Lateral Border Research Articles

Positive-pressure breath-hold positron emission tomography/computed tomography is feasible for respiratory-induced artifact reduction in healthy dogs.

To perform qualitative and quantitative analysis of positron emission tomography (PET)/CT images using spontaneous ventilation (SV) and positive-pressure breath-hold (PPBH) techniques in order to demonstrate the feasibility of PPBH PET/CT to decrease respiration-induced artifacts. 5 healthy female mixed-breed dogs. 2-([18F]fluoro)-2-deoxy-D-glucose (was administered to each anesthetized dog. An SV PET/CT scan was performed from the head to the femur using 8 bed positions (3 min/bed) followed by a PPBH scan centered over the diaphragm with a single bed position (1.5 min/bed). PET image quality, the misalignment of organs between PET and CT images, and standardized uptake values (SUVs) of liver adjacent to diaphragm were compared between SV and PPBH. Overall image quality and conspicuity of anatomic structures were superior in PPBH than in SV PET images. PPBH induced significantly less misalignment of the liver and diaphragm in all planes compared to SV. For the gall bladder, PPBH showed significantly less misalignment than SV only in the transverse plane. The maximum SUV in all of the liver areas was significantly higher with PPBH compared to SV. PPBH exhibited significantly higher mean SUV in the liver adjacent to the left diaphragmatic dome and left lateral border and higher minimum SUV only in the liver adjacent to the left diaphragmatic dome. PPBH was demonstrated to be a feasible PET/CT protocol with higher PET image quality, less organ misalignment on fused PET/CT, and more accurate SUVs of the liver compared to SV PET/CT in healthy dogs.

Human CD99L2 Regulates a Step in TEM Independent of PECAM and CD99 Regulated Steps

CD99‐like 2 (CD99L2; L2) is a highly glycosylated 52 kDa type‐1 membrane protein that is important for leukocyte transendothelial migration (TEM) in mice. Inhibiting L2 using function blocking antibody or genetic ablation significantly reduces the recruitment of leukocytes to sites of inflammation in vivo. Similarly, endothelial L2 knockout mice have an inherent defect in leukocyte transmigration into sites of inflammation, but not the preceding steps in inflammation. The position of neutrophil arrest suggests L2 regulates a step in TEM independent of platelet endothelial cell adhesion molecule (PECAM). However, the role of L2 in inflammation has only been studied in mice and the mechanism by which it regulates TEM is not known.In order to study the relevance to human inflammation, we studied the role of L2 on primary human cells in vitro. Using immunofluorescence and flow cytometry, our data show that human L2 is constitutively expressed at the borders of endothelial cells and on the surfaces of leukocytes. Inhibiting L2 using antibody blockade, L2‐Fc chimera decoy molecules, or genetic knockdown in endothelial cells significantly reduced transmigration of human neutrophils and monocytes across endothelial cells. Furthermore, our data also show that L2 regulates a specific, sequential step of TEM between PECAM and CD99, rather than operating in parallel or redundantly with these molecules. Similar to PECAM and CD99, L2 promotes transmigration by recruiting the lateral border recycling compartment (LBRC) to sites of TEM, specifically downstream of PECAM initiation. Collectively, our data identify a novel functional role for human L2 in TEM and elucidate a mechanism that is distinct from PECAM and CD99.

A comprehensive evaluation of the association of radiographic measures of lateralization on clinical outcomes following reverse total shoulder arthroplasty.

