Anterolateral Region Research Articles

Important role of longitudinal strain evaluated by speckle tracking echocardiography in Japanese Fabry disease patients

Abstract Introduction Fabry disease is an important infiltrative secondary cardiomyopathy caused by a decrease or deficiency in the lysosomal enzyme alpha-galactosidase A activity. The resultant accumulation of glycosphingolipids causes left ventricular hypertrophy (LVH), myocardial fibrosis, and arrhythmias. Recent advances in speckle tracking echocardiography have enabled the detection of early contractile dysfunction in various heart diseases. Purpose We examined whether or not longitudinal strain (LS) evaluated using speckle tracking echocardiography could detect early contractile dysfunction in Japanese patients with Fabry disease. Methods We recruited 56 patients with Fabry disease (22 men and 34 women) who were followed up at our University Hospital and 28 control subjects who showed normal standard echocardiographic findings in the present study. The diagnosis of Fabry disease was based on a mutation analysis of the GLA gene. Comprehensive echocardiography was performed using an ultrasound scanner. Cardiac mechanics were analyzed using the two-dimensional speckle tracking technique via automated function imaging and a Q-analysis software program according to consensus statements on cardiac mechanics quantitation. Using 3 apical views, the LS values of the 17 segments of the left ventricle were calculated for each patient. The global longitudinal strain (GLS) of each patient was also calculated. Results We divided the Fabry disease patients into two groups: patients without LVH (Fabry LVH [-]) and patients with LVH (Fabry LVH [+]). Figure 1 shows the results of the averaged LS values among the control, Fabry LVH (-), and Fabry LVH (+) groups. An analysis of variance detected significant differences in GLS and LS in the anterolateral region of the left ventricle (anterolateral LS) among the 3 groups. A post-hoc analysis revealed a significant decrease in GLS and anterolateral LS in Fabry LVH (-) compared to the control (Figure 2A-B). A receiver operating characteristic (ROC) analysis revealed that both GLS and anterolateral LS could discriminate Fabry LVH (-) from controls (Figure 2C). Using GLS, a cutoff value of -20.0 discriminated Fabry LVH (-) from controls with a sensitivity of 66.7% and specificity of 67.9%. Using anterolateral LS, a cutoff value of -18.8 discriminated Fabry LVH (-) from controls with a sensitivity of 69.7% and specificity of 60.7%. Conclusions These results suggest that early contractile dysfunction can be detected using GLS and anterolateral LS in Japanese patients with Fabry disease, even without LVH. The early detection of contractile dysfunction may be used to identify candidate patients for enzyme replacement therapy or pharmacological chaperone therapy.

Calcific Enthesitis of Lateral Patellofemoral Ligament: A Rare Cause of Anterolateral Knee Pain

AbstractHydroxyapatite deposition disease is a common musculoskeletal pathology that often affects rotator cuff tendons in the shoulder joint. Here, we present the first documented case of acute calcific enthesitis involving the lateral patellar retinaculum, specifically the lateral patellofemoral ligament (LPFL). A 35-year-old male presented with insidious onset atraumatic pain persisting for 3 months on the lateral aspect of the knee, intensifying over the past week. Clinical examination revealed focal tenderness in the anterolateral region of the knee, with no signs of patellar instability. Magnetic resonance imaging was performed, which revealed thickening and calcification within the LPFL and perilesional edema, further confirmed on computed tomography and ultrasonography. Patient was managed successfully with barbotage with complete resolution of symptoms. This case highlights the importance of considering calcification of LPFL in the differential diagnosis of anterolateral knee pain and underscores the importance of different imaging modalities for prompt diagnosis.

