Bone Removal Research Articles

Migration of a Fish Bone From the Esophagus to the Thyroid Gland.

Accidental swallowing of fish bone is one of the most common emergencies in the otolaryngology department. The impacted fish bones are usually found in the palatine tonsil, base of the tongue, valleculae, pyriform sinus, and esophagus, which can be successfully removed after a thorough examination. However, in some cases, the fish bone may penetrate into the neck soft tissue and migrate to extraluminal organs, causing infection, abscess formation, or rupture of vessels. In such cases, prompt recognition and immediate removal of the impacted fish bone are necessary. Herein, we report a rare case of a 60-year-old woman who had accidently swallowed a fish bone 10days prior to visiting the outpatient department. The fiberoptic scope and head and neck computed tomography scans were obtained from the outpatient department. The fish bone was found to migrate from the upper esophagus to the left thyroid gland. First, a rigid esophageal endoscopy was performed in the operating room, but no obvious fish bone was noted over the esophagus. Finally, the fish bone was removed via exploratory cervicotomy with left-sided total lobectomy of the thyroid. The patient recovered after the operation, and there were no further complications during the 3years of follow-up.

Periocover: The lesser known periodontal flaps

Surgical cleansing of the defect and the root surface can re-establish periodontal health when proper plaque control is established. However, different surgical techniques have been advocated to conservatively treat intrabony defects. Conservative surgery involves various surgical approaches whichaim at gaining access to the root surface and accomplish the removal of residual debris with no active removal of bone and most often no resection of soft tissues. The underlying objectives towards the procedures aim to facilitate visual access with minimal reduction in the shape and anatomy of the soft or bone tissues along with alteration in the shape and outline of the soft and, occasionally hard tissues, in order to achieve controlled pocket depth reduction. Minimally invasive periodontal surgical approaches and microsurgical techniques are currently being evaluated and may show advantages in wound-healing outcomes and less recession and patient morbidity. In this manuscript, we intend to discuss about certain flaps like saddle flap, laterally stretched flap, book flap and bridge flap along with incisions which are less discussed and have been recently incorporated in the practice with simple and better results.

Analysis of the therapeutic effect of artificial leather embedding combined with fascial sleeve flap transplantation on chronic wounds of lower limbs with bone and plate exposure

BackgroundAfter severe trauma of lower limbs, bone, tendon or plate graft exposure is common. The traditional repair method is to use a variety of skin flap transplantation to cover the exposed part, but the wound often can not heal after operation, or the wound is cracked, ulcer, sinus, bone and steel plate are exposed again after wound healing. The reason for this result is that when the flap is covered, the space around the bone plate is not well closed, forming a dead cavity, blood and exudate accumulation, hematoma formation or infection, and finally the wound ruptures again. In addition, due to the swelling and contracture of the flap after operation, the suture tension between the flap and the receiving area becomes larger, the skin becomes thinner and broken, and then the wound is formed. In order to solve the above problems, we carried out the study of artificial true skin embedding combined with fascial sleeve flap transplantation in the treatment of chronic bone plate exposed wounds of lower limbs.MethodsIn this paper, 11 cases of chronic wounds with bone exposure and skin necrosis after steel plate implantation were selected. First stage is the wound bed preparation including primary wound expansion, removal of necrotic tissue and incision of sinus wall, removal of deep necrotic bone and fibrotic scarred skin on the outer wall of steel plate to normal tissue on the outer edge of the wound, removal of precipitated peptone and purulent fur in the hole, periphery and bone space of the steel plate, and removal of tendon tissue with basal necrosis and disintegration of the wound. After vacuum sealing drainage (VSD) 1–2 weeks, the peritraumatic basal granulation tissue grew well and there was no necrotic tissue in the wound. In the second stage, the exposed bone was covered with artificial dermis, the steel plate hole or the periphery and the basal space were filled, and the exposed steel plate was completely embedded, and then the fascia sleeve flap was transplanted to cover the wound. The sural neurovascular flap was performed in nine cases and the lateral superior malleolar artery perforator flap in two case.ResultsThe flap survived well in all 11 cases. During the follow-up of 6 months to the removal of the plate, there was no case of rupture, exposure and sinus formation.ConclusionsArtificial dermal covering combined with fascial sleeve flap transplantation can effectively avoid wound dehiscence or sinus formation caused by foreign body retention, infection and flap contracture. It has good effect in repairing chronic wounds with bone plate exposure after severe trauma of lower limbs.

