Anterior Third Research Articles

Optic nerve motion and gaze direction: Their impact on intraorbital tumor radiotherapy

PurposeManagement of inter- and intra-fraction movements of target volumes and organs at risk (OARs) during radiotherapy is essential. While there is little OAR or target volume movement, the movements and orientation of the eyes can be significant during radiotherapy and they can affect the position of the optic nerve. The objective of the present study was to assess the variations of the optic nerve position due to gaze direction and to discuss their clinical consequences on the radiation treatment of intraorbital tumors. Material and methodsThree patients without a history of oculomotor nerve palsy underwent six CT acquisitions with a thermoplastic mask: eyes open with different gaze directions (straight ahead, left, right, up, down) and eyes closed. The acquisition with the straight-ahead gaze was chosen as the reference position. Left and right optic nerves were segmented on the six acquisitions, and total volumes and maximum amplitude motions were calculated in three dimensions. ResultsMaximum differences were observed while looking left and up, with a median maximum amplitude of 5 and 6mm [range: 2–7mm], respectively. These motions induced a position variation of more than 50% of the volume of the optic nerve (compared to the reference position). Greater variations of motion were observed for the anterior portion of the nerve. The gaze position with the fewest variations compared to the reference position was eyes closed. ConclusionOptic nerve positions vary significantly due to the gaze direction, especially for the anterior portion of the nerve. These variations should be taken into account for the treatment of small intraorbital tumors involving the anterior third of the optic nerve.

Does Cage Position Affect the Risk of Cage Subsidence After Oblique Lumbar Interbody Fusion in the Osteoporotic Lumbar Spine: A Finite Element Analysis

This study aimed to evaluate the biomechanical effects of different cage positions with stand-alone (SA) methods and bilateral pedicle screw fixation (BPSF) in the osteoporotic lumbar spine after oblique lumbar interbody fusion (OLIF). A finite element model of an intact L3-L5 lumbar spine was constructed. After validation, an osteoporosis model (OP) was constructed by assigning osteoporotic material properties. SA models (SA1, SA2, SA3) and BPSF models (BPSF1, BPSF2, BPSF3) in which a cage was placed in the anterior, middle, and posterior third of the L5 superior endplate (SEP) were constructed at the L4-L5 segment of the OP. The L4-L5 range of motion (ROM), the stress of the L5 SEP, the stress of the cage, and the stress of fixation were compared among the different models. According to the degree of ROM of L4-L5, the stress of the L5 SEP and the stress of the cage for most physiological motions, the SA and BPSF models were ranked as follows: SA2 < SA1 < SA3, BPSF2 < BPSF1 < BPSF3. In BPSF2, the stress of fixation was minimal in most motions. At the same cage position, the ROM of L4-L5, the stress of the L5 SEP, and the stress of the cage in the BPSF models were significantly reduced compared with those in SA models; compared with SA2, BPSF2 had a maximum reduction of 83.24%, 70.71%, and 73.52% in these parameters, respectively. Placing the cage in the middle third of the L5 SEP for OLIF could reduce the maximum stresses of the L5 SEP, the cage, and the fixation, which may reduce the risk of postoperative cage subsidence, endplate collapse, and fixation fracture in the osteoporotic lumbar spine. Compared with SA OLIF, BPSF could provide sufficient stability for the surgical segment and may reduce the incidence of the aforementioned complications.

The first fossil Parascleroderma (Hymenoptera: Bethylidae): a new species in mid-Miocene Zhangpu amber

The recently discovered amber biota from Zhangpu, China, offers a unique window into the tropical ecosystem of an Asian rainforest during the Mid-Miocene Climatic Optimum (MMCO). Here, the first flat wasp (Bethylidae) from this deposit is documented: Parascleroderma palaeosinica n. sp. is described and figured from a single male, and is the first fossil Parascleroderma known to date. The new extinct species is characterized by its minute size, the pedicel longer than the flagellomeres, the posterior ocelli inserted much posteriad on head, the notauli not impressed on anterior third of anteromesoscutum, and the hypopygium simple, with posterior margin slightly incurved medially. Parascleroderma is a cosmopolitan genus within the Pristocerinae and it is therefore not surprising to find its record in the Zhangpu biota, simultaneously with the northern expansion of the southeastern Asian tropical forest during the MMCO.