Giant cellulitis-like Sweet syndrome mimicking cellulitis: a case report

BackgroundSweet syndrome (acute febrile neutrophilic dermatosis) is an uncommon inflammatory disorder characterized by the abrupt appearance of painful, edematous, and erythematous papules, plaques, or nodules on the skin. There are various subtypes, such as classical, drug-induced, malignancy-associated, and the less common variant giant cellulitis-like Sweet syndrome. This case is unique due to its presentation of the giant cellulitis-like variant of Sweet syndrome in a patient from Ethiopia. The unusual distribution of the skin lesions and the initial lack of response to antibiotics make this case particularly noteworthy. It underscores the importance of considering Sweet syndrome in differential diagnoses when faced with atypical skin manifestations and ineffective antibiotic treatment. This contribution adds valuable insights to the scientific literature by highlighting the need for heightened awareness of this rare variant and improving diagnostic accuracy in similar clinical scenarios.Case presentationA 60-year-old Ethiopian male patient who presented to the accident and emergency department with a 5-day history of fever, chills, sweating, and rigor accompanied by a reddish skin color change around the anterolateral region of the right chest wall. On physical examination, there were erythematous, indurated tender plaques with ill-defined borders over the right antero- and posterolateral chest wall with extension to the lateral part of the right neck and medial aspect of the right arm. Subsequently, the patient was started on antibiotics, but there was a suboptimal response. Skin biopsy revealed features suggestive of giant cellulitis-like Sweet syndrome. He was then started on steroids, which significantly improved his symptoms.ConclusionA cautious stance is essential when identifying Sweet syndrome in individuals displaying erythematous plaque-like skin lesions in atypical areas of the body with uneven distribution. Such presentation may signal Sweet syndrome rather than a common infection. If conventional treatments, such as antibiotics, fail to resolve symptoms, consider Sweet syndrome as a potential diagnosis. This approach ensures timely and appropriate treatment, preventing treatment delay and misdiagnosis.

Construction and validation of a nomogram model for predicting different sites of ankle pain in runners with chronic ankle instability

This study aimed to establish a risk prediction nomogram model for anterolateral, mediolateral, and posterolateral ankle pain in runners with chronic ankle instability (CAI) and analyse the potential risk factors for pain at different ankle sites. Thirty recreational runners with CAI who reported ankle pain in the anterolateral, mediolateral, or posterolateral regions were recruited for this study. Kinematic, kinetic, and electromyographic data during running were collected using motion capture system, 3-D force platform, and surface electromyography system. These data were used to generate a dynamic nomogram. The results showed that anterolateral ankle pain in runners with CAI may be caused by insufficient gastrocnemius muscle strength (OR 0.85, 95% CI 0.73–0.97), excessive ground reaction force (GRF, OR 2.64, 95% CI 1.25–6.22), and an increased percentage of ankle energy absorption (OR 9.11, 95% CI 1.50–77.79). Mediolateral ankle pain might be contributed by greater ankle inversion angle (OR 1.08, 95% CI 1.01–1.00) and GRF (OR 2.13, 95% CI 1.17–4.31). Moreover, posterolateral ankle pain was predicted by increased ankle adduction angle (OR 1.06, 95% CI 1.00–1.12), increased GRF (OR 2.16, 95% CI 1.07–4.80), and decreased dynamic stability (OR 0.20, 95% CI 0.05–0.68). To prevent ankle pain, runners with CAI should be encouraged to focus on improving the neuroreceptor sensitivity of the gastrocnemius muscles, and retraining their energy absorption patterns.

Convergence of the right and left external jugular veins to the midline: a rare finding of anatomical variation

Venous blood from the head and neck are drained mainly by the internal and external jugular veins. The external jugular vein is located in the anterolateral region of the neck taking a complex pathway perpendicularly down the neck to join the subclavian vein, however, there can be anatomical variations that affect its course. To describe an anatomical variation in the left and right external jugular veins discovered during the dissection of a cadaver in Human Anatomy class. The present study is a case report describing an anatomical variation in the external jugular veins observed during a routine dissection for Human Anatomy class at the Faculty of Medical Sciences of Minas Gerais on an adult male cadaver of unknown age, preserved in formaldehyde solution. the dissection showed that the right and left external jugular veins converged toward the midline, joining just above the level of the jugular notch. Knowledge of variations in the neck superficial venous system is crucial to avoid complications from medical procedures. The present variation was not found described in the literature.

Imaging of the anterior cruciate ligament and anterolateral rotational instability of the knee joint

The anterior cruciate ligament (ACL) is essential for the stability of the knee joint and ACL tears are one of the most common sports injuries with ahigh incidence, especially in sports that require rotational movements and abrupt changes in direction. Injuries of the ACL are rarely isolated and are often accompanied by meniscal and other internal knee injuries, which increase the risk of osteoarthritis. The spectrum of ACL injuries includes strains, partial tears and complete tears. Magnetic resonance imaging (MRI) plays apivotal role in the diagnostics as it can accurately depict not only the ACL but also accompanying injuries. Proton density and T2-weighted sequences are particularly suitable for evaluating the ACL, which is usually well visible and assessable in all planes. In addition to depicting fiber disruption as adirect sign and central diagnostic indicator of an ACL tear, there are numerous other direct and indirect signs of an ACL injury in MRI. These include abnormal fiber orientations, signal increases and an anterior subluxation of the tibia relative to the femur. The bone marrow edema patterns often associated with ACL tears are indicative of the underlying injury mechanism. The treatment of ACL tears can be conservative or surgical depending on various factors, such as the patient's activity level and the presence of accompanying injuries. The precise and comprehensive description of ACL injuries by radiology is crucial for optimal treatment planning. Anterolateral rotational instability (ALRI) of the knee joint characterizes acondition of excessive lateral and rotational mobility of the tibia in relation to the femur in the anterolateral knee region. This instability is primarily caused by arupture of the ACL, with the anterolateral ligament (ALL) that was rediscovered about 10 years ago, also being attributed arole in stabilizing the knee. Although ALRI is primarily diagnosed through clinical examinations, MRI is indispensable for detecting injuries to the ACL, ALL, and other internal knee structures, which is essential for developing an optimal treatment strategy.

