Anterior Third Research Articles

Report of One Year Follow up of Patients after TLIF using a 3-Dimensional Expandable Cage for Lumbar Fusion with Lordotic Correction

Introduction The use of a new 3 dimensional (3D) expandable cage for TLIF was extensively studied in biomechanical tests, cadaver specimens and preliminary clinical series. A wide footprint is achieved through a one side portal due to the articulated implant positioned in the anterior third of the disc space. The lordotic correction is accomplished due to the expansion of the device in place assisting on the overall sagittal alignment. Previous reports presented showed initial promising clinical results. One year follow up of the first 10 patients is now reported. Material and Methods Ten patients were included in a 12 months prospective review after a TLIF using a 3D Titanium alloy FLXFit expandable cage. The procedure was done for a single or two level fusion with positioning of the cage under fluoroscopy and expansion for disc space height and lordotic correction. All patients were supplemented with posterior instrumentation. Primary clinical outcomes were evaluated by preoperative, 6 months, 12 months and last follow-up visual analog scale (VAS) and the Oswestry Disability Index (ODI) scores. Complications and neurological impairment were recorded. Radiographic assessment of pre and post-operative results was performed with measurement of correction achieved in the frontal and sagittal planes with EOS imaging technology avoiding any distortion on X-Rays. All patients underwent CT scan control at 12 months. Results All ten patients underwent a successful one or two levels instrumented TLIF without any permanent neurological, vascular or visceral complication. The 3D cage implantation provided lordosis augmentation of 8° (± 2.1°) allowing restoration of the sagittal alignment according to pre-op planning. On early post-op CT scans, good footprint and no endplate violation were shown with no cage subsidence. Clinical outcomes showed significant improvement for both VAS and Oswestry scores ( P < 0.05), 3.7 (± 2.9) and 31% (±11) respectively. Similar outcomes were found at 12 months: no cage subsidence, VAS and Oswestry scores ( P < 0.05), 3.5 (± 2.7) and 28,4% (±12) respectively. Conclusion Lumbar interbody fusion using this new 3D expandable cage provided correction of the lordosis in a shorter and effective surgical procedure. A wide footprint well positioned cage, with customized height and angular correction achievement assured an optimal load transmission and biomechanical environment for fusion. Initial clinical results were followed with successful clinical outcomes in all patients.

The acromiohumeral distance and the subacromial clearance are correlated to the glenoid version

BackgroundThe acromiohumeral distance (ACHD) is a radiographic parameter for evaluating the presence of a rotator cuff rupture. Previous investigations have demonstrated that several factors may influence the magnitude of the acromiohumeral distance, but glenoid version has not yet been considered. HypothesisOur hypothesis was that there is a direct correlation between glenoid version and acromiohumeral distance as well as subacromial clearance. MethodsFour right glenohumeral joints from adult fresh cadavers were anatomically dissected to the level of the rotator cuff. After fixation to a board and positioning of the humeral head in neutral position, an osteotomy of the glenoid neck was carried out and the version was altered in steps of 5°. The ACHD as well as the subacromial clearance (SAC) were measured for every degree of glenoid version. ResultsThe ACHD increased with increased anteversion and consistently decreased with increased retroversion of the glenoid. The SAC also depended on glenoid version. Neutral version was associated with a minimal clearance under the anterior third of the acromion, retroversion transferred the minimal SAC posteriorly and anteversion transferred minimal SAC under the coracoacromial ligament. ConclusionOur results indicate that glenoid version correlates directly with the magnitude of ACHD and SAC. Therefore, variations of glenoid version can lead to false interpretations of cuff integrity. Type of studyBiomechanical investigation. Level of evidenceNot possible to define.

Variability of the Anterior Humeral Line in Normal Pediatric Elbows.

The anterior humeral line (AHL) is considered a valuable radiographic tool in the assessment of pediatric elbow sagittal plane alignment following injury. However, few studies exist that examine the validity of the AHL. The purpose of this study is to report the variability of the AHL in skeletally immature children with normal elbows. A total of 124 true lateral elbow radiographs of normal pediatric elbows were retrospectively identified and examined for the relationship of the AHL to the capitellum. The percentage of AHLs falling outside the middle third of the capitellum was compared among different age and sex groups using Fisher exact tests. In 100% of patients, the AHL touched the ossific nucleus of the capitellum. In 100% (52/52) of patients ≥5 years the AHL goes through the middle third of the capitellum, but this is significantly different from patients less than 5 years of age in whom 25% (18/72) of patients the AHL fell outside of the middle third of the capitellum (P<0.001). In children less than 2 years of age, the AHL was in the anterior third in 30% of the cases. Traditional teaching that the AHL touches the capitellum on a lateral radiograph of a normal elbow in a child is correct, so if the AHL does not touch the capitellum it is appropriate to look for pathology. Similarly, in children 5 years and older the AHL goes through the middle third of the capitellum in all patients, so if it does not, it is appropriate to look for pathology. However, with decreasing age variability increases, with the AHL touching the anterior third of the capitellum in almost 1/3 of children. Level III.