Radial tears in the anterior third of the lateral meniscus are frequently combined with horizontal tears

IntroductionRadial tears of the lateral meniscus are often located in the junction of the middle and posterior third or posterior tibial attachment. However, we observed that a few cases of radial tears occurred in the anterior third of the lateral meniscus, and in many cases, they were accompanied by horizontal tears. HypothesisRadial tears are more frequently accompanied by horizontal tears in the anterior third of the lateral meniscus than in other regions. Material and methodsFrom July 2006 to May 2019, patients who underwent arthroscopic surgery for radial tears of the lateral meniscus were included. Patients with radial tears in the anterior third of the lateral meniscus were classified into the anterior group and those with radial tears in the middle and posterior third were classified into the comparison group. Magnetic resonance imaging and arthroscopic findings were reviewed to evaluate whether radial tears were accompanied by other types of tears, especially horizontal tears. The incidence of complex tears between the two groups was compared. ResultsEighty knees in 79 patients were included. The mean age at the time of surgery was 44.1±16.9 years. The anterior group included 30 knees, and 19 (63.3%) of those also had horizontal tears. In the anterior group, all complex tears were accompanied by horizontal tears, and no other types of accompanying tears were observed. The comparison group included 50 knees, and 16 (32%) of those also had other types of tears. Of the 16 complex tears, 14 had horizontal tears and 2 had longitudinal tears. The incidence of complex tear was significantly higher in the anterior group than in the comparison group (p<.001). ConclusionRadial tears occurring at the anterior third of the lateral meniscus are frequently accompanied by a horizontal tear. It is important to be aware and predict the occurrence of such characteristic tears and to do proper surgical procedures. Level of proofIV; Cross-sectional study.

Radiodensity Analysis of Medial Column Superconstruct Fixation Sites in Midfoot Charcot Neuroarthropathy

Charcot neuroarthropathy (CN) is a highly destructive, pathologic process with devastating consequences to foot structure and viability. The use of intramedullary fixation "superconstructs" allows for "re-bar" support of compromised bone and allows for some dynamic fixation. This study examines radiodensity in Hounsfield units (HU) to compare bone quality of medial column fixation targets using computed tomography scans between patients with and without midfoot CN. A retrospective chart review identified control (nondiabetic, non-CN; n = 29) and midfoot CN (n=21) groups. Patient demographics and medical history were collected. Two reviewers measured the mean HU of a circular region of interest centered on the first metatarsal head and the anterior, middle, and posterior thirds of the talar body. Radiodensity was compared between groups, and among talar locations, Eichenholtz stages and Brodsky types, with statistical significance set at p ≤ .05. Age and body mass index were not significantly different between groups. The CN group maintained greater mean HU than the control group at the metatarsal head (p < .001), and talar body locations (p < .019). The difference in mean HU of these bones was not statistically significant between Stages 0 to 1 and Stages 2 to 3 or Brodsky Types 1 and 2. Mean HU differences among talus positions were not statistically significant. Indirect bone density analysis using HU showed an increased density in CN patients with no significant difference among talar body locations or midfoot Charcot stages and types. These results may assist in optimizing fixation length. Future studies may examine these densities in ankle CN.

