Inferior Side Research Articles

The actor of power in the conditions of modern warfare: David's strategy vs Goliath's strategy

This article is dedicated to solution of the crucial problems of the philosophy of war – the paradox of David and Goliath. The weaker, technically inferior side of military confrontation often defeats the stronger one, which is equipped with the latest technology by the world political actors. The author describes the heterogeneous and asymmetric nature of modern wars, which involve state and non-state actors, and combine regular and irregular combat practices. It is indicated that the mobile and flexible strategy of partisan war, which is more effective than the actions of regular army, is now being adopted by them. Therefore, if an irregular soldier, a partisan, in the conditions of classical inter-state war possessed the status of “unlawful combatant”, in modern wars, the soldiers of regular army must prove their superiority over the partisans. The scientific novelty of this research lies in determination of the two paradigms of warfare relevant to the current situation in the society, which correspond to the strategies of David and Goliath. The first is characteristic to high-tech societies, which have entered the post-heroic era losing imperative of sacrifice. The conclusion is made that the military activity of modern Goliaths is being transformed in accordance with transhumanistic and poshumanistic scenarios. The natural outcome of high-tech warfare of the future should become a post-human war waged by artificial intelligence. The response to high-tech challenges of the leading world political actors is the guerrilla warfare strategy of modern David, which is founded on the idea of sacrifice and willingness to take lethal risks, and debunks the key role of the factor of technological superiority in achieving victory.

Intravascular ultrasound-supported percutaneous angioplasty of post-kidney transplant renal artery bifurcation stenosis.

Transplant renal artery stenosis (TRAS) is an uncommon complication following renal transplantation. Its usual clinical presentation includes worsening hypertension and/or renal function, without any evidence of graft rejection. Bifurcation renal artery stenosis of the transplanted renal artery is rarely encountered. Percutaneous transluminal renal angioplasty (PTRA) with or without stenting is the procedure of choice to treat TRAS. We hereby describe a patient, who presented with impaired renal functions, four months following the renal transplantation. He underwent intravascular ultrasound-guided PTRA of the bifurcation lesion of TRAS.Results and conclusion: Superior renal artery had coronary drug-eluting stent implantation, while inferior renal artery and side branch of the superior renal artery had balloon angioplasty, alone. Post-intervention, the raised serum creatinine level decreased from 2.9 mg% to 1.7 mg%. The index case described the successful PTRA and stenting of the bifurcation lesion of TRAS, the technical results of which was optimized with the use of intravascular ultrasound.

Quantitative and Qualitative Surgical Anatomy of the Acromioclavicular Joint Capsule and Ligament: A Cadaveric Study

Background: The acromioclavicular (AC) capsule and ligament have been found to play a major role in maintaining horizontal stability. To reconstruct the AC capsule and ligament, precise knowledge of their anatomy is essential. Purpose/Hypothesis: The purposes of this study were (1) to determine the angle of the posterosuperior ligament in regard to the axis of the clavicle, (2) to determine the width of the attachment (footprint) of the AC capsule and ligament on the acromion and clavicle, (3) to determine the distance to the AC capsule from the cartilage border of the acromion and clavicle, and (4) to develop a clockface model of the insertion of the posterosuperior ligament on the acromion and clavicle. It was hypothesized that consistent angles, attachment areas, distances, and insertion sites would be identified. Study Design: Descriptive laboratory study. Methods: A total of 12 fresh-frozen shoulders were used (mean age, 55 years [range, 41-64 years]). All soft tissue was removed, leaving only the AC capsule and ligament intact. After a qualitative inspection, a quantitative assessment was performed. The AC joint was fixed in an anatomic position, and the attachment angle of the posterosuperior ligament was measured using a digital protractor. The capsule and ligament were removed, and a coordinate measuring device was utilized to assess the width of the AC capsule footprint and the distance from the footprint to the cartilage border of the acromion and clavicle. The AC joint was then disarticulated, and the previously marked posterosuperior ligament insertion was transferred into a clockface model. The mean values across the 12 specimens were demonstrated with 95% CIs. Results: The mean attachment angle of the posterosuperior ligament was 51.4° (95% CI, 45.2°-57.6°) in relation to the long axis of the entire clavicle and 41.5° (95% CI, 33.8°-49.1°) in relation to the long axis of the distal third of the clavicle. The mean clavicular footprint width of the AC capsule was 6.4 mm (95% CI, 5.8-6.9 mm) at the superior clavicle and 4.4 mm (95% CI, 3.9-4.8 mm) at the inferior clavicle. The mean acromial footprint width of the AC capsule was 4.6 mm (95% CI, 4.2-4.9 mm) at the superior side and 4.0 mm (95% CI, 3.6-4.4 mm) at the inferior side. The mean distance from the lateral clavicular attachment of the AC capsule to the clavicular cartilage border was 4.3 mm (95% CI, 4.0-4.6 mm), and the mean distance from the medial acromial attachment of the AC capsule to the acromial cartilage border was 3.1 mm (95% CI, 2.9-3.4 mm). On the clockface model of the right shoulder, the clavicular attachment of the posterosuperior ligament ranged from the 9:05 (range, 8:00-9:30) to 11:20 (range, 10:00-12:30) position, and the acromial attachment ranged from the 12:20 (range, 11:00-1:30) to 2:10 (range, 13:30-14:40) position. Conclusion: The finding that the posterosuperior ligament did not course perpendicular to the AC joint but rather was oriented obliquely to the long axis of the clavicle, in combination with the newly developed clockface model, may help surgeons to optimally reconstruct this ligament. Clinical Relevance: Our results of a narrow inferior footprint and a short distance from the inferior AC capsule to cartilage suggest that proposed reconstruction of the AC joint capsule should focus primarily on its superior portion.