Wendler Glottoplasty and Voice-Therapy in Male-to-Female Transsexuals: Results in Pre and Post-Surgery Assessment

IntroductionWith the development of new ENT techniques, many male transsexuals who wish to become women usually request a surgical procedure to raise the fundamental frequency of the voice (feminization). The ENT specialist and the voice-therapist have to use an interdisciplinary approach to this growing social demand. The aim of this study was to show the results in a group of transsexual patients after Wendler's anterior synechiae, with additional voice-therapy treatment. MethodsTen male transsexuals who wish to become women patients who had Wendler glottoplasty and voice-therapy were assessed. The surgical procedure consisted of a de-epithelialization of the anterior third of both vocal folds; this area was sutured and the surface of both vocal folds was vaporised with laser diode. Pre- and postsurgery voice assessment consisted of measuring fundamental frequency (Fo) and maximum phonation time, administering the transgender self-assessment questionnaire (TSEQ) and obtaining perceptual voice assessment by inter-rater agreement. ResultsAll the male transsexuals who wish to become women patients significantly increased their Fo (106Hz on average) after the treatment. Furthermore, significant improvements were shown in self-reported satisfaction and in the degree of voice feminization. No improvements in the maximum phonation time were observed. ConclusionsWendler glottoplasty is a surgical procedure to contribute to feminising the voice, with good medium-term results and without noteworthy medical complications. The increase in vocal tone was observed using several pre- and post-surgery control measures and voice therapy.

Fluoroscopy-Guided Sacroiliac Joint Injection: Description of a Modified Technique

Sacroiliac joint (SIJ) pathology is a common etiologic cause for 10 - 27% of cases of mechanical low back pain (LBP) below the L5 level. In the absence of definite clinical or radiologic diagnostic criteria, controlled blocks of the SIJ have become the choice assessment method for making the diagnosis of SIJ pain. The SI joint is most often characterized as a large, auricular-shaped, diarthrodial synovial joint. In reality, its synovial characteristic is limited only to the distal third and anterior third. In SIJ interventions, the lateral view has been underutilized. In our technique, we used the lateral view to create a three-dimensional view of the SIJ to aid in gauging the accurateness of the contrast spread and to obtain a precise block. After obtaining appropriate fluoroscopic images, a curved tip spinal needle was directed into the inferior aspect of the SIJ using a posterior approach. As the needle contacts firm tissues on the posterior aspect of the joint, position of the needle tip is checked using lateral fluoroscopy. In the lateral view, the needle tip position is manipulated to keep it in the anterior third of the SIJ and contrast is injected. Our criteria for accurate SIJ block, in posteroanterior (PA) view, is the injection of the contrast medium should outline the joint space and the contrast medium should be seen to travel cephalad along the joint line. In the lateral view, the contrast medium most densely outlines the parameter of the joint. We have utilized this method with good effect in approximately 30 cases over one year. Out of 30 cases, needle position and contrast spread was satisfactory in 28 and 27 cases, respectively. So satisfactory needle placement and contrast spread was in 93% and 87% cases. Pain relief of 80% or more after intra-articular injection of local anesthetic was seen in 50% (15 of 30) patients; pain relief of 50 - 79% was witnessed in 30% (9 of 30) patients. Thus, pain decreased 50% or more in 80% (24 of 30) of the joints. Out of 24 joints where we got satisfactory needle position and contrast spread, 23 joints got more than 50% relief. Thus, if needle position and contrast spread is satisfactory as per the criteria, pain relief of 50% or more was in 96% (23 of 24) of joints. There are few possible limitations with this study like difficulty to go up to the anterior third of the SIJ, it may be more painful as a narrow joint line has to be travelled in depth, sciatic numbness due to drug leak, or injuring the pelvic structure. Advantages of this method are that depth and level of the needle tip for a SIJ block is described for the more precise block. This will reduce false positive and false negative results, i.e., sensitivity and specificity of SIJ blocks and results for diagnostic blocks become more reliable. It will also reduce the chances of a case getting abandoned due to inappropriate contrast spread obscuring the fluoroscopic landmarks. As we know the depth of the needle, the chances of injuring pelvic structures become less and safety improves.