Concomitant uveal melanoma and papillary thyroid carcinoma: a case report

BackgroundMelanoma develops in the cells that produce melanin; ocular melanoma accounts for 3–4% of all malignant melanomas. Thyroid tumors are the most common endocrine neoplasms, with more than 95% of cases arising from follicular cell origin. Previous studies have reported associations between malignant melanoma and a wide variety of malignancies.Case presentationWe report a 54-year-old Iranian woman who was diagnosed with ocular melanoma based on a mushroom-shaped filling defect with homogeneous echo pattern arising from the anterior third of the temporal side of the globe detected on ocular sonography during routine ophthalmological examination. She underwent right globe enucleation and implant replacement. During tumor surveillance, fluorodeoxyglucose positron emission tomography/computed tomography scan showed low-grade metabolically active tumoral involvement in the anterolateral aspect of the right lobe of thyroid. The patient subsequently underwent thyroidectomy and submandibular lymphadenectomy. Pathologic report demonstrated micropapillary carcinoma (9 × 8 mm2), tall cell variant without lymphovascular or perineural invasion in the base of lymphocytic thyroiditis.ConclusionThis case illustrates the importance of precise active surveillance in case of papillary carcinoma of thyroid or malignant melanoma to avoid missing other associated pathologies and emphasizes the simultaneous treatment of two tumors.

"Hammock" suspending the superior ophthalmic vein: a magnetic resonance imaging study.

The present study aimed to explore the hammock-like structure suspending the superior ophthalmic vein (SOV) using magnetic resonance imaging (MRI). Following conventional MRI examination, 93 outpatients underwent thin-sliced, coronal T2-weighted and contrast imaging of the orbit. SOVs were consistently detected in all 93 patients. In 90.3% of patients, a hammock-like structure suspending the SOV was identified, which was present on both sides in 64.5% of patients. The structure was frequently located in the anterior and middle thirds of the retrobulbar orbit, suspended from the superolateral corner of the orbital walls. The medial edge of the hammocks did not reach the orbital walls; therefore, they partially encased the SOV. The morphology of the hammock was highly variable between patients, although none were tethered to the extraocular muscles. In addition, a septal band connecting the hammock and optic sheath was identified in 36.6% of patients, most frequently located in the posterior third of the retrobulbar orbit. The hammock suspending the SOV and the septal band connecting the hammock and optic sheath may be structures that loosely anchor the SOV to the orbital fat to maintain a constant SOV flow, in addition to preventing excessive bends and obstructions.

Morphological study of the menisci of the knee joint in human cadaver in Jharkhand population

Sports are the leading cause of joint injuries, particularly in the knees. Knee menisci are an important functional unit that aids in load distribution and hence reduces stress on the knee joint. Meniscal morphology provides information on exact size and shape, which is important for meniscal transplantation in cases of meniscal damage. The study's goal is to determine the morphological variation in the shape of menisci, as well as the width and thickness of menisci. This study was conducted at the Rajendra Institute of Medical Sciences (RIMS) Ranchi, Department of Anatomy. In this study, 100 menisci were taken from 50 adult cadaver knee joints available in the dissection hall. Six morphological kinds of menisci were identified after a morphological and morphometric study of 100 menisci. The most common crescent-shaped menisci (96%) were found in 50 medial menisci (MM), while the most common C-shaped menisci were found in 50 lateral menisci (LM, 94%). There was no statistically significant difference in thickness between the anterior, middle, and posterior thirds of the MM in the morphometric analysis. The thickest section of the lateral meniscus (LM) was in the middle third. There was no significant variation in the width of the LM among the different thirds in the current study. The posterior portion of the medial meniscus (MM), on the other hand, was the widest. The findings of this study support meniscal anatomy in terms of surgical technique and arthroscopy of the knee joint, as well as contributing to a better understanding of meniscal architecture and meniscal transplantation. As a result, health workers who treat meniscal injuries should be aware of the probable anatomical differences.

Alteration of the corpus callosum in patients with Alzheimer's disease: Deep learning-based assessment.

