Anatomical Components Research Articles

Approach to Gynecological Adnexal Masses

Gynecological pelvic masses are a common occurrence in women of all ages. The differential diagnosis is extensive and includes masses of all anatomical components of the female reproductive tract. This simple and refined approach leads the reader through the process of narrowing said differential. A thorough history and physical examination are essential steps that can hint to the appropriate investigations such as reproductive hormone levels, serum cancer biomarkers and imaging. Emphasis is put on ultrasound findings, helping differentiate not only diagnoses, but also the benign or malignant character of the mass. It also highlights the Risk of Malignancy Index I, commonly used in clinical practice to assess the risk of malignancy of a mass. Beyond the initial approach, some diagnoses and their management are discussed, from the very common functional cyst to the worrisome ovarian neoplasm, and mentioning more peculiar findings like tubo-ovarian abscess and leiomyoma.

Comparative study of the digastric and the stylohyoid muscles between wild boars (Sus scrofa scrofa) and domestic swine (Sus scrofa domesticus): revisiting the gross anatomy.

Considering Suidae Familie as a perfect and viable experimental biomedical model for research applied to human medicine, it has been sought to describe the comparative anatomy of the digastric and the stylohyoid muscles between boars and domestic swine. Heads of Sus scrofa scrofa and Sus scrofa domesticus were dissected. The digastric muscle presented only one muscle belly as anatomical component of a tendinous origin in the jugular process of the occipital bone, and muscle insertion in the midventral edge of the caudal two thirds of the body of the mandible. Thus, its function is fundamentally associated with the lowering and the retracting of the mandible which, by the way, can deliver greater muscle power at lesser energy expense. For the stylohyoid muscle, the tendinous origin was in the laterocaudal edge of the dorsal third of the stylohyoid bone. The muscle insertion - primarily, was in the lateral and caudal edges from the mid third portion up to the ventral extremity of the thyrohyoid bone, and secondarily as a laterolateral aponeurotic blade which would unite, in a bilateral manner, an insertion that was common to the sternohyoid, the geniohyoid, and the mylohyoid muscles in a median ventral region. This morphology were similar to the two specimens studied expanding the information available, which were completely unknown for the suidae until the moment.

Articular surface failure in hybrid anatomic glenoid components: a unique failure mechanism.

Glenoid loosening is a common failure mechanism of anatomic total shoulder arthroplasty (TSA). New hybrid fixation glenoids allow bony ingrowth and decrease the rates of glenoid loosening. The purpose of this study is to describe a new failure mode of polyethylene dissociation from the ingrowth cage in a single implant design. A retrospective review was performed using an institutional shoulder arthroplasty database of a single hybrid cage glenoid (Exactech, Gainesville, FL). Implants demonstrating this failure mechanism were investigated. Five out of 206 (2.4%) primary TSAs with cage glenoids performed at our institution and 2 referred for revision suffered glenoid articular face failure. Mean age was 57 (range 38-67years). Two of 7 failures (29%) occurred secondary to trauma. Failure occurred at mean 14months after index arthroplasty (range 0-30months). Revision occurred at mean 24months after index arthroplasty (range 6-39months). Six of the 7 patients (86%) had posteriorly augmented glenoids. All 6 patients who had available pre-failure radiographs demonstrated off-axis deviation between the peripheral pegs and central cage (mean 4.8°, range 3°-6°), which may predispose the implant to failure by pre-stressing the material interface. Failure between the glenoid articular face and the central ingrowth cage is a unique failure mechanism to modular hybrid ingrowth glenoids. We hypothesize that this is predisposed by off-axis drilling leading to pre-stressing of the material interface. Surgeons should be aware of the existence of this failure mechanism, particularly when seeing patients with acute pain after an otherwise unproblematic TSA.