The paramedian supracerebellar transtentorial approach to the mediobasal temporal region

The mediobasal temporal region (MTR) is located near the brain stem and surrounded by the eloquent neurovascular structures. The supracerebellar transtentorial approach (STA) is safe access to the posterior MTR structures, however its use for resection of anterior MTR lesions still remains controversial. The article describes the technique and outcome of surgery for different MTR structures using STA. The paramedian STA was used in 18 patients (13 females and 5 males) for 7 years. Ten patients presented with glial MTR tumors, 3 patients with cavernomas, 2 patients with arteriovenous malformations (AVMs), 2 patients with intraventricular meningiomas, and 1 patient with mesial temporal sclerosis. The patient age ranged from 19 to 57 years. In 10 cases, lesions were localized on the left. Epilepsy was the leading symptom in 14 cases. Patients underwent preoperative high-resolution MRI, electroencephalography video monitoring before and after surgery, intraoperative corticography (if necessary), and postoperative CT and MRI. Lesions were located in the anterior third of MTR in 5 patients, in the anterior and middle thirds in 2 patients, in the middle third in 5 patients, in the middle and posterior thirds in 2 patients, in the posterior third in 1 patient, in the anterior, middle, and posterior thirds in 1 patient, and in the ventricular triangle area in 2 patients. In all patients with intraventricular tumors, AVMs, and cavernous malformations and in 8 patients with glial MTR tumors, the lesions were totally resected. Two patients with intracerebral tumors underwent subtotal resection. A patient with intractable epilepsy and mesial temporal sclerosis underwent resection of the anterior two-thirds of the hippocampus and parahippocampal gyrus and, partially, amygdala using intraoperative corticography. There was no surgical mortality; 2 patients developed a transient neurological deficit, and 1 patient had a cerebellar hematoma that was successfully removed during surgery. STA enables resection of lesions localized in all parts of the MTR, without damage to the surrounding nerve and vascular structures.

Quantitative and qualitative analysis of palatal rugae patterns in Gujarati population: A retrospective, cross-sectional study.

Introduction:Palatal rugae are irregular and nonidentical mucosal elevations seen on the anterior third of palate. They are arranged in transverse direction on either side of the median palatine raphe (MPR) and are protected from high temperature and trauma because of their rational position in the oral cavity. Their number and patterns are not uniform in all the individuals, and they appear to vary in different population subsets. The study of palatal rugae is termed as “Rugoscopy” or “Palatoscopy”, and it finds its application in various fields such as anthropology, orthodontics, forensic sciences; including forensic odonto-stomatology.Aim:The aim of this study was to evaluate the quantitative and qualitative parameters of palatal rugae using pre-orthodontic study models of Gujarati samples.Objectives:(1) To identify the predominant palatal arch forms in the study samples. (2) To evaluate and correlate the rugae count in both male and female samples with the different palatal arch forms. (3) To assess the symmetry and/or asymmetry in rugae count between the right and left side. (4) To analyze and correlate the qualitative characters such as size, shape, direction, and unification in male and female study samples.Materials and Methods:One hundred pre-orthodontic maxillary dental stone casts of patients with an age range of 17–25 years were selected. The outlines of the rugae were traced using microtip graphite pencil and examined using magnifying glass for different patterns. The quantity and quality of rugae patterns were recorded according to Thomas et al. classification and the data were statistically analyzed by the statistician using SPSS program.Results:Overall, 962 rugae were observed in the study sample. The mean rugae count was 9.86 in males and 9.38 in females. The left side rugae count was more than the right side in both the sexes and it was not statistically significant. Fifty-six percent of the samples showed asymmetry in rugae count between the right and left. Class B palatal arch form was the most common type in the study samples. The number of primary rugae count was more in both the sexes. The distribution of straight (40.2%) and curved (40.4%) types of rugae were almost equal in males but in females, the straight rugae pattern (42.2%) was more than the curved (36.9%), followed by wavy and circular. Of 962 rugae, 36.4% were of horizontal type followed by forward (33.4%) and backward (29.2%). About 1 % of rugae showed perpendicular pattern and only 9.25% showed unification pattern and the divergent type of unification was more common than the convergent type.Conclusion:There is no gender discrimination in relation to any of the metric or non-metric parameters of the palatal rugae in this study samples. No two samples showed similarity in the distribution of palatal rugae patterns. The straight and horizontal rugae distributions were predominant in our Gujarati Study samples.