Several studies have reported changes in the corpus callosum (CC) in Alzheimer's disease. However, the involved region differed according to the study population and study group. Using deep learning technology, we ensured accurate analysis of the CC in Alzheimer's disease. We used the Open Access Series of Imaging Studies (OASIS) dataset to investigate changes in the CC. The individuals were divided into three groups using the Clinical Dementia Rating (CDR); 94 normal controls (NC) were not demented (NC group, CDR = 0), 56 individuals had very mild dementia (VMD group, CDR = 0.5), and 17 individuals were defined as having mild and moderate dementia (MD group, CDR = 1 or 2). Deep learning technology using a convolutional neural network organized in a U-net architecture was used to segment the CC in the midsagittal plane. Total CC length and regional magnetic resonance imaging (MRI) measurements of the CC were made. The total CC length was negatively associated with cognitive function. (beta = -0.139, p = 0.022) Among MRI measurements of the CC, the height of the anterior third (beta = 0.038, p <0.0001) and width of the body (beta = 0.077, p = 0.001) and the height (beta = 0.065, p = 0.001) and area of the splenium (beta = 0.059, p = 0.027) were associated with cognitive function. To distinguish MD from NC and VMD, the receiver operating characteristic analyses of these MRI measurements showed areas under the curves of 0.65-0.74. (total CC length = 0.705, height of the anterior third = 0.735, width of the body = 0.714, height of the splenium = 0.703, area of the splenium = 0.649). Among MRI measurements, total CC length, the height of the anterior third and width of the body, and the height and area of the splenium were associated with cognitive decline. They had fair diagnostic validity in distinguishing MD from NC and VMD.

Arthroscopic Subacromial Decompression in the Treatment of Shoulder Impingement Syndrome: A Prospective Study in Malaysia.

IntroductionShoulder impingement syndrome (SIS) is one of the common problems which lead to shoulder disabilities. This condition has been described as impingement to the rotator cuff by the anterior third of the acromion process and has been classified into three stages. Treatment option varies depending on the grade of the disease. Arthroscopic subacromial decompression (ASAD) has become more popular in recent years and has shown to have a good outcome. The purpose of this study is to evaluate the outcomes following ASAD in terms of the functional, clinical, and radiological parameters in treating SIS in the ageing population in Kuantan, Pahang, Malaysia.Materials and methodsThis was an observational study looking at the outcomes of patients with stage 2 and stage 3 (partial cuff tear) impingement syndrome who underwent ASAD in Hospital Tengku Ampuan Afzan and International Islamic University Malaysia Medical Centre from May 2018 to June 2019. The functional outcomes were evaluated using American Shoulder and Elbow Surgeons (ASES) score taken at pre-operative, six weeks, three months, and six months post-operation. Clinical outcomes were evaluated using Constant score (CS) taken at six months post-operation. Radiological outcomes were measured by comparing acromiohumeral distance pre- and post-operation on anteroposterior (AP) view radiograph of the affected shoulder.ResultsA total of 28 patients were selected for the study. On functional outcome, there was a significant effect of time on the ASES scoring system (p-value <0.05) from pre-operative to six months post-operation. On clinical outcome, the CS at six months showed 13 patients have excellent scores, 10 have good, and five have fair scores. There was a statistically significant difference in mean values of all categories (p-value <0.05). In terms of the radiological outcome, this study observed a significant increase in patients’ subacromial space on X-ray from the pre-operative and post-operative treatment stages. In this study, we also observed that there was no significant difference in outcomes between partial and intact rotator cuff (RC) tears at six-month post-operation.ConclusionIn this study, ASAD was found to be a beneficial intervention in the treatment of patients with shoulder impingement evidenced by the significant outcomes in terms of functional, clinical, and radiological parameters.

New data on Cryptonella truyolsi García-Alcalde, 1999, cryptonellid (Terebratulidina) of the Cantabrian Mountains (N Spain)

A new population of Cryptonella truyolsi García-Alcalde, 1999 has been found in Caldas de Luna (province of León, Spain), La Vid Group, Coladilla Formation, level M-CAL-15 (upper part), upper Emsian. Most of morphological characters of the new specimens closely agree with those of the original Cryptonella truyolsi collections. However, serial sections made on a specimen of the new population show an anteriorly open cryptonelliform brachial loop that it is wider, and slightly shorter than that of the original material; furthermore, the descending and ascending branches are only fused along the anterior third of the loop, and the transverse band is narrower, and it is folded at its middle part. The diagnosis of Cryptonella truyolsi is consequently emended.

