Anterior Aspect Research Articles

Head CT dose reduction with organ‐based tube current modulation

A helical head CT examination uses a pitch factor (PF) of <1.0, resulting in a part of the slice being directly irradiated twice. This raises the possibility of double irradiation, which may increase the amount of radiation to the lens. Organ-based tube current modulation (OBTCM) is an effective method for reducing lens exposure because it reduces the dose to the anterior aspect of the patient. However, it is challenging to visualize the complex dose distribution when factoring in double irradiation. To visualize twice-irradiated areas in helical head CT in three dimensions and to clarify the exposure reduction effect of OBTCM. A leuco crystal violet (LCV) dosimeter was placed into an empty polyethylene terephthalate bottle 16.5 cm in diameter. Helical scans were performed without and with OBTCM using the following parameters: tube voltage 120 kV, tube current 600 mA, pitch factor 0.637, rotation time 0.5 s, 80 (detector rows) × 0.5 mm (detector collimation), and ten scans. Exposed areas were visualized using an optical computed tomography (OCT) system designed by our group. The dose reduction rate of OBTCM was defined as the ratio of the average values of the histogram with the dose value on the x-axis and the frequency on the y-axis without and with OBTCM at 90° to the anterior midline. The LCV dosimeter visualized the spiral-shaped twice-irradiated areas. Double irradiation resulted in a dose of 2.19/1.90 and 1.38/1.19 Gy (15.0% and 15.9% increase) without and with OBTCM, respectively. The dose reduction using OBTCM was 29.6% at 90° anterolateral. The LCV dosimeter visualized the complex three-dimensional irradiated areas and enabled dose measurement in twice-irradiated areas. Increased exposure from double irradiation was attenuated by OBTCM.

Right ventricular outflow tract endocardial unipolar substrate mapping: implications in risk stratification of Brugada syndrome.

Brugada syndrome (BrS) is a complex arrhythmogenic disease displaying electrical and micro-structural abnormalities mainly located at the epicardium of the right ventricular outflow tract (RVOT). It is well-known that fibrosis, fatty infiltration, inflammation and reduced gap junction expression have been demonstrated at the epicardial anterior aspect of the RVOT providing the arrhythmogenic substrate for ventricular arrhythmic events in BrS. A number of models have been proposed for the risk stratification of patients with BrS. Endocardial unipolar electroanatomical mapping is an emerging tool that has been reintroduced to identify and quantify epicardial electrical abnormalities. Interestingly, current findings correlate the presence of large-sized endocardial unipolar electroanatomical abnormalities with either ventricular fibrillation inducibility during programmed ventricular stimulation or symptom status. This review aims to present existing data about the role of endocardial unipolar electroanatomical mapping for the identification of RVOT epicardial abnormalities as well as its potential clinical implications in risk stratification of BrS.

Retained gallstones: A forgotten complication after laparoscopic cholecystectomy

A 68-year-old woman with history of Laparoscopic Cholecystectomy (LC) for symptomatic gallstones 1 month ago, presented to the emergency department for mid abdominal pain since surgery. The pain is severe, continuous and unrelated to food. Her past medical history is significant for Diabetes Mellitus Type 2. On physical examination, she had localized abdominal tenderness and guarding at two surgical sites with skin induration. Laboratory studies were significant for leukocytosis (WBC 15,200) and elevated C- Reactive Protein of 150 mg/L. A contrast enhanced abdominal and pelvic CT scan showed postsurgical changes in the anterior abdominal wall and peritoneal calcification in the anterior aspect of the peritoneal cavity with associated fat stranding (Figure A and B).

Anatomy of the sphenoidal spine and its implications in endoscopic endonasal surgery of the infratemporal fossa.

