Anterior Superior Spine Research Articles

2198 New Laparoscopic Entry Port for Previous Surgery Cases: Jain Point

Study Objective Laparoscopy in previous surgery cases is a challenge due to risk of encountering adhesions during the first blind trocar entry. This study demonstrates the technique, and relative benefits of a new entry point. Design It is a retrospective study undertaken at a high volume tertiary care referral center for advanced gynecological laparoscopic surgery. Setting Tertiary Care Centre Patients or Participants The total number of patients from January 2011 to March 2019. Total 6830 laparoscopic cases were done between January 2011 to March 2019. In 1948 patients there was a history of previous abdominal surgeries. Interventions Working over the years we found that post surgical adhesions are encountered usually in the midline or right side. The left side is spared as the colon adheres at the pelvic brim and stomach and spleen lie higher up at T 10 level. So we developed a point which is at L4 level and on the left side. It is at the level of umbilicus on a straight line drawn vertically upwards from a point 2.5 cm medial to the anterior superior iliac spine. We first introduce the veress needle perpendicular to the abdomen and then the 5mm telescope from this point, and optimize the 10 mm telescope entry. Jain Point port doubles up as the main working port in due course of surgery. Measurements and Main Results All of the 6830 cases were entered by the Jain Point in an identical manner. Out of these 1948 case were of previous one or multiple surgeries. Conclusion Jain Point offers an alternate safe entry point in previous surgery cases, applicable to upper, mid and lower abdominal scars. Laparoscopy in previous surgery cases is a challenge due to risk of encountering adhesions during the first blind trocar entry. This study demonstrates the technique, and relative benefits of a new entry point. It is a retrospective study undertaken at a high volume tertiary care referral center for advanced gynecological laparoscopic surgery. Tertiary Care Centre The total number of patients from January 2011 to March 2019. Total 6830 laparoscopic cases were done between January 2011 to March 2019. In 1948 patients there was a history of previous abdominal surgeries. Working over the years we found that post surgical adhesions are encountered usually in the midline or right side. The left side is spared as the colon adheres at the pelvic brim and stomach and spleen lie higher up at T 10 level. So we developed a point which is at L4 level and on the left side. It is at the level of umbilicus on a straight line drawn vertically upwards from a point 2.5 cm medial to the anterior superior iliac spine. We first introduce the veress needle perpendicular to the abdomen and then the 5mm telescope from this point, and optimize the 10 mm telescope entry. Jain Point port doubles up as the main working port in due course of surgery. All of the 6830 cases were entered by the Jain Point in an identical manner. Out of these 1948 case were of previous one or multiple surgeries. Jain Point offers an alternate safe entry point in previous surgery cases, applicable to upper, mid and lower abdominal scars.

Pelvic alignment changes during the perinatal period.

BackgroundThe function of the pelvic bones is to transfer load generated by body weight. Proper function of the pelvic bones can be disturbed by alignment changes that occur during pregnancy. Further, misalignment of the pelvic bones can lead to pain, urinary incontinence, and other complications. An understanding of the timing and nature of pelvic alignment changes during pregnancy may aid in preventing and treating these complications.ObjectiveTo investigate the changes in pelvic alignment during pregnancy and one month after childbirth.MethodsThis is a prospective, longitudinal cohort study. Pelvic measurements were obtained for 201 women at 12, 24, 30, and 36 weeks of pregnancy, and 1 month after childbirth. The anterior and posterior width of the pelvis (the distance between the bilateral anterior superior iliac spines and the bilateral posterior superior iliac spines), the anterior pelvic tilt, and pelvic asymmetry (the mean left and right pelvic tilt degrees and the bilateral difference of the anterior pelvic tilt) were measured. For the change in pelvic alignment, a Friedman test was conducted to determine any significant difference in the measurements over time.ResultsThe anterior and posterior width of the pelvis became significantly wider with pregnancy progress and the anterior width of the pelvis at 1 month after childbirth remained wider than that at 12 weeks of pregnancy (p < 0.001). The anterior pelvic tilt increased during pregnancy and decreased after childbirth (p < 0.05).ConclusionSome changes in pelvic alignment occur continuously during the perinatal period. Changes in the anterior width of the pelvis are not recovered at one month post-childbirth. Understanding these perinatal changes may help clinicians avert complications due to pelvic misalignment.

Use of the transverse branch of the superficial circumflex iliac artery as a landmark facilitating identification and dissection of the deep branch of the superficial circumflex iliac artery for free flap pedicle: Anatomical study and clinical applications.