Elastic energy storage in seahorses leads to a unique suction flow dynamics compared with other actinopterygians.

ABSTRACTSuction feeding is a dominant prey-capture strategy across actinopterygians, consisting of a rapid expansion of the mouth cavity that drives a flow of water containing the prey into the mouth. Suction feeding is a power-hungry behavior, involving the actuation of cranial muscles as well as the anterior third of the fish's swimming muscles. Seahorses, which have reduced swimming muscles, evolved a unique mechanism for elastic energy storage that powers their suction flows. This mechanism allows seahorses to achieve head rotation speeds that are 50 times faster than those of fish lacking such a mechanism. However, it is unclear how the dynamics of suction flows in seahorses differ from the conserved pattern observed across other actinopterygians, or how differences in snout length across seahorses affect these flows. Using flow visualization experiments, we show that seahorses generate suction flows that are 8 times faster than those of similar-sized fish, and that the temporal patterns of cranial kinematics and suction flows in seahorses differ from the conserved pattern observed across other actinopterygians. However, the spatial patterns retain the conserved actinopterygian characteristics, where suction flows impact a radially symmetric region of ∼1 gape diameter outside the mouth. Within seahorses, increases in snout length were associated with slower suction flows and faster head rotation speeds, resulting in a trade-off between pivot feeding and suction feeding. Overall, this study shows how the unique cranial kinematics in seahorses are manifested in their suction-feeding performance, and highlights the trade-offs associated with their unique morphology and mechanics.

Isolated medial rectus muscle laceration after bird strike.

A 66 year-old male suffered globe trauma due to A bird, a German Desert Hawk, strike. At the first examination in the emergency ünit a few hours after the injury, the patient reported persistent horizontal diplopia. He had right conjunctival laceration, mild proptosis, subconjunctival hematoma, exotropia with no adduction. Magnetic Resonance Imaging (MRI) revealed that it was suggestive of laceration of the right medial rectus muscle, at about the junction of it's anterior and middle thirds. During surgery; initially, the lacerated proximal end of the distal segment was isolated. The proximal segment of the medial rectus muscle was then carefully dissected. The two lacerated ends were then joined with 6-0 polyglactin sutures. The day after surgery, there was no deviation and diplopia in all diagnostic gaze positions.

Craniometric and Volumetric Analysis of Posterior Vault Distraction Osteogenesis: 10 Year Update.

The purpose of this study is to quantitatively establish the volumetric changes observed with posterior vault distraction osteogenesis in the anterior, middle, and posterior thirds of the cranial vault; characterize change in cranial length, width, and height, correlating these changes to demographic variables that may help identify why younger kids gain more volume; and describe the short-term position of the transport segment. Multisuture craniosynostosis patients who underwent posterior vault distraction osteogenesis were retrospectively reviewed. Pediatric, dose-reduced, thin cut helically acquired head computed tomography scans were analyzed on Materialise Mimics v22 (Materialise, Ghent, Belgium). Pre and post-PVDO and "old" and "young" cohort were compared. Twenty-one patients met inclusion criteria. The change in cranial length was significantly less at a median of 14.9 mm [Interquartile range (IQR) 11.8, 31.6] compared to the X-ray measured AP distraction distance (30 mm [IQR 24, 33]; P < 0.001) and significantly less than the theoretically calculated distance (23 mm [IQR 19, 31]; P = 0.012). Median anterior cranial height was shorter post PVDO (82.9 mm, [IQR 64.8, 92.6] versus 78.7 mm [IQR 57.0, 88.7]; P = 0.030). The younger cohort saw a greater increase in total intracranial volume (median 335.1 mL [IQR 163.2, 452.3, median 37.1%] versus 144.6 mL [IQR 119.0, 184.8, median 12.0%]; P = 0.011). This is the first study to quantify volumetric changes to the anterior, middle, and posterior cranial vaults and demonstrates benefits of preforming PVDO at a younger age to help control turricephaly and produce greater percentage volumetric increases.