The sphenoidal spine protrudes from the roof of the infratemporal fossa (ITF). This study aims to assess the anatomic relationships among the sphenoidal spine and other structures within the ITF from the perspective of an endoscopic endonasal access (EEA), and to explore the implications of these relationships. An EEA to the ITF was completed on six cadaveric specimens (12 sides). The anatomical relationships among the sphenoidal spine and adjacent structures were explored and associated distances from each other were measured using a navigation system. The foramen spinosum is located anterosuperior to the sphenoidal spine, whereas the chorda tympani courses caudal and medial to the sphenoidal spine and the Eustachian tube and parapharyngeal internal carotid artery (pICA) are at its posterior aspect. Two virtual vertical planes, at the anterior and posterior aspects of the sphenoidal spine, respectively, correspond to the posterior trunk of V3 and middle meningeal artery, and the stylopharyngeal aponeurosis. The average length of sphenoidal spine was 8.5 ± 2.43 mm, and the distance from distal apex of the sphenoidal spine to the foramen ovale, foramen spinosum, and pICA were 10.82 ± 0.83 mm, 6.42 ± 0.52 mm, and 5.02 ± 0.54 mm, respectively. The sphenoidal spine is a meaningful landmark for endonasal approaches to the ITF. Measurements and conceptualization of vertical planes prior and posterior to the sphenoidal spine are beneficial to better appreciate the anatomic relationships in the ITF.

The prevalence and distribution of the flexor carpi radialis brevis muscle in the Turkish population

The flexor carpi radialis brevis (FCRB) is a very rare anomalous muscle that is usually asymptomatic but may cause various pathologies, such as radial-sided wrist pain. The aim of this study was to determine the prevalence of FCRB in the Turkish population, its location, and sex differences. Forearm, wrist, and hand magnetic resonance images of 849 individuals aged 18–65 years were retrospectively evaluated in this study. The survey found an FCRB prevalence of 4%, with a prevalence of 3.6% among women and of 4.7% among men. However, the difference between the sexes was not statistically significant (p = 0.629). The origin of all 34 FCRBs identified was the distal third of the anterior aspect of the radius; the insertion site of 28 was the second metacarpal bone, whereas that of the remaining 6 was the os trapezium. In conclusion, the data of this study report the prevalence of FCRB for the first time in the Turkish population, which will contribute to radiological and surgical evaluations in the region and help in early and accurate diagnosis of various pathological conditions that may be caused by FCRB.

LAPAROSCOPIC ANTIREFLUX SURGERY: ARE OLD QUESTIONS ANSWERED? MESH HERNIOPLASTY.

Hiatal hernias are at high risk of recurrence. Mesh reinforcement after primary approximation of the hiatal crura has been advocated to reduce this risk of recurrence, analogous to mesh repair of abdominal wall hernias. However, the results of such repairs have been mixed, at best. In addition, repairs using some type of mesh have led to significant complications, such as erosion and esophageal stricture. At present, there is no consensus as to (1) whether mesh should be used, (2) indications for use, (3) the type of mesh, and (4) in what configuration. This lack of consensus is likely secondary to the notion that recurrence occurs at the site of crural approximation. We have explored the theory that many, if not most, "recurrences" occur in the anterior and left lateral aspects of the hiatus, normally where the mesh is not placed. We theorized that "recurrence" actually represents progression of the hernia, rather than a true recurrence. This has led to our development of a new mesh configuration to enhance the tensile strength of the hiatus and counteract continued stresses from intra-abdominal pressure.

WBCT Can Effectively Diagnose Syndesmotic Instability Among Patients with Weber B Ankle Fractures