Treatment of Unicoronal Craniosynostosis by Rotational Flap Technique Preserves Blood Supply to the Frontal Bone Flap.

Surgical correction of unicoronal craniosynostosis (UCS) remains a challenging problem. Long-term results are often unsatisfactory secondary to recurrence of the original deformity, requiring secondary operations such as fat grafting or complete revision of the calvarial remodeling. Distraction osteogenesis (DO) has recently emerged as a new modality for treatment of UCS, with promising results and decreased rates of reoperation compared with open cranial vault remodeling. A theoretical benefit of DO is preservation of blood supply to the frontal bone following osteotomy, as the frontal bone can be retained in situ compared with the complete removal and reshaping of the frontal bone during traditional fronto-orbital advancement. Preservation of blood supply to the frontal bone may allow for more robust bony healing and preservation of long-term growth potential; however, the vascularity of the frontal bone flap in DO has not previously been demonstrated. Here, we demonstrate unequivocally that blood supply to the frontal bone is preserved after creation of a rotational bone flap in DO management of UCS. Frontal bone flap creation via osteotomy for DO treatment of UCS was performed via previously reported technique. Indocyanine green was injected intravenously, and bone perfusion was assessed with a fluorescence imaging system. Four patients underwent three cranial remodeling and three distractor removal procedures. After frontal bone flap creation via osteotomy for DO, perfusion to the osteotomized portion of the frontal bone flap is preserved. Blood flow is seen crossing the midline of the frontal bone. After removal of the distractor, perfusion in the osteoid consolidate is also observed. Preservation of blood supply has not been previously demonstrated empirically in the setting of DO treatment of UCS. We show for the first time that during frontal bone flap creation, blood flow to the osteotomized portion of the frontal bone flap is maintained. Robust blood flow to the osteoid consolidate is also demonstrated. These data support the use of DO in treatment of UCS, as preserved blood supply to the bone is more likely to support improved healing and long-term results.

Schistosoma mansoni infection induces plasmablast and plasma cell death in the bone marrow and accelerates the decline of host vaccine responses.

Schistosomiasis is a potentially lethal parasitic disease that profoundly impacts systemic immune function in chronically infected hosts through mechanisms that remain unknown. Given the immunoregulatory dysregulation experienced in infected individuals, this study examined the impact of chronic schistosomiasis on the sustainability of vaccine-induced immunity in both children living in endemic areas and experimental infections in mice. Data show that chronic Schistosoma mansoni infection impaired the persistence of vaccine specific antibody responses in poliovirus-vaccinated humans and mice. Mechanistically, schistosomiasis primarily fostered plasmablast and plasma cell death in the bone marrow and removal of parasites following praziquantel treatment reversed the observed cell death and partially restored vaccine-induced memory responses associated with increased serum anti-polio antibody responses. Our findings strongly suggest a previously unrecognized mechanism to explain how chronic schistosomiasis interferes with an otherwise effective vaccine regimen and further advocates for therapeutic intervention strategies that reduce schistosomiasis burden in endemic areas prior to vaccination.

A Simple Method to Retract the Descending Palatine Neurovascular Bundle During Osseous Removal of Posterior Interferences in Le Fort I Osteotomy.

For accurate repositioning of the maxilla in Le Fort I osteotomy, bone removal around the descending palatine neurovascular bundle and maxillary tuberosity is frequently required. Such task can be challenging due to the high vascularity of the region, which is the most common site of hemorrhage during removal of bony interferences. Although a rare occurrence, ligation of the descending palatine artery in cases of intraoperative vascular damage can be related to the development of aseptic necrosis. This article reports a simple technique for retraction and protection of the descending palatine neurovascular bundle during bony removal related to a posterior maxillary impaction, which can be easily reproduced in orthognathic selected cases.

How much acromial bone should be removed to decrease the critical shoulder angle? A 3D CT acromioplasty planning study.