Newborn nasal obstruction due to congenital nasal pyriform aperture stenosis.

Introduction:Nasal obstruction is an important condition that can lead to severe respiratory distress in newborns. There are several differential diagnoses, and one of them is congenital nasal pyriform aperture stenosis (CNPAS). CNPAS is a rare case of respiratory distress caused by excessive growth of the nasal process of the maxilla and leads to narrowing of the anterior third of the nasal cavity. Diagnosis, associated anomalies, and treatment strategies are reviewed by the following presentation of two cases.Case Presentation:We report two cases of infants diagnosed with CNPAS. The patients in the first case had no concomitant comorbidities, and the outcome was successful after surgical correction of stenosis. The patient in the second case had an associated holoprosencephaly, and although surgical correction and nasal cavity patency, the patient remains dependent on tracheostomy due to dysphagia and neurologic impairment.Discussion:Airway obstruction affects 1 in 5000 children, and CNPAS is a diagnosis frequently forgotten and even unknown to neonatal and pediatric intensivists. Newborns are obligate nasal breathers, and, nasal obstruction, therefore, can lead to severe respiratory distress. CNPAS is not only rare but, many times, is not easily recognized. It is important to bear in mind the diagnostic criteria when evaluating infants with nasal obstruction. Conservative treatment should be prioritized, but surgical treatment is required in severe cases with failure to thrive and persistent respiratory distress. Respiratory distress and dysphagia may persist to some degree despite correction of the stenotic pyriform aperture due to associated narrowing of the entire nasal cavity and association with other anomalies.Final Comments:CNPAS is a rare condition and may be lethal in newborns. Differential diagnosis of nasal obstruction must be remembered to recognize this anomaly, and the otolaryngologist must be familiarized with this condition and its diagnosis. Precise surgical treatment in severe cases have high rates of success in children without other comorbidities.

Quantitative and Transverse Changes in the Position of Palatal Rugae after Palatal Expansion

Background: Palatal rugae are irregular and non-identical mucosal elevations seen on anterior third of palate. They are arranged in transverse direction on either side of Median Palatine Raphe [MPR]. Though they are the most stable anatomical structures in the oral cavity, certain conditions like orthodontic treatment contribute to some amount of variations in their pattern qualitatively. During literature review, we found scarcity of articles related to quantitative changes in rugae patterns, before and after palatal expansion. The aim of this study was to compare the number of rugae and its positional changes using before and after Semi Rapid Maxillary Expansion (SRME) study models. Materials and Methods: Seventy nine pairs of pre and post expansion casts showing finer details of palatal rugae from 37 males and 42 females in the age group of 10 to 12 years were selected for this study. The number of rugae and the distance between the median points of the first and the last two rugae on either side of MPR were noted. The data collected were statistically analyzed using SPSS program Results: Descriptive statistics mean and standard deviation were performed for study group before and after treatment at T0 and T1. There was no statistically significant change in number of rugae in the right side but significant differences were noted in the distance between medial points of first two rugae and distance between last two rugae. There was statistically no significant change in any of the variables when the data from male and female samples were compared. Conclusion: During maxillary expansion, there is stability of palatal rugae with respect to its number but not with respect to its position. There is significantly more separation of the medial ends of the opposing rugae on either side of MPR in the anterior region than on the posterior.

Specific features of reelin expression in the brain of fetuses and newborns with internal hydrocephalus

to study reelin expression in the neocortex of fetuses and newborns with internal hydrocephalus (HC) and to reveal its features in relation to the etiology of HC. The brains of fetuses and newborn at 22-40 weeks' gestation with internal HC associated with Sylvian aqueduct malformation (n=9), post-inflammatory (n=4) and post-hemorrhagic (n=5) HC were examined. In a comparison group, the fragments of brain tissue with a slit-like lumen of the lateral ventricles were no more than 0.5 cm (n=20). A standard immunohistochemical method was used to reveal reelin expression in the neocortex of the anterior third of the precentral gyrus. HC associated with Sylvian aqueduct malformation is characterized by a negative reelin immunoexpression. In postinflammatory HC, the expression of reelin decreases significantly (p=0.025) with respect to the conditional norm and, in posthemorrhagic HC it is comparable with that in the comparison group. The features of reelin expression in the brain of fetuses and newborns at 22-40 weeks' gestation with internal HC should be considered as morphological differential and diagnostic criteria for the disease in relation to its etiology.