Category:Ankle; TraumaIntroduction/Purpose:Diagnosing and treating syndesmotic instability that occurs in some Weber B ankle fractures is essential to restore normal ankle joint kinematics and optimize clinical outcomes however subtle instability can be difficult to identify.WBCT evaluates the syndesmotic joint under physiologic load. We compared the diagnostic sensitivities of one-dimensional (1D) distance, two-dimensional (2D) area, and three-dimensional (3D) volumetric measurement of the injured syndesmotic joint on WBCT, in patients with unilateral Weber B ankle fractures with surgically-confirmed syndesmotic instability, to the contralateral uninjured side.Methods:Patients with unilateral surgically confirmed syndesmotic instability accompanying a Weber B type lateral malleolar ankle fracture (n = 23) who underwent preoperative bilateral foot and ankle WBCT were included. A separate group of patients with unilateral Weber B ankle fractures without syndesmotic instability and who underwent bilateral WBCT were included as a control group (n = 18). With the uninjured side serving as an internal control, measurements on bilateral WBCT images included: 1) syndesmotic area, 2) tibiofibular distance measured at the anterior, middle, and posterior aspect of the distal tibiofibular articulation, 3) fibular rotation, 4) distance from fibular tip to plafond, 4) fibular fracture displacement and 5) medial clear space distance. In addition, 3D volumetric measurements: 1) syndesmotic joint volume from the tibial plafond extending to 3cm and 5cm proximally, respectively 2) medial clear space volume, and 3) lateral clear space volume were calculated, and their sensitivities were compared to the aforementioned measurements.Results:Among patients with unilateral syndesmotic instability with Weber B ankle fractures, all WBCT measurements except medial clear space distance, syndesmotic area, and anterior and posterior tibiofibular distance were significantly greater on the injured compared to the uninjured side (p-values ranging from <0.001 to 0.004). Of these measurements, 3D syndesmosis volumetric measurements spanning from the tibial plafond to a level 3cm and 5cm proximally had the highest relative volumetric ratio between the injured and uninjured side, suggesting high sensitivity to distinguish between stable and unstable syndesmotic injuries (p -values ranging from 0.001 to 0.036). In the control group without syndesmotic instability, all evaluated WBCT parameters except for MCS volume, and distal fibular tip to tibial plafond showed no significant side-to-side difference.Conclusion:Bilateral WBCT can effectively diagnose syndesmotic instability among patients with Weber B ankle fractures. While middle incisura distance, fibular rotation, and 3D volumetric measurements can all be used to identify such instability, 3D syndesmotic volume measurements are the most sensitive and thus strongly recommended for future application in scenarios of clinical dilemma of syndesmotic injury-particularly when injuries are subtle. When performing these 3D volume measurements, it appears that syndesmosis volume extending from the tibial plafond to a height of 5cm proximally is best suited to evaluate such instability given the larger absolute side to side difference of 3.5 cm3.

Transvaginal Sonographic Assessment Following Cervical Pessary Placement for Preterm Birth Prevention.

Background Transvaginal sonographic cervical length assessment identifies pregnant women at risk for preterm birth, and the subsequent placement of a cervical pessary may reduce this risk. The mechanism of action remains uncertain, and postplacement transvaginal sonography may provide further insight into the controversial efficacy of this therapy. Objective To identify any pre- or postplacement sonographic findings associated with preterm delivery following cervical pessary insertion among at-risk women. Materials and Methods This retrospective cohort study utilized electronic medical record and imaging review of all women identified within a large tertiary care health system having undergone cervical pessary placement for preterm birth risk reduction and subsequently delivered between January 2013 (the adoption of this therapeutic option in our system) and March 2017. Indications for cervical pessary placement were guided by maternal–fetal medicine consultation and required a functional cervical length measurement on transvaginal sonography of 25 mm or less. Criteria for initial transvaginal cervical assessment included obstetric history, multiple gestation, and current concern on transabdominal imaging for cervical shortening. All pre- and postplacement transvaginal sonographic measurements were determined for study purposes by re-review of each patient's images by a single author blinded to outcome. Results A total of 88 women were identified as having undergone cervical pessary placement for preterm birth prevention, and 52 yielded complete delivery and imaging data for inclusion. As expected, this was a high-risk population with 51.9% carrying multiple gestations, 32.7% with a history of prior preterm birth, and 11.6% with a history of cervical conization. Although previously hypothesized to represent the mechanism of action, neither the change in uterocervical or intracervical angle was associated with gestational age at delivery. Alternatively, preplacement imaging measurements of cervical funneling, anterior cervical length, and cervical diameter were significantly associated with appropriate pessary placement and decreased preterm birth. Forty-two subjects (80.8%) demonstrated both the anterior and posterior aspects of the cervix within the pessary (appropriate placement) and 95.2% of these subjects demonstrated cervical funneling on initial imaging compared with 25% of those with inappropriate placement ( p = 0.002). Anterior cervical length less than 20 mm and cervical diameter less than 33 mm were associated with preterm delivery less than 28 weeks (16.7 vs. 0%, p = 0.039), and anterior cervical length less than 20 mm was associated with preterm delivery less than 32 weeks (41.7 vs. 10.7%, p = 0.025). Cervical diameter less than 33 mm correlated with an “inappropriately placed” pessary among 83.3% in comparison to 48.7% ( p = 0.048) of women with a cervical diameter less than 33 mm. Significant associations were noted between postplacement functional cervical length measurements and preplacement anterior cervical length ( p = 0.001) and cervical diameter ( p = 0.012). Conclusion Contrary to current thinking, no significant changes in uterocervical and intracervical angle following cervical pessary placement were identified. However, preplacement sonographic measurement of funneling, anterior cervical length, and cervical diameter are predictive of appropriate pessary placement and extreme preterm birth. These may represent markers for candidacy of cervical pessary placement. Postplacement transvaginal sonography represents an important tool to assess potential efficacy of this therapeutic modality, and further investigation of these factors is warranted.

