Lateral Border Research Articles

Optimization of supraclavicular lymph node clinical target volume delineation in high-risk breast cancer: a single center experience and recommendation

BackgroundProphylactic irradiation of supraclavicular lymph node drainage areas can improve the regional control rate of lymph node-positive or lymph node-negative disease but a locally-advanced stage breast cancer, and it can reduce breast cancer-related mortality. However, many controversies exist in the clinical target volume delineation of supraclavicular lymph node drainage in patients with breast cancer.MethodsWe retrospectively analyzed 42 patients with breast cancer and supraclavicular lymph node metastasis at our hospital between January 2017 and December 2021. Among these cases, 32 were locally advanced and 10 were stage IV at initial treatment. A patient with breast cancer who did not undergo dissection of the supraclavicular and infraclavicular lymph nodes at our hospital was selected as a standard patient. A contrast-enhanced computed tomography (CT) scan for positioning was used as a template image, and blood vessels, muscles, and bony landmarks were used as references for positioning. The metastatic supraclavicular lymph nodes were identified in all enrolled patients and projected into the template CT images.ResultsThe metastastic pattern of supraclavicular lymph node in breast cancer was proposed: distribution along the posterolateral border of the internal jugular vein (medial supraclavicular group) and along the transverse jugular vein (lateral supraclavicular group). We theorized that the lateral and posterior borders of the clinical target volume in the supraclavicular region should include the lymph nodes in the posterior triangle of the neck (level V) in high-risk individuals. If the metastatic axillary lymph node is extensive, then the superior border of the supraclavicular region should be moved upward appropriately.ConclusionsThis study analyzed patients with breast cancer and supraclavicular lymph node metastasis at initial treatment, explored the metastastic pattern of supraclavicular lymph node, and applied anatomical knowledge to further optimize the target volume delineation of supraclavicular lymph node drainage area in high-risk breast cancer.

The reduction of the left ventricular long-axis early diastolic peak velocity (e') evident by early-middle age occurs in the absence of aging-related slowing of active relaxation.

A decrease in the left ventricular (LV) long-axis early diastolic peak velocity (e') is evident by early-middle age, but it is unknown to what extent this decrease is due to slowing of the speed of active relaxation versus a reduction in LV long-axis excursion during early diastole (EDExc). Pulsed-wave tissue Doppler imaging (TDI) signals were acquired from the septal and lateral borders of the mitral annulus in 62 healthy adult subjects of age 18-45years. EDExc and LV systolic excursion (SExc) were measured as the integrals of the respective TDI signals. The speed of active relaxation was indirectly assessed using time interval measurements related to the TDI early diastolic signal, including the isovolumic relaxation time (IVRT'), the acceleration time (EDAT), and the duration (EDDur). Multiple linear regression analyses were performed to identify the relationships between e', age, EDExc, SExc, and time intervals. The findings were similar for both LV walls. Age was negatively correlated with e' and EDExc, but was not correlated with SExc, IVRT', EDAT, or EDDur. The closest correlate of EDExc was SExc, and EDExc was independently correlated with both SExc and age. e' was also positively correlated with SExc, but the closest correlate of e' was EDExc, and when combined with EDExc, EDDur became an independent predictor of e'. The aging-related decrease in e' evident by early-middle age occurs in the absence of aging-related slowing of active relaxation and therefore can be largely attributed to the accompanying reduction in EDExc.

The anatomical description of the pericruciate fat pad (PCFP) – a brief report of cadaveric dissection

