Layer Of Ligament Research Articles

Arrest and Repair of Inflammatory Root Resorption After an Endodontic Regeneration Procedure – A Hypothesis and Case Report

IntroductionExternal inflammatory root resorption (EIRR) is a significant complication that can occur following traumatic dental injuries, with a prevalence of approximately 18%. Most cases occur during the early stage of the mixed dentition. Specifically, EIRR occurs in approximately 5%–8% of luxation injuries, 30% of replanted teeth following avulsion, and 38% of intruded teeth. Conventional methods for addressing EIRR in immature teeth pose several challenges. This often requires numerous dental visits where Ledermix and calcium hydroxide are used, which may significantly prolong the treatment. Additionally, the effect of prolonged use of calcium hydroxide medication in the root canal is debatable. Recent publications have highlighted the ability of regenerative endodontic treatment (RET) to effectively stop and repair EIRR in a relatively brief time, yielding impressive results. Nevertheless, the underlying mechanism responsible for this effect remains unclear. MethodsA hypothesis is proposed and drawn from existing data, explaining the mechanism by which RET triggers alterations in the root dimensions of necrotic immature teeth, facilitating continuous root maturation. The hypothesis suggests that bioactive molecules, including growth factors, might be able to penetrate the denuded dentin, reach the resorbed area, and attract stem cells from the surrounding periodontal ligament and adjacent bone, leading to the arrest of the resorption process. ResultsThis recruitment may trigger repair mechanisms, ultimately resulting in the coverage of the denuded dentin with a new layer of periodontal ligament, cementoid, and cementum. ConclusionsA hypothesis of the potential mechanism in which RET may arrest EIRR is presented along with a case report.

Arthroscopic repair of the tibiotalar fascicle of deltoid ligament is feasible through anterior ankle arthroscopy.

Although arthroscopic repair of the deltoid ligament is becoming a popular procedure, no studies have assessed which bundles of the deltoid ligament can be reached by anterior ankle arthroscopy. This study aimed to assess the feasibility of the arthroscopic repair of the deep layer of the deltoid ligament. In addition, it aimed to correlate which fascicle of the superficial layer of the deltoid ligament corresponds to the deep fascicle visualised by arthroscopy. Arthroscopy was performed in 12 fresh frozen ankles by two foot and ankle surgeons. With the arthroscope introduced through the anterolateral portal, the medial compartment and the deltoid ligament were explored in ankle dorsiflexion without distraction. Using a suture passer introduced percutaneously, the most posterior fibres of the deep deltoid ligament visualised by anterior arthroscopy were tagged. Then, the ankles were dissected to identify the deep and superficial bundles of the deltoid ligament tagged with a suture. In all specimens (100%), the intermediate part of the tibiotalar fascicle, corresponding to the fibres originating from the anterior colliculus, was tagged with a suture. The posterior part of the tibiotalar fascicle was never tagged with a suture. In all specimens, the intermediate part of the tibiotalar fascicle grasped by the suture correlated with the tibiospring fascicle of the superficial layer. The current study demonstrates the feasibility of the arthroscopic repair of the deep fascicle of the deltoid ligament. By performing anterior arthroscopy, it is possible to visualise and repair the intermediate part of the tibiotalar fascicle (deep layer of the deltoid ligament). These fibres correspond to the tibiospring fascicle of the superficial layer. The clinical relevance of the current study is that the arthroscopic repair of the deep layer of the deltoid ligament is feasible through anterior ankle arthroscopy. Not applicable.

Improved bladder function in radical hysterectomy without worsening oncologic outcome: resection of the posterior layer of the vesicouterine ligament with the procedure limited to the vesical veins.