Mycobacterium chelonae infection in an immunocompromised patient presenting as multiple papulonodules on the leg

Mycobacterium chelonae is a rapidly growing nontuberculous mycobacteria that is a rare cause of cutaneous infections in both immunocompromised and immunocompetent patients. The clinical presentation is heterogeneous and non-specific, and therefore, despite an increasing incidence of these infections, patients are often misdiagnosed. Here we present the case of an immunocompromised 73-year-old female patient that developed tender, erythematous, violaceous to brownish papules and nodules on both the anterior and posterior aspects of her left lower leg. A histopathological examination revealed acid-fast bacilli, and a tissue culture identified M. chelonae. Disease resolution was achieved with long-term targeted antibiotic therapy based on susceptibility testing.

Endoscopic Insertional Achilles Reconstruction with Double Row Suture Bridge Reconstruction: A Technique Tip

Category:Ankle; ArthroscopyIntroduction/Purpose:Insertional Achilles tendinopathy can be a debilitating condition that often fails to improve with non- surgical management such as bracing and physical therapy. Traditional surgical techniques include an open debridement of the diseased tendon and resection of calcaneal spurs. This is followed by repair of the tendon. Suture anchors are often used to secure the tendon, but recent advances in tendon fixation, including the advent of double row repairs, has allowed better biomechanical repairs and faster rehabilitation. Additionally, minimally invasive surgery (MIS) and endoscopic techniques have advanced to allow successful treatment of all aspects of the condition while minimizing wound complications and infectionMethods:The authors present a technique to treat insertional Achilles tendinopathy and calcaneal bone spurs using MIS techniques while also incorporating a percutaneous double row suture anchor repair. The technique utilizes four portals to access two endoscopic working planes. The burr is inserted deep to the tendon and the calcaneoplasty is performed. Subsequently, the endoscope is inserted alongside a shaver to remove bony debris and debulk the anterior aspect of the Achilles areas of tendinopathy. Following this, the portals are used to place a double row suture anchor repair.Results:With over 75 surgeries performed, there have been zero wound complications and patients have been able to return to full weight bearing within 10 days after surgery. Follow up outcome data is currently being collected and will be reported as a case series once sufficient patients have completed their follow up.Conclusion:This study presents double-row repair following an endoscopic assisted MIS calcaneoplasty and Achilles debridement. The technique combines the benefits of the double row suture bridge repair with a minimal incision technique to debride the insertional tendinosis. In order to adequately debride the tendon and the posterior calcaneal tuberosity, the tendon foot print is elevated as the burr removes the bone at the insertion. The anterior portion of the tendon, which may be a pain generator as well, isdebrided endoscopically with the shaver. Finally, a double row suture bridge repair is performed in order to allow early weight bearing and rehabilitation.