A high critical shoulder angle (CSA) is associated with rotator cuff tear (RCT) and retear rate after repair. CSA reduced to less than 33° by acromioplasty is correlated with better clinical results and healing. But up to 24% of patients retain a CSA above 35° after acromioplasty. The objective of the study was to evaluate the use of 3D when planning acromioplasty and measure acromial bone removal volume dimensions. Computed tomography (CT) scans from 45 patients with RCT and CSA ≥ 38° were retrospectively included. A 33° CSA cutting plane was positioned. Acromion was divided into 5mm slices and acromial bone resection measured on each slice. Intra- and inter-observer reproducibility measurements were rated strong or very strong. Patients' mean preoperative CSA was 40° (38°, 49° ± 2.3°). Measurements of acromial resection were: anteroposterior length: 32.7mm (20, 50 ± 7.4); inferior width: 7.6mm (4.2, 19 ± 2.9); superior width: 4.1mm (0, 16 ± 3.0); height: 6.1mm (1.7, 6.7 ± 1.6); and cutting angle: 74° (46, 91 ± 8.0). Maximum width of acromial resection was located 10.6mm (5, 17.5 ± 0.6) from the acromion's anterior edge and decreased gradually moving posteriorly. Preoperative CSA was linearly correlated with width (P < 0.0001, R = 84%) and length (P = 0.0001, R = 28%) of acromioplasty; the higher the CSA, the greater the width and length. 3D CT reconstructions are valid for planning a CSA decreasing acromioplasty. To reduce CSA to 33°, acromioplasty must be performed anterolaterally and resection is at least 2cm long anteroposteriorly. For higher CSAs, acromioplasty may require lateral resection over 1cm in width and up to 5cm in length. To decrease the CSA efficiently, acromioplasty must be adapted to patient anatomy and 3D planning could be considered. IV.

Endoscopic Cholesteatoma Surgery.

Implementation of endoscopes in cholesteatoma surgery resulted in considerable changes in the management of cholesteatoma in the last two decades. Compared to the microscopic approach with an excellent but straight-line view and limited illumination, the introduction of endoscopes provides a wide-angled panoramic view. Moreover, angled lenses allow the surgeon to visualize the middle ear and its hidden recesses through a transcanal, minimally-invasive approach. The endoscope enables the surgeon to remove limited cholesteatoma of the middle ear and its recesses using an exclusive endoscopic technique by taking advantage of these benefits. This reduces the rate of residual disease and sparing external incisions and excessive temporal bone drilling as in a transmastoid approach. Since transcanal endoscopic access is mainly a one-handed technique, it implies the need for specific procedures and technical refinements. This article describes a step-by-step guide as a surgical manual for endoscopic removal of epitympanic cholesteatoma. Different techniques for cholesteatoma dissection and bone removal for epitympanectomy, including curettage and powered instruments such as drills and ultrasonic devices with their outcomes, are discussed. This may offer ear surgeons insight into technical refinements and the latest technological developments and open the horizon for different techniques.

Shortening dome osteotomy for correction of severe cubitus varus secondary to malunited supracondylar fractures in children.

We present retrospective review of prospectively collected data of 18 patients (11 boys and 7 girls) who underwent shortening dome osteotomy between January 2011 and December 2019 for severe cubitus varus deformities (> 30°) secondary to malunited supracondylar fracture. The procedure involved the removal of convexo-concave bone (5-8mm wide) between the two domes. Humero-ulnar angles, lateral condylar prominence index (LCPI), and elbow range of movements were recorded preoperatively and postoperatively. Mean age was 7.5years (range 5years-11years). Indication for surgery was poor cosmesis in all the patients and tardy ulnar nerve symptoms in three patients. Mean preoperative humero-ulnar angle was 26.1° varus (range 22°-34°), while it was 7.1° valgus (range 0°-12°) for contralateral normal elbow. They were followed for a mean duration of 2.2years (range 12months-5.8years). The mean postoperative valgus angle achieved was 7.3° (range 2°-12°) as total angular correction achieved was 34.4° (range 30°-44°) (p < 0.001). Radiological healing was observed in all the patients at mean duration of 7.1weeks (range 5weeks-9weeks). Mean preoperative and postoperative LCPI were - 2.4 (range +4.7 to - 10.5) and - 1.7 (range +4.5 to - 5.1), respectively (p = 0.595). Three patients had pin tract infections and two of them responded to aseptic dressings and oral antibiotics, while another required early pin removal and additional protection in splint. All patients regained preoperative arc of motion within 6months after the procedure. Shortening dome osteotomy is a safe and effective method for correcting severe cubitus varus deformities (> 30°) secondary to malunited supracondylar fracture in children.

