Distal Direction Research Articles

Eccentrically widened bone tunnels after all-inside anterior cruciate ligament reconstruction: a computed tomography and three-dimensional model-based analysis

PurposeTo evaluate the extent of tunnel widening after anterior cruciate ligament reconstruction (ACLR) using the all-inside technique and to establish its correlation with patient-reported clinical outcomes and femoral graft bending angle (GBA).MethodsTunnel widening was evaluated using computed tomography (CT)-based three-dimensional (3D) models, and the femoral GBA was directly measured on CT images using the Picture Archiving and Communication System (PACS) software. Clinical follow-up was routine procedure, and patient-reported clinical outcomes mainly included International Knee Documentation Committee (IKDC), Lysholm, and Knee Injury and Osteoarthritis Outcome Scores (KOOS) scores, and subjective knee stability assessment.ResultsFifty-two patients received standard all-inside ACLR, with a median follow-up of 6 months. Reconstructed anterior cruciate ligaments (ACLs) were scanned during the first 3 days and 6 months after surgery. On both the femoral and tibial sides, bone tunnels were most significantly enlarged at the articular aperture segment; the femoral tunnel was 9.2 ± 1.3 mm postoperatively and was significantly enlarged by 32% to a mean tunnel diameter of 12.1 ± 2.0 mm at 6 months after surgery. Moreover, the extent of tunnel enlargement gradually decreased as the measured levels approached those of the bone cortex. The femoral tunnel center was shifted into the anterior and distal direction, and the tibial tunnel center was shifted into the posterior and lateral direction. Additionally, the mean femoral GBA was 105.9° ± 8.1° at the 6-month follow-up. Tunnel enlargement and GBA were not significantly correlated with patient-reported outcomes.ConclusionsFemoral and tibial tunnels were significantly greater and eccentrically shifted at the 6-month follow-up after all-side ACLR. However, the extent of tunnel widening does not markedly affect the short-term clinical outcomes. Meanwhile, the femoral GBA was not significantly correlated with femoral tunnel widening or patient-reported outcomes. Although the tunnel widening following all-inside ACLR was not associated with clinical outcomes, it potentially caused difficulties in revision ACLR.Level of evidenceLevel IV.

Evaluation of Root Dilaceration by Cone Beam Computed Tomography in Iranian South Subpopulation: Permanent Molars.

Root dilaceration is a developmental anomaly, which was first described in the 19th century as an abrupt change in the axial inclination between the crown and root of a tooth. Such an anomaly would potentially alter the dental therapeutic procedures and often demands special care. Hence, it is of great importance to diagnose dilaceration before starting any treatment procedure on the tooth. The aim of the current study was to evaluate the prevalence of dilaceration in the first and second maxillary and mandibular molar teeth in Shiraz, Iran, using cone-beam computed tomography (CBCT) radiography. In this retrospective study, 472 teeth from 141 CBCT images were studied. Each tooth was assessed by CBCT to diagnose dilaceration, its severity, direction, and anomaly location. In this study, among 472 studied teeth, 136 teeth (28.8%) were diagnosed with root dilaceration. The most frequently affected tooth was the maxillary second molar tooth (45%). The results showed a statistically significant relationship between the gender of the patients and the prevalence of dilaceration. Most dilacerations were observed in distal direction, with a mild intensity, and located in the apical third of the roots. In this study, CBCT was presented as an advanced method for diagnosing dilaceration in maxillary second molar teeth and especially in the mesial root, which can be influenced by gender and it can play an important role in designing the treatment plans.

Ageing-related effects of dye penetration in the apical 5 mm mesiobuccal and mesial roots of molars.

This study examined how the tubular permeability in the apical 5 mm of mesial roots was affected by age, direction, distance from root apex, canal shape and canal number. Twenty mesiobuccal/mesial roots of maxillary/mandibular molars from three age groups (<30, 30-60, >60 years) were prepared. Maximal dye penetration in buccal, lingual, mesial and distal directions was measured at 1-mm segment depth and analysed statistically. The <30 years group, when comparing to the >60 years group, had significantly deeper dye penetration in buccal and lingual directions. The permeability in proximal directions was not affected by either age or canal number. In the >60 years group, neither direction, segment depth nor canal number significantly impacted the permeability. However, these parameters significantly impacted samples younger than 60 years. Effective removal of infected root canal dentine would depend on age and its related preferred direction, distance from root apex and canal number.