Evidence of a functional clitoris in dolphins

In species that copulate during non-conceptive periods, such as humans and bonobos, sexual intercourse is known to be pleasurable for females. Dolphins also copulate throughout the year, largely to establish and maintain social bonds1. In dolphins, the clitoris is positioned in the anterior aspect of the vaginal entrance2, where physical contact and stimulation during copulation is likely. Clitoral stimulation seems to be important during female-female sexual interactions in common bottlenose dolphins (Tursiops truncatus), which rub each other's clitorises using snouts, flippers, or flukes3. Determining a sexual pleasure response in animals not amenable to neurobehavioral examination is difficult, but investigation of the clitoris may elucidate evidence of functionality. In this study, we assessed macro- and micromorphological features of the clitoris in common bottlenose dolphins to examine functional features, including erectile bodies with lacunae, extensible collagen and/or elastin fibers, and the presence and location of sensory nerves. Our observations suggest the clitoris of dolphins has well-developed erectile spaces, is highly sensitive to tactile stimulation, and is likely functional. VIDEO ABSTRACT.

Diabetic ulcer with diabetic neuropathy: a rare clinical image.

A diabetic ulcer is a non-healing ulcer seen in people with uncontrolled blood sugar. High blood sugar causes the formation of sorbitol from sugar, which causes demyelination of large nerve fibers. Here we reported a case of a 62-year-old male who came to the medicine outpatient department with the complaint of a large ulcer over the anterior aspect of the right leg. In diabetic patients, there is an altered immune system and poor blood flow. On physical examination, there is loss of epithelium with granulation tissue formation and decreased sensation, doctors suggested a diagnosis of diabetic ulcer with diabetic neuropathy. On lab investigation, the patient was diagnosed with Type II diabetes with an uncontrolled blood sugar of chronic duration.

Risk Factors for Nonunion in Pediatric Lateral Column Lengthening (Mosca) Procedures

Category:HindfootIntroduction/Purpose:The Evans/Mosca procedure remains the most utilized extra-articular osteotomies for correction of pes planus. This desired lengthening is created by inserting a graft in the anterior aspect of the calcaneus through a complete transverse osteotomy. Failure of conservative methods, particularly for rigid pes planus, is a primary consideration for surgical management. Complications of the Evans procedure include delayed union, nonunion, malunion, subluxation of the calcaneocuboid joint, and persistent lateral column pain. Our study analyzes risk factors for development of non-union.Methods:After IRB approval 120 patients charts and 157 feet were analyzed for incidence of non-union which was defined by clinical and radiographic evidence of absence of union >6 months. Delayed union was diagnosed if there was clinical evidence of healing without complete union at >6 months. Exclusion criteria included age >18 and revision lateral column lengthening. Patients' medical records were reviewed for basic demographics, complications, and surgical technique.Results:The cohort consisted of 75 females (47.8%) and 82 males (52.2%). The median age was 12 with an interquartile range (IQR) of 3. A total of 6 patients (3.7%) had wound complications or nerve injury. Nonunion occurred in 7 of 157 feet (4.5%) with 2 of 157 feet (1.3%) experiencing delayed union. The median age for patients with nonunion was significantly higher than those who achieved union (13.2 (IQR 2.75) vs. 11.2 (IQR 3) respectively). The fixation construct used was associated with increased risk of nonunion. Patients with screw fixation had the highest rate of nonunion at 50% (2/2) compared to pin and/or staple fixation at 6.8% (5/73), no fixation at 4% (3/75), and plate fixation at 0% (0/2). Both delayed union patients were treated with ultrasound bone stimulation, both patients were able to achieve complete union. Revision was attempted in 5/7 nonunions with all operative patients achieving union.Conclusion:Our study analyzed risk factors for developing non-union in patients undergoing calcaneal lengthening osteotomy for pediatric pes planus. We found age at time of surgery and graft fixation method to be significant risk factors for development of non-union. Our study highlighted that those patients who had non-union was on average >2yrs older at time of surgery. Overall, lateral column lengthening is a well-tolerated procedure with a complication rate, including non-and delayed union, of 10.8%. Surgeons should be aware, in the largest cohort of pediatric Evans/Mosca procedures to date, patient age and type of fixation were associated with nonunion.