Hill Repair—Why It Is Still Relevant and Should Be Taught

The Hill repair for gastroesophageal reflux disease, though effective, durable, and in some regards a superior repair, has unfortunately seen less widespread adoption in the laparoscopic era relative to Nissen and Toupet fundoplications. Some purported objections to the Hill repair include conceptual and technical barriers, need for intraoperative manometry, and lack of clear-cut advantages. However, it has proven to be remarkably durable at 20 years and beyond relative to other repairs, with a low side-effect profile; there are also unique applications of the Hill repair and Hill sutures which broaden one’s armamentarium for managing the spectrum of patients with reflux disease. Lastly, understanding its anatomic components strengthens the surgeon’s knowledge of the anatomy and function of the gastroesophageal junction and antireflux repairs.

Telocytes of the male urogenital system: Interrelationships, possible functions, and pathological implications.

The male urogenital system is composed of the reproductive system and the urinary tract; they have an interconnected embryonic development and share one of their anatomical components, the urethra. This system has a highly complex physiology deeply interconnected with the circulatory and nervous systems, as well as being capable of adapting to environmental variations; it also undergoes changes with aging and, in the case of the reproductive system, with seasonality. The stroma is an essential component in this physiological plasticity and its complexity has increased with the description in the last decade of a new cell type, the telocyte. Several studies have demonstrated the presence of telocytes in the organs of the male urogenital system and other systems; however, their exact function is not yet known. The present review addresses current knowledge about telocytes in the urogenital system in terms of their locations, interrelationships, possible functions and pathological implications. It has been found that telocytes in the urogenital system possibly have a leading role in stromal tissue organization/maintenance, in addition to participation in stem cell niches and an association with the immune system, as well as specific functions in the urogenital system, lipid synthesis in the testes, erythropoiesis in the kidneys and the micturition reflex in the bladder. There is also evidence that telocytes are involved in pathologies in the kidneys, urethra, bladder, prostate, and testes.

Clinical and radiographic results of eccentric glenoid reaming in anatomical total shoulder arthroplasty using 3D planning and PSI

BackgroundTreatment of deformed type B glenoids with anatomical total shoulder arthroplasty (TSA) can be challenging when using standard imaging and instrumentation. 3D planning and PSI-guided (patient-specific instrumentation) eccentric reaming may substantially aid in both the glenoid correction and implantation of anatomical components in difficult cases. We hypothesized that the implementation of preoperative planning and a PSI-guided anatomical component protocol would result in accurate correction of the glenoid deformity and precise glenoid implant positioning. MethodsTwenty-two consecutive patients with primary glenohumeral osteoarthritis, intact rotator cuff and modified-Walch type B glenoids were treated with anatomical total shoulder arthroplasty. Preoperative 3D planning and PSI were used to guide eccentric reaming and correct glenoid deformity. Postoperative clinical and radiographic outcomes were assessed in all patients with a minimum follow-up of 2 years (mean of 26 months). Postoperative corrections of glenoid version and inclination were measured and the variation between preoperative planning and postoperative implant position was evaluated on CT 3D reconstructions. Similarly, both humeral subluxation in the axial scapular plane and glenoid joint line medialization were compared between preoperative and postoperative computed tomographic imaging. ResultsThe mean age was 57 years (range, 54-68). Significant improvements in pain and functional outcome measurements were seen in all 22 subjects. Mean native glenoid version and inclination were −15° ± 5° and 3° ± 5°, respectively. Postoperatively, version was corrected to −7° ± 6° and inclination to 1° ± 2°. Cortical central peg perforation was noted in 1 case and cement perforation in 3 cases. The mean deviation from the preoperative plan was 3° ± 3° for version and 2° ± 2° for inclination. Humeral head subluxation improved from 68% ± 6% to 37% ± 6% and re-centering on the glenoid implant was achieved in all cases. The mean executed medialization of the glenoid joint line was 6 ± 3 mm and proved accurate to within 1 ± 1 mm of the planned medialization. A strong linear correlation was found between the degree of correction of retroversion and the amount of medialization (R = 0.82; P< .001). Conclusion3D preoperative planning and PSI guided correction of deformed modified-type B glenoids resulted in accurate postoperative correction of the glenoid deformity, correct glenoid component implantation with low deviation from the planned position and excellent short-term functional and radiographic results. Level of Evidence: Level IV; Case Series; Treatment Study.