The deep branch of the superficial circumflex iliac artery (SCIA) should be included when a large superficial circumflex iliac artery perforator (SCIP) flap is necessary, or when anatomical structures perfused by the deep branch are procured. The aim of this study was first to describe the anatomical features of the "transverse branch" of the deep branch of the SCIA in cadavers, and then to assess the efficacy of its use as a landmark for identification and dissection of the deep branch of the SCIA through clinical applications. Twenty groin regions from 10 cadavers were dissected. The course and the takeoff point of the transverse branch were documented. With the transverse branch used as a landmark for pedicle dissection, 27 patients (16 males and 11 females) with an average age of 51.7 years underwent reconstructions that used vascularized structures nourished by the deep branch of the SCIA. Aside from the skin paddle, an iliac bone flap was used in 10 cases, a lateral femoral cutaneous nerve flap in four cases, and a sartorius muscle flap in three cases. The defect locations included the head (seven cases), the foot (six cases), the hand (six cases), the arm (five cases), and the leg (three cases). The causes of reconstruction were tumors in 13 patients, trauma in six patients, infection in four patients, surgical procedures in three patients, and refractory ulcer in one patient. In all specimens, the transverse branch was found underneath the deep fascia caudal to the anterior superior iliac spine (ASIS). The average distance from the ASIS to the transverse branch was 25.5 ± 13.0 mm (range, 5-50 mm). The average dimension of the flap was 13.1 × 5.9 cm2 . All the flaps survived completely after the surgery; lymphorrhea was seen in one patient at the donor site. The average follow-up period was 12.9 months (range, from 2 to 42 months), and all patients had good functional recovery with satisfactory esthetic results. The transverse branch was found in all specimens, branching from the deep branch of the SCIA. Successful results were achieved by using it as the landmark for identification and dissection of the deep branch of the SCIA. This method allows safe elevation of a large SCIP flap or a chimeric SCIP flap.

Meralgia paraesthetica following lumbar spine surgery: A study in 120 consecutive surgically treated cases

Background: Meralgia paresthetica is a non–life-threatening neurological disorder characterized by numbness, tingling, and burning pain over the anterolateral aspect of thigh due to impingement of the lateral femoral cutaneous nerve. This disorder has been seen in patients with diabetes mellitus and obesity, but has also been observed in patients after procedures such as posterior spine surgery, iliac crest bone grafts, lumbar disk surgery, hernia repair, appendectomies, and pelvic osteotomies that ultimately lead to compression or damage to the lateral femoral cutaneous nerve. Overall, permanent sequelae of meralgia paresthetica are rare, however, some cases do require intervention. Study design: In this prospective study of 120 patients who underwent elective lumbar spinal surgery, the incidence, possible risk factors, etiopathogenesis and management of MP were analysed. Result: There were 70 males and 50 females. The age of the patients ranged from 15 to 81 years (mean 46.9 yrs.). Thirteen patients (12%) suffered from MP. It is more common in thinner individuals due to pressure injury to the nerve at its exit point. Ninety-two percent of the patients were asymptomatic at follow-up after 6 months. In 7 out of 13 patients, patchy sensory loss on clinical examination was seen at 6 months. Conclusion: MP after posterior lumbar spinal surgery is uncommon. Smaller bolsters may avoid some of the vulnerable pressure points, as the surface area available is relatively smaller. The posts of the Hall-Relton frame over the anterior superior iliac crest should be adequately padded. The condition is usually self-limiting. Surgical division or decompression of the LCFN is reserved for persistent or severe MP.

Application of individualized transiliac crest nail-grafting guide plate in deep pelvic external fixator implantation