The classic Okabayashi nerve-sparing radical hysterectomy involves complete resection of the posterior leaf of the vesicouterine ligament, whereas in the simplified nerve-sparing radical hysterectomy, only the vesical veins and some connective tissue of the posterior layer of the vesicouterine ligament are resected. This study aimed to compare bladder function and cervical carcinoma relapse-free survival between these two techniques. We conducted a retrospective, historical control study. All female patients aged >20 years who were diagnosed with cervical cancer stage IB1-IIB and underwent radical hysterectomy with pelvic lymphadenectomy between 2009 and 2022 were enrolled. Patients who had a history of other cancers and those who were treated with non-surgical approaches or non-radical hysterectomy were excluded. The primary outcome was relapse-free survival during the follow-up period. A total of 114 patients who underwent curative-intent radical hysterectomy were included in this study. The median follow-up duration was 60 months. No significant difference was observed in relapse-free survival between the two surgical procedures. The simplified nerve-sparing radical hysterectomy was superior in terms of both motor and sensory bladder function outcomes. Resection of the posterior layer of the vesicouterine ligament, with the procedure limited to the vesical veins, is an effective and safe method for radical hysterectomy. It may be more useful for preserving the bladder function, without leading to unfavorable oncologic outcomes.

Clinical implications of the superficial uterine vein pattern for the dissection of the anterior layer of the vesicouterine ligament in radical hysterectomy.

To describe anatomic patterns of the superficial uterine vein (sUV) and assess their association with aspects of the dissection procedure of the anterior layer of the vesicouterine ligament (aVUL) by retrospectively reviewing surgical videos. We analyzed patients who underwent laparoscopic radical hysterectomy for early-stage cervical cancer from 2014 to 2019. The primary endpoint was the time required for aVUL dissection. Multiple linear regression analyses were performed to identify factors influencing the time required for aVUL dissection. Fifty-three Japanese patients were included. Two sUV configurations were observed: type 1 (the vein ran ventral to the ureter along the uterine artery) and type 2 (the vein did not run along the usual ventral course; it ran dorsal to the ureter or was absent). Approximately 30% of the sUVs were type 2. The total time for dissection of both sides of the aVUL was significantly shorter for type 2 sUVs than for type 1 sUVs. The number of hemostatic interventions during dissection of each side of the aVUL was significantly lower for type 2 sUVs than for type 1 sUVs. In the multivariate analysis, the sUV configuration was the factor significantly influencing the duration of aVUL dissection on each side (right side: β=-143.4; left side, β=-160.4). We demonstrated that the sUV had 2 types of courses, ventral and others, and its course affected the time required for dissection and the number of hemostatic interventions. Our results provide information supportive of improved radical hysterectomy outcomes.

Safe Talar Tunnel Placement During Reconstruction of the Deep Layer of the Deltoid Ligament: A Comparison of 4 Different Anatomic Landmarks on the Lateral Malleolus.

Deltoid ligament reconstruction of the ankle can be considered when the ruptured ligament is insufficient for direct repair. To compare the safety of talar tunnels oriented toward 4 different anatomic landmarks on the lateral malleolus during reconstruction of the deep layer of the deltoid ligament (DDL). Descriptive laboratory study. A total of 30 computed tomography scans of the ankle joint in healthy adults were collected to generate 3-dimensional models. Virtual talar tunnels with a diameter of 5 mm and with different lengths (20.0, 25.0, and 30.0 mm) were created from the talar insertion of the DDL and were oriented toward the talar neck as well as the most anterior, the most distal, and the most posterior points of the distal fibula. The minimal safe distance (MSD) of a drilling route was calculated for the tunnels, and the safe distance from the end of the tunnel to the bone surface was measured for each tunnel. The nonpaired Student t test was used to detect differences among the safe distances of the 4 different bone tunnels. For the 20.0-mm tunnels, the safe distance of the tunnel oriented toward the talar neck (5.90 ± 1.16 mm) did not meet the MSD (6.0 mm). For the 25.0-mm tunnels, the safe distances of the tunnels oriented toward the talar neck (4.53 ± 1.13 mm) and the anterior point of the fibula (5.91 ± 1.52 mm) did not meet the MSD (6.9 mm). Tunnels that were 5 mm in diameter and 20.0 and 25.0 mm in length, oriented toward the most distal or most posterior point of the distal fibula, were safe for DDL reconstruction. Knowledge of safe talar tunnel placement is important, especially to avoid bone surface penetration during DDL reconstruction.