Although reverse total shoulder arthroplasty (RTSA) has excellent reported outcomes and satisfaction, patients often have postoperative limitations in range of motion (ROM), specifically internal rotation. Increased lateralization is thought to improve ROM following RTSA. The purpose of this study was to evaluate the association between radiographic measurements of lateralization and postoperative ROM and clinical outcome scores following RTSA. The authors hypothesized that increased radiographic lateralization would be associated with improved postoperative ROM, specifically internal rotation, but have no significant association with clinical outcome scores. Patients who underwent RTSA with a 135° neck-shaft angle prosthesis and minimum 2-year clinical and radiographic follow-up were included and retrospectively reviewed. Postoperative radiographs were evaluated for several lateralization measurements including the lateralization shoulder angle (LSA), distance from the lateral border of the acromion to the lateral portion of the glenosphere, distance from the glenoid to the most lateral aspect of the greater tuberosity, and the distance from the lateral aspect of the acromion to the most lateral aspect of the greater tuberosity. Linear regression analyses were used to evaluate the independent association of each radiographic measurement of lateralization on forward flexion, external rotation, internal rotation, and the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) index score at 2 years postoperation. Receiver operating characteristic (ROC) curves were constructed to identify significant thresholds of each radiographic lateralization measurement. A total of 203 patients were included. For internal rotation, a greater LSA (P = .007), shorter acromion to glenosphere distance (meaning more glenoid lateralization) (P = .005), and a greater acromion to greater tuberosity distance (with the tuberosity more lateral to the acromion) (P = .021) were associated with improved internal rotation. Overall, ROC analysis demonstrated very little significant data, the most notable of which was the LSA, which had a significant cutoff of 82° (sensitivity 57%, specificity 68%, P = .012). Of the numerous radiographic measures of lateralization after RTSA, the LSA is the most significantly associated with outcomes, including improved internal rotation and a decrease in forward flexion and ASES score. The clinical significance of these statistically significant findings requires further study, as the observed associations were for very small changes that may not represent clinical significance.

The Correction of Plagiocephaly

Real Plagiocephaly is a rare form of craniosynostosis, resulting from the premature fusion of the coronal suture on one side, leading to a deformed head and to an apparently exteriorized homolateral eye. We present a simple and straightforward technique, based on removal of the involved suture, with the surgical incision prolonged to the orbital roof till near the ethmoide. After having sectioned the lateral border of the orbit at the junction of the zygomatic and frontal bones, a paramedian incision is made on the frontal bone, from the anterior fontanel (always carefully preserved), till the glabella. Then follows simple osteoclasia of the frontal bone and placement of a bone graft obtained from the adjacent parietal bone and that will maintain the forward projection of the frontal bone (but in slight hypercorrection). The grafts are simply fixed with silk sutures, placed through perforating holes in the bones, no metal being used. The transverse surgical wound, going almost from ear to ear, is closed in the usual way.

Inclusion of a latissimus dorsi segment in an extended lower trapezius musculocutaneous flap facilitates complex defect reconstruction

The pedicled lower trapezius musculocutaneous flap (LTMF) can extend far beyond the lateral border of the trapezius muscle, with a reliable blood supply. However, the distal part of the extended LTMF lacks a muscular component, limiting its usage in complex defect reconstruction, which often requires obliteration of dead space and coverage of vital structures. To overcome this limitation, we modified the LTMF by adding a segment of latissimus dorsi muscle (LDM). Between 2014 and 2021, the modified extended LTMF was used to reconstruct complex defects in the head, neck, shoulder, and contralateral chest wall and back in 19 patients. By preserving the interconnections between the branches of the posterior intercostal arteries, we were able to include various amounts of LDM within the extended LTMF. The LDM component was used to obliterate dead space and repair wounds involving cerebrospinal fluid leakage, infection, radioactive osteomyelitis, exposed carotid artery, lung, and implant materials. The average flap size was 30.7cm × 10.9cm (range: 25 × 8 cm-40 × 14cm). The average size of the LDM was 113.9 cm2 (range: 27.7-216.6 cm2). Partial flap necrosis occurred in two patients and the secondary defects were reconstructed using a local flap. The remaining 17 flaps survived completely. The LTMF carrying a segment of the LDM could be considered for patients undergoing reconstruction of complex defects in the head, neck, shoulder, and contralateral chest wall and back and for patients who are ineligible for free flap reconstruction.

Determination of a neurologic safe zone for bicortical S1 pedicle screw placement