The Effectiveness of Gelfoam Technique before Percutaneous Vertebroplasy: Is It Helpful for Prevention of Cement Leakage? A Prospective Randomized Control Study.

ObjectivePreinjection gelfoam embolization during percutaneous vertebroplasty (PVP) has been thought alternative technique to prevent the leakage of bone cement. The goal of this study was to evaluate whether the gelfoam techniques are useful to reduce bone cement leakage.MethodsTotal 100 PVPs of osteoporotic spine compression fractures were performed by 1 spine surgeon who experienced more than 500 PVP cases under prospective control study. Operation was done in T-L junction (T10-L2) fractures with bi-transpedicular approach. Preinjection gelfoam PVP was done in the 50 levels. As control group, PVP without gelfoam was done in the 50 levels. We did not perform preoperative venography. We inserted normal saline-mixed gelfoam to the anterior third of vertebral body via PVP needle, and then 3mL of polymethylmetacrylate (PMMA) was injected. We prospectively evaluated the incidence and leakage pattern of PMMA by postoperative computed tomography.ResultsBetween gelfoam and control groups, there were 11 leaks (22%) versus 12 leaks (26%). The mean operation time was 7.00 minutes versus 6.30 minutes. In gelfoam group, there were 6 spinal canal leaks, 4 paravertebral venous leaks, and 1 soft tissue leaks. In control group, there were 4 spinal canal leaks, 8 paravertebral venous leaks, and 1 disc space leak. In spite of cement leakage, there was no symptomatic case in both groups. Statistically, gelfoam technique was not related to decrease the incidence of leakage (p=0.64).ConclusionOur prospective study showed that it did not significantly decrease cement leakage when vertebroplasty is performed by experienced spine surgeon.

The posterior intrafocal pin improves sagittal alignment in Gartland type III paediatric supracondylar humeral fractures

IntroductionClosed reduction and percutaneous Kirschner wire fixation are widely recommended for displaced supracondylar humeral fractures. However, the optimal K-wire configuration is still controversial. The purpose of this study was to compare the results of crossed pinning with or without a posterior intrafocal pin in Gartland type III supracondylar humeral fractures. Patients and methodsWe retrospectively reviewed 93 children who underwent crossed pinning for Gartland type III supracondylar humeral fractures between January 2009 and December 2013. One surgeon preferentially added one posterior intrafocal pin onto the crossed pins in 35 children, and the other surgeons used standard crossed pinning technique in 58 children. Results were assessed by range of elbow motion and radiographic measures including the Baumann angle, the lateral humerocapitellar angle and the position of the anterior humeral line (AHL). ResultsThe demographic data were comparable between the 2 groups. Children treated with the additional posterior intrafocal pin had greater range of elbow motion (138.7° vs. 133.6°, p=0.01) and had a greater lateral humerocapitellar angle (44.9° vs. 37.8°, p=0.01) measured 3 months postoperatively. The percentage of AHL position in the posterior third was significantly higher in children with the posterior intrafocal pin immediately after fixation (odds ratio [OR]: 6.26) and 3 months later (OR: 2.84). The percentage of AHL position in the anterior third was also significantly lower in children with the posterior intrafocal pin 3 months postoperatively (OR: 0.29). No pin site infection or nerve injury was associated with the additional posterior pin. ConclusionsAdding one posterior intrafocal pin to crossed pinning can facilitate fracture reduction and enhance fixation stability. Better sagittal alignment and elbow motion support this safe and effective technique in treating type III humeral supracondylar fractures.