Usefulness of Radiation Protection Cloths in Fluoroscopy with Clean Areas

Lowering the dose limit for the lens of the eye incorporated into the Regulation on Prevention of Ionizing Radiation Hazards, effective on April 2021, and dose reduction will become more and more important in the field of radiation. Radiation protective cloth is used as a protective equipment in fluoroscopy rooms. Although it is usually used to protect staff from radiation exposure during endoscopic retrograde cholangiopancreatography, we investigated whether there is a way to use it for procedures in clean areas. Assuming ureterostomy fistula replacement in urology, the protective cloth was suspended on the side of the patient's head and posterior aspect of the tube, and the distance between the anterior aspect of the X-ray tube and the patient's foot was 55 cm. As a result of measuring the dose rate, a 10% dose reduction was obtained for the lens of the eye of the surgeon, and the distribution of air dose rate in the examination room was significantly reduced. Although scattered radiation from the radiation protection cloth appeared in some areas, the radiation dose to the patient was reduced throughout the body, and a high degree of radiation protection was obtained, especially for the lens of the eye. It is expected that the radiation protection cloths may be useful even when the length of the cloths is limited due to the cleanliness of the area.

Surgical anatomy of the femoral nerve in formalin prefixed cadavers in an adult Kenya population

Background: Ethnic variations involving femoral nerve have been described in literature. This nerve is the largest branch of the lumbar plexus. It innervates the hip flexors, knee extensors, and sensory function to medial and anterior aspects of the thigh. Risks of insults to nerve can be non-iatrogenic (trauma), and iatrogenic (approaches to the acetabulum, pelvis and proximal femur). The study aimed at providing precise description of variant anatomy of nerve, hence will help surgeons avoid iatrogenic insults.Methods: An anatomic descriptive cross-sectional study design involving fifty six (56), formalin prefixed adult cadaveric specimens. The length of the femoral nerve in relation to the inguinal ligament and its bony attachments, and the patterns of distribution of main branches in the regions were defined. Results: Males- 35 (Left=17, Right=18); Females- 21(Left=7, Right=14). Femoral nerve location: 53.02 mm (SD 14.59) from the ipsilateral anterior superior iliac spine (ASIS). Nerve trunk in relation to inguinal ligament measured: 47.85mm (SD 13.719) from the psoas muscle proximally and branched 29.32 mm (SD 14.239) distally. Innervations and branches: quadriceps in all specimens (Posterior); Sartorius muscles (Anterior), with noted variability in individual muscles. Branching pattern variations: 6 limbs (10.71%) at ligament level, 2(3.57%) limbs more proximal, while one nerve was split by a slip from the psoas muscle and then united 25.88mm proximal to ligament. The variations in sex were not statistically significant (p> 0.05).Conclusion: The anatomical course, length and branches of the femoral nerve in relation to inguinal ligament concur to great extent with described anatomic studies with some noted variability. Surgeons should be aware of the anatomic variations of femoral nerve and be cautious when operating in the zones traversed by the nerve.