Hyperostotic Invasive Meningioma of the Sphenoid Ridge Surgical Considerations: 2-Dimensional Operative Video.

Hyperostotic invasive sphenoid ridge meningiomas are a distinct and recognized entity.1-4 They are characterized by extensive bone involvement and expansive “en plaque” intradural extension.3,5 The goal of this surgery is improving and preserving the visual function and ocular motility while esthetically correcting and reconstructing the exophthalmos and temporal deformity.4,5 The surgery includes radical removal of the involved bone of the sphenoid ridge, orbital walls, and middle fossa floor, in addition to the “en plaque” dural and periorbital involvement and intradural extension.3,5,6 Early decompression of the optic nerve and orbital elements allows preventing visual function deterioration and yields frequent improvement. Thorough planned reconstruction can be achieved by molding a malleable mesh to the patient's skull before the extensive bone removal. Careful orbital wall reconstruction allows one to achieve a good postoperative cosmesis and prevent enophthalmos.4 We demonstrate the principles of this surgery through 2 cases of 46-year-old and 53-year-old women. The first case demonstrates the importance of middle fossa extensive drilling of involved bone and reconstruction while the second case demonstrates the visual decompression and postoperative improvement. The patients consented to the surgeries and publication of their images.

Proposal for a New Bioactive Kinetic Screw in an Implant, Using a Numerical Model

A new biomechanism, Bioactive Kinetic Screw (BKS) for screws and bone implants created by the first author, is presented using a bone dental implant screw, in which the bone particles, blood, cells, and protein molecules removed during bone drilling are used as a homogeneous autogenous transplant in the same implant site, aiming to obtain primary and secondary bone stability, simplifying the surgical procedure, and improving the healing process. The new BKS is based on complex geometry. In this work, we describe the growth factor (GF) delivery properties and the in situ optimization of the use of the GF in the fixation of bone screws through a dental implant. To describe the drilling process, an explicit dynamic numerical model was created, where the results show a significant impact of the drilling process on the bone material. The simulation demonstrates that the space occupied by the screw causes stress and deformation in the bone during the perforation and removal of the particulate bone, resulting in the accumulation of material removed within the implant screw, filling the limit hole of the drill grooves present on the new BKS.

Bone suppression on pediatric chest radiographs via a deep learning-based cascade model

Background and objectiveBone suppression images (BSIs) of chest radiographs (CXRs) have been proven to improve diagnosis of pulmonary diseases. To acquire BSIs, dual-energy subtraction (DES) or a deep-learning-based model trained with DES-based BSIs have been used. However, neither technique could be applied to pediatric patients owing to the harmful effects of DES. In this study, we developed a novel method for bone suppression in pediatric CXRs. MethodsFirst, a model using digitally reconstructed radiographs (DRRs) of adults, which were used to generate pseudo-CXRs from computed tomography images, was developed by training a 2-channel contrastive-unpaired-image-translation network. Second, this model was applied to 129 pediatric DRRs to generate the paired training data of pseudo-pediatric CXRs. Finally, by training a U-Net with these paired data, a bone suppression model for pediatric CXRs was developed. ResultsThe evaluation metrics were peak signal to noise ratio, root mean absolute error and structural similarity index measure at soft-tissue and bone region of the lung. In addition, an expert radiologist scored the effectiveness of BSIs on a scale of 1–5. The obtained result of 3.31 ± 0.48 indicates that the BSIs show homogeneous bone removal despite subtle residual bone shadow. ConclusionOur method shows that the pixel intensity at soft-tissue regions was preserved, and bones were well subtracted; this can be useful for detecting early pulmonary disease in pediatric CXRs.