A New Stapes-Head Coupler for the Vibrant Soundbridge System

Introduction: The Vibrant Soundbridge (MED-EL Medical Electronics, Austria) is an active middle ear implant with a floating mass transducer (FMT) for patients with conductive, sensorineural, or mixed hearing loss. While the FMT is vertically aligned above the stapes head (SH) with the current Vibroplasty Clip coupler (MED-EL Medical Electronics), the new SH coupler was developed to mount the FMT on the inferior side of the stapes and to fit in the reduced middle ear space after canal-wall-down mastoidectomy. Methods: Using 11 human cadaveric temporal bones (TBs), placements of the new SH couplers on the stapes were examined, and effective stimuli to the cochlea were evaluated by measuring piston-like motion of the stapes footplate with a current of 1 mA on the FMT. The results were assessed in comparison with the Vibroplasty Clip coupler. Results: The new SH coupler showed perfect coupling on the stapes in 9 out of 11 TBs. A small gap between the SH and the plate of the connection link part was unavoidable in 2 TBs but had negligible effect on vibrational motion of the stapes. Vibrational motion of the stapes with the new SH coupler was reduced at frequencies above 3 kHz compared to the corresponding motion with the current Vibroplasty Clip coupler, but the relative attenuation over all 11 cadaveric temporal bones was <10 dB. Conclusions: The new SH coupler provides an alternative with more stable fixation when placement of the current Vibroplasty Clip coupler is limited due to insufficient space after canal-wall-down mastoidectomy, while still delivering effective stimuli to the cochlea.

Double-Sling Augmentation for Anterior Shoulder Dislocation

Anterior capsule ligament deficiency occurs in complicated anterior shoulder dislocation and poses a challenge to surgeons because of the irreparability of the capsule labrum structure or the nonoptimal healing potential after repair. Single-sling augmentation with either conjoined tendon or the long head of the biceps brachii has been reported to enhance the anterior stability of the shoulder. However, single-sling augmentation may still not be enough in cases of complicated anterior shoulder dislocation. Thus we introduce a double-sling anterior shoulder augmentation technique in which both the conjoined tendon and the long head of the biceps brachii are transferred to the anterior inferior side of the glenoid. Our clinical experience indicates that this procedure is effective to address complicated anterior shoulder dislocation. We believe that the introduction of this technique will provide a special choice in the treatment of anterior shoulder dislocation.