Major change in morphology of the talofibular ligaments during fetal development and growth.

Ankle sprain is often attributed to damage of theanterior and posterior talofibular ligaments (ATFL, PTFL). We compared the morphology of these ligaments in fetuses of different gestational ages (GAs) with the horizontal configuration in adults. Histological sections of unilateral ankles were examined in22 fetuses, 10 at GA of 9-12weeks and 12 at GA of 26-39weeks. At a GA of 9 to 10weeks,theATFL and PTFL consisted of horizontally running straight fibers. The initial ATFL appeared as a thickening of the capsule of the talocrural joint, although the initial PTFL was distant from this joint. Until a GA of 12weeks, the talus and fibula were separated by an expanding joint cavity. Thus, the initial horizontal ligaments were "pulled" in a distal direction. The distal parts of the ligaments consisted of thin collagenous fibers that had an irregular array, whereas the short proximal parts had thick fibers and a horizontal array. In near-term fetuses, the ligaments contained no horizontal fibers. The ATFL had a wavy course around the thick synovial fold, and was exposed to the joint cavity along the entire course; the distal part was thinner than the proximal part.The PTFLwas bulky and consisted of fibers with an irregular array. Therefore, the morphology in a near-term fetus was quite different from that in adults. The horizontal and straight composite ankle fibers in adults apparently result from postnatal reconstruction, depending on mechanical demand.

Influence of the Digestive Tract on Enzyme Activity

Enzyme activity at the digestive tract level was experimentally studied on rabbits and mini-pigs. The enzyme activity in the blood flow supplied to and from the rabbit stomach and intestines was assessed. In rabbits, the arteriovenous oxygen difference revealed a decrease in the lactate dehydrogenase and amylase activity under an increase in the alkaline phosphatase activity. A regular dependence in the dynamics of gamma-glutamyl transferase activity in the intestinal mucosa and chyme fractions was established. It was found that gamma-glutamyl transferase activity decreases in the distal direction in the mucosa of the small intestine wall. Its maximum activity was determined in the soluble fraction of the small intestine chyme, with a characteristic decrease in the distal direction. Due to the hydration of the cavitary mucus glycoproteins in the chyme and the existence of the latter in the form of an enteroplasm, the enzyme is assumed to localize in the enteric medium between the soluble and dense endogenous fraction with the purpose of displaying the maximum transport activity. A conclusion was made about the plasma-forming role of the digestive tract in terms of blood enzyme activity.

Dosimetric effect of set-up error in accelerator-based boron neutron capture therapy for head and neck cancer.

The dosimetric effect of set-up error in boron neutron capture therapy (BNCT) for head and neck cancer remains unclear. In this study, we analyzed the tendency of dose error by treatment location when simulating the set-up error of patients. We also determined the tolerance level of the set-up error in BNCT for head and neck cancer. As a method, the distal direction was shifted with an interval of 2.5 mm, from 0.0 mm to +20.0 mm and compared with the dose at the reference position. Similarly, the horizontal direction and vertical direction were shifted, with an interval of 5.0 mm, from −20.0 mm to +20.0 mm. In addition, cases with 3.0 mm and 5.0 mm simultaneous shifts in all directions were analyzed as the worst-case scenario. The dose metrics of the minimum dose of the tumor and the maximum dose of the mucosa were evaluated. From unidirectional set-up error analysis, in most cases, the set-up errors with dose errors within ±5% were Δdistal < +2.5 mm, Δhorizontal < ±5.0 mm and Δvertical < ±5.0 mm. In the simulation of 3.0 mm shifts in all directions, the errors in the minimum tumor dose and maximum mucosal dose were −3.6% ±1.4% (range, −5.4% to −0.6%) and 2% ±1.4% (range, 0.4% to 4.5%), respectively. From these results, if the set-up error was within ±3.0 mm in each direction, the dose errors of the tumor and mucosa could be suppressed within approximately ±5%, which is suggested as a tolerance level.