The Role of Computed Tomography with External Rotation and Dorsiflexion in Decision Making for Acute Isolated Posterior Malleolar Fractures Bartoníček and Rammelt Type II: A Cross-Sectional Study

Category: Ankle; Sports Introduction/Purpose: A ligament-centered analysis is currently incorporated in the assessment of joint stability in malleolar fractures. Although several imaging tests are available, in the setting of acute isolated non-displaced posterior malleolar fractures Bartoníček/Rammelt types II and IV diagnosing syndesmotic instability remains challenging. The objective of this multi-center cross- sectional study was to evaluate the syndesmotic and fracture instability using conventional ankle CT with external rotation and dorsiflexion in the setting of acute, isolated non-displaced Bartoníček and Rammelt type II posterior malleolar fractures. Methods: Between March 2018 and September 2022, a consecutive sample of 123 individuals with an ankle sprain were assessed for eligibility. In total, 33 participants met the inclusion criteria. All participants underwent a CT scan (CTSM), comprising a first phase with the ankles in a neutral position, then a stress phase with the ankles in external rotation and dorsiflexion and semiflexed knees. Investigators used the patterns of ligament tear found at MRI and instability at CTSM to classify all participants into West Point grades I, IIA, IIB, or III. Mann-Whitney test was used to test the differences in the numerical variables between injured and uninjured syndesmoses. The Spearman correlation tested the strength of the association between the tibial joint surface involved in posterior malleolus fracture and syndesmotic instability. Results: In MRI reading parameters two patterns of syndesmotic ligament injury predominated. A completely torn AITF and IO ligaments and a completely torn AITF was combined with a partially torn IO. Regarding the deep layer of the deltoid ligament, participants were classified as normal, strained and partially torn. In CT scan reading parameters in the neutral phase, the median difference of 0.2 mm in d measurements between injured and uninjured syndesmoses was not statistically significant (P = 0.057). During the stress phase, the injured and uninjured syndesmoses had distinct behavior, and the 2.3 mm median difference for d measurement was statistically significant (P < 0.0001). Conclusion: The conventional computed tomography with external rotation and dorsiflexion represent a reproducible and accurate diagnostic option for the detection of syndesmosis instability and fracture instability in acute isolated posterior malleolar fractures Bartonícek and Rammelt type II.

Effect of Plate and Screw Fixation on Stability of Weber B/Supination-External Rotation Fractures with Partial Deltoid Ligament Injury (SER4a): Robotic-Based Joint Testing

Category: Trauma; Ankle Introduction/Purpose: Fibular fractures with signs of concomitant deltoid ligament injury have been operated on with plate and screw fixation of the fibula for decades. More recently, clinical studies have suggested that some fibular fractures have only partial deltoid ligament injury and that the deep posterior tibiotalar ligament may be intact (SER4a), allowing for nonoperative treatment. The purpose was to determine whether fibula fracture fixation using plate and screws improves stability and restores normal joint kinematics in such fractures. It was hypothesised that fixation of the fibula fracture does not add significantly to the stability of SER4a models or restore normal joint kinematics. Methods: Fifteen cadaveric foot and ankle specimens underwent biomechanical testing using a six-degrees-of-freedom force- movement robotic arm in three states: intact joint, SER4a model (anterior inferior tibiofibular ligament sectioned + oblique trans syndesmotic fibular osteotomy + superficial layer of deltoid ligament sectioned + deep anterior tibiotalar ligament sectioned) and SER4a model + plate and screw fixation of the fibula. Joint stability was measured in lateral translation, valgus, and talar internal- and external rotation in three talocrural joint positions: 20° plantarflexion, neutral, and 10° dorsiflexion. Fluoroscopy was used to measure isolated talar lateralisation and talar tilt. The foot was rigidly fixed to a custom pedestal, while the tibia was rigidly fixed to the robot arm through a load cell. Talar lateral translation at neutral ankle position was the primary outcome. Results: Fixation of the fibular fracture reduced lateral translation by 0.16 millimetres (P = .101) at neutral ankle position (See Figure 1). In general, the tests for lateral translation and valgus showed no differences between the SER4a models and the SER4a models with fibular fracture fixation. As for talar internal rotation, the fixation only slightly increased stability. But, when the talus was externally rotated, the fixation provided stability. Although the fixation improved stability during rotations, it did not fully restore the native ankle kinematics. Conclusion: The results suggest that plate and screw fixation of the fibular fracture does not significantly reduce instability or restore intact joint stability in SER4a models. These results support the nonoperative treatment of these fractures, as suggested by previous clinical studies.