WITHDRAWN: Effect of ageing on different swallowing pattern using electromyography

Swallowing is the process, which plays a important role in the digestive system. Swallowing can be smooth as well as little harsh too it depends on the type of food or fluids consumed. The difficulty in the swallowing disorders called as the dysphasia. The two important muscles which helps in swallowing are submantel and infrahyoid muscles. The submantel muscle is located between mylohyoid muscle on the superior side and platysma muscle on the inferior side. The submantel muscle potential giving a key point to analyze the swallowing disorders. This proposed study explained about the relation between the electromyography signals with respect to the age. To pick up the muscle signals the, four different swallowing patterns are induced, for three different age groups. The Group I 18–40 years, Group II 40 – 60 years and Group III 60 and above years were taken. The EMG module and the Ag/AgCl electrodes are used to pick up the electromyography signals. Two Ag/AgCl electrode has placed on the submantel muscle and a reference electrode is placed on the collar bone. The muscle potential signals has been recorded using the NI-DAQ acquisition system for different swallowing patterns i.e. dry swallowing, 16 ml, 20 ml and 100 ml. This study concludes that, as age increases the submantel muscle potential will be decreases.

The physiopathology of osteoarthritis: Paleopathological implications of non-articular lesions from a modern surgical sample

ObjectivesThis research focused on osteoarthritis (OA) lesions on modern patients to 1) identify consistently observed lesions not included within current paleopathological measures of OA, 2) assess the correspondence of bone and cartilage lesions with clinical OA diagnostic criteria, and 3) discuss the correspondence of bone lesions with sources of pain reported in clinical literature. MaterialsTibial plateaus from 62 patients undergoing total knee replacement surgery due to OA were examined. MethodsPlateaus were scored for several non-standard OA criteria, including non-articular and X-ray visible lesions and pre-maceration cartilage lesions, as well as articular surface criteria standard in paleopathology. ResultsProliferative bone in the intercondylar region was present in 95 % of specimens, while areas of dense trabecular bone and lytic defects, both on the inferior side of the plateaus, were present in 98 % and 83 %, respectively. ConclusionsThe inferior lytic defects may be physical evidence of bone marrow lesions (BML), a clinical OA indicator visible via MRI. Previous research has linked BML to pain, inflammation, and ligament pathology. The latter conditions have also been associated with intercondylar enthesophytes and third intercondylar tubercle of Parsons (TITP), both of which were observed in the intercondylar regions. SignificanceSeveral non-articular lesions not currently included in paleopathological measures of OA were consistently observed. Suggestions for future researchA similar analysis of a control sample of non-OA tibial plateaus would better contextualize these results. LimitationsThe sample’s high average age (65.8 years) and severe OA stage may hamper generalizability to archaeological collections.

3D Surface Imaging as a Viable Replacement for Permanent Tattoos for Patients Undergoing Breast EBRT - A Feasibility Study on a Phantom

Cutaneous tattoos have historically been required for the setup and alignment of patients undergoing breast RT. This point-based approach yields low resolution of the underlying surface anatomy and leaves patients with permanent markings that can be psychologically distressing. Moreover, the validity of tattoo-based setup with DRR matching to internal bony landmarks can be challenging when used to align an external mobile target. The issue is particularly pronounced for patients with larger body habitus or pendulous breasts. The emerging 3D surface imaging can theoretically address the technical shortcomings of tattoos and simultaneously provide for an improved patient experience since no permanent markings are left behind. A feasibility study was therefore designed to investigate whether 3D surface imaging can replace permanent tattoos for breast RT. A phantom was immobilized on a Linac couch and five tattoos were made on the right breast per our institutional simulation protocol. These were aligned with in-room lasers. Couch coordinates at this position were recorded as the ground truth for the purpose of comparison. A reference surface image was then captured by a 3D surface imaging system. Five ROIs were designed for image registration and phantom shift calculation. ROI1 = RT breast; ROI2 = RT breast + 1/3 LT breast; ROI3 = RT breast + 1/3 LT breast + RT lateral side; ROI4 = RT breast + 1/3 LT breast + RT lateral side + RT superior side (up to inferior border of supraclavicular fossa) and ROI5 = RT breast + 1/3 LT breast + RT lateral side + RT superior side + RT inferior side. Except for ROI1, the others were asymmetric about the beam central axis. For each ROI, the phantom was repeatedly aligned to its pre-defined treatment position from a lowest random couch position with lasers off. A good alignment was defined as translations≤0.3 mm and rotations≤0.3°, as measured by the 3D surface imaging system. The elapsed time from start to an acceptable alignment and the final couch coordinates were recorded. Three measurements were made for each ROI. The same measurements were also performed for the tattoo cohort with lasers only. The mean setup times for each approach were: 86.3s (tattoos), 102.7s (ROI1), 86.7s (ROI2), 57.3s (ROI3), 55.7s (ROI4), and 48.7s (ROI5). For the 3D surface imaging cohort, the setup time was inversely proportional to the ROI size. Fitting a linear regression model yielded a linear coefficient of R2 = 0.892. The larger the ROI, the more robust and faster the setup became. The more asymmetric the ROI, the more effective and sensitive the ROI was in detecting rotational shifts. Post-setup residual errors as measured by couch coordinates were comparable in magnitude for each. With a properly-designed asymmetric ROI, 3D surface imaging may be able to replace tattoos as a viable and effective alternative for breast RT patient setup. The accuracy of this novel approach can be further enhanced by optimizing the topographical height of the skin surface.