3-D DISTRIBUTION OF BONE PARAMETERS ACROSS THE DISTAL FEMUR FROM WEIGHT BEARING CT FOLLOWS PATTERNS ACCORDING TO JOINT SPACE NARROWING PHENOTYPE: A MULTICENTER OSTEOARTHRITIS STUDY INVESTIGATION

Weight bearing CT (WBCT) technology has been increasingly used in imaging of knee osteoarthritis in recent years because of its ability to assess the weight bearing joint space. However, relatively little is known regarding the extent to which this cone beam technology can provide useful information on peri-articular bone beyond the subchondral regions. To explore relationships between WBCT-derived 3-D cortical bone thickness and trabecular bone attenuation at the distal femur with concurrent joint space narrowing phenotypes. WBCT imaging was obtained ancillary to the Multicenter Osteoarthritis Study at the 144-month visit. After semi-automatic segmentation, femoral cortical thickness (fCT) and trabecular attenuation (fTA) maps were created for each of 663 available distal femurs using cortical bone mapping. A template was registered to each individual distal femur and a 3-D statistical shape model created, followed by transfer of fCT and fTA distribution maps onto the template. A statistical parametric mapping (SPM) general linear model adjusted for age, sex, BMI, and the first 5 shape modes (controlling for effects of systematic misregistration) was used to test the dependence of fCT and fTA in turn on the experimental variables of concurrent radiographic medial and lateral OARSI joint space narrowing (JSN) grade. One knee from each participant was selected for inclusion, taking the side with worse compartmental baseline JSN grade or randomly if equal. 16 knees were excluded due to unachievable registration, with a final study set of a single knee from 386 individuals. 219 were female, mean ± SD age was 63.6 ± 9.6 yrs, mass 82.3 ± 17.7 kg, height 169 ± 9 cm, and BMI 28.5 ± 5.0 kg/m 2 . SPM significance ROIs according to baseline medial (left, figs 1 & 2) and lateral (right, figs 3 & 4) JSN phenotypes are shown for fCT (top row, figs 1 & 3) and fTA (bottom row, figs 2 & 4). SPM revealed significantly greater fCT by up to ∼0.1mm and fTA by up to ∼40 attenuation units (AU) for each increment in baseline JSN grade along the outer margin of the respective compartments (unmasked blue zones in each figure). Significantly greater fCT by up to ∼0.1mm for each increment in medial JSN grade also spread across the anterior aspect of the medial femoral condyle suggesting a wider regional relationship. 3-D distribution of fCT and fTA follow distinct patterns according to OARSI JSN phenotype, relating to recognised distributions of marginal osteophytosis and subchondral sclerosis. These results indicate that cone beam WBCT can quantify cardinal bony structural features of osteoarthritis and that their distribution is related to specific osteoarthritis OARSI JSN phenotypes. National Institutes of Health, University of Kansas (R01AR071648), University of Iowa. (U01AG18832), University of California-San Francisco (U01AG19069), Boston University (U01AG018820). NS is a consultant for Integra BioLife, Trice Medical and Pacira Biosciences. The authors would like to thank participants and staff of the MOST study. CORRESPONDENCE ADDRESS: tom@turmezei.com

Bone chip versus myositis ossificans after supracondylar fracture of humerus.

A 44-year-old male presented to the department of physiotherapy with the primary concern of inability to fully straighten his right elbow. As per the history given by the patient, he had sustained a fall on an outstretched hand 10 months ago. He had sustained a fracture around the elbow, which was managed conservatively with plaster cast for six weeks by a local practitioner. He had pain and swelling around the elbow after the injury, but it had subsided two months ago. On examination, terminal 30 degrees of the range of motion (ROM) of right elbow was limited. Although, forearm supination-pronation was full. The X-ray revealed bone chip at the anterior aspect of the distal humerus, along with supracondylar fracture of the humerus that was not completely healed. Bone chip can be differentiated from myositis ossificans, which is a common complication of fractures around the elbow, by its well-defined margins. As a part of physiotherapy intervention, gentle active ROM of right elbow and functional use of right hand for light activities of daily living was emphasized. The patient was advised to avoid use of heat, massage and jerky movements of elbow as these can lead to myositis ossification. He was assured that he had functional ROM of 30 degrees to 130 degrees elbow flexion, so lack of terminal extension should not bother him in his lifestyle.