Introduction. Fat pads of the human knee joint are relatively well-known structures except for the pericruciate fat pad (PCFP). Aim. The study aimed to describe (1) the anatomy of the pericruciate fat pad (PCFP) and (2) its relation to the middle genicular artery (MGA). Materials and methods. Four male cadaveric lower limbs were dissected. PCFP was excised, and its horizontal and vertical lengths and volume were measured. The presence of MGA was assessed, and its internal diameter was registered. Results. PCFP was located in the intercondylar fossa. Its superior, inferior, medial&lateral and posterior borders were the intercondylar roof, tibial plateau, femoral condyles, and posterior knee capsule, respectively. The anterior part of the PCFP enveloped the posterior cruciate ligament (PCL). PCFP had a homogenous appearance of adipose tissue with small lobules. It was connected to the PCL with a fibrous process. The mean horizontal&vertical length and volume were 56.85±3.4 mm (range 52.1-60.2 mm), 42.8±5.8 mm (range 34.2-46.1 mm) and 43.75±4.79 ml (range 40-50 ml), respectively. The MGA penetrated the PCFP in all four examined limbs; its mean diameter was 1.18±0.33 mm (range 0.8-1.55 mm). Conclusions. PCFP is a relatively large structure, with MGA present within all examined cases. Care must be taken when performing surgeries involving the posterior intra-articular part of the knee because the PCFP may present an underestimated potential for oedema and bleeding.

Anterolateral surgical triangle of the cavernous sinus: a cadaveric study of neurosurgical importance.

The anterolateral triangle around the cavernous sinus is a surgical skull base triangle used as a neurosurgical landmark essential to skull-based surgeries. There are few reports of its measurements with little attention paid to anatomical variations. A total of 15 adult human cadaveric skulls were dissected to expose the anterolateral triangle on both sides. The triangle was defined and measurements of the three borders were taken precisely and the area of each triangle was calculated using Heron's formula. On an average, the length of the anteromedial border is 11.4 (+ 2.2mm); the length of the posteromedial border is 8.7 (+ 2.6mm); the length of the lateral border is 13.06 (+ 2.6mm) and the area of the anterolateral triangle is 48.05 (+ 17.5mm2). Concise understanding of anterolateral triangle is essential to skull-based surgeries; comprehending its anatomy helps with better surgical planning and provides insight into local pathology.

Evaluation of diode laser efficacy in treating benign oral soft tissue masses: A case series

Introduction and importanceThe diode laser, with a wavelength ranging from 810 to 980 nm, is a modern treatment modality that offers significant advantages in the management of benign oral soft tissue masses. Therefore, this report aimed to assess the efficacy of diode laser application for excisional biopsy of such masses. Case presentationThree female patients, aged 9, 39, and 45 years, visited the Oral Medicine Clinic with complaints of painless masses in the oral cavity persisting for two to three months. Their intraoral examination showed the presence of pedunculated or sessile exophytic lesions with a smooth surface. The lesions appeared as single, pink to red protrusions located in various sites, including the left buccal mucosa, right lateral border of the tongue, and lower gingiva. Clinical discussionExcisional biopsy of the masses was carried out in the patients using the diode laser. The surgical procedures ranged from 10 to 20 min, with minimal intraoperative bleeding and precise cutting, while no pain was reported. Postoperatively, at two weeks and four months follow-up, the intraoral wounds exhibited excellent healing without complications such as pain, bleeding, swelling, scarring, infection, or mass recurrence. The clinical diagnosis of irritational fibroma (two cases) and fibrous epulis were confirmed by histopathological examination. ConclusionDiode laser emerges as a highly efficacious method for the excisional biopsy of benign oral soft tissue masses, providing intraoperative and postoperative advantages over scalpel surgery.

Preoperative assessment of depressor anguli oris to prevent myectomy failure: An anatomical study using high-resolution ultrasound

Myectomies of the lower lip depressor muscles have unexplained high failure rates. This study aimed to examine the depressor anguli oris (DAO) muscle using high-resolution ultrasound to identify potential anatomical explanations for surgical failures and to determine the accuracy of utilizing preoperative ultrasound assessment to improve myectomies. Anatomical features of DAO and the surrounding anatomy were examined in 38 hemifaces of human body donors using high-resolution ultrasound and dissection. The ultrasound and dissection measurements showed the DAO muscle width to be 16.2±2.9 versus 14.5±2.5mm, respectively, and the location of the lateral muscle border 54.4±5.7 versus 52.3±5.4mm lateral to the midline. In 60% of the cases, the facial artery was either completely covered by lateral DAO muscle fibers or was found to be in direct contact with the lateral border. Significant muscle fiber continuity was present between the DAO and surrounding muscles in 5% of cases, whereas continuity between the depressor labii inferioris and surrounding muscles was considerably more common and pronounced. High-resolution ultrasound can accurately reveal important preoperative anatomical information in myectomies. Two potential explanations for the surgical failures were discovered: an overlap of lateral DAO muscle fibers over the facial artery could lead to inadequate resections and continuity with the surrounding muscles might lead to muscle function takeover despite adequate resections. Both can be uncovered preoperatively by the surgeon through a brief, directed ultrasound examination, which may allow for modification of the surgical plan to reduce surgical failure.