Limited effect of anatomical insert geometry on in vitro laxity in balanced anatomic posterior cruciate ligament retaining total knee arthroplasty.

The present study assessed the effect of insert articular surface geometry (anatomical versus conventional insert design) on anteroposterior (AP) translation and varus-valgus (VV) laxity in balanced posterior cruciate ligament (PCL) retaining total knee arthroplasty (TKA). Secondly, we evaluated if the AP translation and VV laxity in the reconstructed knee resembled the stability of the native knee. Nine fresh-frozen full-leg cadaver specimens were used in this study. After testing the native knee, anatomical components of a PCL-retaining implant were implanted. The knee joints were subjected to anteriorly and posteriorly directed forces (at 20° and 90° flexion) and varus-valgus stresses (at 20°, 45° and 90° flexion) in both non-weightbearing and weightbearing situations in a knee kinematics simulator. Measurements were performed in the native knee, TKA with anatomical insert geometry (3° built-in varus, medial concave, lateral convex), and TKA with symmetrical insert geometry. In weightbearing conditions, anterior translations ranged between 2.6 and 3.9mm at 20° flexion and were < 1mm at 90° flexion. Posterior translation at 20° flexion was 2.7mm for the native knee versus 4.0mm (p = 0.047) and 7.0mm (p = 0.02) for the symmetrical insert and the anatomical insert, respectively. Posterior translation at 90° flexion was < 1.1mm and not significantly different between the native knee and insert types. In non-weightbearing conditions, the anterior translation at 20° flexion was 5.9mm for the symmetrical and 4.6mm for the anatomical insert (n.s.), compared with 3.0mm for the native knee (p = 0.02). The anterior translation at 90° flexion was significantly higher for the reconstructed knees (anatomical insert 7.0mm; symmetrical insert 9.2mm), compared with 1.6mm for the native knee (both p = 0.02). Varus-valgus laxity at different flexion angles was independent of insert geometry. A valgus force in weightbearing conditions led to significantly more medial laxity (1°-3° opening) in the native knee at 45° and 90° flexion compared with the reconstructed knee for all flexion angles. Insert geometry seems to have a limited effect with respect to AP translation and VV laxity, in the well-balanced PCL-retaining TKA with an anatomical femoral component. Secondly, AP translation and VV laxity in the reconstructed knee approximated the laxity of the native knee.

Anatomical and Histological Components of the Bilaminar Zone of the Temporomandibular Joint. A Narrative Review

Anatomical and Histological Components of the Bilaminar Zone of the Temporomandibular Joint. A Narrative Review

Revision Reverse Shoulder Arthroplasty for Anatomical Glenoid Component Loosening Was Not Universally Successful: A Detailed Analysis of 127 Consecutive Shoulders.

Glenoid component loosening is a primary cause of failure of anatomical total shoulder arthroplasty (TSA) and is commonly associated with glenoid bone loss. The purpose of the present study was to evaluate the outcome and survival following revision to a reverse total shoulder arthroplasty (RSA) for the treatment of loosening of a polyethylene cemented glenoid component in the setting of failed TSA. Between 2010 and 2017, 151 shoulders underwent revision to RSA for the treatment of loosening of an anatomical polyethylene glenoid component. Shoulders with staged reconstruction for the treatment of infection were excluded. One hundred and twenty-seven patients (67 women and 60 men) had a single-stage reconstruction and were available for follow-up. The mean age at the time of surgery was 70 years (range, 41 to 93 years). In all cases, the humeral component was revised and a standard glenoid baseplate was utilized. Bone graft was used at the discretion of the treating surgeon. Medical records and radiographs were reviewed to collect demographic, intraoperative, and postoperative data; to quantify glenoid bone loss; and to determine the radiographic outcome. The mean duration of follow-up was 35 months (range, 24 to 84 months). Revision to RSA resulted in significant improvements in terms of pain and motion. Sixteen shoulders (13%) underwent revision surgery for the treatment of baseplate loosening. Radiographic baseplate loosening was present in 6 additional shoulders (overall rate of baseplate loosening, 17%). Intraoperative fracture or fragmentation of the greater tuberosity occurred in 30 shoulders (24%). Other reoperations included resection for deep infection (3 shoulders), arthroscopic biopsies for unexplained persistent pain (2 shoulders), humeral tray exchange for dislocation (2 shoulders), revision for humeral loosening (1 shoulder), irrigation and debridement for hematoma (1 shoulder), and internal fixation of periprosthetic fracture (1 shoulder) (overall reoperation rate, 20%). Among shoulders with surviving implants at the time of the most recent follow-up, pain was rated as none or mild in 83 shoulders (65.4%) and the average active elevation and external rotation were 132° and 38°, respectively. With the numbers available, no risk factors for failure could be identified. Revision RSA for the treatment of loosening of an anatomical polyethylene component was associated with a 17% glenoid mechanical failure rate. Although this procedure resulted in improvements in terms of pain and function, it was not universally successful and thus needs further refinement in order to improve outcomes. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Three-dimensional measures of posterior bone loss and retroversion in Walch B2 glenoids predict the need for an augmented anatomic glenoid component.