To explore the application of individualized transiliac crest nail-grafting guide plate prepared by computer-aided design and three-dimensional (3D) printing technology in deep pelvic external fixator implantation. Five patients with pelvic fractures were collected between May 2017 and February 2018. There were 4 females and 1 male with an average age of 52 years (range, 29-68 years). Pelvic fractures were classified as type B in 3 cases and type C in 2 cases by Tile classification. The interval between injury and operation was 6-14 days (mean, 9 days). The preoperative CT images of pelvic fractures were collected. The data was reconstructed by 3D imaging reconstruction workstation. An individualized transiliac crest nail-grafting guide plate was designed on the virtual 3D model. The individualized transiliac crest nail-grafting guide plate and the solid pelvic model were produced with the 3D printing technology. The individualized transiliac crest nail-grafting guide plate was used for intraoperative deep pin position on iliac crest after the preoperative simulation. The follow-up CT scans were used to determine the differences in distance from anterior superior iliac spine, convergence angle, and caudal angle between the preoperative plan and postoperative measurement. During the operation, the individualized transiliac crest nail-grafting guide plate was used to guide the placement of 20 pins. X-ray film and CT examination showed that all pins were well positioned. The average depth of pins was 83.16 mm (range, 70.13-100.53 mm). Fitted 3D reconstruction images showed that the entry point and orientation of the pins were all consistent with preoperative schemes. Compared with the planned nail path, there was no significant difference in the distance from anterior superior iliac spine, convergence angle, and caudal angle in the actual nail path ( P>0.05). No loosening and rupture of pin, no damage of blood vessels and nerve, and shallow or deep infection occurred during 3 months follow-up, and the incisions healed by first intention. All patients were satisfied with the treatment process. The ranges of motion of hip and knee were normal, and the visual analogue scale (VAS) score was 0-3 (mean, 0.5). The individualized transiliac crest nail-grafting guide plate technique is the improvement of traditional technique. It can increase accuracy and effective depth of pin position, enable patients to obtain pelvic mechanical stability quickly after operation, and reduce the risk of complications related to nail path.

Anatomical Study of Profunda Femoris Artery and it’s Variations – Cadaveric Study

Background and Aims: Profunda femoris artery is the largest branch of femoral artery. It is the principal supply to the muscles of the thigh as well as head and neck of femur. Its branches form anastomosis around the head of the femur. Profunda femoris artery is also used for arteriography. It is frequently used in vascular reconstructive procedures in the proximal thigh. It forms main route of collateral circulation in occlusion of femoral artery. The study of variation of Profunda femoris artery is of great value for radiologists and surgeons during diagnostic and surgical intervention. Aim of the study is to observe the origin of Profunda femoris artery, to measure the distance between midinguinal point and site of origin of Profunda femoris artery and to study the anatomy of Profunda femoris artery and its branches and to find out any variations in its course and its branches. Materials and Methods: The study was conducted as a prospective study from April 2018 to October 2018. All the lower limbs with the intact Femoral artery and Profunda femoris artery and their branches were included. Femoral artery and its branches had got cut during dissection were not included in the study. Thirty two Profunda femoris arteries (20 on the right side and 12 on the left side) were studied in the department of Anatomy. The femoral triangle was exposed by making incisions along the inguinal ligament from pubic symphysis to anterior superior iliac spine. Midpoint was taken as Midinguinal point (MIP). MIP was marked with a coloured pen. The distance between MIP and the site of origin of Profunda femoris artery was measured. We observed any variation in the site of origin of Profunda femoris artery, medial and lateral circumflex femoral artery and any variations in the branches of each vessel. Results: The Profunda femoris artery was found to be originated from lateral aspect of Femoral artery in 21(65%) of lower limbs. Lateral Circumflex femoral artery was found to be originating from lateral aspect of Profunda femoris artery in 28(87%) of lower limbs. Medial Circumflex femoral artery was found to be originating from medial aspect of Profunda femoris artery in 16(50%) of lower limbs. Lateral Circumflex femoral artery was found to be originating from Femoral artery in 3(10%) of lower limbs. We observed distance of origin of Profunda femoris artery from the midpoint of inguinal ligament as 10 – 20 mm in 10(31%) lower limbs. We observed absence of Lateral Circumflex femoral artery in 1(3%) of lower limbs and absence of medial Circumflex femoral artery in 6(18%) of lower limbs. Conclusions: The Profunda femoris artery is an important branch of the Femoral artery and is of clinical importance to the surgeon. Femoral artery and Profunda femoris artery were used for various imaging procedures including Cathetarization. Such a large &amp; unexpected artery may be damaged while collecting blood in infants from Femoral vein or at the time of exposure of Saphenous vein for ligation at its junction with the femoral vein. During surgery, these vessels may be damaged easily at this region. Knowledge of anatomy and variations of Profunda femoris artery are important for surgeons in reducing intra – operative haemorrhage and postoperative complications

Arterial Anatomy of the Anterior Abdominal Wall: Evidence-Based Safe Sites for Instrumentation Based on Radiological Analysis of 100 Patients.