The intra-muscular course and distribution of the anterior interosseous nerve within pronator quadratus: An anatomical study

BackgroundThe anterior interosseous nerve (AIN) is a terminal motor branch of the median nerve innervating the following three muscles from proximal to distal: Flexor pollicis longus (FPL), the radial half of flexor digitorum profundus (FDP), and the pronator quadratus (PQ). The aim of this study was to define the course of the AIN within the PQ to aid surgeons performing distal radial procedures. MethodsTen embalmed cadaveric forearms were dissected to identify the path of the AIN within PQ. An en-bloc excision of the PQ with its supplying AIN and vasculature was performed to identify a safe zone where PQ can be elevated without damaging AIN. A scoping literature search was performed to identify other studies reporting the path of AIN through PQ. ResultsThe mean distance from the radial border of the radius perpendicular to the point at which the AIN enters the PQ was 22.3 mm (range 21–24 mm). The mean distance from the distal wrist crease to the AIN entering PQ was 74.3 mm (range 59–84 mm). The mean number of nerve branches to PQ was 5.2 (range 3–8). In all specimens, the AIN was found to lie on the radial side of the anterior interosseous artery (AIA). ConclusionsThe AIN courses on the deep surface of the PQ in a longitudinal proximal to distal direction. A ‘safe zone’ was identified within 20 mm of the radial border of the distal radius, which may be utilised by surgeons in a muscle-splitting approach to the distal radius.

Shape Sensing for Continuum Robots by Capturing Passive Tendon Displacements With Image Sensors

Continuum robots and soft robots have shown great potential in industrial and medical applications. Sensing the shapes of continuum robots is a challenging but significant problem for enhancing their performance during various tasks. In this letter, we present a novel method to estimate the shapes of continuum robots by capturing passive tendon displacements with image sensors. This method is reliable but low-cost. To reconstruct the shape of the continuum robot, an intuitive way based on screw theory and the material frame is also presented. The displacements of passive tendons are related to the integral of the geometric parameters of the continuum robot. By using passive tendon displacements, not only bending but also twisting of the robot can be calculated. The experiments show that our method can estimate the shapes of the robot deformed in different conditions. The mean distal position error is 3.01&#x0025; of the length and the mean shape error is 1.86&#x0025; of the length. The mean distal direction error is 4.1 degrees. Besides, sensing the shapes of continuum robots in real-time is also achieved.

The Effects of Increased Maxillary Canine Bracket Angulation on Tooth Movement and Alignment Efficiency: A Prospective Clinical Study.

This study aimed to evaluate the effects of a 10° angulation of a maxillary canine (Mx3) bracket on Mx3 and maxillary central incisor (Mx1) tooth movements and alignment efficiency in treatments involving maxillary premolar extraction. This split-mouth study included 29 individuals in a +10° angulation study group and a 0° angulation control group. The initial (T0) and 12th week (T1) orthodontic models were prepared and digitized with a three-dimensional scanner and superimposed using the OrthoAnalyzer analysis program. The movements of Mx3 and Mx1 were measured, and the alignment efficiency was assessed using Little's Irregularity Index. The Shapiro-Wilk test was used to test the data for a normal distribution. T1 and T0 measurements within the group and T1 and T0 differences between groups were compared using a paired samples t-test. The significance level was set to P < .05. The linear movements of Mx3 in the distal direction significantly increased, and Little's Irregularity Index values statistically significantly decreased in both groups. Distal movements of Mx3 were significantly higher in the control group than in the study group (P< 0.01 and P< 0.05). The movements of Mx1 and Little's Irregularity Index measurements did not show statistically significant differences between the groups (P > 0.05). A +10° Mx3 bracket angulation increased the inclination of Mx3 to the mesial, but it decreased the Mx3 distal linear movement and the retraction of Mx1, with no difference in terms of alignment efficiency between the+10° and 0° Mx3 bracket angulations.