BACKGROUND CONTEXTLumbosacral fixation is commonly used for the management of lumbosacral instability. As the sacrum mainly consists of cancellous bone, bicortical fixation, in which the pedicle screw penetrates the anterior sacral cortex, can help increase the strength of fixation. However, this method carries a risk to the L5 nerves which lie anterior to the sacrum at this level. PURPOSEThe goal of this study is to determine a safe zone for the placement of S1 pedicle screws to decrease the likelihood of L5 nerve injury. STUDY DESIGNRetrospective imaging review. PATIENT SAMPLEThis study evaluated imaging data of patients who underwent lumbar spine magnetic resonance imaging (MRI) at our institute between September 1, 2020 and September 1, 2021. OUTCOME MEASUREST1-weighted axial MRIs were measured at the level of S1 pedicle screw placement. The space medial and lateral to the L5 nerve root on the anterior sacrum were measured and defined as safe zones. Additionally, the nerve width and sacral lengths were measured at this level. METHODSThe distribution of the measurements were evaluated to determine a medial and lateral safe zone, as well as the average nerve width at the level of S1 pedicle screw placement. Correlation analysis was performed to determine a relationship between safe zone sizes and sacral size. RESULTSA total of 400 MRIs were analyzed. The average medial safe zone measured was 32.8 mm (95% CI: 32.2–33.4) with no nerves lying within 22.3 mm of the midline sacrum. The average lateral safe zone measured was 17.7 mm (95% CI: 17.1–18.2), with no nerves within 5.3 mm of the lateral border of the sacrum. The average nerve root width was 6.2 mm (95% CI: 6.13–6.34). An increased sacral length was associated with a larger medial (p<.001) and lateral (p<.001) safe zone. CONCLUSIONSOur study revealed lateral and medial safe zones for the placement of S1 pedicle screws to avoid iatrogenic nerve injury in a retrospective cohort of 400 patients. There were no L5 nerve roots found within 22.3 mm of the sacrum's mid-axis or within 5.3 mm of the sacrum's anterolateral border. These defined safe zones can be used during pedicle screw planning and placement to decrease the risk of injury to the L5 nerve root.

Florid squamous papilloma of the tongue

A 47-year old Chinese woman presented with a 2-year history of multiple small flammulated papilloma-liked lesions on her tongue. She has noted an increase of the size and number of lesions within the past month, with significant harsh feeling, but the taste sensation is normal. The physical examination showed diffusely multiple, florid, and slight raised spots in different sizes, measuring from 1 to 3 mm in dimensions, appearing on the dorsal surface and lateral borders of the tongue (Figure 1A and 1B). Incisional biopsy of the lesion area showed papillary mucosal epithelial, dermal superficial collagen bundle and mucous matrix hyperplasia (Figure 1C). She denied any other cutaneous or systemic abnormalities. Based on histopathological examination, a diagnosis of squamous papilloma was made.

Differences in mediolateral dynamic stability during gait initiation according to whether the non-paretic or paretic leg is used as the leading limb.

We investigated mediolateral dynamic stability at first foot off and first initial contact during gait initiation according to whether the paretic or non-paretic leg was used as the leading limb. Thirty-eight individuals with stroke initiated gait with the paretic and non-paretic legs as the leading limb, and their movements were measured using a 3D motion analysis system. Margin of stability (i.e., the length between the extrapolated center of mass and lateral border of the stance foot) was used as an index of dynamic stability, with a large value indicating dynamic stability in the lateral direction. However, an excessively large margin of stability value (i.e., when the extrapolated center of mass is outside the medial border of the stance foot) indicates dynamic instability in the medial direction. Differences in the margin of stability between tasks were compared using the Wilcoxon signed-rank test. The minimum margin of stability was observed just before first foot off. When the non-paretic leg was used as the leading limb, the margin of stability tended to be excessively large at first foot off compared with when the paretic leg was used (p < 0.001). In other words, the extrapolated center of mass was outside the medial border of the paretic stance foot. In conclusion, lateral stability was achieved when using the non-paretic leading limb because the extrapolated center of mass was located outside the medial border of the stance foot. However, medial dynamic stability was lower for the non-paretic leading limb compared with the paretic leading limb.

P152 A rare case of necrotising vasculitis presenting with calf swelling in a 15-year-old female

