolar Fractures: A Cadaveric Study

Category:Ankle; TraumaIntroduction/Purpose:Posterior malleolus fractures (PMFs) are typically associated with trimalleolar ankle fractures and have been reported to occur in 10-40% of ankle fractures. The PM may be fixed by direct ORIF or indirect percutaneous reduction. Direct reduction via a posterolateral approach is required for larger fragments, which requires prone or lateral decubitus positioning. Indirect reduction and fixation with anterior to posterior (AP) screws remains the most common method, in which screw threads are not entirely across the fracture site to allow interfragmentary compression.Objective: Determine the risk to anatomic structures utilizing a percutaneous technique for posterior to anterior (PA) screw fixation. It is advantageous as it places all the threads across the fracture site even for small fragments and can be performed in the supine position.Methods:10 fresh-frozen, morphologically normal cadaver lower leg. Under fluoroscopic guidance, 1.35 mm Kirschner wire was inserted percutaneously from anteromedial to posterolateral. Guidewire was inserted from a starting point just medial to the tibialis anterior tendon and aimed at a point just lateral to the Achilles tendon. Small skin incision was made over the wire posteriorly, displacing the Achilles tendon medially as required. The wire was then over-drilled in posterior to anterior direction and replaced with a 4.0 mm partially threaded cannulated screw directed posterior to anterior. Each specimen was dissected, and adjacent soft tissue and neurovascular structures were identified. The distance from the guidewire to each anatomic structure of interest was measured. Descriptive analysis and the correlation between the mean distances from the guidewire to each structure was calculated using SPSS version 26.Results:The sural nerve was directly transected in 1/10 specimens (10%) and in contact with the wire in a second specimen (10%). There was a significant correlation between the proximity of the guidewire to the apex of Volkmann’s tubercle and its proximity to the sural nerve.(r= 0.705, p = 0.034) The flexor hallucis longus (FHL) muscle belly was perforated by the guidewire 40% of the time but was not tethered or entrapped by the screw. The neurovascular bundles were safely away from the wire in all cases. The lateral 1-2 mm of the Achilles tendon was pierced by the guidewire 20% of the time. Although suboptimal, these injuries may be of little clinical consequence, and the screw passed without tethering the tendon in all cadaveric specimens.Conclusion:Percutaneous PA screw placement is a safe technique which can be improved with several modifications. A mini- open technique is recommended to protect the sural nerve. The surgeon may consider aiming slightly more medial and closer to the Achilles tendon in order to avoid injury to the sural nerve. It is also advisable to use a soft tissue guide when over-drilling the guidewire. There may be potential for tethering of the FHL with use of a washer or large screw head. Risk to the anterior and posterior neurovascular bundles is minimal.

Cinematic rendering enhancements to virtual bronchoscopy: assessment of emergent tracheal pathology.

Utilizing complex lighting models, cinematic rendering is a novel technique for demonstrating computed tomography data with exquisite 3D anatomic detail. The tracheal lumen, tracheal wall, and adjacent soft tissue structures are represented with photorealistic detail exceeding that of conventional volume rendering or virtual bronchoscopy techniques. We applied cinematic rendering to a spectrum of emergent tracheal pathologies: traumatic tracheal tears, tracheoesophageal fistulas, tracheal foreign bodies, tracheal stenosis (intrinsic and extrinsic causes), tracheal neoplasms, and tracheomalacia. Cinematic rendering images enable visually accessible evaluation and comprehensive understanding of acute tracheal pathology, which is likely to be of value to both interventional pulmonologists and thoracic surgeons who are determining patient treatment plans.