Morphometric Analysis of the Tibial Attachment Shape of the Anterior Cruciate Ligament and Its Relationship With the Location of the Anterior Horn of the Lateral Meniscus

Background: The success of anterior cruciate ligament (ACL) reconstruction relies on the accurate replication of the native ACL anatomy, including attachment shapes. The tibial attachment of the ACL exhibits significant shape variations with elliptical, C, and triangular shapes, highlighting the need for objective classification methods and additional information to identify individual anatomic variations. Hypothesis: The location of the attachment of the anterior horn of the lateral meniscus (AHLM) may determine the shape of the ACL attachment. Study Design: Cross-sectional study; Level of evidence, 3. Methods: The study used 25 knees from 17 Japanese cadavers for macroscopic anatomic examination and quantitative analysis. The shape of the ACL attachment was quantified using principal component analysis with elliptical Fourier descriptors, whereas the AHLM location was quantified by measuring its mediolateral and anteroposterior positions on the superior surface of the tibia. Reliability was assessed statistically. Results: The shape of the tibial attachment of the ACL varied among individuals and was classified as elliptical, C-shaped, or triangular. Scatterplots of the principal components of the ACL attachment shape showed overlapping regions of elliptical, C-shaped, and triangular ACL attachments, indicating that a C-shaped attachment is intermediate between elliptical and triangular attachments. The location of the AHLM attachment also varied, with areas in the anterolateral, anteromedial, or posteromedial region. The ACL shape and AHLM location were related, with elliptical, C-shaped, and triangular ACL attachments corresponding to anterolateral, anteromedial, and posteromedial AHLM attachments, respectively. Conclusion: The AHLM attachment location influences the shape of the ACL attachment. Information on the location of the AHLM attachment can aid in predicting the shape of the ACL attachment during ACL reconstruction, potentially improving footprint coverage.

High-throughput micro-CT analysis identifies sex-dependent biomarkers of erosive arthritis in TNF-Tg mice and differential response to anti-TNF therapy.

Development of reliable disease activity biomarkers is critical for diagnostics, prognostics, and novel drug development. Although computed tomography (CT) is the gold-standard for quantification of bone erosions, there are no consensus approaches or rationales for utilization of specific outcome measures of erosive arthritis in complex joints. In the case of preclinical models, such as sexually dimorphic tumor necrosis factor transgenic (TNF-Tg) mice, disease severity is routinely quantified in the ankle through manual segmentation of the talus or small regions of adjacent bones primarily due to the ease in measurement. Herein, we sought to determine the particular hindpaw bones that represent reliable biomarkers of sex-dependent disease progression to guide future investigation and analysis. Hindpaw micro-CT was performed on wild-type (n = 4 male, n = 4 female) and TNF-Tg (n = 4 male, n = 7 female) mice at monthly intervals from 2-5 (females) and 2-8-months (males) of age, since female TNF-Tg mice exhibit early mortality from cardiopulmonary disease at approximately 5-6-months. Further, 8-month-old WT (n = 4) and TNF-Tg males treated with anti-TNF monoclonal antibodies (n = 5) or IgG placebo isotype controls (n = 6) for 6-weeks were imaged with micro-CT every 3-weeks. For image analysis, we utilized our recently developed high-throughput and semi-automated segmentation strategy in Amira software. Synovial and osteoclast histology of ankle joints was quantified using Visiopharm. First, we demonstrated that the accuracy of automated segmentation, determined through analysis of ~9000 individual bones by a single user, was comparable in wild-type and TNF-Tg hindpaws before correction (79.2±8.9% vs 80.1±5.1%, p = 0.52). Compared to other bone compartments, the tarsal region demonstrated a sudden, specific, and significant bone volume reduction in female TNF-Tg mice, but not in males, by 5-months (4-months 4.3± 0.22 vs 5-months 3.4± 0.62 mm3, p<0.05). Specifically, the cuboid showed significantly reduced bone volumes at early timepoints compared to other tarsals (i.e., 4-months: Cuboid -24.1±7.2% vs Talus -9.0±5.9% of 2-month baseline). Additional bones localized to the anterolateral region of the ankle also exhibited dramatic erosions in the tarsal region of females, coinciding with increased synovitis and osteoclasts. In TNF-Tg male mice with severe arthritis, the talus and calcaneus exhibited the most sensitive response to anti-TNF therapy measured by effect size of bone volume change over treatment period. We demonstrated that sexually dimorphic changes in arthritic hindpaws of TNF-Tg mice are bone-specific, where the cuboid serves as a reliable early biomarker of erosive arthritis in female mice. Adoption of automated segmentation approaches in pre-clinical or clinical models has potential to translate quantitative biomarkers to monitor bone erosions in disease and evaluate therapeutic efficacy.