Multiple medical interventions require percutaneous instrumentation of the anterior abdominal wall, all of which carry a potential for vascular trauma. We assessed the presence, position, and size of the anterior abdominal wall superior and inferior (deep) epigastric arteries to determine the safest site with respect to vascular anatomy of the rectus sheath. In a review of 100 arterial phase, contrast-enhanced abdominal computed tomography scans, anterior abdominal wall arteries were assessed bilaterally at three axial planes: transpyloric, umbilicus, and anterior superior iliac spine (ASIS). The mean age of patients was 69.2 years (SD ± 15), with 62 male and 38 female. An artery was visible least frequently at the transpyloric plane (5%), compared with the umbilicus (72-79%) and ASIS (93-96%), on the left (χ2 (4) = 207.272; P < 0.001) and right (χ2 (4) = 198.553; P < 0.001), with a moderate strength association (Cramer's V = 0.588 (left) and 0.575 (right)). The arteries were most commonly observed within the rectus abdominis muscle at the level of the umbilicus and ASIS on both sides (62-68%). The inferior epigastric artery was observed to be larger in diameter, start more laterally, and move medially as it travelled superiorly. These data suggest that the safest site to instrument the rectus sheath, with respect to vascular anatomy, is at the transpyloric plane. This information on anatomical variation of the anterior abdominal wall vasculature may be of particular interest to anesthetists performing rectus sheath block and surgeons during laparoscopic port insertion. Clin. Anat. 33:350-354, 2020. © 2019 Wiley Periodicals, Inc.

Effectiveness of center-mounted airbag in far-side impacts based on THOR sled tests

Objective: The study aimed to evaluate the protection offered by a center-mounted airbag in far-side impacts using the Test device for Human Occupant Restraint (THOR) anthropometric test device (ATD).Methods: A rigid buck was designed based on a production vehicle. The buck consisted of a rigid seat, center console, dash, and far-side door structure. The center console and dash were covered with paper honeycomb (152 kPa), and the far-side door structure was covered with Ethafoam 220 padding material. The airbag was mounted on the seat, to the right of the occupant. The THOR-M50 ATD was positioned according to the standard seating procedure and restrained using a standard 3-point seat belt with a pretensioner and retractor. The buck was mounted on an acceleration sled in 2 orientations. Four tests at 45° (oblique) and 2 tests at 90° (lateral) orientations were conducted. Tests were performed with and without an airbag at 30 km/h delta-V and 14 g acceleration. The head accelerations, neck forces and moments, thoracic accelerations and forces, pelvis accelerations, anterior superior iliac spine (ASIS) forces and moments, and belt webbing loads were obtained from sensors, and the external kinematics was obtained using an optical motion capture system and high-speed digital cameras.Results: With the center-mounted airbag, in 90° and 45° tests, reductions were observed for the following parameters: head lateral excursions by 6% and 11%, head vertical excursions by 19% and 26%, and peak head resultant accelerations by 36% and 11%. Other regional accelerations, forces, and moments were also reduced for both impact angles. A reduction in seat belt forces with the airbag was observed in 90° tests.Conclusion: The center-mounted airbag reduced the ATD excursions and accelerations in the 45° and 90° tests, thus reducing the risk of injury due to contact with the intruding structure. The results of this study may assist in designing countermeasures for vehicles in far-side impact.

Intrathecal baclofen therapy for treatment of spasticity in infants and small children under 6years of age.

The aim of this study is to prove the efficacy and safety of intrathecal baclofen therapy in infants and children below 6years of age by retrospective analysis of our pediatric cohort of 135 primary pump implantations. Between 2007 and 2018, 17 patients with pump implantations were below 6years of age. Data were acquired retrospectively with a follow-up of 12months to 11years regarding complications. The youngest infant was 11months at implantation with a bodyweight of 6, 4kg, and 63cm length. Surgical complications were comparable to published literature and mainly involved the catheter (2 catheter dislocations and 1 catheter transection) and one pump infection resulting in 4 revision surgeries in 3 patients. One baclofen-related apnea during titration and an overdose after refill were treated conservatively. Using a subfascial implantation technique, we observed neither skin ulceration nor pump infection since 2007. In a growing child, catheter slides are common and related to growth, scoliosis, spine surgery, and surgical failure. Intrathecal baclofen therapy in infants and small children is as safe and effective as published for older pediatric patients; therefore, intrathecal baclofen can be considered in all infants as long as an 8-cm incision fits into the triangle of the anterior superior iliac spine, costal margin of the 10th rib, and navel. We suggest the utilization of subfascial surgical technique for implantation pump and catheter. Titration of intrathecal baclofen should be performed slowly to avoid bradycardia in infants. This is a retrospective study (level of evidence 4).