Biomechanical characterization of the small intestine to simulate gastrointestinal tract chyme propulsion

Regular intestinal motility is essential to guarantee complete digestive function. The coordinative action and integrity of the smooth muscle layers in the small intestine's wall are critical for mixing and propelling the luminal content. However, some patients present gastrointestinal limitations which may negatively impact the normal motility of the intestine. These patients have altered mechanical and muscle properties that likely impact chyme propulsion and may pose a daily scenario for long-term complications. To better understand how mechanics affect chyme propulsion, the propulsive capability of the small intestine was examined during a peristaltic wave along the distal direction of the tract. It was assumed that such a wave works as an activation signal, inducing peristaltic contractions in a transversely isotropic hyperelastic model. In this work, the effect on the propulsion mechanics, from an impairment on the muscle contractile ability, typical from patients with systemic sclerosis, and the presence of sores resultant from ulcers was evaluated. The passive properties of the constitutive model were obtained from uniaxial tensile tests from a porcine small intestine, along with both longitudinal and circumferential directions. Our experiments show decreased stiffness in the circumferential direction. Our simulations show decreased propulsion forces in patients in systemic sclerosis and ulcer patients. As these patients may likely need medical intervention, establishing action concerning the impaired propulsion can help to ease the evaluation and treatment of future complications.

Ultrasound-Guided Injection Approach of Treating Tennis Elbow and Elbow Joint Synovitis Simultaneously Under One Needle Insertion Point.

A 52-yr-old man with right elbow pain for 6 mos visited an outpatient rehabilitation clinic. An obvious tender spot at the lateral epicondyle area was palpated with positive Cohen test.1 The patient had received autologous platelet-rich plasma injection but without much improvement.2 Musculoskeletal ultrasound images revealed thickening of the common extensor tendon, combined with diffuse heterogeneity and focal hypoechogenicity. Bony irregularity was observed at the tendon insertion site. The diagnosis of lateral epicondylitis, also known as “tennis elbow,” is a common cause of elbow pain. The exact pathogenesis remains elusive and is often difficult to treat. Ultrasound-guided injection to the bone and common extensor tendon interface may not be effective as many patients are also bothered with elbow joint synovitis.3 As a result, this article describes an important ultrasound-guided injection approach to treat tennis elbow and joint synovitis simultaneously under one needle insertion point. When applying ultrasound-guided injection to treat tennis elbow, the elbow is flexed at a 90-degree angle. The ultrasound linear probe is placed over the lateral epicondyle, along the longitudinal axis of the common extensor tendon origin. Under this sonographic view, the common extensor tendon, the lateral epicondyle, and the elbow joint can be observed. Conventionally, injection can be done under the longitudinal view, in a distal-to-proximal or proximal-to-distal direction, by guiding the needle to the bone tendon (extensor carpi radialis brevis tendon) interface.4 For patients who are also bothered with elbow joint synovitis, simultaneous injection to the bone-tendon interface, and aspiration of the joint fluid followed by the injection of an injectant may be needed (Figs. 1A, B).3 However, under the in-plane or longitudinal view, needle insertion into the elbow joint can be difficult because of the convex curvature of the radial head (Fig. 1B). Therefore, a different injection approach is recommended. Similar to the conventional method, the linear probe is placed longitudinally on top of the elbow joint. The needle is then inserted in a lateral-to-medial direction under the out-of-plane approach or short-axis view into the elbow joint (Figs. 2A, B). The needle is observed as a hyperechoic dot inside the elbow joint. Aspiration of the joint fluid followed by injection can then be performed. Still under the short-axis view, the needle is retracted and then guided in a slightly obliqued direction to the bone-tendon interface to commence subsequent injection treatment (Figs. 3A, B). Steroid was the injectant used. Elbow pain was greatly improved after the treatment.FIGURE 1: A, The linear ultrasound transducer is placed longitudinally on top of the right elbow to visualize the lateral epicondyle, common extensor tendon, bone-tendon (extensor carpi radialis brevis) interface, and the elbow joint. Conventionally, injection can be done under the longitudinal view and in a distal-to-proximal direction by guiding the needle to the bone-tendon interface. B, The needle is accurately guided to the bone-tendon (extensor carpi radialis brevis) interface (*). Due to synovitis, increased hypoechogenicity (resembling fluid accumulation) can be observed in the elbow joint (+). Using the distal-to-proximal direction needle approach, insertion into the elbow joint can be difficult because of the convex curvature of the radial head.FIGURE 2: A, With the linear ultrasound transducer placed longitudinally on top of the right elbow, the needle is inserted in a short-axis or out-of-plane view relative to the transducer and guided into the elbow joint (pink area). B, Under the short-axis view, the injection needle can be visualized as a hyperechoic dot inside the elbow joint.FIGURE 3: A, After completing elbow joint injection, the needle is then retracted and the syringe is moved slightly in a distal direction to guide the needle to the lateral epicondylar area (curved white arrow). B, Still under the short-axis view or slightly obliqued short-axis view, the needle is guided to the bone-tendon interface.