Variability in tibia-fibular geometry is associated with increased tibial strain from running loads.

Variation in tibial geometry may alter strain magnitude and distribution during locomotion. We investigated the effect of tibia-fibula geometric variations on tibial strain with running loads applied at various speeds. Participant-specific three-dimensional models of the tibia-fibula were created using lower limb computed tomography scans from 30 cadavers. Finite-element models were developed in FEBio, and running loads from 3, 4 and 5 m s-1 were applied to extract effective strain from the tibial shaft. Linear regression models evaluated the relationship between geometric characteristics and effective strain along the tibial shaft. We found a statistically significant positive relationship between: (i) increased thickness of the midshaft to upper tibia with increased condyle prominence and effective strain at points along the distal anterolateral and proximal posterior regions of the tibial shaft; and (ii) increased midshaft cortical thickness and effective strain at points along the medial aspect of the distal tibial shaft. It is possible that increased thickness in the more proximal region of the tibia causes strain to redistribute to areas that are more susceptible to the applied loads. A thickness imbalance between the upper and distal portions of the tibial shaft could have a negative impact on tibial stress injury risk.

Microsurgical thinned anterolateral thigh perforator flap to repair soft tissue defects of foot and ankle

To explore method and clinical effect of microsurgical thinned anterolateral thigh perforator flap to repair soft tissue defects of foot and ankle. From March 2017 to January 2022, totally 20 patients with soft tissue defects of ankle joint were treated with micro-thinning anterolateral perforator flap for free transplantation, included 13 males and 7 females, aged from 22 to 58 years old with an average of (36.45±12.36) years old. The size of flap ranged from 8.0 cm×5.0 cm to 20.0 cm×12.0 cm. Before operation, perforating vessels on the anterolateral thigh region were detected and marked with a portable Doppler detector. For the defect width less than 8 cm, 11 patients were repaired with a single flap. For the defect width more than 8 cm, the wound could not be sutured directly, and the lobulated flap technique was used in 9 patients, the width was converted to length, and the donor site was closed directly. Under the microscope, all flaps were thinened in a stepwise manner from the center of the pedicle to the periphery. After operation, survival of the flap, the shape, texture, sensory function recovery were observes, and recovery of foot function was evaluated by Maryland foot function evaluation standard. All 20 patients with microsurgical thinned anterolateral thigh perforator flaps were survived. Venous crisis occurred in 1 patient due to subcutaneous hematoma, after removal of the hematoma, the crisis was relieved and the flap survived successfully. The wounds in the donor and recipient sites healed well, and only linear scars left in the donor sites. Twenty patients were followed up for 3 to 26 months after operation, good shape of flaps without bloated, and good texture. The two-point discrimination of free flaps ranged from 9.0 to 16.0 mm, and the protective sensation was restored. The ankle flexion and extension function recovered well and patients could walk normally. According to Maryland foot function evaluation standard, 8 patients got excellent result, 10 patients good and 2 middle. Microsurgical thinned anterolateral thigh perforator flap is an ideal method to repair soft tissue defects in functional area of foot and ankle, with good appearance and texture of the flap, no need for re-plastic surgery, reduced hospitalization costs, and less donor site damage.

AYURVEDOKTA AUSHADHI CHIKITSA OF NAADIVRANA – A CASE REPORT

Here we are presenting a case of 35-year-old female patient, diagnosed with sinus tract in left anterior perianal and posterior vulval region along with collection in anterolateral vulval region and was suggested to undergo operative for the same. We corelated the symptoms with Naadivrana and designed our treatment protocol. The main aim of treatment was to heal the tract formed and to avoid abnormal granulations. Our treatment included administration of Ayurvedic oral medications viz. Somtajvir, Sukshma Triphala and Triphala Guggulu which helped the patient to be symptom-free within a duration of 4 months. Significant positive changes were observed on MR Fistulogram also.