The purpose of this study is to evaluate whether the amount of measured posterior bone loss on 2- and 3-dimensional (2D and 3D) imaging of Walch B2 glenoids can reliably predict the plan for an augmented anatomic glenoid component. Patients with Walch B2 glenoids and preoperative computed tomography (CT) scans were retrospectively identified. 2D axial CT scans were reviewed and posterior bone loss was measured by 3 independent reviewers. Images were then formatted into BluePrint (Wright Medical) preoperative planning software. The same 3 reviewers again measured posterior bone loss on 3D imaging. Additionally, all cases were planned with BluePrint software. An augment was used when the following criteria were unable to be satisfied with standard implants: <10° retroversion, <10° superior inclination, ≥90% backside contact, <2 mm medial reaming, and ≤1 peg perforation. Forty-two patients were included in the final analysis with a mean age of 63.1 ± 6.3 years. As measured by BluePrint, the mean retroversion was 23° ± 7° (range = 9°-40°), the mean superior inclination was 5° ± 6° (range = -9° to 22°), and the mean posterior subluxation was 80% ± 17% (range = 41%-95%). The mean 2D bone loss measurements (3.5 ± 1.6 mm) were significantly lower than the mean 3D bone loss (4.0 ± 1.8 mm) measurements (P = .03). There was substantial agreement between reviewers on both 2D and 3D measurements with an interclass correlation of 0.815 (95% confidence interval [CI] 0.714-0.889, P < .001) and an interclass correlation of 0.802 (95% CI 0.683-0.884, P < .001), respectively. Augments were used in 73.8%, 63.4%, and 63.4% of cases by reviewers 1, 2, and 3, respectively, with moderate agreement with a Fleiss kappa of 0.592 (95% CI 0.416-0.769, P < .001). Augment size was moderately, positively correlated with the amount of bone loss on 3D imaging but not with 2D imaging. After multivariate logistic regression, both 3D bone loss and retroversion were found to be predictive for a plan to use an augment. Planning for a posterior augment in Walch B2 glenoids is better predicted with 3D imaging than with 2D imaging, as 2D imaging may underestimate posterior bone loss. Additionally, use of a larger augment size is moderately correlated with posterior bone loss on 3D imaging but not 2D imaging. Standard 2D imaging may be limited in cases of posterior bone loss, and 3D imaging may be beneficial for preoperative planning in Walch B2 glenoids.

Long-Term Outcomes for Cementless Anatomic Femoral Components, Compared by Area of Porous Coating, in Patients Younger Than 50 Years Treated for Hip Dysplasia