ОСНОВНІ ОЗНАКИ УРАЖЕННЯ КІСТОК ПРИ МНОЖИННІЙ МІЄЛОМІ

This article is devoted to the main signs of bone damage in multiple myeloma, identified by MRI. MRI allows direct visualization of the tumor component and its relationship with the adjacent soft tissue structures. The relevance of the direction of analysis and processing of medical images is, firstly, in the rapid development of medical diagnostic technology based on the new application of physical methods of research, and secondly, the rapid development of computer technology and methods of mathematical image analysis have led to the fact that the image analysis has become not speculative, but a practical task that can be solved directly in the workplace of a doctor. Detection of pathological processes is one of the most important tasks of processing and analysis of medical images; at the same time, as is known, early diagnosis of various pathologies, including cancer, significantly increases the chances of recovery of patients.The aim of this work is to study the signs of multiple myeloma, the nuances of its influence on the human body and the features of the manifestation of modern methods of visualization.This article describes the main features of imaging MM, its reflection on the musculoskeletal system, the images showing lesions, as well as images of MRI of the lumbar spine in normal and pathological conditions.Modern imaging techniques such as magnetic resonance and x-ray computed tomography are informative methods for diagnosing bone destruction syndrome in the vertebrae. Their results allow to identify and assess the foci of destruction in the vertebrae, as well as to clarify the prevalence of the process. An integrated approach to the examination using an optimized algorithm can improve the effectiveness of early diagnosis of MM, to fully assess the prevalence of the pathological process and choose the tactics of treatment.Detection of multiple myeloma manually, that is, «on the eye» of a specialist, is a routine process, and there is a high probability that the so-called places of interest will be unnoticed, which can lead to irreversible processes associated with human life; in addition, a large number of lesions in one patient make it difficult to manually segment all lesions, so it is impossible to quantify the total volume of the tumor on the new year's day. Therefore, it is necessary to develop methods for automatic detection of lesions and segmentation.

Optimal Screw Fixation in Treating Jones Fractures

Category: Midfoot/Forefoot Introduction/Purpose: Jones fractures are among the most common fractures in the foot, mainly occurring in athletes. In order to facilitate return to sport and good functional outcomes, management with intramedullary screw fixation is often recommended [1-3]. While optimal screw dimension and location parameters have varied in the literature, it is clear that maximizing pull-out strength, providing adequate compression across the fracture, and minimizing irritation to surrounding soft tissue structures are of paramount importance. The aim of this study was to improve our guidelines regarding optimal insertion trajectory and screw parameters of Jones fractures by more accurately defining the bony and soft tissue anatomy of the fifth metatarsal bone and its intramedullary canal. Methods: 21 fifth metatarsal bones were harvested from cadaveric feet. Three reference screws were placed on each bone for registration. 3D CT model of each bone with outer cortex, intramedullary canal and the articular cortex was created (Figure A). The insertions of the PB and PF and the reference screws of each bone were carefully digitized and mapped onto corresponding 3D model. The anatomic insertions and the surface areas were determined. Based on the length of the bone, the shape of the intramedullary canal, and the diameter of the canal at its narrowest point, the perceived ideal screw and placement was then modulated for each bone model. Also, the fracture zone where Jones fractures occur was determined (Figure B) based on Lawrence/Botte classification [1]. Screw and thread length were calculated in this position, and the impact of screw placement on the insertion sites of both the PB and PF were recorded. Results: The mean length of the bones was 74.4±3.6 mm, with the narrowest diameter of the intramedullary canal being 4.3±0.7 mm. Ideal screw position was identified as parallel to the cuboid and coaxial with the intramedullary cortex; this placement, however, was found to partially sacrifice the PB and PF insertions in 62% (13/21) and 33% (7/21) of cases, respectively; with an average of 1.6±0.8 mm of the PB and 1.3±0.8 mm of the PF insertion. The mean ideal screw length in this position was found to be 47.8±5.8 mm, with a minimal thread length of 28±6.8 mm and a minimal diameter of 4.5 mm (Figure B). The ratio of screw length to the total bone length was 0.64 (range 0.50-0.72). Conclusion: In order to maximize compression and pull-out strength and minimize sacrifice of the adjacent soft tissue structures during screw placement, Jones fractures should be fixed with hardware parallel to the cuboid and collinear with the intramedullary cortex—which mitigates but does not avoid injury to the peroneal tendon and plantar fascia. Average optimal length of the screw should be 64% of the length of the bone, with a minimum 4.5 mm diameter and 50% thread length (relative to bone length). Given variability in metatarsal anatomy, screw choice should be tailored to the individual.