Effects of carotenoid supplementation on colour, growth and physiological function of the endemic dwarf chameleon fish (Badis badis).

The global ornamental fish trade is expanding in response to increased demand for indigenous fish on the global market, while exogenous carotenoids can improve colouration. The 60-day trial investigated the effect of carotenoid supplementation, via Artemia, on colouration, growth and immunophysiology of Badis badis (dwarf chameleon fish). Carotenoid was enriched at 40 ppm (T1), 80 ppm (T2) and 120 ppm (T3) and compared with controls, C1 (unenriched) and C2 (oil-enriched). Fish larvae (average weight 0.12 g) were fed enriched-unenriched Artemia in triplicates (5 × 3) in aquarium tanks (15 L). C1 and T2 had better skin colour (lightness and whiteness) in the posterolateral and caudal fins respectively. The value of redness (a*) in the anterolateral region was higher in T2 and T3 (p < 0.05). The anterolateral red index was higher (p < 0.05) in T2 and T3, whereas in the posterolateral and caudal fins, T1 and T2 were higher (p < 0.05). Compared to C1 and C2, the hue angle in carotenoid groups was found to be low (p < 0.05). No significant change in the growth performance was noticed (p > 0.05). Immune scores such as lysozyme and alkaline protease were highest in T3 (p < 0.05), whereas protease activity was highest in T2 (80 ppm). Stress biomarkers, viz., superoxide dismutase, catalase and malondialdehyde were low in groups fed enriched Artemia (p < 0.05). The integrated biomarker response means and star plot area were lower in the enriched groups (T1-T3), while T2 was the lowest. Overall findings reveal that dietary carotenoid improves the colouration and immune status, but fail to promote growth. Furthermore, 80 ppm enrichment dose improves the overall performance. The findings can help fish keepers improve fish colour and health status through carotenoid supplementation.

Localizing the position of the Segond fracture bed under CT measurements to determine the functional tibial insertion of an anterolateral ligament.

Many studies have confirmed the existence of ligament structures in the anterolateral region of the knee that maintain rotational stability of the knee joint, namely, the anterolateral ligament (ALL). Most scholars believe that knee joint reconstruction should be considered during revision surgery and a high level of pivot displacement test (stage 2 or 3). During ALL reconstruction, the choice of ligament reconstruction sites affects the success rate and prognosis of the operation. Therefore, the choice of ligament reconstruction sites is particularly important. There is little research on the lateral ALL tibia insertion point, and most clinicians use the midpoint Gerdy's tubercle and fibular head as insertion points. However, the reconstruction effect is not ideal. This study aims to measure the position of the Segond fracture bed on CT images to determine the ALL position of the tibia. To determine the position of the Segond fracture bone bed, the CT AM Volume Share 2 system was used to manually measure the position of bone fragments in 23 Segond fracture patients. Using the highest point of Gerdy's tubercle in the CT axial slices and the outermost point of the fibular head in the CT axial slices as reference points, the direction and angle of the CT slices were adjusted to ensure that the highest point of the Gerdy tubercle, the outermost point of the fibular head, and the center of Segond fracture bed were in the same sagittal slice. A CT sagittal slice measures the vertical distance from the center of the Segond fracture bed to the Gerdy-fibular line segment (G-F line segment), which is the line connecting the highest point of the segment to the outermost point of the fibula. The distance from the vertical point at the center of the Segond fracture bed of the G-F line to the highest point of the Gerdy tubercle was measured. All measurements were performed using the same measurement standard and were expressed as a percentage of the length of the G-F line. The measured results were statistically analyzed using SPSS 25.0 descriptive statistical research methods. The average length of the G-F segment measured on CT images was 39.6 ± 2.0 mm, and the average vertical length from the center of the Segond fracture bed to the G-F segment was 13.1 ± 1.1 mm, accounting for 33.2% ± 2.1% of the length of the G-F segment. The length from the vertical point of the fracture bed on the G-F line segment to the highest point of the Gerdy tubercle was 14.7 ± 1.3 mm, accounting for 37.1% ± 2.9% of the length of the G-F segment. Through the study of the CT measurement of the Segond fracture location, we obtained the location of the functional tibial insertion of ALL, which is different from the anatomical insertion of ALL and is more inclined to the Gerdy tubercle and above, which has reference value for the treatment of recovering the function of anterolateral ligament after reconstruction.