Abstract Background/Aims We present the case of MF, a 15-year-old female who presented to the paediatric clinic with swelling and pain affecting her right calf. She was previously fit and well. Initial imaging was suggestive of localised myositis but a subsequent muscle biopsy was in keeping with necrotising vasculitis. Methods In May 2021, MF presented to a general paediatric clinic with a 6-week history of right lateral calf pain and swelling to the lateral border of the right proximal fibula. She was systemically well. Blood tests and an x-ray were normal. An ultrasound scan of the right calf showed fusiform thickening of the peroneus longus muscle proximally. There was no discrete mass. The appearance was thought to be an inflammatory process such as myositis. An MRI scan was advised. Over the course of the next few weeks, the swelling and pain to the right calf progressed and she was unable to fully weight bear. Repeat blood tests were normal except CRP 11. CK was normal. At the end of June, an MRI scan of the right lower leg showed significant swelling and oedema along the length of the peroneus longus musculature as demonstrated on ultrasound. Florid oedema extended to involve the soleus and to a lesser extent the lateral head of gastrocnemius. There was thickening and oedema through the subcutaneous fat circumferentially compared to the left side (see images). The appearances were thought to be consistent with myositis but an inflammatory malignancy could not be fully excluded and an opinion from the Birmingham team was recommended. The Birmingham MDT advised that malignancy was unlikely but a CT scan was recommended. The CT scan confirmed the MRI findings (see image). Results MF's symptoms progressed rapidly over a short period of time with diffuse swelling of the right lower limb with associated pain and numbness. She also developed purpuric lesions around the ankle (see photos). The CRP increased to 59 and then 123. CK remained normal. Local rheumatology opinion was sought once malignancy had been excluded. The initial impression was of a focal myositis but a muscle biopsy was requested urgently. IV steroids were administered followed by high dose oral prednisolone as a reducing course. The symptoms improved rapidly. The subsequent biopsy showed a florid necrotising vasculitis affecting the small-medium arterial vessels. There was no evidence of myositis (see image). ANCA was negative and CT renal and abdominal angiogram was normal. Nerve conduction studies showed a very severe sensory lesion of the right sural nerve, which explained the persistent numbness. Mycophenolate mofetil was added and clinical improvement is ongoing. Conclusion We present a rare case of localised vasculitis in the right calf. A literature review indicates this is the first case presented in an adolescent. Disclosure S.C. Earl: None. J. Smith: None. A. Ramanan: Grants/research support; Abbvie.

Technical Guide and Tips to Posterior Arthroscopic Latissimus Dorsi Transfer for Irreparable Posterosuperior Rotator Cuff Tears

Latissimus dorsi (LD) transfer is a reliable treatment option for irreparable posterosuperior (PS) rotator cuff tears in young and active patients that need to recover the range of motion for their daily living activities. The technique starts with an arthroscopic assessment of the tear. The next step is the mini-open stage for muscle release from the subcutaneous layer of the skin, the teres major (TM), the triceps, and the lateral border and inferior angle of the scapula. Later, the scope is used to prepare the footprint (arthroscopy) and for the release and the harvest of the tendon (endoscopy), taking care not to detach the TM and not to damage the radial nerve. A grasper is used to push the LD to its correct path medial to the triceps. After that the same instrument is placed from the anterolateral and the anterior arthroscopic portals toward the mini-open incision to catch the sutures previously loaded on the LD tendon with Krackow stitches. The LD is transferred to the greater tuberosity and is attached with one medial and one lateral knotless anchors. A third point of fixation enables a partial RC repair and ensures a surface of bone to tendon healing.

Axillary lymphadenectomy in dogs: A description of surgical technique.

The axillary lymph center drains a large area; however, axillary lymphadenectomy is rarely reported in series detailing lymph node extirpation in dogs. No surgical technique has yet been described for axillary and superficial axillary lymphadenectomy. This study describes a technique for excision of nodes in the axillary lymph center of the dog. Two male neutered and two male intact cadavers weighing between 6.3 and 36.1kg were used. With cadavers in dorsal recumbency and the shoulder extended, an incision was made in the caudal axillary region. Blunt dissection was used to separate the pectoralis profundus and latissimus dorsi muscles and loose connective tissue was dissected until the axillary lymph node was identified caudal to the brachial vein. The axillary lymphatic trunk was followed caudad from the axillary lymph node to identify the accessory axillary lymph node, deep to the lateral border of the pectoralis profundus muscle, for subsequent extirpation. Axillary lymph nodes were successfully removed in all axillae, and accessory axillary lymph nodes were located in 6/7 axillae and could not be visualized within the axillary lymphatic trunk in the remaining axilla. The described surgical technique allowed consistent identification of the axillary lymph node and the lymphatic trunk associated with the accessory axillary lymph node. This technique description provides a guide for surgeons to facilitate axillary and accessory axillary lymphadenectomy in the dog. While anatomic variation must be considered, the use of the axillary lymphatic trunk as a landmark may simplify identification of the small and inconsistent accessory axillary lymph node.

Deltoid Intramuscular Injections: A Systematic Review of Underlying Neurovascular Structures to the Muscle and Proposing a Relatively Safer Site.