Lead placement in extravascular ICD recipients: the first step to prevent P-wave oversensing

Abstract Background Extravascular (EV) implantable cardiac defibrillators (ICD) with substernal lead have recently proved to be a safe and effective alternative to conventional transvenous (TV) and subcutaneous defibrillators (S-ICDs) 1, owing to the possibility to deliver antitachycardia and asystole pacing while saving intravascular hardware. However, inappropriate shock delivery occurred in 9.7% of patients, and P-wave oversensing accounted for 42% of inappropriate shocks in the EV ICD Pivotal Study. Purpose to investigate the difference of lead placement in patients with and without P-wave oversensing. Method 17 patients undergoing implantation as part of the EV ICD Pivotal Study received the substernal lead placement based on computer tomography imaging (CT) and following the protocol recommendations. Lead placement beyond the left lateral sternum border was attempted whenever possible, based on CT guidance. P-wave detectability (P detected visually but non sensed by the device) on the sensing vector and P-wave oversensing by the device were investigated at each follow-up. The distance of sensing ring electrodes (R1 and R2) from the mid-spine line (line connecting the spinous processes from cervical to lumbar vertebral processes) was measured in each patient on the posterior-anterior chest radiogram. Results Mean age, BMI, NYHA class and left ventricular ejection fraction (LVEF) were respectively 53±9yrs, 25.3 ±6 kg/m2, 2 ±0.7, and 39±14%. The main aetiology was non-ischemic cardiomyopathy (12/17), including 3 arrhythmogenic cardiomyopathy patients and one with hypertrophic cardiomyopathy. The implantation was successful in 16 (6 females) out of 17 patients without any complication, with one implant failure due to inadequate sensing (0,5 mV) despite several attempts at tunnelling in different locations (rightward and leftward of the sternum). One patient with P-wave detectability had lead dislodgement after 2 weeks, and underwent repositioning to a more leftward location, where P-wave was not detectable. Only one patient had P-wave oversensing at follow-up, and received inappropriate shocks (Figure A); the remaining 15 patients neither had detectable P-wave on the sensing vector nor inappropriate shocks (Figure B). The median sensing amplitude at implantation was 2,7±1.4 mV and 2.6±1.2 mV along a 18±4 months follow-up, with R1-R2 being the final sensing vector chosen for 14/16 and R2-Can for 2/16 patients. The distance of R1 and R2 from the mid-spine line was significantly longer in patients with detectable P-wave compared to those without (37±13mm vs 18 mm and 30±15 vs 16 mm, respectively). Conclusions Placement of the EV ICD lead leftward to the left sternum border is safe, and prevents P-wave detection. The mid-spine line represents an easy landmark to guide lead placement during implantation. R1 distance ≥ 25 mm and R2 distance ≥ 20 mm from the mid-spine line provide a reliable marker of freedom from P-wave oversensing.Figure AFigure B

TRANSCORACOID DRILLING FOR CORACOCLAVICULAR LIGAMENT RECONSTRUCTIONS IN PATIENTS WITH ACROMIOCLAVICULAR JOINT DISLOCATIONS RESULT IN ECCENTRIC TUNNELS