Knee Flexion Angle Measurement Using Virtual Assessment Tools: Correct Procedure and Potential Pitfalls

Virtual patient assessment will inevitably require smartphone technology to remotely measure knee range of motion. We conducted an experiment to analyze the impact of observer position relative to the flexed knee on the perceived angle measured using an electronic application (Dr. Goniometer) for iPhone. Two observers measured the apparent knee flexion angle from 7 different positions at 3 different heights relative to the center of the knee joint. Intraclass correlations were calculated to evaluate the intraobserver and interobserver variability using two-way mixed-effects models. The intraclass correlation for interobserver variability was excellent at 0.804 (95% confidence interval 0.663-0.889). When the observer was greater than 15° from the knee perpendicular, the true angle of knee flexion (90°) was not observed in any of the measurements. This was the case when observed from both proximal (range 95°-121°) and distal (range 92°-108°) directions. Ideally the camera lens should be perpendicular to the long axis of the lower limb in the proximal-distal direction and at the same height. However, if the camera lens is within 15° of the perpendicular, then at 90° of true flexion, the perceived angle will not be greater than 95° in 94% of cases.

Limited Open Achilles Repair Without Instrument-Guided Assistance

Background: The limited open Achilles tendon repair technique has recently gained popularity as a treatment option for acute Achilles tendon ruptures. This surgical technique video describes a limited open Achilles tendon repair without instrument guided assistance, demonstrating improved clinical outcomes for patients while also reducing reliance on operative equipment, cost, and the duration of surgery. Indications: The indications for this limited open Achilles tendon repair technique include an Achilles tendon rupture less than 6 weeks from injury occurring in the watershed area. Technique Description: The patient is prone and a 2- to 3-centimeter longitudinal incision is made over the Achilles tear. In the proximal stump, 3 nonabsorbable sutures are passed horizontally from proximal to distal direction. In the distal stump, the same is done in a nonlocking manner. The stumps are then reflected and the deep fascial compartment is released. The foot is plantarflexed to reduce tension on the repair site. The nonlocking sutures are tied sequentially from distal-distal to proximal-proximal direction. A running box suture using a nonabsorbable suture followed by 0-Vicryl around the rupture site is performed. Results: This technique has demonstrated, at a median follow-up of 3.7 years, restored pre-injury function along with no wound complications, re-ruptures, or re-operations in 33 patients. The median time from injury to surgery was 10 (range, 1-45) days and the mean time for returning to pre-injury level of activity was 5.6 (range, 1.7-22.1) months. After the procedure, patients demonstrated significant improvements in mean Foot and Ankle Disability Index (49.1-98.4), mean Visual Analog Scale pain score (4.8-0.2), and mean Foot and Ankle Outcome Score (FAOS) subscales such as FAOS pain (54.8-99.2), FAOS symptoms (84.6-97.0), FAOS activities of daily living (61.4-97.2), FAOS sports and recreational activity (39.5-98.5), and FAOS quality of life (39.7-88.7). Conclusion: Patients who underwent a limited open Achilles tendon repair without instrument-guided assistance demonstrated significant improvements in outcome scores with minimal complications.

Distinct displacement of the superficial and deep fascial layers of the iliotibial band during a weight shift task in runners: An exploratory study.