108 FACTORS AFFECTING PREGNANCY RATES IN RECIPIENTS RECEIVING IN VITRO-PRODUCED EMBRYOS BY FIXED TIME EMBRYO TRANSFER

A retrospective analysis of factors that affect pregnancy rates from 4214 fresh in vitro-produced (IVP) embryos that were transferred at a fixed-time (FTET) in 20 different farms. Recipients were all cycling cows or heifers that were synchronized with 1 of 3 treatments: 1) treatments with progesterone (P4) devices and 2 mg of oestradiol benzoate (EB) on Day 0 (day of insertion) and 24 h after device removal (Day 8); 2) treatments with P4 devices and EB on Day 0, but with 0.5 mg of oestradiol cypionate (ECP) at device removal (Day 8); or 3) treatments with P4 devices and GnRH on Day 0 and a second GnRH 60 h after device removal (Day 5). Cows in all treatment groups also received 500 µg of cloprostenol (prostaglandin F2α) at the time of P4 device removal and 400 IU of eCG either at device removal or 3 days before device removal. All embryos were transferred 7 or 8 days after the expected time of oestrus (24 h after EB, 48 h after ECP or at the time of the second GNRH for each synchronization treatment, respectively). On the day of embryo transfer, recipients were examined by ultrasonography and those with corpus luteum &gt;14 mm in diameter received a fresh, IVP embryo in the uterine horn ipsilateral to the corpus luteum. Pregnancy rates were determined by ultrasonography 35 days after FTET. Data were analysed by logistic regression. Independent variables were classified into the following three categories. 1) Factors related to the recipient and the environment; there were no significant differences in pregnancy rates for corpus luteum diameter (≥14 and &lt;16 mm, ≥16 and &lt;18 mm, or ≥18 mm; P = 0.46), number of corpus luteum (1 or ≥2; P = 0.26), and category of recipient (cow or heifer; P = 0.21). However, there were significant effects of farm (P = 0.01) and body condition score (BCS; P = 0.01). Cows with BCS ≥4.5 (1 to 5 scale) resulted in lower pregnancy rates (4/20, 20.0%) than those with BCS 2 (74/225, 32.9%), 2.5 (502/1434, 35.0%), 3 (570/1467, 38.9%), 3.5 (193/532, 36.3%), and 4 (44/118, 37.3%). 2) Factors related to the synchronization treatment; there were no significant differences between recipients receiving eCG at device removal (84/209, 40.2%) or 3 days before device removal (874/2291, 38.1%; P = 0.35). However, recipients synchronized with P4 devices and ECP had higher (P = 0.01) pregnancy rates (232/483, 48.0%) than those treated with EB (679/1888, 36.0%) or gonadotropin-releasing hormone (47/129, 36.4%). 3) Factors related to the embryo transfer technique; day of the recipient’s oestrous cycle (P = 0.36), stage of embryo transferred (IETS stages 6 or 7; P = 0.62), and operator (P = 0.57) did not affect pregnancy rates. However transfers made in the anterior third of the uterine horn resulted in higher (649/1545, 42.0%) pregnancy rates than those in the mid-third (845/2511, 33.6%) or in the distal third (6/35, 17.1%; P = 0.01). It was concluded that factors related to the recipient and the environment (farm and BCS), the synchronization treatment (ECP), and the embryo transfer technique (site of deposition) affect pregnancy rates in recipients of embryos produced in vitro and transferred at a fixed time.

Brachytherapy: state‐of‐the‐art radiotherapy in prostate cancer

Brachytherapy: state‐of‐the‐art radiotherapy in prostate cancer

Forensic Application of Palatal Rugae in Dental Identification

The palatal rugae are anatomical folds or wrinkles located on the anterior third of the palate behind the incisive papilla on each side of the palatal raphe. The rugae patterns have been studied for various purposes mainly in the field of anthropology, comparative anatomy, genetics, prosthodontics, orthodontics and forensic odontology. This study is aimed to determine the difference in number and pattern of palatal rugae in males and females. This is a prospective study in which maxillary impressions of 50 volunteers, 25 males and 25 females were taken and the casts prepared. The boundaries of the rugae were marked with a HB pencil and were observed with a magnifying glass following the classification used by Kapali, et al, (1997). Association between rugae number and sex and rugae shape and sex were tested using two sample unpaired t test. The study revealed significant difference in the pattern of converge rugae which were found to be higher in females than males, however, no statistical significant difference was found in the number of rugae between the two sexes. The rugae pattern can be an additional method of differentiation between the males and females in conjunction with the other methods used in forensic sciences.

Palatal Rugae Patterns in Edentulous Cases, Are They A Reliable Forensic Marker?

One of the main objectives of the forensic sciences is establishing a person's identity which can be a very complex process. The analysis of the teeth, fingerprints and DNA evaluation are probably the most used techniques allowing fast and secure identification processes. Palatal rugae or transverse palatine folds are asymmetrical and irregular elevations of the mucosa located in the anterior third of the palate and are permanent, prominent and unique for individuals and thus can be used as identification for forensic purposes widely in edentulous patients wherein no teeth are present in the oral cavity. In forensic odontology dentists play a prime role in supporting legal and criminal issues. Palatoscopy or palatal rugoscopy is the name given to the study of palatal rugae in order to ascertain a person's identity. Studies have demonstrated that no two individual rugae patterns are alike in their configuration and the characteristic rugae pattern of the palate does not change as a result of growth. Hence this article reviews the significance of palatal rugae patterns in edentulous cases as a reliable forensic marker.