The harvestion and application experience of free multi-lobed anterior thigh flap

Objective: To introduce the technique and clinical application of free lobed anteromedial thigh perforator pedicle flap. Methods: From September 2015 to September 2021, 72 patients with perforating buccal and oral cancer defects were treated at the Oncology Plastic Surgery Department of Hunan Cancer Hospital. There were 61 males and 11 females, with an average age of 36.7 years (31-56 years). According to Union for International Cancer Control (UICC) TNM staging, there were 20 cases of T3N1M0, 13 cases of T3N2M0, 24 cases of T4N0M0, and 15 cases of T4N1M0. All defects were planned to be repaired with free lobed anteromedial perforator flaps. When there was only one set of vascular pedicle, the perforating vascular pedicle artery was anastomosed with the superior thyroid artery, and the accompanying vein was anastomosed with the superior thyroid vein by end-to-end. Results: The areas of soft tissue defects after radical resection of oral and buccal cancers in 72 patients were between 5.0 cm × 4.0 cm and 11.0 cm×7.0 cm; the areas of the first anterior femoral skin islands were between 5.0 cm × 4.0 cm and 13.0 cm×7.0 cm; the areas of the second anterior femoral skin islands were between 5.0 cm × 3.0 cm and 10.0 cm × 7.0 cm; and all flap donor sites were directly closed. In 35 cases, the vascular pedicle was accompanied by a lateral femoral muscle flap for filling the gap defect at the base of the mouth. The average length of the vascular pedicles of the flaps was 7.2 cm (range: 6.8-8.2 cm). The average diameter of the vascular pedicle arteries was 1.6 mm (range: 1.4-2.2 mm). The blood flow reconstruction of flap was completed by anastomosing one accompanying vein. The average diameter of the accompanying veins was 2.1 mm (range: 1.6-2.8 mm). Postoperative hematoma occurred in 3 patients, with one having vascular crisis. After emergency exploration, 2 of them were successfully saved, and the other one had complete necrosis of skin flap, which was repaired by pedicled pectoralis major skin flap transplantation. With following up of 12-38 months, the appearances of the flaps were satisfactory without significant swelling. The mouth opening and language function were satisfactory in all cases, and only linear scars were left in the donor sites, with no significant impact on thigh functions. Five patients with local recurrence of tumor were treated with second radical resection and repair with pedicled pectoralis major myocutaneous flap. Six patients developed cervical lymph node metastasis (4 on the same side and 2 on the opposite side) and underwent neck dissection again. Conclusion: The anatomical basis of the branches of the anteromedial femoral perforating branches in the anterolateral region of the thigh can be helpful to prepare the anterolateral femoral lobed flap, which is suitable for repairing the perforating defects after the radical operation of oral and buccal cancers.

A Procedure for Measuring Anterior Scalene Morphology and Quality with Ultrasound Imaging: An Intra- and Inter-rater Reliability Study.

Ultrasound (US) imaging is an essential tool for clinicians because of its cost-effectiveness and accessibility for assessing multiple muscle metrics including muscle quality, size and shape. Although previous studies highlighted the importance of the anterior scalene muscle (AS) in patients with neck pain, studies analyzing the reliability of US measurements for this muscle are lacking. This study aimed to develop a protocol for assessing AS muscle shape and quality measured with US and investigating its intra- and inter-examiner reliability. Through use of a linear transducer, B-mode images of the anterolateral neck region at the C7 level were acquired in 28 healthy volunteers by two examiners (one experienced and one novel). Cross-sectional area, perimeter, shape descriptors and mean echo-intensity were measured twice by each examiner in randomized order. Intra-class correlation coefficients (ICCs), standard errors of measurement and minimal detectable changes were calculated. Results indicated no muscle side-to-side asymmetries (p > 0.05). Gender differences were found for muscle size (p < 0.01), but muscle shape and brightness were comparable (p > 0.05). Intra-examiner reliability was good to excellent for all metrics for the experienced and (ICC >0.846) and novel (ICC >780) examiners. Although inter-examiner reliability was good for most of the metrics (ICC >0.709), the estimates for assessing solidity and circularity were unacceptable (ICC <0.70). This study found that the described ultrasound procedure for locating and measuring anterior scalene muscle morphology and quality is highly reliable in asymptomatic individuals.

Cortical and trabecular bone deficit in middle-aged men living with HIV.