The deltoid is the preferred site for intramuscular injection (IMI) because of its easy accessibility for drug and vaccine administration. Government immunization advisories, standard anatomy textbooks, and researchers have proposed various injection techniques and sites, but specific guidelines are lacking for the administration of IMIs in the increasingly used deltoid site. This study analyzes the procedures of administering IMIs in the deltoid related to the neurovascular network underlying the muscle and proposes a preferred site with the least chance of injury. The review protocol was submitted with PROSPERO (ID: 319251). PubMed, Google Scholar, and Websites of National Public Health Agencies were searched from 1950 up to 2022 for articles, advisories, and National Immunization Guidelines using Medical Subject Headings (MeSH) terms, including IMIs, deltoid muscle, safe injection sites, to identify recommendations for safer sites and techniques of administering deltoid IMIs. All the authors strictly adhered to a well-developed registered review protocol throughout the study and followed the risk of bias in systematic reviews (ROBIS) guidance tool. The proposed sites and landmark data were tabulated, and each site was analyzed based on the underlying neurovascular structures. Data were depicted by self-generated images.The initial search identified 174 articles. After applying the inclusion and exclusion criteria, 57 articles were shortlisted. Out of the 39 selected articles, 18 focused on the administration of deltoid IMIs, whereas seven focused on the variations in the underlying neurovascular structures in proximity to the deltoid muscle. The remaining 14 articles were the immunization guides issued by the National Public Health Agencies of the Government of India and abroad, whose data was used for comparison. Twelve deltoid IMI sites and techniques were identified. A site 1-3 fingerbreadths/5 cm below the mid-acromion point (7 studies); mid-deltoid site/densest part of the deltoid (1 study); a site at the middle third of the deltoid muscle (1 study); triangular injection site (1 study). Limitations included the unavailability of free access to complete text in many articles resulting in exclusion. The area around the shoulder joint and up to the lower level of the intertubercular sulcus is highly vascularized by the presence of many anomalous arterial patterns. To avoid injury, a safer site is proposed of 5 fingerbreadths/10 cm below the midpoint of the lateral border of the acromion. The authors received no specific funding for this study except for the journal publication charges.

Oral hairy leukoplakia in an immunocompetent patient treated with topical steroids for oral lichen planus

<h3>Objectives</h3> Oral Hairy Leukoplakia (OHL) is an Epstein-Barr Virus (EBV)-related lesion of the oral mucosa, most commonly affecting immunocompromised patients. Although HIV-infection appears to be the most frequent pre- disposing factor, OHL cases have been reported in patients with other causes of systemic or even local immuno- suppression. Herein, we present a case of OHL arising in an HIV-negative immunocompetent patient treated with topical steroids for Oral Lichen Planus (OLP). <h3>Findings</h3> A 62 years old male patient with biopsy-proven OLP presented for his regular follow-up. He was un- der treatment with topical steroids: fluocinonide (oral gel) and dexamethazone (oral solution). Clinical examina- tion revealed a white plaque of irregular surface involving the right lateral border of the tongue, which had not been noticed in the previous follow up appointment, 2 months ago. With a differential diagnosis of morsicatio linguarum, hypertrophic OLP and leukoplakia, an incisional biopsy was performed. Histopathologic examination revealed hyperkeratotic squamous epithelium with surface corrugations and the presence of "balloon cells" in the upper spinous layer, some of which exhibited nuclear beading in high power magnification. Immunohistochem- ical examination for EBV-LMP1 and in-situ hybridization for EBV were positive, establishing a diagnosis of OHL. Although no symptoms or signs of immunosuppression/HIV infection were present, the patient underwent blood examinations, including an HIV ELISA antibody test, which were within normal limits. In the absence of any in- dications of systemic causes, a diagnosis of OHL associated with local immunosuppression due to long-term use of topical corticosteroids was rendered. <h3>Conclusions</h3> OHL may be associated with different types of immunosuppression. In recent years, few cases of OHL developing in patients treated with topical steroids have been reported, the majority of which were linked to inhalers for pulmonary diseases. Topical steroid-induced immunosuppression in patients with oral mucocutaneous diseases should be considered as a possible, albeit unusual, cause of OHL.

Subgemmal neurogenous plaque of posterolateral region in tongue: A case report and review of literature.