BackgroundWe investigated whether the proximal circumferential porous coating of cementless stems would make implant survival of >20 years possible in young patients. MethodsData for patients younger than 50 years with hip dysplasia who had an anatomic stem implanted with a proximal porous coating with hydroxyapatite/tricalcium phosphate were reviewed. Noncircumferential porous (non-C-type) stems were used in 17 hips (13 cases), and circumferential porous (C-type) stems were used in 87 hips (68 cases). Acetabular components with conventional polyethylene were used for all hips. The mean ages at surgery for patients with non-C-type stems and those with C-type stems were 43.3 and 44.7 years, respectively. Stems that had not loosened were retained at the time of acetabular revision. The average duration of follow-up for patients with non-C-type stems was 26.9 years and was 22.3 years for those with C-type stems. ResultsMean survival rates as determined by the Kaplan-Meier method were 74.9% at 20 years and 59.9% at 25 years for non-C-type stems and were 100% at 20 years and 94.0% at 25 years for C-type stems. The survivorship for C-type stems was significantly higher than that for non-C-type stems (P < .01). Focal osteolysis in the shoulder of 37 hips with C-type stems suppressed the spread of osteolysis to the distal femur. ConclusionAnatomic femoral stems with a circumferential porous coating provide excellent durability in patients with hip dysplasia who are 50 years of age or younger. Level of EvidenceTherapeutic Level IV.

3D Printing of Rapid, Low-Cost and Patient-Specific Models of Brain Vasculature for Use in Preoperative Planning in Clipping of Intracranial Aneurysms.

We developed a practical and cost-effective method of production of a 3D-printed model of the arterial Circle of Willis of patients treated because of an intracranial aneurysm. We present and explain the steps necessary to produce a 3D model from medical image data, and express the significant value such models have in patient-specific pre-operative planning as well as education. A Digital Imaging and Communications in Medicine (DICOM) viewer is used to create 3D visualization from a patient’s Computed Tomography Angiography (CTA) images. After generating the reconstruction, we manually remove the anatomical components that we wish to exclude from the print by utilizing tools provided with the imaging software. We then export this 3D reconstructions file into a Standard Triangulation Language (STL) file which is then run through a “Slicer” software to generate a G-code file for the printer. After the print is complete, the supports created during the printing process are removed manually. The 3D-printed models we created were of good accuracy and scale. The median production time used for the models described in this manuscript was 4.4 h (range: 3.9–4.5 h). Models were evaluated by neurosurgical teams at local hospital for quality and practicality for use in urgent and non-urgent care. We hope we have provided readers adequate insight into the equipment and software they would require to quickly produce their own accurate and cost-effective 3D models from CT angiography images. It has become quite clear to us that the cost-benefit ratio in the production of such a simplified model is worthwhile.

Glenoid Innovations in Shoulder Arthroplasty

Anatomic and reverse total shoulder arthroplasty have demonstrated reliable pain relief and improvement in function in select patient populations with glenohumeral arthritis. Certain scenarios have been associated with decreased longevity of the implant, inferior results, and increased complications including glenoid bone loss, revision arthroplasty, and glenoid arthrosis in the young, active patient. Multiple innovations exist to address these scenarios and have demonstrated early success. These innovations include augmented anatomic glenoid components, augmented reverse glenoid baseplates, and in-lay anatomic glenoid components. We review these glenoid innovations and provide case examples of each.

Developing a novel functional disc emulator to investigate the nucleus pulposus replacement

We have developed a simple, inexpensive and innovative device for reproducing the global mechanical behavior of spinal motion segments and the local mechanical environment experienced by lumbar intervertebral discs. The device has several broad functions: (1) exploration of the basic mechanics underlying this complex skeletal system, (2) connecting changes in tissue characteristics with overall motion segment function, and (3) evaluation of strategies for repair and replacement of disc components. This “disc emulator” consists of three main parts: (1) an artificial annulus fibrosus (AAF), made out of silicone, with lumbar disc geometry and adjustable material properties, (2) a hydrogel nucleus pulposus (NP) also with lumbar disc geometry and adjustable material properties, and (3) simulated vertebral bodies 3D printed with trabecular bone simulated by a rigid polymer (Acrylonitrile Butadiene Styrene, ABS) and end plates crafted from a compliant polymer (Thermoplastic Polyurethane, TPU). Mechanical compression experiments have been conducted using the disc emulator under similar protocols to published studies of human cadaver samples. Bulging of the artificial annulus fibrosus was examined under axial compression loads using digital image correlation (DIC), and results show close agreement. We see this approach of using anatomical geometry and multiple adjustable components as a useful means of creating accurate local stress/strain environments for preliminary material evaluation, without the variability and difficulty inherent indirect testing of cadaveric materials.