A significant increase in risk of hip fracture was observed in middle-aged men living with human immunodeficiency virus (MLWH), almost a decade earlier than those without infection. Data regarding cortical and trabecular bone deficit of hip, an important determinant of bone strength, in MLWH are limited. Quantitative computed tomography was performed in consecutive MLWH aged ≥30 years between November 2017 and October 2018 at Severance Hospital, Seoul, Korea. Volumetric bone mineral density (vBMD) and cortical bone mapping parameters of hip (cortical thickness, CTh; cortical bone vBMD, CBMD; cortical mass surface density, CMSD; endocortical trabecular density, ECTD) were compared to age- and body mass index (BMI)-matched controls (1:2), using a community-based healthy adults' cohort. Among 83 MLWH and 166 controls (mean age: 47.2 years; BMI: 23.6 kg/m2 ), MLWH had lower total hip vBMD (280 ± 41 vs. 296 ± 41 mg/cm3 ), CMSD (155 vs. 160 mg/cm2 ), and ECTD (158 vs. 175 mg/cm3 ) than controls that remained robust after adjustment for covariates (adjusted β: total hip vBMD, -18.8; CMSD, -7.3; ECTD, -18.0; p < 0.05 for all). Cortical bone mapping revealed localized deficit of CTh, CBMD, and CMSD in anterolateral trochanteric region and femoral neck in MLWH compared to controls, with more extensive ECTD deficit. In MLWH, lower CD4 T cell count (/100 cells/mm3 decrement) and protease inhibitor (PI)-based regimen (versus non-PI regimen) at the time of antiretroviral treatment initiation were associated with lower total hip vBMD (adjusted β -7.5 for lower CD4 count; -28.3 for PI-based regimen) and CMSD (adjusted β -2.6 for lower CD4 count; -12.7 for PI-based regimen; p < 0.05 for all) after adjustment for covariates including age, BMI, smoking, alcohol use, HCV co-infection, tenofovir exposure, and CT scanners types. MLWH had lower hip bone density with cortical and trabecular bone deficit compared to community-dwelling controls. This article is protected by copyright. All rights reserved.

Medullary branches of the vertebral artery: microsurgical anatomy and clinical significance.

Since the medullary arteries are of a great neurologic and neurosurgical significance, the aim was to perform a detailed microanatomic study of these vessels, as well as of the medullary infarctions in a group of patients. The arteries of 26 halves of the brain stem were injected with India ink and gelatin, microdissected and measured with an ocular micrometer. Neurologic and magnetic resonance imaging (MRI) examinations were performed in 11 patients. The perforating medullary arteries, averaging 6.7 in number and 0.26mm in diameter, most often originated from the anterior spinal artery (ASA), and rarely from the vertebral (VA) (38.5%) and the basilar artery (BA) (11.6%). They supplied the medial medullary region. The anterolateral arteries, 4.8 in number and 0.2mm in size, most often arose from the ASA and PerfAs, and nourished the anterolateral region. The lateral arteries, 2.2 in number and 0.31mm in diameter, usually originated from the VA and the posterior inferior cerebellar artery (PICA). They supplied the lateral medullary region. The dorsal arteries, which mainly arose from the PICA and the posterior spinal artery (PSA), nourished the dorsal region, including the roof of the 4th ventricle. The anastomotic channels, averaging 0.3mm in size, were noted in 42.3%. Among the medullary infarctions, the lateral ones were most frequently present (72.8%). The obtained anatomic data, which can explain the medullary infarctions symptomatology, are also important in order to avoid damage to the medullary arteries during neurosurgical and neuroradiologic interventions.