Does perfusion matter? Preoperative prediction of incisional hernia development.

Incisional hernias complicate 12-15% of general surgery cases with higher rates reported after laparotomy for aortoiliac occlusive disease (10-17%) and aneurysmal disease (17-38%). We hypothesize that inadequate perfusion of the abdominal wall promotes future hernia development. Thirty-eight patients undergoing midline laparotomy or thoracoabdominal approach for aortic disease with at least 2years of follow-up were included in the study. Preoperative imaging was reviewed to assess vessel patency, contributing to the abdominal wall perfusion. Patency of the superior epigastric artery was determined at the T10 level, the inferior epigastric artery at the L4 level, and the deep circumflex iliac artery at the anterior superior iliac spine. Lumbar arteries were considered patent if they were seen branching from the aorta. Clinic notes and hospital medical records were reviewed to evaluate the hernia development post-procedure. Thirteen patients (34%) developed an incisional hernia. Absent flow from bilateral superior epigastric arteries or absent flow from ipsilateral superior and inferior epigastric arteries was found to be predictive of hernia development (P = 0.013, 0.011, respectively). There was no association identified with perfusion from the lumbar or deep circumflex iliac arteries. Absent patency of the abdominal wall vasculature is a novel risk factor for incisional hernia development in the setting of aortic disease. Preoperative assessment of perfusion may convey the risk of hernia development and may be a tool to guide measures such as prophylactic mesh placement to reduce the future risk of incisional hernia.

Relative position of the supra-acetabular bone to the crestal plane: a radiological analysis

IntroductionDisplaced unstable pelvic injuries are life threatening and require rapid reduction and stabilisation, typically achieved with an external fixator. Recently, the benefits of supra-acetabular pins have been proven; however, these...

Radioanatomical Study of the Pedicle of the Superficial Circumflex Iliac Perforator Flap.

The superficial circumflex iliac perforator (SCIP) flap has many ideal features, such as fast dissection, possibility to harvest thin, pliable, wide skin island, and concealed donor site scar. In spite of these features, its use was limited because of the wide anatomical variation of the pedicle, which is relatively shorter and has a smaller caliber than other more popular perforator flaps. Several names were given to the branches and perforators in the literature, thus adding confusion to the understanding of its anatomy. We performed a surgical and a radioanatomical study of the SCIP pedicles analyzing high-resolution contrast-enhanced computed tomography (CT) scan of 95 groins, with particular attention to the deep branch (DB) of the superficial circumflex iliac artery (SCIA). Twenty-three of these patients were also studied by detecting the surgical anatomy during SCIP flap harvest. We employed a system of coordinates based on the line between pubic tubercle (PT) and anterior superior iliac spine (ASIS) to describe the position of the perforator of the DB. We found a 100% correlation between surgical and radiological findings. The length of the DB from the origin to the point in which its perforator pierced the sartorius fascia ranged from 1.6 to 6.5 cm, mean = 3.62 ± 0.92 cm. The distance between the origin of the DB and the inguinal ligament ranged from 1.1 to 7.5 cm, mean = 2.8 ± 1 cm. The perforator of the DB could be found in 91% of the cases within a box of 4 cm × 3 cm drawn caudally to the line joining the PT with the ASIS. This vessel can show a vertical or horizontal course in the subcutaneous layer. Our findings confirm other previous studies and add new information about the position and the course of the perforator of the DB of the SCIA. Important features of the SCIP pedicles can be investigated by the color Doppler ultrasound and CT scan.

Anatomical variations of the inguinal morphometric features in patients with inguinal hernia and its association with the type of inguinal hernia: a prospective clinical study

Background: Variations of inguinal canal and inguinal nerves are not uncommon. Knowledge about those variations is important to avoid inadvertent injury to the vital structures and to prevent recurrence.Methods: This prospective clinical study included all patients undergoing open inguinal hernia repair. Laparoscopic hernia repair, emergency surgery for complication and recurrent inguinal hernia were excluded. Parameters studied include interspinous distance, length and obliquity of inguinal ligament, attachment of conjoint tendon, condition of transversalis fascia and position and variations of ilioinguinal nerve.Results: The study included 192 patients. The mean interspinous distance (ISD) was 22±3.45 cm (CI: 30-32). ISD was not significant different among the two types of hernia. The mean length of internal oblique on inguinal ligament from anterior superior iliac spine was significantly longer in patients with indirect inguinal hernia (4±0.791 vs. 4.27±1.34; p=0.000). Significant patients in the direct hernia had weak transversalis fascia ((95% vs. 43%). 80% of the patients with direct hernia had defect in the transversalis fascia compared to only 8.8% in the indirect hernia. The difference is statistically significant. The nerve variation was present in only 1.3% in direct hernia group compared to 3.5% in the indirect hernia group.Conclusions: It was observed that the type of hernia did not significantly influenced by the length of inguinal ligament, the mean distance of midinguinal point, obliquity of the inguinal ligament. The nerve variation was present in only 1.3% in direct hernia group compared to 3.5% in the indirect hernia group.