CLINICALLY SIMILAR BUT NOT THE SAME: 2 LINGUAL SWELLING

<h3>Introduction</h3> The presence of lingual lesions in pediatric patients represents a diagnostic challenge, since most of these may feature a similar clinical presentation but unique histopathologic characteristics. <h3>Case Report</h3> Case #1, a 4-year-old female patient with a lingual swelling of approximately 3 cm located on the anterior and middle third of the ventral surface of the tongue. The patient's parents refer that this lesion has been present since birth but has grown significantly during the last year. TC scan shows a circumscribed hypodense lesion; a yellow and brown doughy material was seen on gross examination. The histopathologic final diagnosis was dermoid cyst. Case #2, an 8-year-old female patient presented with an asymptomatic swelling of approximately 7 cm in the middle third of the tongue, with a soft consistency and 2-year evolution. An excisional biopsy was performed; a mucoid material was seen on gross examination. The final diagnosis was a lingual cyst with a respiratory epithelium. <h3>Discussion</h3> Only 34 cases of lingual cyst with respiratory epithelium have been reported. This is a congenital cyst characterized by the presence of pseudostratified columnar ciliated epithelium with mucus secreting cells PAS+, while the dermoid cyst produces keratin, and its capsule contains cutaneous annexes. The treatment for both lesions includes complete surgical enucleation. <h3>Conclusions</h3> The presence of lingual lesions must include differential diagnoses such as epidermoid cyst, dermoid cyst, mesenchymal tumors, mucocele, lymphangioma, hemangioma, and choristomas. Another rare differential diagnosis to consider is congenital cysts with respiratory or gastric lining.

Arthroscopic Primary Repair of Proximal Anterior Cruciate Ligament Tears With Suture Augmentation

Background: Historically, the midterm outcomes of open anterior cruciate ligament (ACL) repair were rather disappointing, and ACL reconstruction subsequently became the surgical standard for ACL injuries. Recent studies, however, have shown that there might be a role for arthroscopic primary repair in appropriately selected patients with proximal ACL tears. Indications: Due to more prominent blood supply in the proximal ligament region, ACL repair should only be performed in patients with proximal tears and good-to-excellent tissue quality. Although all patients are potential candidates, this procedure is preferably performed acutely and in adult patients. Technique Description: First, it is identified whether a proximal tear with good tissue quality is present. Then, both ACL bundles are sutured individually from distal to proximal using a Bunnell-type pattern and a self-retrieving suture passer. The posterolateral bundle is then reattached first in anatomical fashion, using a 4.75-mm vented biocomposite suture anchor. Next, the suture anchor of the anteromedial bundle is preloaded with an internal suture tape augmentation. After anchor deployment, the suture tape augmentation is channeled through a small 2.5-mm tibial tunnel in the anterior third of the tibial ACL footprint. Finally, the suture augmentation is tensioned near full extension and fixed to the tibia’s anteromedial cortex using single suture anchor fixation. Results: Recently, we have published a series of the first 113 consecutive repair patients with minimum 2-year follow-up, of which 60 received additional suture augmentation. In this cohort, the overall failure rate was 13%, which was similar to 3 other studies on modern-day ACL repair (range: 5%-15%). Subgroup analysis showed that the failure rate was much higher in patients ≤21 years (38%) but low in patients &gt;21 years (0%). Finally, it has been shown that there is an earlier return of knee motion, complications are rare, and there is less joint awareness after ACL repair as compared with ACL reconstruction. Conclusion: Selective, modern-day, arthroscopic primary ACL repair with suture augmentation seems to be a good alternative to ACL reconstruction in carefully selected patients, which include patients with proximal tears and good tissue quality and aged ≥22 years.