IntroductionThe subgemmal neurogenous plaque is a well-defined subepithelial neural plexus associated with taste buds, located within foliate, fungiform, and circumvallate papillae of the human tongue, that is poorly known by dentists and medical professionals. The hyperplasia of subgemmal neurogenous plaque may occur and it manifests as a papule, nodule, plaque, or ulcer in the lateral posterior border of the tongue inducing the overdiagnosis of reactive, cystic, or neoplastic lesions. The aims of this study are to report a case of a patient with subgemmal neurogenous plaque, and to provide a comprehensive review of other subgemmal neurogenous plaque in the posterolateral tongue with challenging diagnosis.Presentation of caseA 28-year-old female with a little yellowish nodule, asymptomatic, located in posterior left lateral border of the tongue. Accurate diagnosis was based in excisional biopsy and histopathological examination showing a superficial neurofibroma-like pattern, and a neuroma-like in the deep zone. The final diagnosis was subgemmal neurogenous plaque.DiscussionThe subgemmal neurogenous plaque has an erythematous nodule or papule in the border of the tongue that are frequently misdiagnosis as foliate papillitis and lymphoepithelial cyst. Despite the subgemmal neurogenous plaque be considered a normal structure, the biopsy is recommended for differential diagnosis with other benign or malignant lesions in tongue.ConclusionContributing with the dentists and medical professionals in their clinical practice, we reviewed the literature and added a case of subgemmal neurogenous plaque in the posterolateral region of the tongue, highlighting the importance of its recognition to avoid misdiagnosis.

Prevalence of Positive Level IIb Lymph Nodes in Tongue Carcinoma: Experience From a Tertiary Care Center in North India.

IntroductionComplications during and after dissection of level IIb lymph nodes include spinal accessory nerve (SAN) dysfunction, which results in the limitation of shoulder movements and, thus, hurts the quality of life. The current study aims to know the occurrence of level IIb lymph node positivity in tongue carcinoma.MethodsThis cross-sectional study was conducted from January 2019 to December 2019 in a tertiary care center in North India. Adult cases with primary ulcer-proliferative growth over the lateral border of the tongue were included in the study. The level IIb lymph node positivity from the postoperative histopathology report was the primary outcome measure of this study. To investigate the potential association of tumor size on level IIb lymph node positivity, we compared the maximum tumor dimensions among the level IIb lymph node-positive and -negative groups. In addition, to analyze the impact of the tumor's invasive nature on level IIb lymph node positivity, we compared the depth of invasion and proportion of cases with muscle involvement among the level IIb lymph node-positive and -negative groups. Lastly, to investigate their concurrent occurrences, we compared the number of level IIb lymph node-positive cases among the level IIa lymph node-positive and -negative groups.ResultsA total of 39 patients fulfilling the inclusion criteria were included in the study. Only six had positive level-IIb lymph nodes. No significant associations of tumor size, invasion depth, muscle invasion, or involvement of level IIa lymph nodes with the positivity of level IIb lymph nodes were found. However, only three were level IIb lymph node-positive in 28 level IIa lymph node-negative cases.ConclusionConsidering the low risk of isolated level IIb lymph node positivity in level IIa lymph node-negative cases, the dissection of level IIb nodes could be omitted during the surgical excision of the tumor. However, radiological investigations detecting metabolic activity should be used in the preoperative period and postoperative follow-up to detect early lymph node involvement and disease recurrence.

The Myopectineal Orifice: A Study of Thai Cadavers.

ObjectiveThis study aimed to determine the myopectineal orifice size measured in Thai human cadavers.Materials and MethodsA total of 30 human cadavers, comprising 55 groins, were assessed. Myopectineal orifices (MPOs) were measured in two dimensions: height from the lower border of the conjoined tendon to the upper border of the pectineal ligament and width from the lateral border of pubic tubercle to the medial border of the iliopsoas muscle.ResultsThe mean MPO size is 7.13 + 0.14 cm in width and 6.66 + 0.32 m in height. The mean width and height in male cadavers are 7.16 + 0.14 and 6.84 + 0.27 cm, respectively. The mean width and height in female cadavers are 7.09 + 0.12 and 6.45 + 0.24 cm, respectively. The mean MPO area is 37.26 ± 0.027 cm2, compared with the area of mesh graft 10 cm × 15 cm, 150 cm2. Although the shrinkage of cadaveric tissue and mesh size were adjusted, which were 39.56 ± 0.029 and 81 cm2, respectively, they were found to be sufficient for the mean MPO area. It was found that the mesh size was sufficient for the mean MPO area.ConclusionA mesh size of 10 cm × 15 cm is found to be the appropriate size to cover the MPO among Thais.