A confirmatory trial of modified radical hysterectomy for patients with FIGO stage IB1 cervical cancer with tumor diameter preoperatively estimated at 2 cm or less: Japan Clinical Oncology Group study, JCOG1101.

5532 Background: The standard surgery for Stage IB1 uterine cervical cancer is radical hysterectomy (RH, Piver class III hysterectomy). However, RH is highly invasive, and there is a need to establish less invasive techniques. We conducted a single-arm confirmatory trial (JCOG1101) to evaluate the efficacy and safety of modified radical hysterectomy (MRH) in patients with tumor diameter ≤ 2 cm Stage IB1 cervical cancer (jRCT: jRCTs031180167). Methods: From January 2013 to August 2017, 240 patients were enrolled from 40 institutions in Japan. Eligibility criteria included: (1) FIGO 2008 Stage IB1 cervical cancer; (2) histologically proven squamous cell carcinoma, adenocarcinoma (mucinous or endometrioid) or adenosquamous carcinoma; (3) tumor diameter ≤ 2 cm (measured by MRI or conization specimen); and (4) neither distant LN metastasis nor distant metastasis in CT. In case that the cancer could be microinvasive, conization was required to exclude Stage IA cases. The protocol surgery involved cutting the anterior layer of the vesicouterine ligament of the uterus and dissecting regional lymph nodes. Only laparotomy was permitted: laparoscopy and robotic surgery were not allowed. Postoperative irradiation was administered in cases where pelvic LN or parametrial invasion was positive, depth in the cervical wall invasion was ≥ 2/3, or surgical margin was < 1 cm by pathological findings. The primary endpoint was 5-year overall survival (OS). We set the expected 5-year OS of MRH at 95.8% (5-year OS of RH in JCOG0806A, retrospective observational study) and the threshold 5-year OS at 90.8%. Results: Among 225 eligible patients, 193 (85.8%) were pT1b1 (UICC 7th), and 184 (81.8%) had pathological maximal tumor diameter ≤ 2 cm. Parametrial involvement, lymph node metastasis, ≥ 2/3 stromal invasion and < 1 cm surgical margin were observed in 3 (1.3%), 16 (7.1%), 30 (13.3%) and 11 (4.9%) patients, respectively. Thirty-nine patients (17.3%) underwent adjuvant (chemo)radiation. Median follow-up was 77.7 months. Five patients (2.2%) died, and 5-year OS was 98.2% (90% CI: 96.0-99.2, > 90.8%). Thirteen patients (5.8%) relapsed (8 local recurrence and 5 distant recurrence), and 5-year relapse-free survival was 94.7% (95% CI: 90.8-96.9%). Self-urination was observed in all patients, and residual urine disappearance up to 56 days after urethral catheter removal was observed in 213 patients (94.7%). Median time to disappearance of residual urine after urethral catheter removal was 1 day. There was no treatment-related death. Grade 3/4 non-hematological adverse events were observed in 17 patients (7.6%), including 8 infection and 4 hemorrhage. Conclusions: In this study, MRH was as effective as RH and less invasive. MRH can be considered a standard surgery for tumor diameter ≤ 2 cm Stage IB1 uterine cervical cancer. Clinical trial information: UMIN000009726 , jRCTs031180167 .

Study on the correlation between the thickness of superficial fascia at Dazhui(GV14) and cervical spondylosis