Are Bone Metabolism and Bone Material Strength Evaluations Worthwhile?: Commentary on an article by Tamara D. Rozental, MD, et al.: "Longitudinal Changes in Serum Markers of Bone Metabolism and Bone Material Strength in Premenopausal Women with Distal Radial Fracture".

Commentary The article by Dr. Tamara D. Rozental and colleagues introduces us to 2 innovative methods to improve our understanding of bone strength and fracture-healing biochemistry that maybe relevant to clinical practice. Bone mineral density (BMD) is the standard for determining bone quality and fracture risk but does not define the structural and mechanical properties of bone1. Impact microindentation provides information on the material properties of cortical bone that we as orthopaedic surgeons need in order to improve our choice of fixation strategy2. Markers of bone metabolism (MBM) have been used to assess the results of osteoporotic treatment but have not been applied to the non-osteoporotic patient to assess fracture healing or to predict potential osteoporosis3,4. Impact microindentation is a minimally invasive technique that measures the ability of the tibial cortex to resist a standardized impact force. This measures the bone’s material quality, which is the interaction of the bone’s mineral and organic elements to resist failure. This technique might allow for a better determination of the ability of bone to hold implants that are used for fracture fixation (for example, the ability to achieve screw purchase). A greater understanding of such variables would facilitate fixation decisions, including the potential need to augment fixation with use of locking screws or bone substitutes. In this study, the microindentation technique did not prove valuable in assessing bone quality, but the investigators demonstrated that the test was possible to administer in a clinical setting. MBM have demonstrated promise as markers of the healing response following the treatment of a fracture5. Sclerostin (a glycoprotein produced by osteocytes) and Dickkopf 1 (DKK1) both decrease bone formation were initially increased but then both dropped to low levels allowing the healing response to occur. Tartrate-resistant acid phosphatase (TRAP) and C-terminal telopeptide (both of which are indicators of osteoclastic activity) peaked early, indicating the need for bone removal secondary to fracture site necrosis. Bone-formation markers such as N-terminal extension propeptide of type-I collagen (P1NP) and bone-specific alkaline phosphatase (BSAP) increased throughout the healing phase. These longitudinal results are evidence that, in premenopausal women, the biochemistry of fracture healing can be evaluated. This study provides the impetus to evaluate whether MBM can determine problems in fracture healing earlier than radiographic evidence and also whether MBM can serve as an indication of early osteopenia and osteoporosis in premenopausal women6. This article had a number of strengths. Patient selection was appropriate (although it was limited to a specific group of premenopausal women with a distal radial fracture). The fractures were classified with use of an acceptable system that can be used to determine severity on the basis of the mechanism of injury (i.e., high or low energy). Finally, the study included both operatively and nonoperatively managed patients, with the former demonstrating an elevated BSAP. This article also had also several areas of concern. MBM vary depending on patient activity and the time of day when the samples are taken. The authors acknowledge this limitation, but it is important for the reader to understand that the controls were only sampled once, so any assumption regarding longitudinal MBM levels may not hold. Another issue is that there is no consensus on what constitutes a meaningful clinical difference in these results. As this study is the first to measure MBM during fracture healing, one is unsure of what these results mean. It is obvious that the results appear to coincide with our understanding of fracture healing, but this relationship has not been proven. Although this study has limitations, including a small sample size in a very specific patient population, it opens the door to a better understanding of fracture healing. Orthopaedic surgeons, particularly those specializing in fracture care, should consider this study as an impetus to further investigate the physiology and biochemistry of fracture healing.

How Neanderthals gripped retouchers: experimental reconstruction of the manipulation of bone retouchers by Neanderthal stone knappers

When studying bone retouchers, researchers pay close attention to the morphological characteristics of the tool’s active zone, and the lithic raw material processed. In our research, we found that the orientation of the bone retoucher in the hand and the grip employed to retain and manipulate it are crucial factors that affect the morphological characteristics of the retoucher’s active zone. By examining two alternative grips for manipulating bone retouchers ((1) Using all the fingers of one hand in a power grip; (2) Using only the first three digits of one hand in a pinch grip), we found that when the retoucher is held in the first manner, the active area is larger, as is the amount of bone removed by the retoucher. When the retoucher was pinched with only three fingers in a precision grip, retouch damage was more densely concentrated and less bone was removed. The orientation of the retoucher in the hand and the grip employed have a greater influence on the active area than the extent of retoucher use, which we assessed by measuring the number of stone tool edges processed. By gripping the retoucher with all the fingers of one hand, the knapper automatically applies greater force, which results in the removal of more bone. Comparison of experimental bone retouchers with those recovered from Middle Paleolithic archaeological contexts in Chagyrskaya Cave (Altai, Russia) revealed that Altai Neanderthals practiced two methods of grasping bone retouchers, with a three-finger pinch grip being dominant.