Motion of the fascial layers of the iliotibial band (ITB), as a reinforcement of the deep fascia lata, is likely to be relevant for its function and mechanical behaviour. This exploratory study aimed to evaluate the ITB fascial layers displacement during a weight shift task. Thirteen pain-free runners performed a 6-second standing weight shift task. B-mode ultrasound imaging using an automated fascicle tracking algorithm was used to measure proximal and distal displacement of superficial and deep ITB layers at the middle region. To study the potential contributors to individual variation of fascial motion, we recorded the activity of five hip/thigh muscles with electromyography (EMG), thigh/pelvis/trunk position with accelerometers, and centre of pressure with a force plate. Linear regressions estimated the relationship between displacement of fascial layers and hip/trunk angles. Independent t-tests or Fisher's exact tests compared EMG and movement-related parameters between participants who demonstrated motion of the fascia in the proximal and distal directions. Thickness of the ITB and the loose connective tissue between its layers were calculated. Proximal displacement was observed in six (-4.1±1.9mm [superficial]) and two (-6.2±2.0mm [deep]) participants. Distal displacement was observed for seven participants for each layer (3.1±1.1mm [superficial]; 3.6±1.3mm [deep]). Four participants did not show displacement of the deep layer. Trunk lateral flexion and gluteus medius muscle activity were determinants of proximal motion of the superficial layer. Loose connective tissue was thinner in participants without displacement of the deep layer. Displacement of the ITB fascial layers varies between individuals. Variation related to differences in joint movements and muscle activity. This study highlights the complex interaction between fascia and movement.

Influence of access cavity preparation on the dentine thickness of mesial canals of mandibular molars prepared with reciprocating instruments

To evaluate the influence of traditional and conservative access cavity preparations on the remaining dentine thickness in the coronal third of mesial canals of extracted mandibular molars prepared with reciprocating instruments using micro-computed tomography as the analytical tool. Seventy extracted mandibular molars were scanned at a pixel size of 19μm. From this initial sample, 20 teeth were selected, pair-matched and distributed into two groups (n=10) according to the access cavity preparation: traditional (TradAC) or conservative (ConsAC). The root canals were sequentially enlarged with Reciproc Blue R25 (size 25, 0.08v taper) and R40 (size 40, 0.06v taper) instruments. A new scan was performed and the postoperative stacks were coregistered with their respective preoperative datasets. A colour-coded cross sections of the roots were created and used to identify and measure the smallest dentine thickness related to both MB and ML canals at 1.0-mm intervals from the furcation level of up to 5mm in the apical direction, in both mesial and distal aspects of the roots, before and after preparation. The statistical analyses were performed with paired-samples t-test, independent-samples Student T-test and Chi-Square test with a significance level of 5%. At all levels of both groups, dentine thickness before preparation was greater than after preparation (p<.05). No difference in the percentage of dentine reduction was observed between TradAC and ConsAC groups (p>.05), but a significantly greater reduction was observed to the distal aspect of the roots (p<.05). After root canal preparation, dentine thinner than 0.5mm was observed mostly along the distal aspect of the root (10% to 15%) of the MB and ML canals, with no influence of the access cavity type on its incidence to either mesial (X2 =1.66; p=.2) or distal (X2 =0.40; p=.5) directions. In the TradAC group, dentine thickness in most slices was greater than 1.0mm after preparation (n=124) whilst, in the ConsAC, it ranged from 0.5 to 1.0mm (n=136). Traditional or conservative access cavity preparation in extracted mandibular molars did not influence the remaining dentine thickness in the coronal third of mesial canals enlarged with thermomechanically treated nickel-titanium reciprocating instruments.

Design of customized soft-tissue substitutes for posterior single-tooth defects: A proof-of-concept in-vitro study.