Do Coronal or Sagittal Plane Measurements Have the Highest Accuracy to Arthroscopically Diagnose Syndesmotic Instability?

To compare the accuracy of arthroscopic sagittal versus coronal plane distal tibiofibular motion toward diagnosing syndesmotic instability. Arthroscopic assessment of the syndesmosis was performed on 21 above-knee cadaveric specimens, first with all ligaments intact and subsequently with sequential transection of the anterior inferior tibiofibular ligament, the interosseous ligament, the posterior inferior tibiofibular ligament, and the deltoid ligament. A lateral hook test, an anterior-to-posterior (AP) translation test, and a posterior-to-anterior (PA) translation test were performed under 100 N of applied force. Anterior and posterior third coronal plane diastasis and AP and PA sagittal plane fibular translations were measured relative to the static tibia. Receiver operating characteristic (ROC) curve analysis revealed that the area under the curve (AUC) was higher for the combined AP and PA sagittal measurements (AUC, 0.91; accuracy, 83.5%; sensitivity, 78%; specificity, 89%) than the coronal plane measurements (anterior third: AUC, 0.65; accuracy, 60.5%; sensitivity, 63%; specificity, 59%; posterior third: AUC, 0.73; accuracy, 68.5%; sensitivity, 80%; specificity, 57%) (P < .001), underscoring the higher accuracy of sagittal plane measurements. Arthroscopic measurement of sagittal plane fibular translation is more accurate than coronal plane diastasis for evaluating syndesmotic instability. Clinicians should focus on distal tibiofibular motion in the sagittal plane when arthroscopically evaluating suspected syndesmotic instability. Biomechanical cadaveric study.

Does Proximal Placement of the Syndesmotic Reduction Clamp Affect the Optimal Position for the Medial Tine? A Cadaveric Pilot Study

Sagittal plane syndesmotic malreduction is associated with off-axis, eccentric reduction clamping and preferential placement of the medial tine anteriorly has been proposed to minimize the malreduction risk. Although clamp placement 1cm proximal to the plafond is recommend, no previous study has assessed whether differences in the anatomic position of the fibula within the incisura (eccentric 1cm superior and concentric 2 cm superior to the tibial plafond) affect the optimal position for the clamps medial tine during reduction of the syndesmosis. The purpose of the present cadaveric pilot study was to evaluate and compare the sagittal syndesmotic malreduction rate with various clamping vectors, 1cm and 2cm from the tibial plafond, respectively. Six through the knee cadaveric specimens were obtained. Kirschner wires and a surgical maker were used to denote placement of the reduction clamp laterally on the peroneal ridge of the fibula, and medially within the anterior, middle, and posterior thirds (Zones A, B, C) of tibia's width; 1 cm and 2 cm from the plafond. CT scans were obtained as controls, followed by destabilization of the syndesmosis. Reductions were then performed sequentially at each level (1 cm, 2 cm) and zone (A, B, C); and CT scans repeated for assessment. In most specimens (n = 5), an eccentric (1 cm) to concentric (2 cm) positional transition was observed within incisura fibularis. The transition altered the resulting fibular displacements in some specimens (2A anterior, vs 2B posterior), resulting in a higher malreduction rate with anterior (zone 2A, 33%) vs central (Zone 2B, 17%) positioning of medial tine. Although no definitive conclusions can be reached from the present pilot study, future studies with a greater number of specimens and clamping vectors are warranted to determine whether positional transitions of the fibula within the incisura fibularis affect the optimal position for the clamps medial tine.

Arthroscopic characterization of syndesmotic instability in the coronal plane: Exactly what measurement matters?