Subacromial Balloon Spacer: Indications, Rationale, and Technique.

First, a diagnostic arthroscopy is performed. In addition to evaluating the rotator cuff, care is taken to evaluate the tendinous insertion of the subscapularis as well as the long head of the biceps tendon, the labrum, and the articular cartilage of the joint. Synovectomy, bursectomy, and biceps tenodesis or tenotomy are performed as appropriate. For cases with an intact or repairable subscapularis, an acromioplasty is performed. The balloon size is determined with use of a probe through the lateral portal, measured from 1 cm medial to the superior glenoid rim to the lateral border of the acromion. The balloon-insertion device is advanced through the lateral portal, and the balloon is inflated with sterile saline solution after appropriate subacromial positioning. The balloon is then sealed and detached from the insertional device. Most treatment algorithms attempt to reduce pain and dysfunction with initial nonoperative treatment options4. For cases in which nonoperative treatment has failed, several surgical techniques have been described. These include partial rotator cuff repair, graft interposition, graft augmentation, superior capsular reconstruction, tendon transfers, and reverse total shoulder arthroplasty5. Ideal candidates for this procedure are patients with irreparable symptomatic rotator cuff tears. These patients should primarily complain of pain and have a preserved range of motion. Alternatively, if they have reduced range of motion because of pain, then their range of motion should improve after a corticosteroid injection. It is also important that the patient has an intact or repairable subscapularis. The balloon is beneficial in patients with medical comorbidities that would limit the use of other techniques dependent on biologic tissue healing or that would limit the use of arthroplasty. Poor candidates would be patients with pseudoparalysis, axillary nerve palsy, irreparable subscapularis tears, or severe glenohumeral arthritis (Hamada grade ≥3). A recent randomized clinical trial demonstrated the 2-year efficacy, safety, and benefits of the InSpace subacromial balloon spacer6. The authors reported significant early clinical benefit that was maintained over 2 years. Additionally, this benefit was equivalent or superior to the partial-repair control group at all included time points. The multiyear clinical efficacy of the subacromial balloon spacer in that study was similar to that reported by Familiari et al. and Senekovic et al. at 3 and 5 years postoperative, respectively1,7. Together, these studies would suggest that the initial benefit of the subacromial balloon spacer lasts beyond its biodegradation at 12 months postoperatively. Proper placement of the lateral portal should be made parallel to the supraglenoid tubercle. Such placement allows easy insertion and orientation of the balloon at the midpoint of the supraglenoid tubercle.Arthroscopic evaluation of the subscapularis must be performed. For cases with a torn subscapularis, partial or complete repair is recommended to maximize anteroposterior coupling forces that are critical to the function of the balloon.Preservation of the medial bursa and coracoacromial ligament will provide structural constraints against medial migration of the balloon into the supraspinatus fossa.Acromioplasty can be performed to create a smooth articulating surface and minimize friction on the implant, but should only be done in cases in which there is an intact or repairable subscapularis to minimize the risk of anterior escape.Adequate debridement, with acromioplasty as needed, will provide full visualization of the subacromial space to allow proper sizing of the spacer. Proper implant sizing will reduce the risk of subsequent balloon displacement postoperatively.If the measurement of the balloon is between 2 sizes, the larger spacer can be selected to limit displacement.Overinflation of the balloon can cause excessive tension on the deltoid. Underinflation increases the risk of escape. To optimize inflation of the balloon, the senior author prefers to fill the balloon to the recommended maximum volume and then remove saline solution until the balloon reaches the recommended final volume.If there is partial tearing of the long head of the biceps, a tenotomy or tenodesis is recommended. ROM = range of motionRCT = randomized clinical trialTSA = total shoulder arthroplastySCR = superior capsular reconstructionRC = rotator cuffISP = infraspinatusSSP = supraspinatusSSC = subscapularisRI = rotator intervalCAL = coracoacromial ligamentCA = coracoacromialC = coracoidMRI = magnetic resonance imagingSAD = subacromial decompressionPRO = patient-reported outcomeFDA = U.S. Food and Drug Administration.