ObjectivesSoft‐tissue volume augmentation treatments do not provide the satisfactory long‐term functional and esthetic outcomes. The aim of the study was to develop a standardized digital procedure to design individual soft‐tissue substitutes (STS) and apply mathematical modeling to obtain average shape STS for single posterior tooth defects.Material and methodsThirty‐three casts from 30 patients were scanned. STS were designed with a computer‐aided design software and a systematic procedure standardized the measurements across all STS using 3D‐analysis software. The occlusal, mesial–distal, and buccal–lingual planes were defined to partition, each STS and produce a mesh. The thickness values of each 3D slice were documented in a coordinate system chart to generate a scatter graph. Graphs were embedded into images (Orange software) and images were analyzed via hierarchical clustering.ResultsThree STS groups were identified according to shape. Two shapes corresponded to the maxilla defects: a square (n = 13) with dimensions of 10 mm in a lingual–buccal (length) and 7–10 mm in a mesial–distal (width) direction; a rectangle (n = 11) of 11 mm in length and 4–7 mm in width. The average shape for mandible defects (n = 9) was smaller (6–8 mm in length, 5–10 mm in width). The highest thickness in all STS was in the buccal portion, above the alveolar ridge, with median values of 2 mm. The lowest thickness of 0.2 mm was at the edges.ConclusionsThe study developed novel methodology to design customized, as well as average shape STS for volume augmentation. Future STS harboring adapted geometry might increase volume augmentation efficiency and accuracy, while reducing surgical time.

Hybrid vascular interventin for multilevel peripheral arterial disease

Abstract Objective To increase the effectiveness of intervention for the lower limb arteries multilevel lesion (MPAD) in patients with type C and D lesions by TASC II classification. Materials and methods 87 hybrid vascular reconstructions (74 male and 13 female, 59% (n=52) smokers) for MPAD were performed from 2017 to 2020. The average age was 64,6±8,1y. CLI was diagnosed in 47% (n=41) by Fontaine- Pokrovsky classification. Following concomitant disease were diagnosed: stage 2–3 of CHF by HYHA classification 33% (n=29), COPD 23% (n=20), arterial hypertension stage 2–3 54% (n=47), CAD 66% (n=58), postinfarction cardiosclerosis 29% (n=26). Registered lesion of iliac-femoral segment type A/B=44 (51%) and C/D=43 (49%); registered lesion of femoro-tibial segment A/B=14 (16%), C/D=73 (84%) by TASC-II classification. Common femoral artery (CFA) bifurcation was most important to perform hybrid intervention. Through CFA with patented method (RU 2621395C) we performed remote endartherectomy from external iliac or superficial femoral arteries, that allowed us to remove a total prolonged occlusion (&amp;gt;15–20 cm), reducing the time and complexity of the endovascular stage. The key note is that we perform CFA plasty with using an autovenous patch with a “trunk” through which we provide endovascular stage of hybrid intervention on natural blood flow, restored after open endartherectomy. This technique allows you to change the direction of introducer in both distal and proximal direction without the need for extra punctures or temporary clamping of the arteries. Results Technical success rate was 98%. Local aneurysm of EIA was found in one case that restricted to provide the loop endarterectomy. The average duration of hybrid operation was 223,7±88,2 min (134,2±72,3 min for open and 89,9±52,9 for endovascular stages). Average blood loss was 225,3±130,7 ml. ICU staying duration was 20,6±2,8 hours. 30-days patency was 98,8%, 12 and 36 months primary patency was 98% and 88,5% respectively. There were no deaths within 30 days after hybrid operation. The following complications occurred: bleeding n=2 (2,3%), acute thrombosis n=1 (1,2%), surgical site infection n=1 (1,2%) but cured safely. Limb salvage in critical ischemia was in 100% of patients for 20 months. Conclusion Hybrid surgery of MPAD is highly effective, reduces operation trauma, improves its results and limb salvage. By reducing trauma of surgical intervention reduces admition in ICU, postoperative risks, especially in patients with severe concomitant pathology. Funding Acknowledgement Type of funding sources: None.