The Bermuda`s Triangle a Didactic Description of the Retroperitoneal Anatomy

Study Objective The objective of this video is to teach an ¨effective¨ technique to find and clip the uterine arteries, previous to a total laparoscopic hysterectomy (TLH). Design video article. Setting Private Hospital. Patients or Participants N/A Interventions Hysterectomy is one of the most common surgical procedures around the world; Just in the USA, around 600,000 procedures are done yearly. The total laparoscopic hysterectomy has become one of the most common used techniques. According to the actual literature, the complication rate is in the range of 5.7/1000 procedures and bleeding is one of the most stressful complication. The purpose of this video article is to describe ¨The Bermuda´s Triangle¨ a very didactic description of the retroperitoneal vascular anatomy; With this description, it will be extremely easy to find and clip the uterine arteries, before performing a total laparoscopic hysterectomy. We named The Bermuda`s Triangle, because on the Atlantic Ocean the Bermuda's triangle is one of the most enigmatic and scare places, the same happened with the retroperitoneal space With the uterine arteries occluded, we decrease the uterine blood supply by 79%. After the initial anatomic pelvic inspection, we will see the pelvic side wall, we can draw an inverted triangle, that is formed from the superior side by utero-ovaric ligament, from the inferior side by the ureter and from the external side from the IP ligament, at the middle of the triangle we are gaining access into the retroperitoneal space; it will be quite easy to identify the vascular structures, nerves and ureter. The internal iliac artery will be identified, giving a bifurcation into uterine artery and superior vesical artery. The titanium clips are placed on the uterine artery. Measurements and Main Results N/A Conclusion The uterine arteries are clipped at the base, in an extremely easy and safe style. Doing this, we are decreasing the chances of a hemorrhage.

Examination of the Annular Tendon (Annulus of Zinn) as a Common Origin of the Extraocular Rectus Muscles: 2. Embryological Basis of Extraocular Muscles Anomalies

PurposeMany reports have described anomalous connections of the superior rectus (SR) with other extraocular rectus muscles, in which additional heads of the other three rectus muscles likely provided the connections. We examined how these connections are established during fetal development.MethodsWe analyzed paraffin-embedded horizontal sections from 25 late-stage fetuses. Horizontal sections are best suited for understanding the mediolateral relationships of muscle origins.ResultsWe confirmed a common tendinous origin of the lateral rectus (LR), inferior rectus (IR) and medial rectus (MR) muscles that was separated from the SR origin. Notably, eight fetuses (32%) had tendinous or muscular connections between the SR and other rectus muscles that had one of four morphologies: (a) a thin tendon from the SR to the common tendon of the three rectus muscles (2 fetuses), (b) a thin tendon to the LR (one fetus), (c) a thin tendon to the inferior rectus muscle origin (two fetuses), and (d) SR muscle fibers arising from an additional head of the LR (three fetuses).ConclusionsThe SR seemed to issue a thin tendon that passed along the inferior or lateral side of the oculomotor nerve. Conversely, the LR and inferior rectus muscle were likely to carry a supernumerary bundle that reached the SR. The accessory head of the medial rectus muscle showed a stable morphology in that it seemed to also provide an anomalous double head. However, the presence of an accessory head in the LR was rare. In contrast with our previously published diagram of the orbital apex, the accessory head of the medial rectus muscle passed along the lateral side of the superior oblique.