Melorheostosis: a Rare Sclerosing Bone Dysplasia.

Melorheostosis is a rare sclerosing bone dysplasia that affects both cortical bone and adjacent soft tissue structures in a sclerotomal distribution. In this review, we describe the natural history, radiological features, proposed pathogenesis, and management options for this debilitating condition. Since its first description in 1922, about 400 cases of melorheostosis have been reported, either as single reports or in small case series. Melorheostosis affects the appendicular skeleton more commonly than the axial skeleton and usually presents with lower limb deformity. Diagnosis is based on a combination of clinical and radiological features that help differentiate this condition from other sclerosing bone dysplasias. LEM domain-containing protein 3 (LEMD3) gene mutations have been demonstrated in several familial cases, but these have been more strongly correlated with other hereditary dysplasias, such as osteopoikilosis, and are not thought to be the causative gene for melorheostosis. The exact etiology of classic sporadically occurring melorheostosis remains unknown, with possible causes being somatic LEMD3 mutations, somatic mutations in the bone morphogenetic protein/transforming growth factor-beta pathway, mutations in multiple genes, or other non-genetic causes. Management in recent years has involved nitrogen-containing bisphosphonates in addition to traditional orthopedic surgical approaches and physical therapy. Melorheostosis may present as mixed or atypical osseous involvement in addition to the classically described "dripping candle wax" appearance of hyperostosis. Some patients may have overlap with osteopoikilosis or Buschke-Ollendorff syndrome. In the future, better characterization of genetic and developmental factors predisposing to melorheostosis may lead to the development of targeted therapy for this condition, as well as for more commonly encountered skeletal abnormalities.

Ultrasonic osteotome: A cutting edge technology, our experience in 96 patients

The ultrasonic osteotome is a tissue-specific device that allows the surgeon to make precise osteotomies while protecting collateral or adjacent soft tissue structures. The recurring impacts pulverize the noncompliant crystalline structure resulting in a precise cut. The more compliant adjacent soft tissue is not affected by the ultrasonic oscillation. The purpose of this study is to present our experience of using this technology in osteotomies. We reviewed 96 patients, both male and female; of different ages in which ultrasonic osteotome was used to perform an osteotomy of different manners (Craniotomy, laminotomy, facetectomy, etc.). Patients with head injury, spine injury, degenerative spine diseases, and brain tumors were included in this study. In all these patients, the bone cut was even with minimal surrounding bone loss. The time required for the osteotomy was reduced to half. There was no damage to underlying dura, cord or nerve structures. Ultrasonic osteotome is a safe and effective ultrasonic bone cutting device that can be used to facilitate osteotomies in various types of cranial and spinal surgeries. This device allows precision bone cutting with minimal surrounding bone loss and obviates the risk associated with the use of high-speed burrs and oscillating saws.

Polyostotic fibrous dysplasia of the mandible and bony nasal septum with intracranial expansion

Fibrous dysplasia is an uncommon benign tumour in the nasal cavity. Due to adjacent vital soft tissue structures surgery is often the treatment of choice. We report a rare case of polyostotic fibrous dysplasia of the mandible and the ethmoid bone including nasal bony septum with intracranial expansion, and include a review of the literature. The tumour was successfully resected using a combined transnasal and craniotomy approach. Fibrous dysplasia is a rare benign tumour in the head and neck region, which often limits its growth during the follow-up period. Careful monitoring of the patient is necessary because in some rare cases there can be severe symptoms due to the growth of the tumour, which are indications of immediate surgery in the head and neck region.