Morphometry of the shoulder joint and justification of new modular reverse shoulder endoprosthesis sizes using computed tomography data

Reverse shoulder arthroplasty is effective surgery because most of patients have positive long-term results. However, the search for the «perfect» endoprosthesis continues. Objective. To justify the dimensions of a new modular reverse shoulder endoprosthesis using additive technologies based on spiral computed tomography data. Methods. Two data sets of healthy shoulder joints (right — R, left — L) of 100 patients obtained on a spiral computed tomography AQUILION 128 sections (Toshiba, Japan) were processed. Each set consisted of 11 morphometric parameters — linear and angular values. For each of them, three data samples (combined, R and L) are calculated: minimum, maximum, mode, median, mean, standard deviation, distribution asymmetry coefficient. Pearson’s correlation coefficient was calculated, cluster analysis was performed. Results. It is proved that most of the parameters of R and L data sets can be considered homogeneous and can be analyzed as a combined group of 200 cases. It was found that the width and height of the glenoid are more homogeneous data sets, and the value of the endosteal diameter of the humerus decreases in the distal direction. The cervical-diaphyseal angle averages 137.4° ± 4.66°. The correlation between different parameters is more pronounced within most clusters than in the sample as a whole. Conclusions. It is necessary to create different sizes of the distal part of the conical stem, to which securely fix a wide proximal part, as well as in different sizes, in the form of a cup for fixing the liner. The height of the proximal part of the reverse shoulder endoprosthesis should be not less than 20 mm, the diameter of the base of the proximal parts of the stem — 38, 40, 42 mm. It is proposed to use a conical stem of the implant with a wider proximal part, to create the angle 135° between the cup of the proximal part and the stem. Three standard sizes of basic glenoid plates with a diameter of 26, 30, 32 mm are defined. Key words. 3D-printing, arthroplasty of the shoulder joint, glenoid, cluster analysis, correlation analysis.

Infrapatellar Saphenous Nerve Is at Risk During Tibial Nailing: An Anatomic Study.

Objectives:To determine the location and stage of the tibial nailing procedure where infrapatellar saphenous nerve (IPSN) injury may occur.Methods:Fourteen fresh-frozen right cadaveric knees underwent tibial nailing. Six knees underwent a suprapatellar approach and 8 a medial parapatellar approach. Two proximal medial-to-lateral screws were placed using the aiming guide. The incisions were then closed. After the procedure, medial retinacular and saphenous nerves were dissected under surgical 2.5× loupe magnification from a proximal to distal direction. The branch of the IPSN closest to the locking screws was measured, as was the distance between the IPSN branch and the inferior pole of the patella.Results:Twelve of 14 cadavers had prominent IPSN (main branch from the saphenous proper) with an average of 2.5 sub-branches. The mean (SD) distance from the main branch of the IPSN to the inferior pole of the patella was 40.9 (24.4) mm. Four medial retinacular nerve branches, branching from the femoral nerve and not IPSN, were identified proximal to the patella during the medial parapatellar approach. All were cut after the medial parapatellar arthrotomy. The mean (SD) distance from the IPSN to the nearest locking screw was 10.2 (14.1) mm. Seven of 14 had IPSN injuries, and one had hamstring injury. Two direct screw entrapments occurred, whereas two IPSNs were lacerated by the incision. Suture closure entrapped three nerve branches, and one specimen had injured fibers of the hamstring tendinous insertion.Conclusions:Injury to the IPSN can occur at different locations and stages of tibial nailing, including approach, proximal locking screw insertion, and closure.

The VISTA Approach in Canine Disimpaction.

Canine disimpaction is always a challenging orthodontic treatment overall, even when the impacted permanent canine is in a high position, especially when in tight relation with the upper incisors’ roots. Conventional treatment methods are usually not capable of performing the correct force direction, consisting of the contemporary movement in the distal and vestibular directions of the canine crown, often provoking, as side effects, the presence of decubitus on the mucous of the lips and cheeks or a poor final appearance of the periodontal support of the disimpacted canine. Among the different approaches, the vertical incision subperiosteal tunnel access (VISTA) technique shows good performance with regard to the direction of the forces and the canine’s periodontal conditions when erupted; it is usually realized through an elastic chain connected to a temporary anchorage device (TAD) in the posterior area. In this paper, a different protocol for the VISTA method is also presented, to be resorted to in cases of difficult miniscrew positioning due to the anatomic conditions or stage of dentitions. The new protocol also considers the use of nickel–titanium coil springs in order to avoid the need of frequent reactivation of the device and consequent patient discomfort, highlighting its advantages and indications with respect to the traditional approach.