FEMORAL HEAD DECOMPRESSION AND GRAFT: TECHNIQUE WITH NEW INSTRUMENTS.

ABSTRACTIntroduction: Osteonecrosis of the femoral head (ONFH) is a pathology that can be treated with many approaches by the hip surgeon. Advanced decompression is a technique that aims to prevent the collapse of the femoral head and the arthrosis process of the joint, a technique already widespread and used by hip surgeons. In this study, we performed the technique with a new retractable blade and a new bone substitute as graft for the femoral head.Objective: To evaluate the technique with new instruments (EasyCore Hip®) and a calcium phosphate bone substitute (Graftys® HBS).Methods: Patients with osteonecrosis of the femoral head without major degenerative changes, such as femoral head collapse, were selected. Femoral head decompression was performed using the EasyCore Hip® retractable blade along with the calcium phosphate bone substitute as graft (Graftys® HBS).Results: The instruments proved to be reliable and reproducible, and the bone substitute presented good mechanical resistance, maintaining its temperature during the surgery. The disposable retractable blade presents variation in size and angle, which is an advantage in the removal of necrotic bone. However, we must take some precautions in order to achieve a better result.Conclusion: using EasyCore Hip® instruments and a calcium phosphate bone substitute (Graftys® HBS) is safe; however, some precautions must be taken during the use of the technique. Level of Evidence IV, Case Series.

Reabilitação de mandíbula absorvida com implantes colocados através de dente incluso próximo à estrutura anatômica – relato de caso com acompanhamento de 5 anos

Alveolar resorbed bone near to noble anatomical structures has been a challenge to dental implants. However, this situation is more defiant when, with these structures, there is an impacted tooth. This study aimed to present a case of rehabilitation with dental implants in the posterior mandible of a patient with an impacted tooth near the mandibular canal, where the implants were placed through the tooth, aiming to avoid alveolar bone removal and subsequent bone graft reconstruction with a more complex surgery. Dental implants placed through the tooth were viable alternatives after a 5-year follow-up without any type of biologic complications.

Biologic Shaping in Periodontal Therapy

This article focuses on biologic shaping during periodontal treatment. This is especially important if there is concavity or unevenness of the enamel near the edge of the crown. This can create an unmanageable situation and increase the risk of further loss of bone support. The point is that biologic shaping in periodontal therapy limit unnecessary bone removal and create a biocompatible environment. Biologic shaping preserve bone, creating the biologic width necessary for tooth restoration. However, putting biological shaping into practice requires a team approach with a deep understanding of fundamentals, anatomy, surgical and reconstructive procedures, materials, and final reconstructive contours. When performed correctly, it can improve the long-term prognosis of dental health.

The Technique for Performing Posterior Vertebral Column Resection with En-Bloc Fixation/Reduction in Adult Spine Deformity Surgery.