Study of spatiotemporal liquid dynamics in a vibrating vocal fold by using a self-oscillating poroelastic model.

The main purpose of this study is to investigate the spatiotemporal interstitial fluid dynamics in a vibrating vocal fold. A self-oscillating poroelastic model is proposed to study the liquid dynamics in the vibrating vocal folds by treating the vocal fold tissue as a transversally isotropic, fluid-saturated, porous material. Rich spatiotemporal liquid dynamics have been found. Specifically, in the vertical direction, the liquid is transported from the inferior side to the superior side due to the propagation of the mucosal wave. In the longitudinal direction, the liquid accumulates at the anterior-posterior midpoint. However, the contact between the two vocal folds forces the accumulated liquid out laterally in a very short time span. These findings could be helpful for exploring etiology of some laryngeal pathologies, optimizing laryngeal disease treatment, and understanding hemodynamics in the vocal folds.

Radiologic evaluation of the mastoid segment of the facial nerve tract in the intact temporal bone.

To localize the facial nerve course in the mastoid segment and to measure its distances relative to the tympanic membrane. This is a cross-sectional descriptive study. During 2019 in a tertiary hospital, 129 non-contrast and non-pathologic temporal CT images were studied in a tertiary hospital. Facial nerve distances were measured from the planes passing through the annulus in the axial cross-sections at superior, umbo, and inferior levels of the tympanic membrane. It was done in two different dimensions which are anteroposterior (toward the plane of the ear canal wall) and mediolateral (toward the plane of the tympanic membrane). The least mean anteroposterior distance between the facial nerve and the posterior ear canal wall was at the level of umbo (3.66 ± 0.76mm). The nearest point of the nerve toward the tympanic membrane was the inferior level (-0.03 ± 0.81mm). Overall external ear canal lengths were statistically significantly lower in women rather than men. There was a reverse correlation between the age and the ear canal length. Posterior canalplasty seems to be safe unless dissection does not cross the plane of annulus. In this study, the safe margin was 1.4mm in posterior canal wall drilling. It also should be performed carefully if it extends to the inferior side of the canal. Measuring the mediolateral dimension of the nerve toward the annulus in the axial CT images seems to be practically beneficial, especially in the inferior where the ear canal wall turns and might not act as a good landmark. Paying attention to this plane may reduce the risks of nerve injury in any procedures with transcanal approaches, particularly in inferior canaloplasty.

MRI evaluation of distance between tonsillary fossa and internal carotid artery in children

ObjectivesThe presence of the internal carotid artery (ICA) near tonsils can also cause severe bleeding during a tonsillectomy. We investigated the relationship between tonsil width and volume; and superior, middle and inferior tonsil-ICA distances in 5–9 and 10–15 years of age children. MethodsCranial MRI images of 200 children between 5 and 15 years of age were evaluated retrospectively. There were 100 children in group 1 (5–9 years of age) and 100 children in group 2 (10–15 years of age). Palatine tonsil width and volume; and superior, middle and inferior tonsil-internal carotid artery (ICA) measurements were performed bilaterally. ResultsOur results showed that bilateral tonsil width and volume; and left superior, middle and inferior tonsil-ICA distance of 5–9 years of age group were lower than those of the 10-15 year-of age group (p < 0.05). The nearest distance between ICA and palatine tonsil is at the inferior tonsil-ICA distance side in both age groups. Especially mean inferior and middle tonsil-ICA distances were lower than 8 mm in 5–9 years of age group and lower than 9 mm in 10–15 years of age group. Minimum middle tonsil-ICA distances were 2.0–2.50 mm in smaller children and 2.0–3.50 mm in older children. Similarly, the minimum inferior tonsil-ICA distances were 2.00 mm in smaller children and 2.20–3.00 mm in older children. There were positive correlations between tonsil width, volume, and superior tonsil-ICA distance; and middle and inferior tonsil-ICA distances (p < 0.05). ConclusionIn younger children, lower tonsil width; and in all children, lower tonsil volume can be a warning sign in terms of lower tonsil superior-ICA distance. During tonsillectomies, working at the middle and inferior tonsillary fossa, maximum attention must be performed for the possibility of the ICA being very closer to the tonsil to avoid unwanted bleedings.