Regularized multi-structural shape modeling of the knee complex based on deep functional maps.

The incorporation of a-priori knowledge on the shape of anatomical structures and their variation through Statistical Shape Models (SSMs) has shown to be very effective in guiding highly uncertain image segmentation problems. In this paper, we construct multiple-structure SSMs of purely geometric nature, that describe the relationship between adjacent anatomical components through Canonical Correlation Analysis. Shape inference is then conducted based on a regularization term on the shape likelihood providing more reliable structure representations. A fundamental prerequisite for performing statistical shape analysis on a set of objects is the identification of corresponding points on their associated surfaces. We address the correspondence problem using the recently proposed Functional Maps framework, which is a generalization of point-to-point correspondence to manifolds. Additionally, we show that, by incorporating techniques from the deep learning theory into this framework, we can further enhance the ability of SSMs to better capture the shape variation in a given dataset. The efficiency of our approach is illustrated through the creation of 3D models of the human knee complex in two application scenarios: incomplete or noisy shape reconstruction and missing structure estimation.

The cornea IV immunology, infection, neovascularization, and surgery chapter 1: Corneal immunology

Purposeof Review: This review offers an informed and up-to-date insight on the immune profile of the cornea and the factors that govern the regulation of such a unique immune environment. SummaryThe cornea is a unique tissue that performs the specialized task of allowing light to penetrate for visual interpretation. To accomplish this, the ocular surface requires a distinct immune environment that is achieved through unique structural, cellular and molecular factors. Not only must the cornea be able to fend off invasive infectious agents but also control the inflammatory response as to avoid collateral, and potentially blinding damage; particularly of post-mitotic cells such as the corneal endothelium. To combat infections, both innate and adaptive arms of the inflammatory immune response are at play in the cornea. Dendritic cells play a critical role in coordinating both these responses in order to fend off infections. On the other side of the spectrum, the ocular surface is also endowed with a variety of anatomic and physiologic components that aid in regulating the immune response to prevent excessive, potentially damaging, inflammation. This attenuation of the immune response is termed immune privilege. The balance between pro and anti-inflammatory reactions is key for preservation of the functional integrity of the cornea. Recent findingsThe understanding of the molecular and cellular factors governing corneal immunology and its response to antigens is a growing field. Dendritic cells in the normal cornea play a crucial role in combating infections and coordinating the inflammatory arms of the immune response, particularly through coordination with T-helper cells. The role of neuropeptides is recently becoming more highlighted with different factors working on both sides of the inflammatory balance.

Clinical application of distal femoral patient-specific cutting guide based on knee CT and full-length X-ray film of lower extremities