The Association Between Sublingual Varices and Cardiovascular Risk Factors.

ObjectiveTo study the association between sublingual varices (SV) and cardiovascular (CVD) risk factors.MethodsA total of 989 consecutive dental patients aged 55–84 years participated in the study, which applied a survey about risk factors, diseases and medications. Digital photos of the lateral borders of the tongue, height, weight, waist, hip and blood pressure were registered, and blood samples were analyzed. Those with SV were compared with those without SV (nSV).ResultsThose with SV had more hypertension 41.8% vs 27.0% (p<0.0001), a higher systolic blood pressure (BP) 139.5 (SD 18.6) mmHg vs 134.3 (SD 18.8) mmHg (95% CI −7.73 ─ −2.72), more diabetes type 2 (DM-2) 7.4% vs 3.8% (p=0.014), a higher fasting plasma glucose 5.9 (SD 1.5) mmol/L vs 5.7 (SD 1.0) mmol/L (95% CI −0.42 ─ −0.05), more dyslipidemia 24.1% vs 17.7% (p=0.018), lower HDL 1.6 vs 1.7 (p=0.003), a greater waist circumference 97.0 cm vs 93.9 cm (95% CI −4.66 ─ −1.46), a greater waist/hip ratio 0.92 cm/cm vs 0.90 cm/cm (95% CI −0.03 ─ −0.01), and a higher BMI 26.6 kg/m2 vs 26.0 kg/m2 (95% CI −1.11 ─ −0.03). The following associations with SV were found in multivariate analysis: hypertension OR=1.6 (95% CI 1.19 ─2.13), a high systolic BP OR =1.5 (95% CI 1.11 ─2.13), a high fP-glucose OR= 1.8 (95% CI 1.03 ─3.21), a low HDL OR= 1.8 (95% CI 1.15 ─2.92), a greater waist circumference OR= 1.68 (95% CI 1.10 ─2.58), a greater waist/hip ratio OR=2.21 (95% CI 1.36 ─3.58), and a higher BMI OR=1.05 (95% CI 1.02 ─1.09).ConclusionThis study shows an association between SV and a high BP, a high fP-glucose, hypertension, diabetes mellitus type 2, dyslipidemia, abdominal obesity, older age and smoking.

Minimizing sampling error using a unique ink-stained reflectance confocal microscopy-guided biopsy technique to diagnose a large lentigo maligna

An 88-year-old man with a history of melanoma presented with a 5.0-cm × 5.5-cm patch with variegated pigmentation (Fig 1, A) involving the right zygomatic area. An 8-mm scar from a previous biopsy was present near the lateral aspect of the lower portion of the right eyelid. On dermatoscopy, perifollicular hyperpigmentation with globules was noted adjacent to the scar, near the lateral border (Fig 1, B).

Morphological characteristics of subaxial cervical pedicles and surrounding critical structures in patients with vertebral artery dominance - an anatomical study based on computed tomographic imaging

BackgroundNo study has assessed the feasibility and safety of cervical pedicle screw implantation in patients with vertebral artery dominance (VAD), a common vertebral artery (VA) variation which can increase VA injury (VAI) risk. This study was to assess morphological characteristics of the subaxial cervical pedicles and surrounding critical structures, and identify their correlations in patients with VAD.MethodsComputed tomography arteriography scans of 152 patients were used for retrospectively measuring parameters including pedicle outer width (POW), the distance from the lateral pedicle border to the closest part of VA (DPVA), diameter of VA (DVA), area of VA (AVA), area of transverse foramen (ATF) and occupational ratio of transverse foramen (TF). Moreover, correlations among some critical parameters were assessed.ResultsOne hundred eight males and 44 females, with a mean age of 55.9 years were included. POW was smaller on the dominant side than on the non-dominant side, whereas DPVA, DVA, AVA, ATF, and TF were larger on the dominant side than those on the non-dominant side. On both sides, POW < 4 mm and POW + DPVA < 5 mm were observed most frequently at C3 and C4. On both sides, POW was correlated to ATF, and ATF was correlated to DVA and AVA. DPVA was correlated to ATF on the dominant side.ConclusionPatients with VAD exhibited smaller POW on the dominant side, most frequently at C3 and C4. Dominant VA may indirectly affect POW. TF may be a key determinant of DPVA and POW.