The use of iliac flap pedicled with superficial circumflex iliac artery and sartorius in treatment of femoral neck fracture of young adults

Objective To investigate the effect of iliac flap pedicled with superficial circumflex iliac artery and sartorius in the treatment of femoral neck fracture of the young adults. Methods From April, 2012 to March, 2017, 50 cadaveric lower limbs were injected with red latex, and the origin, diameter, course and distribution of the superficial circumflex iliac artery and arteries of the sartorius were observed. The iliac flap pedicled with superficial circumflex iliac artery and sartorius was used to treat the femoral neck fracture in young adults in 11 cases. There were 9 males and 2 females with an average age of 34.5(ranged from 16 to 54) years. The fractures were classified according to Garden: 4 cases of type III and 7 cases of type IV. Regular outpatient follow-up was made. Results The superficial circumflex iliac artery originated from the femoral artery and the initial diameter was (1.2±0.3) mm. The length of the superficial circumflex iliac artery to the anterior superior iliac spine was (8.8±1.3) cm. The superficial circumflex iliac artery run to the anterior superior iliac spine and sent 1-3 periosteal branches into the iliac crest. The sartorius originates from the anterior superior iliac spine, and its proximal artery arises from the superficial circumflex iliac artery and the femoral artery. Link-pattern arterial anastomosises were formed in sartorius by branches of adjacent vascular pedicles, which nourished the ilium flap. All incisions healed by first intention. All cases were followed-up from 16 to 42 months, with an average of 32.3 months. All fractures healed for 3-7 months, with an average of 4.6 months. No fracture nonunion, femoral head necrosis and other complications occurred. Harris hip scores was 93.02±5.33. Seven cases were excellent and 4 cases were good. Conclusion The iliac flap pedicled with superficial circumflex iliac artery and sartorius has rich blood supply, easily performed conducive to promoting fracture healing, and reducing the occurrence of femoral head necrosis. It is an effective method for the treatment of femoral neck fracture in young adults. Key words: Superficial circumflex iliac artery; Sartorius; Ilium flap; Femoral neck fracture; Transplantation

Testing landmark redundancy for sex-based shape analysis of the adult human os coxa.

To test the individual effectiveness of common landmarks used in sex estimation of whole adult coxal bones in sex-based shape analysis and propose a method to determine how many principal components of sex-based shape to include for discriminant function analysis. Three-dimensional models (NextEngine desktop laser scanner) of left and right os coxae from 396 individuals (William Bass Skeletal Collection, Forensic Anthropology Centre, University of Tennessee, Knoxville, TN) were subjected to shape analysis using 32 landmarks (Landmark 3.6, Institute for Data Analysis and Visualization). Each landmark was individually removed and subjected to a new principal component analysis to identify the effect omitting a landmark has on PC1/PC2 ordination. Landmarks that poorly discriminated sex-based shape were considered redundant for analysis on sex estimation. This study identified 17 landmarks that represent sex-based shape of right and left coxal bones most effectively, these are: the anterior superior iliac spine; posterior superior iliac spine; posterior inferior iliac spine; iliac crest; apex of the auricular surface; greater sciatic notch; ischial spine; superior, inferior and distal points on ischial tuberosity; superior, inferior and midpoint on the symphyseal face; arcuate eminence; ischiopubic ramus; posterosuperior and anterosuperior points on the acetabular rim. The first and second PCs of the 17-landmark configuration correctly predicted sex in 98.5% of cases; better than a 32-landmark configuration (96%) and better than previous landmark studies on whole coxal bone sex-based shape. These 17 landmarks represent more meaningful data for sex-based shape analysis in PC1 and 2 and concentrate meaningful sex-based shape data to the first five PCs that make up over 50% of the total shape variance.

Use of Strict Patient Selection Criteria to Achieve Significant Surgical Outcomes from a Low DIEP Flap Breast Reconstruction.