To discuss the feasibility and accuracy of distal femoral patient-specific cutting guide in total knee arthroplasty (TKA) based on knee CT and full-length X-ray film of lower extremities. Between July 2016 and February 2017, 20 patients with severe knee joint osteoarthritis planned to undergo primary TKA were selected as the research object. There were 9 males and 11 females; aged 53-84 years, with an average of 69.4 years. The body mass index was 22.1-31.0 kg/m 2, with an average of 24.8 kg/m 2. The preoperative range of motion (ROM) of the knee joint was (103.0±19.4)°, the pain visual analogue scale (VAS) score was 5.4±1.3, and the American Hospital of Special Surgery (HSS) score was 58.1±11.3. Before operation, a three-dimensional model of the knee joint was constructed based on the full-length X-ray film of lower extremities and CT of the knee joint. The distal femoral patient-specific cutting guide was designed and fabricated, and the thickness of the distal femoral osteotomy was determined by digital simulation. The thickness of the internal and external condyle of the distal femur osteotomy before operation and the actual thickness of the intraoperative osteotomy were compared. The intraoperative blood loss, postoperative drainage loss, and hidden blood loss were recorded. The ROM of knee joint, VAS score, and HSS score at 3 months after operation were recorded to evaluate effectiveness. The position of the coronal and sagittal plane of the distal femoral prosthesis were assessed by comparing the femoral mechanical-anatomical angle (FMAA), anatomical lateral distal femoral angle (aLDFA), mechanical femoral tibial angle (mFTA), distal femoral flexion angle (DFFA), femoral prosthesis flexion angle (FPFA), anatomical lateral femoral component angle (aLFC), and the angle of the femoral component and femoral shaft (α angle) between pre- and post-operation. TKA was successfully completed with the aid of the distal femoral patient-specific cutting guide. There was no significant difference between the thickness of the internal and lateral condyle of the distal femur osteotomy before operation and the actual thickness of the intraoperative osteotomy ( P>0.05). All patients were followed up 3 months. All incisions healed by first intention, and there was no complications such as periarticular infection and deep vein thrombosis. Except for 1 patient who was not treated with tranexamic acid, the intraoperative blood loss of the rest 19 patients ranged from 30 to 150 mL, with an average of 73.2 mL; the postoperative drainage loss ranged from 20 to 500 mL, with an average of 154.5 mL; and the hidden blood loss ranged from 169.2 to 1 400.0 mL, with an average of 643.8 mL. At 3 months after operation, the ROM of the knee was (111.5±11.5)°, and there was no significant difference when compared with the preoperative one ( t=-1.962, P=0.065). The VAS score was 2.4±0.9 and HSS score was 88.2±7.5, showing significant differences when compared with the preoperative ones ( t=7.248, P=0.000; t=-11.442, P=0.000). Compared with the preoperative measurements, there was a significant difference in mFTA ( P<0.05), and there was no significant difference in aLDFA, FMAA, or DFFA; compared with the preoperative plan, there was no significant difference in FPFA, aLFC, or α angle ( P>0.05). The use of distal femoral patient-specific cutting guide based on knee CT and full-length X-ray film of lower extremity can achieve precise osteotomy, improve coronal and sagittal limb alignment, reduce intraoperative blood loss, and obtain satisfactory short-term effectiveness.

Anatomical Understanding of Vitapa Marma by Means of Cadaveric Dissection

Background of study:&#x0D; Marma are those spots on the body which are painful on application of pressure and shows abnormal pulsation. Marma are conglomeration of Mamsa, Sira, Snayu, Asthi and Sandhi. [1] There are 107 Marma.[2] Individual Marma are catagorized on different groups on the basis of various aspects such as Rachananusara, Parinamanusara, Sthananusara, Pramananusara etc.&#x0D; Vitapa Marma is the Adhoshakagata, Vaikalyakara Marma[3,4] of 1 Anguli Pramana.[5,6] The explanation of the Vitapa Marma in the classical texts cannot specify the particular anatomical entity so the study is undertaken to fulfill the deficit knowledge.&#x0D; Objectives:&#x0D; To evaluate the Snayu &amp; Sira component of Vitapa Marma.&#x0D; To evaluate structural entity of Vitapa Marma in relation to given Pramana and Viddha Lakshana.&#x0D; Materials and methods:&#x0D; Cadaveric Study. Observation of the structures exposed during cadaveric dissection and correlation with textual description were done and the conclusion was drawn.&#x0D; Results: Vitapa Marma lies on the inguinal region at the superficial inguinal ring. The anatomical components of this Marma are the structures related to and passing through superficial inguinal ring.&#x0D;

Validation of New Real-Time Three-Dimensional Transesophageal Echocardiographic Scoring System in Prediction of Immediate and Long-term Outcome After Percutaneous Balloon Mitral Valvuloplasty