This study aimed to describe the morphology of the coracoid process and determine the frequency of commonly observed patterns. The second purpose was to determine the location of inferior tunnel exit with superior based tunnel drilling and the superior tunnel exit with inferior based tunnel drilling.A sample of 100 dry scapulae for the morphology aspect and 52 cadaveric embalmed shoulders for tunnel drilling were used. The coracoid process was described qualitatively and categorized into 6 different shapes. A transcoracoid tunnel was drilled at the centre of the base. Twenty-six shoulders were used for the superior-inferior tunnel drilling approach and 26 for the inferior-superior tunnel drilling approach. The distances to the margins of the coracoid process, from both the entry and exit points of the tunnel, were measured.Eight coracoid processes were of convex shape, 31 of hooked shape, 18 of irregular shape, 18 of narrow shape, 25 of straight shape, and 13 of wide shape. The mean difference for the distances between superior entry and inferior exit from the apex was Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation 3.65+3.51mm (p=0.002); 1.57+2.27mm for the lateral border (p=0.40) and 5.53+3.45mm for the medial border (p=0.001). The mean difference for the distances between inferior entry and superior exit from the apex was 16.95+3.11mm (p=0.0001); 6.51+3.2mm for the lateral border (p=0.40) and 1.03+2.32 mm for the medial border (p=0.045).The most common coracoid process shape observed was a hooked pattern. Both superior to inferior and inferior to superior tunnel drilling directed the tunnel from a more anterior and medial entry to a posterior-lateral exit. Superior to inferior drilling resulted in a more posteriorly angled tunnel. With inferior to superior tunnel drilling cortical breaks were observed at the inferior and medial margin of the tunnel.

Low-Cost, Durable Sheepskin Uterine Model for Obstetric Hemorrhage Emergency Simulation.

Postpartum hemorrhage is a common obstetrical emergency. Because the majority of cases respond to conservative medical therapies, trainees have limited clinical experience with hemostatic sutures or placement of a Bakri intrauterine balloon for refractory postpartum hemorrhage. Simulations provide an invaluable adjunct to resident education to learn and practice these hemostatic techniques. We aimed to create a low-cost, reproducible simulation model to prepare residents for uterine atony interventions such as B-Lynch, Bakri balloon placement, and uterine artery ligation. Using low-cost supplies, a reusable, life-sized recent postpartum uterus was constructed from pieces of sheepskin and sewn together with various expired suture. The sheepskin material allowed for repeated, secure placement of B-Lynch and O'Leary sutures and Bakri balloons, as well as offering the required compressibility to simulate a boggy uterus. Finally, sections of a red robin catheter were incorporated along the lateral lower borders of the model to simulate blood vessels for practicing uterine artery ligations. The model was used about 50 times over the span of 3 years to practice uterine hemostatic suturing. Residents found this model lifelike, accurate in size, and multifunctional for practicing these various techniques. The sheepskin material proved to be very resistant to repeated suturing, and also provided strong suture pull through strength. The durability of the sheepskin material demonstrates that this model can be used for repeated simulations or individual practice. The sheepskin uterus model provides trainees a realistic, low-cost, reproducible, simulation of a hypotonic uterus and allows for multiple modalities for managing postpartum hemorrhage. · We provide instructions for the creation of a sheepskin model for obstetric hemorrhage simulation.. · We demonstrate use of the sheepskin model in various obstetric hemorrhage management techniques.. · We demonstrate that the model is durable and lifelike based off of resident feedback..

The Risk of Iatrogenic Posterior Neurovascular Injuries in Lateral Meniscal Repair Based on the Standard Arthroscopic Knee Position: A Magnetic Resonance Imaging Study.