BackgroundAlthough ankle arthroscopy is increasingly used to diagnose syndesmotic instability, precisely where in the incisura one should measure potential changes in tibiofibular space or how much tibiofibular space is indicative of instability, however, remains unclear. The purpose of this study was to determine where within the incisura one should assess coronal plane syndesmotic instability and what degree of tibiofibular space correlates with instability in purely ligamentous syndesmotic injuries under condition of lateral hook stress test (LHT) assessment. MethodsAnkle arthroscopy was performed on 22 cadaveric specimens, first with intact ankle ligaments and then after sequential sectioning of the syndesmotic and deltoid ligaments. At each step, a 100N lateral hook test was applied through a lateral incision 5 cm proximal to the ankle joint and the coronal plane tibiofibular space in the stressed and unstressed states were measured at both anterior and posterior third of the distal tibiofibular joint, using calibrated probes ranging from 0.1 to 6.0 mm, in 0.1 mm of increments. The anterior and posterior points of measurements were defined as the junction between the anterior and middle third, and junction between posterior and middle third of the incisura, respectively. ResultsAnterior third tibiofibular space measurements did not correlate significantly with the degree of syndesmotic instability after transection of the ligaments, neither before nor after applying LHT at all the three groups of different sequences of ligament transection (P range 0.085-0.237). In contrast, posterior third tibiofibular space measurements correlated significantly with the degree of syndesmotic instability after transection of the ligaments, both with and without applying stress in all the groups of different ligament transection (P range <0.001-0.015). Stressed tibiofibular space measurements of the posterior third showed higher sensitivity and specificity when compared to the stressed anterior third measurements. Using 2.7 mm as a cut off for posterior third stressed measurements has both sensitivity and specificity about 70 %. ConclusionSyndesmotic ligament injury results in coronal plane instability of the distal tibiofibular articulation that is readily identified arthroscopically with LHT when measured in the posterior third of the incisura. Clinical relevanceWhen applying LHT, tibiofibular space measurement for coronal plane instability along the anterior third of the incisura is less sensitive for identifying syndesmotic instability and may miss this diagnosis especially when subtle.

Nutcracker Esophagus: Investigation In A Female Patient With Dysphagia And Odinophagy

Introduction: Odinophagia and dysphagia are important symptoms related to the upper gastrointestinal tract, specifically at the level of the oropharynx and esophagus. Objective: to investigate the possible cause of these symptoms through clinical history and complementary exams, thus outlining a more specific approach. Methodology: anamnesis was performed followed by neck ultrasound, fine needle aspiration (FNAP), videolaryngoscopy, computed tomography of the neck, ultrasound with thyroid dopller, esophagogastroduodenal seriography, esophageal manometry, hormone and thyroid antibodies dosage, and evaluation of thyroid antibodies. speech therapy. Results: neck ultrasound with topical thyroid gland, diffusible to swallow, diffusely heterogeneous, mixed nodule in upper / middle and anterior third of the left lobe measuring about 2.2cm x 1.6cm x 1.0 cm, in addition to sparse colloidal cysts by the glandular parenchyma, no larger than 0.6 cm, cervical lymph nodes increased in number and dimensions, some coalescent, the largest being located in the left submandibular region, measuring 1.8 cm in its longest axis. US-guided FNAB: Oncotic Cytology- Benign nodule (Category II of the Bethesda system) consistent with benign follicular nodule (Colloid goiter). Paraffin inclusion- Some follicular epithelial ceslls, in addition to leukocytes, amidst eosinophilic background (system I category) Bethesda). High digestive endoscopy without changes. Videolaryngoscopy without alterations. Computed tomography of the neck showing homogeneous prominent palatine tonsils. Heterogeneous thyroid lobes. Submandibular prominent lymph node on the right (IIA) measuring 1.1 cm. Ultrasonography with thyroid doppler confirms the p revious findings. Manometry showed hypertonia of the lower esophageal sphincter, compatible with nutcracker esophagus. Final Considerations: A patient admitted to investigate dysphagia with two months of evolution associated with odynophagia reaches a final diagnosis of nutcracker esophagus, in addition to a benign thyroid nodule. Thus, the investigation should be supplemented on an outpatient basis with high-resolution manometry. He is discharged with a medical prescription and guidance to start monitoring with a gastroenterologist.