The low deep inferior epigastric perforator (DIEP) flap was first introduced in 2016 as it had aesthetic advantages over the conventional DIEP flap. With our experience of over 100 low DIEP flap procedures to date, we have conspicuously lowered complication rates and established more definitive criteria to select proper candidates. We analyzed 103 patients who underwent breast reconstruction with the low DIEP flap at our hospital between May 2014 and June 2018. Demographics, patient selection criteria, flap specifics, surgical outcomes including postoperative complications, and the location of the abdominal scar and umbilicus were reviewed retrospectively. The mean patient age was 46.7 years, and the average body mass index was 23.7 kg/m2. A low DIEP with an average weight of 377 g was utilized within 6 hours 17 minutes in this cohort. There was no significant difference in the rate of venous congestion or fat necrosis compared with the conventional DIEP flap. The average distance from the pubic hairline to the abdominal scar was 0.6 cm and from the anterior superior iliac spine to the abdominal scar was -0.4 cm. The postoperative location of the umbilicus was 7.0 cm above the pubic hairline. The low DIEP flap is not only a reliable option for a breast reconstruction but is an aesthetically superior approach with a lower abdominal scar and natural umbilicus. Patients may benefit from this technique if prudently selected by computed tomography (CT) angiography. A perforator that is larger than 1 mm in diameter and well enhanced on CT angiography from the division of the external iliac artery to the abdominal skin particularly in the intramuscular course should be selected.

Mapping of both column acetabular fractures with three-dimensional computed tomography and implications on surgical management

BackgroundThe primary goal of this study was to create a frequency map of a series of surgically treated both-column fractures and to explore its implications on surgical management.MethodsWe used a consecutive series of 71 both-column fractures to create 3-dimensional reconstruction images, which were superimposed and oriented to fit a model hemipelvis template by aligning specific pelvis landmarks. Fracture lines were identified and traced to create a fracture map of both-column fractures. Then the possible clinical implications of fracture line map were explored.ResultsFracture location is closely related to the distribution of fracture line. Of 71 fractures that met the criteria for inclusion, we found the most common pattern demonstrated by coexisting fracture lines. The anterior column was involved by 66% of the fractures extending obliquely from the anterior superior spine to the ischial spine, while 62% of the fractures involved the anterior column extending approximately vertically from the iliac crest to the acetabular roof. Additionally, 39% of the fractures involved the posterior column traversing posterior wall. Furthermore, the high fracture line intensity (n = 65, 92%) formed a Y-shaped pattern, which highlighted the consistency of the patterns.ConclusionsSurgically treated both-column fractures display very common patterns. The most common pattern is the low anterior column fracture in nearly two thirds of cases, the high anterior column fracture in three fifths of cases and the posterior column fracture with posterior wall involvement in nearly two fifths of cases. These study results may help surgeons to yield insight relevant to surgical approaches, reduction, fixation strategies and even implant design for both-column fractures.

Changes in Alignment of Ipsilateral Knee on Computed Tomography after Total Hip Arthroplasty for Developmental Dysplasia of the Hip.

ObjectiveTo assess the changes in alignment of ipsilateral knee joint after total hip arthroplasty (THA) for patients with developmental dysplasia of the hip (DDH).MethodsThirty‐four patients with DDH (38 hips) who underwent THA between February and December 2008 were included in the study: 4 men and 30 women with a mean age of 56.2 years. According to Crowe classification, 11 patients were grade I, 12 were grade II, 9 were grade III, and 6 were grade IV. Computed tomography scans were performed from the anterior superior iliac spine to the tibial tubercle before surgery and at last follow‐up. Femoral anteversion angle, leg lengthening, and knee alignment, including patellar tilt angle, lateral patellar displacement, and tibiofemoral rotation angle, were measured on computed tomography scans, and their relationships were analyzed.ResultsThe mean follow‐up period was 51.5 months (range, 39–70 months). There were no intraoperative fractures, and no infections occurred during the follow‐up period. One patient developed deep venous thrombosis and another suffered from femoral nerve palsy. The mean preoperative Harris Hip Score was 48.9 ± 7.5 and improved to 91.2 ± 8.3 by the last follow‐up (P < 0.001). There was no sign of prosthetic loosening in all hips. Postoperatively, mean leg lengthening was 26.08 ± 21.81 mm (P < 0.001), femoral anteversion decreased 9.03° ± 12.80° (P < 0.001), and patellar tilt, lateral patellar displacement, and tibiofemoral rotation increased by 3.58° ± 4.96° (P < 0.001), 1.78 ± 3.36 mm (P = 0.002), and 2.56° ± 3.37° (P < 0.001), respectively. Postoperative increase in patellar tilt and lateral patellar displacement had significant linear relationships with the decrease in femoral anteversion (r = 0.621, P < 0.001 and r = 0.437, P = 0.0037, respectively). These results revealed that patellofemoral alignment would change more with the decrease in femoral anteversion. Postoperative increase in external rotation of the tibia had significant positive linear relationships with leg lengthening (r = 0.34, P = 0.037) and the decrease in femoral anteversion (r = 0.693, P < 0.001). These results revealed that the external rotation of the proximal tibia would increase with the leg lengthening or the decrease of femoral anteversion. Postoperative changes in patellar tilt and lateral patellar displacement had no significant linear relationships with leg lengthening (P = 0.795 and P = 0.082, respectively).ConclusionsTotal hip arthroplasty for DDH could induce changes in alignment of ipsilateral patellofemoral and tibiofemoral joints, with increases in patellar tilt and displacement, and increases in external rotation of the tibia. These secondary alterations still existed at medium‐term follow‐up after surgery, which should be considered during THA for patients with DDH. Extended follow‐up is necessary to evaluate long‐term changes in the knee joint.