Repair of the posterior horn of the lateral meniscus using an all-inside meniscal repair device involves the risk of iatrogenic posterior neurovascular injuries. Previous studies that have evaluated this risk were based on preoperative magnetic resonance imaging (MRI) with the knee in 30° of flexion and used landmarks that are impractical in the actual operative situation. To use an MRI model simulating actual knee arthroscopic conditions to (1) compare the potential risk of injuries related to the lateral border of the posterior lateral meniscus root (LMR) through the anterolateral versus anteromedial portal and (2) establish "safe" and "danger" zones to reduce the possibility of injuries to posterior neurovascular structures when performing lateral meniscal repair in relation to the lateral border of the posterior LMR. Descriptive laboratory study. Using 29 axial MRI scans of knees in the figure-of-4 position with joint fluid dilatation at the level of the lateral meniscus, direct lines were drawn to simulate a straight all-inside meniscal repair device deployed from the anterolateral and anteromedial portals to the lateral border of the posterior LMR, extending 14 mm beyond the joint capsule. If the line passed through or touched a posterior neurovascular structure, a risk of iatrogenic injuries was noted, and measurements were made to determine the safe zone in relation to the lateral border of the posterior LMR. Repairing the lateral meniscus through the anterolateral portal in relation to the lateral border of the posterior LMR resulted in a significantly greater risk of posterior neurovascular injuries compared with repairing through the anteromedial portal, with injury incidences of 68.97% and 10.35%, respectively (P = .001). The safe zones of lateral meniscal repair through the anterolateral and anteromedial portals were 4.15 ± 1.87 and 6.57 ± 0.98 mm, respectively, beyond the lateral border of the posterior LMR. The risk of posterior neurovascular injuries when repairing posterior lateral meniscal tissue was found to be significantly greater through the anterolateral portal compared with the anteromedial portal. Surgeons can use the safe zones as defined in this study to decrease the risk of iatrogenic posterior neurovascular injuries during arthroscopic lateral meniscal repair.

Quantitative radial force measurements of Woven EndoBridge devices.

Lateral/radial forces and the mechanical properties of Woven EndoBridge (WEB) devices have significant importance for therapeutic success. In other words, adequate apposition of the lateral wall of a cerebral aneurysm is critical for preventing recurrence or re-rupture risk. This study aimed to investigate the pressure values applied by different WEB devices to the lateral walls of aneurysms and the relationships between these pressure measurements and the diameters of WEB devices. By placing four WEB devices of different sizes and types between two rigid metal plates, the lateral forces applied by these WEB devices to plates of different apertures were measured quantitatively. We tested a single device of each size over multiple periods. The total number of examined WEB devices is four. There was a significant negative relationship between plate distances and pressure values (correlation coefficient:-0.956, p = 0.000). The lateral wall apposition pressure of a 4- or 5-mm aperture size was higher than a 6-mm aperture size for SL-type WEB devices with a 7-mm diameter. Similarly, the lateral wall apposition pressure detected for a 3- or 3.5-mm aperture size was higher than a 4-mm aperture size for W5-4.5-3 and W5-5-3.6. It was observed that maximum lateral wall pressure was detected in plate measurements of SLS-type devices compared to SL-type devices. The diameter and height values of 3 of the 4 unconstrained WEB devices analyzed differed from the catalog values. It seems that SLS-type devices apply more pressure on the aneurysm's lateral borders than SL-type devices.

Flexor hallucis longus. A cadaveric study of its distal insertion

Objective: Describe flexor hallucis longus (FHL) distal insertion. Methods: Ten cadaver feet were dissected to evaluate FHL distal insertion, the width of insertion, and the distance between insertion borders and medial-lateral phalangeal borders. Results: All specimens showed a lateral tendon fascicle inserted more lateral and distal than the main insertion. The mean lateral and medial insertion distance to the phalangeal border was 3 mm and 5.2 mm. The FHL long axis was 12.36% laterally deviated at the metatarsophalangeal (MTP) joint and 14.07% at the interphalangeal (IP) joint. Conclusion: The FHL has a closer insertion to the lateral phalanx border, and its long-axis midpoint is laterally located in relation to the IP and MTP joint. The detailed knowledge of the FHL true anatomy. The discovery of a lateral deviated axis, a lateral fascicle, and a lateral footprint.