Effect of the Location of Endplate Cement Extravasation on Adjacent Level Fracture in Osteoporotic Patients Undergoing Vertebroplasty and Kyphoplasty

Background: The most widely researched risk/complication following vertebroplasty (VP) or kyphoplasty (KP) is that of adjacent level fracture (ALF). Current literature results regarding the effect of intradiscal extravasation of cement on the risk of ALF is conflicting with about half of the studies concluding there is no added risk with endplate extravasation and half of the studies reporting opposite conclusions. Objective: The purpose of the study is to further stratify the data to determine whether specifically the location and extent of endplate cement extravasation more strongly affect ALF risk in osteoporotic patients following either VP or balloon KP. Study Design: Retrospective cohort study. Setting: University teaching hospital Methods: One hundred and fifty-six cemented levels in 80 patients, treated at a single center between 2008 and 2012 were reviewed. Age, gender, T-score, body mass index, and osteoporosis type (primary or secondary) were recorded. An ALF was defined as a fracture: 1) in a non-cemented vertebra; 2) adjacent to a cemented level; and 3) not due to trauma or malignancy. Location of the cement extravasation (anterior, middle, or posterior third of the vertebral body) and extravasation extent (percentage of the intervertebral disc height occupied by the bolus) were measured. A logistic modeling strategy permitted examining the association between the location and extent of extravasation and the odds of ALF. Results: ALF occurred in 14 of the 52 patients (27%) and 20 of the 98 levels (20.4%) remaining after exclusions. Odds of ALF were 5.9 times higher (95% CI: 1.6 to 21.2, P = 0.008) with extravasation when compared to no leakage. Odds of ALF in a given patient were 22.6 times higher (95% CI: 3.0 to 170.9, P = 0.003) with anterior extravasation when compared to no leakage. Leakage in the middle or posterior thirds and extent of extravasation were not associated with ALF. Limitations: Limitations of the study include the retrospective study design and small sample size as well as the retrospective implementation of follow-up criteria posing risk of selection bias. Conclusions: Cement endplate extravasation isolated to the anterior third of the vertebral body is associated with is significantly higher odds of ALF after VP or KP in patients with osteoporosis. Key words: Adjacent vertebral fracture, intradiscal leak, osteoporotic compression

Bilateral V-Y advancement gluteal fold flaps following vulvo-vaginal melanoma resection

The soft tissue defects of the anterior perineum can be caused by tumour excision, trauma, burns, Fournier’s gangrene and genital mutilation. Various reconstruction methods were described: vacuum-assisted closure, skin grafts and skin substitutes, pedicled or free flaps. In the case of defects following oncologic surgery, flaps are the reconstructive method of choice. We present the case of a 65 year-old woman diagnosed with stage III A vulvo-vaginal melanoma affecting also the distal urethra. Radical vulvectomy and en-bloc excision of the anterior third of the vagina and distal urethra, along with bilateral inguinal lymphadenectomy was performed. The resulting defect was covered with bilateral V-Y advancement gluteal fold flaps. A local vaginal recurrence appeared 18 months after surgery and was safely removed. The patient followed chemotherapy with Dacarbazine. The gluteal fold flap offered good defect coverage and survived completely. Follow-up period was two years without distant metastases. Functional result was excellent, urinary function being normal and patient satisfaction high. Due to the gluteal flap’s advantages (appropriate thickness, good vascularity, minimal donor site morbidity, and same operative field allowing for shorter operating time), reconstruction of the anterior perineum after oncological resection with bilateral V-Y advancement gluteal flaps is a viable solution.

Laparoscopic anatomy of the autonomic nerves of the pelvis and the concept of nerve-sparing surgery by direct visualization of autonomic nerve bundles