PO-05-226 ORTHODROMIC RECIPROCATING TACHYCARDIA RELYING ON ABERRANT CONDUCTION: NEED FOR A LAGER CIRCUIT

Aberrant conduction during orthodromic reciprocating tachycardia (ORT) can prolong the ventriculo-atrial conduction time, which is found essential for the reentry in certain situations. To investigate the prevalence and different mechanism of aberrancy-dependent ORT. ORT cases relying on aberrancy from 220 cases in our center were searched using the following criteria: (1) Multiple episodes of ORT with aberrant conduction in ECG ; (2) No baseline BBB during sinus rhythm; (3) Absence of narrow QRS form during tachycardia unless isoproterenol used; (4) Restoration of bundle branch conduction giving rise to tachycardia termination or circuit alteration. ECGs and intracardiac tracings during study were carefully examined. 3 patients from 220 patients (1.4%) with ORT showed the phenomenon of dependence on aberrancy. Clinical tachycardia episodes of the patients were short in time. All accessory pathways (APs) were located at anterolateral regions of atrioventricular annulus. None of them had baseline bundle branch block. Creating functional bundle branch block was necessary to induce the tachycardias. In the first patient with ORT and left bundle branch block (LBBB), a late-delivered premature ventricular contraction (PVC) was able to advance the next A and reset the tachycardia, which was diagnostic for ORT with aberrancy. Meanwhile, left bundle branch conduction was restored which narrowed the next QRS complex. Tachycardia was then terminated by the advanced wavefront reaching the ventricular insertion site of AP which was refractory. In the second case, termination of the tachycardia was always preceded by a spontaneous LBBB restoration, with the V and subsequent A at MA advanced, suggesting anterograde block in the AV node. In the other case was, induction required both right BBB and slow pathway conduction. When isoproterenol was given, fast pathway recovered followed by BBB restoration, which made anterograde limb again switched to slow pathway. All pathways were successfully ablated during the procedure. All patients have been free of arrhythmias for at least 6 months. Extra transseptal time caused by aberrancy can be an integral part of ORT, which can explain the infrequent or late onset and unsustainable episodes of ORT in certain patients and is useful in understanding the circuit and localizing the pathway.

Technique and clinical application of free lobed anteromedial thigh perforator flap

To introduce the technique and clinical application of free lobed anteromedial thigh perforator flap. Between October 2017 and December 2021, 65 patients with buccal and oral cancer penetrating defects were planned to treat with free lobed anterolateral thigh flap transplantation, of which 15 cases were found that the sole anterolateral thigh perforator was actually a branch of the anteromedial thigh perforator, and then the free lobed anteromedial thigh perforator flap was harvested for repair. There were 12 males and 3 females with an average age of 34.6 years (range, 29-55 years). According to Union for International Cancer Control (UICC) TNM staging, there were 7 cases of T 4N 0M 0, 4 cases of T 4N 1M 0, 2 cases of T 3N 1M 0, and 2 cases of T 3N 2M 0. The disease duration was 1-10 months (mean, 6.3 months), and the area of secondary soft tissue defect left after radical resection of buccal and oral cancer was from 5 cm×4 cm to 10 cm×6 cm. The anterolateral thigh skin flap ranged from 5 cm×4 cm to 13 cm×6 cm, and the anteromedial thigh skin flap ranged from 5 cm×3 cm to 10 cm×6 cm. The free trilobed anteromedial thigh flap was prepared according to the actual branches of the main trunk of the anteromedial thigh perforator in 4 cases, and the vastus medialis muscle flap was used to fill the cavity defect of the floor of mouth in 7 cases. Among the 15 patients, the vessel pedicles of the anteromedial thigh perforators were derived from the main femoral artery and vein in 8 cases, from the main descending branch of the lateral femoral circumflex artery in 4 cases, and from the main lateral femoral circumflex artery in 3 cases. Hematoma occurred in 2 cases after operation, which was successfully saved after emergency exploration. No vascular crisis occurred, and partial necrosis of anterolateral femoral skin island occurred in 1 case, which was healed with debridement. The remaining flaps survived successfully, and the wounds and donor site incisions healed by first intention. All the patients were followed up 12-36 months (mean, 14.6 months). The appearance of the flap was satisfactory, and no obvious swelling was found; the mouth opening and language function were satisfactory; only linear scar was left in the donor area, and the thigh function was not significantly affected. Local recurrence occurred in 3 cases, and the defect after tumor resection was repaired with pedicled pectoralis major myocutaneous flap. Four patients with neck lymph node metastasis, including ipsilateral side in 3 patients and contralateral side in the other 1 patient, all underwent neck lymph node dissection again. The 3-year survival rate was 86.7% (13/15). The anteromedial thigh perforator vessels distributed in the anterolateral region of the thigh can be used to prepare the anterolateral thigh split lobed flap to repair the buccal and oral cancer penetrating defects.

Recurrent Spigelian Hernia: case report

The protrusion of adipose tissue, peritoneal sac or abdominal viscera in the anterolateral region of the abdomen can configure the so-called Spigelian hernia. A 53-year-old patient with comorbidities is admitted for reoperation of Spiegel's hernia. Aging and the presence of obesity, multiparity and previous surgery may have predisposed the appearance of this type of hernia. For recurrence, obesity may have been a contributing factor, although factors related to the surgical procedure and the hernia itself should also be considered. Spiegel's hernia is a rare abdominal hernia whose treatment is surgery, bearing in mind the risks of recurrence and the possibilities of mitigating them.