CLINICAL CASE OF SEVERE ANEMIA IN A NEWBORN CHILD

The aim of the work – based on our own clinical experience, the observation and treatment of a newborn with severe anemia caused by complicated birth trauma to demonstrate the complexity of diagnosis and therapeutic approach to this pathology.Material and Methods. The study is based on an analysis of the evaluation and treatment of a newborn with severe anemia caused by birth trauma. The complex diagnostic measures included clinical and laboratory methods, radiological examinations (X-ray and spiral computed tomography) and ultrasound examinations.Results. Comprehensive treatment of the child with severe anemia resulted in signifi cant improvement of the patient’s condition, allowing the child to be discharged from the hospital at the age of one month. Considering the possible etiological and pathogenetic factors of anemia in newborns, congenital hemostatic disorders were excluded. For further investigation, a contrast- enhanced CT scan was performed, which showed signs of subcapsular hematoma with contusion on the lateral border of the right hepatic lobe, subcapsular hematoma with contusion on the lateral border of the right kidney, contusion with hematoma of the right adrenal gland, no contrast accumulation at the time of examination, with signs of hemolysis of the hematoma in the right kidney and right adrenal gland. The results of the chest x-ray showed a right- sided tension hydropneumothorax, which became a direct indication for urgent surgical treatment. Themain therapeutic measures included the following steps: conservative therapy – correction of anemia and hemostasis, surgical treatment.There were no intraoperative or postoperative complications.Conclusions.1. In case of severe anemia in a newborn it is necessary to exclude sources of bleeding, namely: congenital hemostatic disorders and consequences of birth trauma.2. If the patient has consequences of birth trauma, it is necessary to determine the priority direction of treatment (conservative, surgical, combined).3. Conservative treatment of severe anemia in newborns should include infusion of drugs that correct hemostasis and anemia.4. Urgent surgical intervention should be performed in cases of insuffi cient or ineff ective results of conservative treatment, with the aim of stabilizing hemodynamics and eliminating the consequences of associated pathology.

Oral squamous cell carcinomas and oral potentially malignant disorders: A Latin American study.

To determine the frequency of oral squamous cell carcinoma (OSCC) associated or not with oral potentially malignant disorders (OPMD), and the epidemiological profile and traditional risk factors in Latin America. A retrospective observational study was conducted in 17 Latin American centres. There were included cases of OSCC, analysing age, gender, OSCC and their association with previous OPMD. Clinicopathological variables were retrieved. The condition of sequential-OSCC versus OSCC-de novo (OSCC-dn) was analysed concerning the aforementioned variables. Quantitative variables were analysed using Student's t-test, and qualitative variables with chi-square. In total, 2705 OSCC were included with a mean age of 62.8 years old. 55.8% were men. 53.75% of the patients were smokers and 38% were common drinkers. The lateral tongue border was the most affected site (24.65%). There were regional variations in OPMD, being leukoplakia the most frequent. Of the overall 2705 OSCC cases, 81.4% corresponded to OSCC-dn, while s-OSCC were 18.6%. Regarding lip vermillion SCC, 35.7% corresponded to de novo lip SCC and 64.3% were associated with previous OPMD. In Latin America, OSCC-dn seems to be more frequent with regional variations of some clinical and histopathological features. Further prospective studies are needed to analyse this phenomenon.

A novel proneural function of Asense is integrated with the sequential actions of Delta-Notch, L'sc and Su(H) to promote the neuroepithelial to neuroblast transition.

In order for neural progenitors (NPs) to generate distinct populations of neurons at the right time and place during CNS development, they must switch from undergoing purely proliferative, self-renewing divisions to neurogenic, asymmetric divisions in a tightly regulated manner. In the developing Drosophila optic lobe, neuroepithelial (NE) cells of the outer proliferation center (OPC) are progressively transformed into neurogenic NPs called neuroblasts (NBs) in a medial to lateral proneural wave. The cells undergoing this transition express Lethal of Scute (L'sc), a proneural transcription factor (TF) of the Acheate Scute Complex (AS-C). Here we show that there is also a peak of expression of Asense (Ase), another AS-C TF, in the cells neighboring those with transient L'sc expression. These peak of Ase cells help to identify a new transitional stage as they have lost NE markers and L'sc, they receive a strong Notch signal and barely exhibit NB markers. This expression of Ase is necessary and sufficient to promote the NE to NB transition in a more robust and rapid manner than that of l'sc gain of function or Notch loss of function. Thus, to our knowledge, these data provide the first direct evidence of a proneural role for Ase in CNS neurogenesis. Strikingly, we found that strong Delta-Notch signaling at the lateral border of the NE triggers l'sc expression, which in turn induces ase expression in the adjacent cells through the activation of Delta-Notch signaling. These results reveal two novel non-conventional actions of Notch signaling in driving the expression of proneural factors, in contrast to the repression that Notch signaling exerts on them during classical lateral inhibition. Finally, Suppressor of Hairless (Su(H)), which seems to be upregulated late in the transitioning cells and in NBs, represses l'sc and ase, ensuring their expression is transient. Thus, our data identify a key proneural role of Ase that is integrated with the sequential activities of Delta-Notch signaling, L'sc, and Su(H), driving the progressive transformation of NE cells into NBs.