Age-related changes in inguinal region anatomy from 0 to 19 years of age.

Knowledge of the age-related changes in inguinal region anatomy is essential in pediatric urological and abdominal surgery, yet little is published. This study aimed to determine the position of inguinal region structures and growth of the surrounding pelvis and inguinal ligament in subjects from 0 to 19 years of age. Anonymized contrast-enhanced CT DICOM datasets of 103 patients (63 male: 40 female) aged from 0 to 19 years had left and right sides analyzed by three independent observers. Exclusion criteria were applied. Growth of the pelvis and inguinal ligament were determined using fixed bony reference points. The position of the deep inguinal ring and femoral vasculature were determined as ratio of inguinal ligament length, measured from the anterior superior iliac spine. Growth of the pelvis in vertical and horizontal dimensions and of the inguinal ligament followed a positive polynomial relationship with increasing age, with no observed increase in growth rate during puberty. From 0 to 19 years, the deep inguinal ring moved superolaterally with respect to the inguinal ligament (from 0.74 to 0.60 of the distance along the inguinal ligament) and the femoral artery and vein moved medially (from 0.50 to 0.58, and 0.61 to 0.65 of the distance along the inguinal ligament, respectively). The position of the femoral artery, vein, and deep inguinal ring followed a logarithmic relationship with age. No significant left:right side or male:female differences were observed. From 0 to 19 years of age the femoral vasculature and deep inguinal ring change position as the pelvis grows around them. Clin. Anat. 32:794-802, 2019. © 2019 Wiley Periodicals, Inc.

Varied influence of the femoral or tibial component on quadriceps angles: Verified by imaging studies

ObjectiveThe aim of this study was to evaluate the varied influence of femoral or tibial component on Quadriceps angles (Q-angle) measured with magnetic resonance image (MRI) and full-length standing scanogram (FLSS) techniques. MethodsTwo groups of patients were studied. The first group underwent MRI studies and the second group underwent FLSS studies. Two-step procedures were carried out. Knee MRI in 60 consecutive adult patients simply taken for meniscus or ligament injuries were utilized at the first step. The standardized patellar center (PC) and tibial tubercle (TT) on the frontal plane of MRI were positioned. At the second step, the FLSS in other 100 consecutive young adult patients taken for chronic unilateral lower extremity injuries were used for locating the two landmarks from MRI. The Q-angle was then determined on the anterior superior iliac spine, standardized PC, and TT on the FLSS. ResultsFor 60 patients, the standardized PC was at the point 42% from the lateral end of the trans-epicondylar line of the femur. The TT was at the point 2 cm distal to the tibial articular surface and 37% from the lateral end of the tibial width. For 100 patients, the Q-angle was an average of 9.5° and 65.2% of the Q-angle was contributed by the upper arm (the femur). Women had a larger Q-angle (10.1° vs. 8.8°, p = 0.02) and a shorter femur (41.1 vs. 44.7 cm, p < 0.001). ConclusionThe Q-angle is about 9.5° with 65.2% contributed by the femur. The Q-angle may mainly be influenced by the femoral component. Level of evidenceLevel IV, Diagnostic Study.