Subcutaneous adipose tissue distribution and serum lipid/lipoprotein in unmedicated postmenopausal women: A B-mode ultrasound study

Abstract Background It has been observed that gluteal-femoral adipose tissue has a protective effect against risk factors for cardiovascular disease but has not yet been concluded how different evaluation methods of fat distribution affect the results. Methods To test the hypothesis that B-mode ultrasound-measured subcutaneous adipose tissue distribution is associated with cardiovascular risk factors, 326 Japanese unmedicated postmenopausal women aged 50–70 years were analyzed. Subcutaneous adipose tissue thickness at 6 sites (anterior and posterior aspects of trunk, upper-arm, and thigh) and serum total (TC) and high-density lipoprotein cholesterol (HDLC) was measured, and a ratio of HDLC to TC (HDLC/TC) was calculated. We used Bayesian linear regression with 4 separate models with each model predicting HDLC/TC. Results Our first model provided evidence for an inverse correlation (r = –0.23) between ultrasound measured body fat (6 site measurement) and HDLC/TC. The second model noted evidence for an inverse correlation between trunk fat and HDLC/TC and found evidence for the null with respect to the correlation between thigh fat and HDLC/TC. Therefore, we added thigh fat to the null model to produce Distribution Model 2. Within this model, we noted an inverse correlation (r = –0.353) between trunk fat and HDLC/TC. Our last model determined that within the trunk fatness, the abdominal area (anterior trunk) was a larger predictor than the subscapular site (posterior trunk). Conclusion These results support the evidence that ultrasound-measured abdominal subcutaneous adipose tissue thickness is a non-invasive predictor for monitoring the risk for dyslipidemia in postmenopausal women.

A Case Report on Ayurvedic Management of Dushta Vrana

Dushta vrana is a commonly encountered problem in day-to-day practice. Contemporary progress in the field of surgery has reduced the incidence of wound infection to a great extent along with the use of antibiotics. But still the management of ulcer encounters many glitches. This case study discusses about a 58-year-old male patient who presented with a chronic non healing ulcer in the anterior aspect of the left ankle joint associated with pain, burning sensation, foul smelling and inflammation with no history of varicose veins. Patient was treated with Karaskara ksheera kashaya dhara followed by dressing with Jathyadi ghrta. Punarnavadi kashayam and Guggulupanchapala choornam was given internally for a period of 35days. Virechana with Avipathy Choornam was given once during the whole course of the treatment. Raktamokshana was done twice as Jaloukavacharana. In order to enhance the speedy recovery, traditional use of Kupeelu was considered. A highly potent drug among the Upavisha which is well known for properties like Vranahara, Soolahara, Kushtahara, Sothaghna etc. which augments the peripheral blood circulation, reduces pain, burning sensation and inflammation. The wound healed within a period of 35 days and got complete relief from pain, burning sensation and swelling. Thus, the patient was successfully treated with no complications.

The Anterior Trans–Superior Temporal Gyrus Approach for Selective Amygdalohippocampectomy

Different surgical approaches have been described for selective amygdalohippocampectomy in patients with pharmacoresistant temporal lobe epilepsy. The aim of this study was to report the results of the innovative anterior trans-superior temporal gyrus approach in a single-center series. Patients' characteristics, postoperative outcomes, and complications were reviewed in a series of 8 consecutive patients with temporal lobe epilepsy operated on using the anterior trans-superior temporal gyrus approach between November 2015 and April2017. Over a mean 2.5-year follow-up, 7 of 8 patients (87.5%) remained seizure-free (Engel class I). Only 1 patient (12.5%) was not cured (Engel class III) with no clear explanation for treatment failure. Mean operative time was 237 minutes, which was 80 minutes shorter compared with the classic transsylvian approach. No perioperative deaths were recorded and there were no visual field defects or visual acuity impairments secondary to the approach. One patient experienced a left posterior thalamocapsular stroke. The anterior trans-superior temporal gyrus approach is feasible, fast, and safe for selective amygdalohippocampectomy in patients with drug-refractory temporal lobe epilepsy. This approach allows preservation of the optic radiation but cuts part of the uncinate fasciculus and potentially the anterior aspect of the anterior bundle of the middle longitudinal fasciculus.