Submucosal tunneling endoscopic full-thickness resection for management of a rare case of esophageal GI stromal tumor

Video 1The mass was identified at the upper- to mid-esophagus, 25 cm from the central incisors. No varices were seen on further examination of the esophagus. A 4-mm injector force needle was used to create a large submucosal injection using BlueBoost lifting agent proximal to the mass. A longitudinal mucosal incision was then made using the hybrid T-type electrocautery knife, 20 cm from the central incisors.The cutting current was the preset Endocut Q mode, and the coagulation setting was spray coag mode, effect 2 and 40 W.Next, tunnel creation by submucosal dissection was performed with a focus on keeping the submucosal space as clean as possible. Carbon dioxide was used for insufflation to prevent pneumoperitoneum.A smooth-surfaced oval mass was identified originating from the muscularis propria layer. Dissection was extended 2 cm distally beyond the mass. Next, resection of the mass was performed. First, the mucosal surface of the mass was dissected. Dissection began at the distal portion, proceeded to the left and right lateral borders, and then continued toward the proximal portion. The mass was dissected away from the muscularis propria.We focused on freeing the mass, ensuring this esophageal mass was intact throughout dissection. The attached bands of muscularis propria at the distal portion were carefully resected completely.Water irrigation was used at this time to ensure better visualization for resection. The remaining attached bands of muscularis propria were resected, ensuring complete en bloc resection. Afterward, the mass was suctioned into the cap and carefully retrieved as shown, and then sent to pathology for processing.The entire defect bed was inspected post-resection, and no perforation or bleeding was identified.The mucosal defect was completely closed with through-the-scope hemostatic clips in a longitudinal fashion beginning with approximation of the defect at the distal portion.

Normobaric hypoxia does not influence the sural nerve cutaneous reflex during standing.

Hypoxia increases postural sway compared to normoxia, but the underlying sensorimotor factors remain unclear. An important contributor to balance control is cutaneous feedback arising from the feet, which can be partially characterized by electrically evoking a reflex from a purely cutaneous nerve (i.e., sural) and sampling the subsequent motor activity of a muscle. The purpose of the present study was to determine how normobaric hypoxia influences sural nerve reflex parameters during a standing posture. It was hypothesized that normobaric hypoxia would reduce cutaneous reflex area compared to normoxia. Participants (n = 16; 5 females, 11 males) stood with their feet together while receiving two trials of 50 sural nerve stimulations (200-Hz, 5-pulse train, presented randomly every 3-6s) at baseline (BL; normoxia), and at 2 (H2) and 4 (H4) h of normobaric hypoxia (~ 0.11 fraction of inspired oxygen in a hypoxic chamber). The sural nerve reflex was recorded using surface electromyography from the left medial gastrocnemius, and characterized by area and duration of the initial positive and negative peaks of the response. When normalized to pre-stimulus electromyography, the area of the peak-to-peak cutaneous reflex was not different than BL (p ≥ 0.14) for up to 4 h of normobaric hypoxia (BL: 0.26 ± 0.22, H2: 0.19 ± 0.19, H4: 0.22 ± 0.20 A.U.). Furthermore, the duration of the response was not different during hypoxia (BL: 73.2 ± 42.4; H2: 75.2 ± 47.0; H4: 77.6 ± 54.6ms; p ≥ 0.13) than BL. Thus, reflexes arising from cutaneous afferents of the lateral border of the foot are resilient to at least 4 h ofnormobaric hypoxia.