Dear Editor,The guidelines recommend percutaneous mitral balloon commissurotomy (PMBC) as the first choice therapy for symptomatic patients with moderate or severe mitral stenosis (MS) with favorable valve morphology and for asymptomatic MS patients with pulmonary hypertension (1). Echocardiography is the main diagnostic imaging method for assessing mitral valve stenosis and evaluating the severity and hemodynamic consequences of MS as well as valve morphology and disease extension (2). The main predictor of successful BMV is mitral valve morphology. Therefore, the MV scoring system using echocardiography is very important. Several two-dimensional echocardiographic scoring systems have been proposed to evaluate MV morphology, the severity of which is related to immediate and long-term outcome (3). Most cardiologists use the Wilkins score for evaluation of MV anatomy. Although, none of the available 2DE scores have not been shown to be superior to any of the other scores (4). The evaluation of the MV Wilkins score depends on the assessment of four parameters, which include: leaflets mobility, thickness, calcification, and subvalvular involvement. Each parameter is given a score of 1-4 and by calculating its sum, the total score of 1-16/16 (mild involvement = 1-4/16, moderate involvement = 5-8/16, and severe involvement &gt; 8/16) is obtained (3). The ideal echocardiographic scoring system should have the following characteristics:Quantitative and qualitative evaluation of each component of the MV apparatus separately to determine the deformity in a specific portionThe inclusion of all the points that have been proven through a large study affects the BMV resultEasy to use and interpretable by most cardiologists at a reasonable timeHigh reliability and reproducibility (4)In recent years, real-time three-dimensional echocardiography technology has evolved rapidly. RT3DE provides detailed morphologic display and analysis of the mitral valve structure. Improving the RT3DE probe technology, especially transesophageal probes, highlights the need to introduce a RT3DE scoring system (5). Anwar et al. introduced the first scoring system using real-time three-dimensional transthoracic echocardiography (RT3D-TTE) in patients with mitral valve stenosis candidate BMV, and compared the new score with the Wilkins score in predicting outcome after BMV. In the new RT3DE score, each leaflet was divided into three scallops (anterolateral A1-P1, middle A2-P2, and posteromedial A3-P3) and each scallop was scored separately for thickness, calcification, and mobility, as follows: 0 for normal thickness and mobility, 1 for abnormal thickness and restricted mobility, and for scoring calcification: 0 for the absence of calcification, 1 for calcification of middle scallop (A2 or P2) and 2 if there is calcification of commissural scallops (A1, A3-P1, P3). For scoring subvalvular apparatus, the anterior and posterior chordae were scored at three levels as follows: proximal (valve level), middle, and distal (papillary muscle level). Each level was scored separately for thickness and separation in between as follows: 0 for normal thickness, 1 for abnormal thickness, also 0 in case of normal chordal separation (distance in between &gt;5 mm), 1 in case of partial separation (distance in between &lt;5 mm) and 2 in case of absence separation. From the sum of these points, a total score of 0-31/31 (mild MV involvement &lt;8, moderate MV involvement 8-13, and severe MV involvement &gt;14) is obtained (6). 3D-Anwar score is complex and time consuming. This is due to the many anatomical and morphological components to achieve an accurate assessment. The available 3D score is highly selective for optimal BMV result, which leads to more patients being referred for surgery (5). So we decided to introduce a three-dimensional transesophageal (3D-TEE) echocardiographic scoring system that meets the criteria of an ideal echocardiographic scoring system, and evaluate the validity of the new score in predicting the immediate and long-term outcome of patients after BMV. We also believe that many studies are needed to achieve an ideal RT3DE scoring system.

Classification of postoperative edema based on the anatomic division with mandibular third molar extraction

PurposeSeveral investigations have been performed for a postoperative edema after extraction, but the results have been controversial due to low objectivity or poorly reproducible assessments of the edema. The aim of this study was to suggest a classification and patterns of postoperative edema according to the anatomical division associated with extraction of mandibular third molar as a qualitative evaluation method.MethodsThis study was conducted forty-four mandibular third molars extracted and MRI was taken within 48 h after extraction. The postoperative edema space was classified by MRI (one anatomic component—buccinator muscle—and four fascial spaces—supra-periosteum space, buccal space, parapharyngeal space, and lingual space), and evaluated independently by two examiners. The inter-examiner reliability was calculated using Kappa statistics.ResultsThe evaluation of buccinator muscle edema showed good agreement and the fascial spaces showed constant high agreement. The incidence of postoperative edema was high in the following order: supra-periosteum space (75.00%), buccinator muscle (68.18%), parapharyngeal space (54.55%), buccal space (40.91%), and lingual space (25.00%).ConclusionPostoperative edema could be assessed clearly by each space, which showed a different tendency between the anatomic and fascial spaces.