Morphometrıc evaluatıon of acetabulum

Amaç: Kalça kemiğinin dış yüzünde bulunan ve femur başı ile eklem yapan çukura acetabulum denir. Acetabulum os ilium, os ischii, os pubis olmak üzere üç kemikten oluşur. Bu üç kemiğin birleşmesi 14–16 yaşlarında başlar ve 23 yaşına kadar devam eder. Bu çalışmanın amacı, acetabulum'un morfometrik ölçümlerini yaparak, kalça operasyonlarında klinisyenlere yardımcı olmaktır.Yöntemler: Bu gözlemsel çalışmada Erciyes Üniversitesi Anatomi Anabilim Dalındaki 96 adet os coxae (50 sağ, 46 sol) kullanıldı. Kuru kemik üzerinde dijital kumpas yardımı ile sağ ve sol ayrı ayrı olmak üzere, corpus ischii acetabulum kenarı ile acetabulum ön kenarı arası uzunluğu (CİAK-AÖK) ortalama, incisura acetabulum’un transvers çapı (ATÇ), incisura acetabuli (IAU) uzunluğu, acetabulum’un derinliği (AD) ortalama, spina iliaca anterior inferior tarafındaki acetabulum kenarı ile acetabulum arka kenarı arası uzunluk ortalama (SİAİ), facies lunata alanı, limbus acetabuli uzunluğu, incisura acetabuli orta noktası ile limbus orta noktası arası mesafe ortalama, acetabulum’un şekli hesaplanarak 9 parametre değerlendirildi. Kuru kemik üzerinden alınan görüntüler bilgisayar ortamına aktarıldı ve ImageJ programı ile facies lunata’nın alanı ve limbus acetabuli’nin uzunluğu hesaplandı.Bulgular: Yapılan ölçümler sonucunda ortalama değerleri, sağ-sol olarak CİAK-AÖK 53,04-54,67 mm, ATÇ 50,57-51.44 mm, IAU 18,08-20,25 mm, AD 24,87-22,85 mm, SİAİ mesafe 52,38-45,63 mm, facies lunata alanı ortalama 13,25-13,65 cm2, limbus acetabuli uzunluğu 13,65-3,61 cm (ortalama 13,63 cm), incisura acetabuli orta noktası ile limbus orta noktası arası mesafe ortalama 56,45-57,12 mm hesaplandı. Acetabulum’un şekli ise 41 kemikte düz şekilli, 8 kemikte düzensiz, 27 kemikte eğimli ve 20 kemikte açısal şekilde hesaplandı.Sonuç: Elde ettiğimiz acetabulum’a ait bu indeks değerlerininin kalça dislokasyonu ve total kalça ameliyatlarında klinisyenlere ve aynı zamanda literatüre katkı sağlayacağını düşünmekteyiz.

Incidence and morphology of the incisive suture in CT scanning of young children and human fetuses.

Incisive suture is a suture classically described on the oral face of the palate in fetuses and young children. The aim of our study was to describe the evolution of the incisive suture in human fetuses and to evaluate the incidence of this suture in a population of young children under 4years, to determine if there is a possibility of improving the anterior growth of the maxilla, by stimulation of this suture. One hundred and thirty CT scan images of patients aged from birth to 48months have been studied and nine fetal palates aged from 18 to 26weeks of development, have been scanned using high-resolution X-ray micro-computed tomography RESULTS: The CT scan images of patients showed that an incisive suture was present in 33/130 cases (25,4%). All the patients with a suture were under 2years old. The fetal palate study showed that the suture was present in the inferior aspect of the palate (oral cavity) in all cases. The incisive suture increased from 18 to 24weeks. At 26weeks it stopped growing although the intercanine length increased. Considering the closure of the suture in a vertical plane, our study on fetuses has shown that the incisive suture is closing from its superior side (nasal side) to its inferior side. Considering all these results it appears to us that the incisive suture is partially ossified after birth, it cannot be stimulated by orthodontic appliances.

Stop and Flip: A Simple and Safe Phacoemulsification Technique.