All surgeries are performed with the patient in the prone position under continuous neuromonitoring. The posterior approach to the spine and spinal instrumentation are performed in a standard fashion3. The S2-alar-iliac technique is utilized for sacropelvic fixation when indicated4. A minimum of 6 fixation points above and 6 below the level of resection are obtained, resulting in 2 instrumented blocs proximally and distally. A wide decompressive laminectomy with foraminotomies is then performed at the resection level, allowing for visualization of the spinal cord and exiting nerve roots. In the thoracic spine, disarticulating 3 to 4 cm of the medial rib at the resection level allows for better visualization and accessibility. Temporary fixation is then obtained by a unilateral rod spanning the osteotomy site. Focus is then directed toward the inferior and superior articular facets and pedicle, which are resected in a piecemeal manner from lateral to medial. Care must be taken to avoid damaging nearby nerve roots, especially at the inferomedial aspect of the pedicle. Cancellous bone removal from the vertebral body is then performed in a piecemeal manner through a lateral extra-cavitary approach from each side. This step necessitates transferring temporary fixation to the contralateral side in order to ensure adequate resection bilaterally. Posterior cortex is then resected. The anterior dura is carefully freed of any ligament or bone. Resection of the discs above and below the resection level is then performed, and the end plates are prepared for arthrodesis. The next step is to measure the defect. The sizing of the cages must be kept in line with the desired degree of correction, preventing overlengthening of the spinal column and subsequent stretching of the spinal cord. An en-bloc reduction-fixation across the osteotomy site is performed with use of intercalary connecting rods in order to achieve the desired correction. In situ benders at this stage may be utilized to manipulate the intercalary rods in order to widen the resection space anteriorly. The rods will subsequently be replaced. This technique minimizes stress on the junctional segments through load distribution across the various fixation points in the proximal and distal blocs. Finally, after decortication of the posterior elements, the bone graft is placed prior to layered closure in the standard manner. Alternative treatments to the pVCR include a standard pedicle-subtraction osteotomy. A standard pedicle-subtraction osteotomy offers a substantial amount of correction; however, correction is limited to the sagittal plane because the wedge osteotomy is hinged on the anterior cortex. This limitation makes the pVCR a better candidate for patients with severe biplanar deformities. pVCR is a complicated and technically challenging procedure that offers substantial correction in the coronal and sagittal planes for patients with rigid spinal deformities. It has also been shown to significantly improve patient quality of life5 Complication rates, however, are reportedly as high as 25% among older patients with poor physiologic reserve, with postoperative risks including medical complications, neurological deficiencies, surgery-related complications and others6. Previous studies have demonstrated improved outcomes with increasing surgeon experience2. Medial rib resection in the thoracic spine allows easy access to the lateral vertebral column.En-bloc fixation-reduction minimizes fixation failure above and below the level of resection and provides a rigid foundation during the correction maneuver.Ensure that the anterior column is disconnected all the way across in order to avoid excessive shortening of the spinal cord and the potential neurologic sequelae.Complete resection of the posterior cortex and scar tissue anterior to the dural sac is required prior to the correction maneuver.Ensure an adequate number of fixation points above and below the resection level.

Comprehensive review of the incisive branch of the inferior alveolar nerve.

The incisive branch of the inferior alveolar nerve is a vital anatomical structure within the anterior mandible that has not been thoroughly defined and outlined in reports in the literature until recent years. Advances in radiological imaging, particularly the widespread use of cone-beam computed tomography has allowed for accurate visualization of the mandibular incisive canal (MIC) and its associated incisive branch of the inferior alveolar nerve. Surgical damage to the MIC, which could result in hemorrhage and sensory disturbance, may occur in commonly practiced oral and maxillofacial procedures, such as chin bone harvesting, implant placement, fracture repair and removal of pathologic entities of the anterior mandible. Knowledge of both the presence, dimensions and location of the incisive branch is a vital component to pre and peri-operative planning of oral and maxillofacial surgeries performed within the mandible, particularly within the interforaminal zone. In this article, the terminology, anatomy, imaging, surgical consideration, and pathology of the incisive branch will be discussed.

Removal of the Posterior Wall of the Sphenoid Sinus During Trans-sellar Skull Base Surgery: The Meniscus Sign

Trans-sellar surgical approaches can be difficult and unpredictable. Tumors can distort the appearance of the posterior wall of the sphenoid sinus and a surgeon's concerns for avoiding the proximal vascular structures of the region may compromise access for the neurosurgical portion of the operation. Bone removal from the sellar dura is sometimes suboptimal. The meniscus sign is a convenient and reliable method for removal of the posterior wall of the sphenoid sinus during trans-sellar skull base surgery. It is a safe technique that maximizes bone removal and surgical access between the cavernous sinuses and internal carotid arteries. The senior author has employed the meniscus sign in trans-sellar surgery for over 15 years, noting that the technique has been free of surgical complications, reproducible amongst trainees, and reliable in safely providing maximum exposure for the intradural portion of the operation.