To demonstrate the laparoscopic neuroanatomy of the autonomic nerves of the pelvis using the laparoscopic neuronavigation technique, as well as the technique for a nerve-sparing radical endometriosis surgery. Step-by-step explanation of the technique using videos and pictures (educational video) to demonstrate the anatomy of the intrapelvic bundles of the autonomic nerve system innervating the bladder, rectum, and pelvic floor. Tertiary referral center. One 37-year-old woman with an infiltrative endometriotic nodule on the anterior third of the left uterosacral ligament and one 34-year-old woman with rectovaginal endometriosis. Exposure and preservation by direct visualization of the hypogastric nerve and the inferior hypogastric plexus. Visual control and identification of the autonomic nerve branches of the posterior pelvis. Exposure and preservation of the hypogastric nerve and the superficial part of the left hypogastric nerve were achieved on the first patient. Nerve roots S2, S3, and S4 were identified on the second patient, allowing for the exposure and preservation of the pelvic splanchnic nerves and the deep portion inferior hypogastric plexus. Radical surgery for endometriosis can induce urinary dysfunction in 2.4%-17.5% of patients owing to lesion of the autonomic nerves. The surgeon's knowledge of the anatomy of these nerves is the main factor for preserving postoperative urinary function. The following nerves are the intrapelvic part of the autonomic nervous system: the hypogastric nerves, which derive from the superior hypogastric plexus and carry the sympathetic signals to the internal urethral and anal sphincters as well as to the pelvic visceral proprioception; and the pelvic splanchnic nerves, which arise from S2 to S4 and carry nociceptive and parasympathetic signals to the bladder, rectum, and the sigmoid and left colons. The hypogastric and pelvic splanchnic nerves merge into the pararectal fossae to form the inferior hypogastric plexus. Most of the nerve-sparing techniques involve the dissection and exposure of the pelvic splanchnic nerves and the inferior hypogastric plexus. However, knowledge of the topographic anatomy and awareness of the landmarks for avoiding intraoperative nerve injuries seem to be the most important factors in avoiding postoperative bladder and bowel dysfunction, although this latter nerve-sparing technique seems to be associated with reduced radicality and symptom persistence. This video demonstrates a technique to expose the sympathetic and parasympathetic nerves of the pelvis to preserve them in radical pelvic surgery, by means of direct visualization, in a similar fashion to the technique used to preserve the ureters. An alternative to this technique is to use landmarks for limiting dissection and avoiding intraoperative nerve injury. Despite being safe and more easily reproducible, this latter technique is associated with a higher rate of symptom persistence.

Frequency considerations for deep ablation with high-intensity focused ultrasound: A simulation study.

The objective of this study was to explore frequency considerations for large-volume, deep thermal ablations with focused ultrasound. Though focal patterns, focal steering rate, and the size of focal clusters have all been explored in this context, frequency studies have generally explored shallower depths and hyperthermia applications. This study examines both treatment efficiency and near-field heating rate as functions of frequency and depth. Flat, 150 mm transducer arrays were simulated to operate at frequencies of 250, 500, 750, 1000, 1250, and 1500 kHz. Each array had λ2 interelement spacing yielding arrays of 2000-70 000 piston-shaped elements arranged in concentric rings. Depths of 50, 100, and 150 mm were explored, with attenuation (α) values of 2.5-10 (Np/m)/MHz. Ultrasound propagation was simulated with the Rayleigh-Sommerfeld integral over a volume of homogeneous simulated tissue. Absorbed power density was determined from the acoustic pressure which, in turn, was modeled with the Pennes bioheat transfer equation. Using this knowledge of temperature over time, thermal dose function of Sapareto and Dewey was used to model the resulting bioeffect of each simulated sonication. Initially, single foci at each depth, frequency, and α were examined with either fixed peak temperatures or fixed powers. Based on the size of the resulting, single foci lesions, larger compound sonications were designed with foci packed together in multiple layers and rings. For each depth, focal patterns were chosen to produce a similar total ablated volume for each frequency. These compound sonications were performed with a fixed peak temperature at each focus. The resulting energy efficiency (volume ablated per acoustic energy applied), near-field heating rate (temperature increase in the anterior third of the simulation space per unit volume ablated), and near- and far-field margins were assessed. Lesions of comparable volume were created with different frequencies at different depths. The results reflect the interconnected nature of frequency as it effects focal size (decreasing with frequency), peak pressure (generally increasing with frequency), and attenuation (also increasing with frequency). The ablation efficiency was the highest for α = 5 (Np/m)/MHz at a frequency of 750 kHz at each depth. For α = 10 (Np/m)/MHz, efficiency was the highest at 750 kHz for a depth of 50 mm, and 500 kHz at depths of 100 and 150 mm. At all sonication depths, near-field heating was minimized with lower frequencies of 250 and 500 kHz. Large-volume ablations are most efficient at frequencies of 500-750 kHz at depths of 100-150 mm. When one considers that near-field heat accumulation tends to be the rate limiting factor in large-volume ablations like uterine fibroid surgery, the results show that frequencies as low as 500 kHz are favored for their ability to reduce heating in the near-field.