We introduce a simple, easy to learn, fast and safe technique to facilitate nucleus management in patients with zonular weakening in uncomplicated cases. The surgery begins with a temporal 3.2 mm clear corneal incision under topical anesthesia. Two side-port incisions are made on the inferior and superior sides. Anterior continuous curvilinear 5–6 mm diameter capsulorhexis and hydrodissection are performed to loosen capsule cortical attachments. The nucleus is not rotated, and an appropriated groove (80–90% depth) is sculpted using phaco machine. The groove is cracked into two hemispheres; lateral pressure and a side port manipulator. Then, 15–30 degree phaco tip is introduced and embedded into one hemisphere of nucleus beside the capsulorhexis edge at temporal or nasal part. After complete removal of the first hemisphere, the second is flipped again from bag into iris plane and phacoemulsified in the same manner.

Extra-articular synovial osteochondroma of the Hoffa's fat pad involving the patellar tendon: A case report and literature review.

Synovial osteochondroma (SO) is a relatively uncommon tumor affecting the synovial joints that is characterized by the development of hyaline cartilage from the synovial membrane. The basic pathophysiology of SO is thought to be the metaplastic change of the synovium to hyaline cartilage. Large extra- or para-articular lesions in the Hoffa's fat pad are relatively uncommon. A 56-year-old woman complained of knee pain associated with a large lesion on the anterior of the right knee. She also had restricted range of motion in the knee. Examination revealed an elastic hard 8x9-cm lesion involving the patellar tendon. Computed tomography and magnetic resonance imaging demonstrated a mosaic-intensity mass lesion in the inferior side of the Hoffa's fat pad as well as the patellar tendon. The patient underwent needle biopsy. Histological analysis revealed a solitary SO. There were no atypical features suggestive of malignancy and the mass was resected marginally. The patient had no recurrence or knee functional disorder 3 years postoperatively. There are no reports of SO involving the patellar tendon with restriction of range of motion. Removal of the mass lesion for management for SO, as in the present case, is unusual. To the best of our knowledge, this is the first case of extra-articular SO in the Hoffa's fat pad involving the patellar tendon causing a restriction of range of motion of the knee. Marginal surgical resection improved knee function.

A pilot study of blood supply of the coracoid process and the coracoid bone graft after Latarjet osteotomy.

Latarjet osteotomy is still one of the most reliable and commonly used surgeries in treating recurrent anterior shoulder dislocation. The coracoid process (CP) is the main structure of this surgery. However, the blood supply of CP is not fully understood, and the extent of destruction of blood supply of coracoid bone graft after Latarjet osteotomy procedure is still controversial. Five embalmed cadaveric upper limbs specimens were employed for macro observation of the blood supply of CP. The conjoint tendon (CT) and CP interface were dissected for histology. Sixteen fresh frozen shoulder specimens were used for perfusion and micro CT scanning. Eight specimens were used to present the whole vessel structure of CP. The other eight underwent Latarjet osteotomy procedure. The coracoid bone grafts in both groups were scanned to clarify the remnant blood supply. It was found that the CP was nourished by supra-scapular artery (SSA), thoracic-acromial artery and branch from second portion of the axillary artery (AA). After Latarjet osteotomy procedure, no artery from CT was detected to penetrate the CP at its attachment. Only in one specimen the blood vessel that originated from the CT penetrated the bone graft at the inferior side. Therefore, most of the blood supply was destroyed although there is a subtle possibility that the vessels derived from the CT nourished the inferior side of the CP. In a nutshell, CP is a structure with rich blood supply. The traditional Latarjet osteotomy procedure would inevitably cut off the blood supply of the coracoid bone graft.

Assessment of Acetabulum Deformity During Preoperative Planning for Hip Arthroplasty