OP04.08: Pattern recognition of fetal lateral ventricular border irregularity and their clinical significance

OP04.08: Pattern recognition of fetal lateral ventricular border irregularity and their clinical significance

Hindfoot Stability Test: Introduction and Validation of a Diagnostic Test of Subtalar Instability in Deltoid Ligament injury Associated with Ankle Fractures

Category: Ankle; Trauma Introduction/ Purpose: Deltoid ligament complex (DLC) injury repair in the presence of an ankle fracture remains a topic of controversy in the current literature. No work in the current literature has commented on hindfoot and subtalar instability in the presence DLC injury associated with ankle fracture fixation. Objective Our aim was to introduce and validate a new method for assessment of hindfoot instability, when fixing an ankle fracture with associated DLC injury. Methods: DLC injury, specifically superficial DLC, controls not only the ankle but the subtalar joint and medial longitudinal arch. Valgus stressing can unmask subtalar instability. It was noted by referencing the hindfoot position to a line parallel with the lateral aspect of the fibula, the lateral fibula line, subtalar instability was proabbale. We used six morphologically normal cadaveric specimens to validate the test. Results: Ten cadaveric specimens were used for validation of the hindfoot stability test. Pre-injury, no specimen illustrated bisection5-injury, all specimens showed bisection of the calcaneal tuberosity by the lateral fibular line on hindfoot stability test. Conclusion: The hindfoot stability test assesses hindfoot stability on valgus stressing of the hindfoot using the calcaneal tuberosity bisection of the a line drawn from the lateral border of the fibula as a reference point for instability. This was validated using morphologically normal cadavers.

Fixation in Missed Lisfranc Injuries: Should This Be Attempted?

Category: Trauma; Midfoot/Forefoot Introduction/Purpose: The Lisfranc injuries are not so uncommon. However, subtle injuries are often either missed or misdiagnosed as “mid foot sprain” during initial assessment. Missed lisfranc injuries causes various problems like chronic pain, fallen medial arch, functional loss etc. The decision regarding whether to fix such missed or chronic injuries or to do an arthrodesis is still a topic of debate. So the purpose of this study was to evaluate the outcomes of delayed fixation of missed lisfranc injuries. Methods: A total of 10 patients with missed lisfranc injuries (more than 6 weeks after injury) were included in the study. Most of the patients had previous history of subtle, low energy injuries to their foot which was treated conservatively. All the patients preoperatively underwent weight bearing radiographs of foot and distance between lateral border of medial cuneiform and medial border of 2nd metatarsal base were measured for degree of displacement. Patients were treated with an open reduction and internal fixation as opposed to arthrodesis. Outcomes were assessed using VAS score, American Orthopaedic Foot & Ankle Society (AOFAS) Mid foot score, post operative radiographic evaluation and return to work time. Out of 10 patients, 70% were female and 30% were male. The average time interval between injury and surgery was 9.6 + 2.50 weeks. The mean age was 41.5 and mean follow up duration was 33.6 + 12.98 months. Results: The average degree of displacement between lateral border of medial cuneiform and medial border of 2nd metatarsal base was 5.14 mm. At final follow up no patients had radiographic signs of a late diastasis at the Lisfranc joint. The pre operative VAS score improved from 7.5 + 1 to 1.6 + 0.69 post operatively. One patient had developed arthritis at 1st and 2nd TMT joints but did not had any symptoms. The average AOFAS mid foot score pre & post operatively was 37.6 + 10.8 & 84.2 + 6.54 respectively, with two patients having excellent outcome, six patients having good outcome and two patients having fair outcome. At final follow up all patients could perform their ADL & recreational activities independently. Conclusion: Subtle, low velocity missed lisfranc injuries can be well managed with open reduction and internal fixation. In our series, delayed fixation resulted in decreased pain scores and a fair to good functional outcome and returned to their pre injury work.