Purpose of the study — to improve the two-dimensional planning of total hip joint arthroplasty to ensure precise positioning of the acetabular component in the deformed acetabulum. Materials and methods. Features of roentgenological anatomy of acetabulum and its coverage were studied on 1058 hip joint x-rays in the AP view in accordance with the procedure developed by the authors to define acetabular square — the site of standard positioning of a spherical femoral head in the acetabulum or of a hemispherical acetabular component. The method consisted of identifying the apex of “teardrop” figure; the most lateral points of the pelvic terminal line and roof of the acetabulum; superior part of the acetabular cavity; medial and inferior points of acetabular coverage, and building the sides of acetabular square — medial, inferior, lateral and superior boundary lines. Connection of “teardrop” apex and lateral point of the pelvic terminal line formed the medial side of acetabular square, and a perpendicular to that line drawn through the “teardrop” apex to its inferior side. The lateral side was drawn either through the intersection of the ascending diagonal line — bisector from the top of the “teardrop” figure with the contour of the acetabulum roof, or was a part of the projection of the most lateral point of the acetabular roof on the inferior side of the square. The superior side was a perpendicular connecting the intersection of the ascending diagonal and lateral bounding lines with the medial side of the acetabular square. The area of the deformed acetabular cavity located outside of the acetabular square was assessed as the acetabular defect. Results. Method of defining the acetabular square allowed to identify types of ratios between acetabular cavity and acetabular coverage in transverse (9 types) and longitudinal (7 types) direction. Combination of transverse ratio of acetabular cavity and coverage with longitudinal type allowed to define the options of acetabular deformities in two-dimensional view. The authors identified 25 types of acetabular deformities. Bone defects of acetabular walls were of the major importance among all anatomical features. Cranial defect of acetabulum was observed in 450 cases, medial wall defect — in 38 cases, defect including cranial and medial areas — in 7 cases. Conclusion. The method suggested by the authors to determine acetabular square and acetabular deformity variations allows to screen the anatomical features of the acetabulum during two-dimensional preoperative planning and to make an informed decision on the need to use other planning techniques. The type of acetabular deformity identified during preoperative planning allows to elaborate the indications for replacement of acetabular bone defects and/or resection of acetabular osteophytes.

Correlation of capillary plexus with visual acuity in idiopathic macular epiretinal membrane eyes using optical coherence tomography angiography

Objective: To observe changes in foveal avascular zone(FAZ) and capillary plexus in idiopathic macular epiretinal membrane (IMEM) in optical coherence tomography angiography (OCTA) and analyze their correlation with the visual acuity. Methods: Cross-sectional study. 42 patients (15 Males and 27 females, age 64.8) from the Eye Hospital of Wenzhou Medical University were included with 51 eyes diagnosed as IMEM (IMEM group), and 23 normal eyes (9 Males and 14 females, control group). All patients received the examination of fissure lamp combined with fundus pre-set lens, best corrected visual acuity (BCVA), OCT angiography (OCTA) and fundus photo. OCTA was performed on 3 mm× 3 mm sections centred on the fovea. The software automatically measured the superficial capillary plexus (SCP) and deep capillary plexus (DCP) vessel density(VD) and retinal thickness(RT) and FAZ area. The IMEM eyes were compared with the normal eyes and correlation between the parameters of OCTA and BCVA was analyzed in IMEM. Independent-sample t test and MannWhitney test were used for comparison between groups, and Spearman test was used for correlation analysis. Results: LogMAR BCVA in the IMEM group was 0.40(0.15, 0.70), in the control group was 0.10(0.05, 0.22). FAZ area of IMEM group was (0.09±0.05) mm(2), while that of control group was (0.34±0.13)mm(2).Compared with the control group, in IMEM group, the BCVA was worse (Z=-4.443, P<0.001), FAZ area was smaller (t=-9.198, P<0.001), RT was increased (P<0.001), The foveal DCP and SCP vessel density was increased (t=4.280, 9.079, P<0.01), The parafoveal DCP vessel density was decreased (P<0.05), The parafoveal SCP vessel density was decreased in superior, inferior and nasal side (t=-2.759, Z=-3.998, Z=-2.108; P<0.05). The BCVA was negatively correlated with FAZ area (r=-0.337, P=0.017), positively correlated with center macular thickness (r=0.324, P=0.020). The BCVA was no correlated with foveal VD and parafoveal DCP vessel density (P>0.05), but correlated with SCP vessel density(P<0.05). Conclusions: In the IMEM eyes the BCVA was worse, FAZ area was smaller, foveal vessel density was increased and the parafoveal vessel density was decreased compared with the normal eyes. The smaller the FAZ area, the smaller foveal SCP vessel density, the poorer BCVA. There was no correlation between BCVA and DCP vessel density. Changes in VD in IMEM eyes may lead to changes in vision. (Chin J Ophthalmol, 2019, 55:757-762).