To observe the correlation between the thickness of superficial fascia at Dazhui (GV14) acupoint and cervical spondylosis, so as to explore the essence of its morphological and structural changes of acupoint sensitivity. A retrospective study was conducted. According to the diagnostic criteria of "Guidelines for Diagnosis, Treatment and Rehabilitation of Cervical Spondylosis" (2017), 344 cases of cervical spine magnetic resonance imaging (MRI) examination were included and divided into control group (73 cases) and observation group (271 cases). The control group was healthy population, and the observation group was patients with cervical spondylosis conforming to the diagnostic criteria, including cervical spondylosis of neck type, cervical spondylosis radiculopathy, cervical spondylotic myelopathy, cervical spondylosis of vertebral artery type, and sympathetic cervical spondylosis. According to MRI images of cervical spine, the structure of GV14 acupoint including skin, superficial fascia layer and aponeurosis ligament layer were measured. The acupoint depth and the superficial fascia thickness at GV14 in the observation group were (56.6±8.8) mm and (22.8±7.6) mm, the acupoint depth and the superficial fascia thickness at GV14 were (49.8±7.0) mm and (16.6±6.6)mm in the control group, which were significantly greater in the observation group than in the control group (P<0.01). The superficial fascia thickness at GV14 of cervical spondylotic mye-lopathy, cervical spondylosis of neck type and cervical spondylosis radiculopathy in the observation group was (23.8±8.1)mm, (23.0±7.3)mm and (22.6±6.5)mm, the acupoint depth of GV14 was (58.7±8.8)mm, (56.2±9.1)mm and (55.8±6.4)mm, which were significantly thicker than the superficial fascia thickness and the acupoint depth in the control group (P<0.01). In the observation group，the superficial fascia thickness of GV14 of cervical spondylosis myelopathy was significantly thicker than those of sympathetic cervical spondylosis (17.8±8.1) mm and cervical spondylosis of vertebral artery type (19.9±5.9) mm (P<0.01, P<0.05). In the observation group, the depth of GV14 of cervical spondylosis myelopathy was thicker than that of cervical spondylosis of neck type, cervical spondylosis radiculopathy, sympathetic cervical spondylosis and cervical spondylosis of vertebral artery type(P<0.05，P<0.01)； the depth of GV14 of sympathetic cervical spondylosis was thinner than that of cervical spondylosis of neck type and cervical spondylosis radiculopathy (P<0.01). The superficial fascia thickness at GV14 was correlated with cervical spondylosis, and it is also related to cervical spondylotic myelopathy, cervical spondylosis of neck type and cervical spondylosis radiculopathy. The morphological and structural changes of GV14 in the state of cervical spondylosis were mainly the thickness of the superficial fascia.

Morphometry of the Bony Orbit and Periorbital Structures: Personal Perspectives From Decades of Related Research.

The author introduces his personal perspectives on the bony orbit, nerves, arteries, and ligaments relating to orbital re- construction surgery. A supraorbital fissure was 40.0 ± 2.5 mm from the supraorbital notch. Posterior ethmoidal foramen was 31.7 ± 3.0 mm from the anterior lacrimal crest. The infraorbital fissure, where the infraorbital groove started, was 26.4 ± 2.6 mm from the infraorbital foramen. The supraorbital fissure was 34.3 ± 2.7 mm from the frontozygomatic suture. The medial palpebral ligament consisted of 2 layers. The superficial layer of the palpebral ligament (SMPL) was from the anterior lacrimal crest to the upper and lower tarsal plates. The deep layer of the palpebral ligament (DMPL) lay from the anterior lacrimal crest to the posterior lacrimal crest, covering the lacrimal sac. Horner muscle was at the posterior lacrimal crest just lateral to the attachment of the DLPL and ran laterally to the tarsal plate deep to the SLPL. Three components of the lateral canthal area are: (1) lateral palpebral raphe, (2) superficial lateral palpebral ligament (SLPL), and (3) deep lateral palpebral ligament (DLPL). The lateral ends of superior and inferior orbicularis oculi muscles interlaced at the lateral commissure and formed the lateral palpebral raphe. The superficial lateral palpebral ligament extended from the lateral ends of the tarsal plate to the periosteum of the lateral orbital rim. The lateral palpebral ligament extended from the lateral ends of the tarsal plate deep to the origin of SLPL to the Whitnall tu- bercle on the zygomatic bone. The palpebral branch of the in- fraorbital artery emerged from the infraorbital foramen and ran superior and lateral to the orbital septum. After passing through the orbital septum, distributed to the orbital fat.

Anatomical location of the surgically identifiable bladder branch of the inferior hypogastric plexus for nerve-sparing radical hysterectomy

ObjectiveWe aimed to demonstrate the entire structure of the inferior hypogastric plexus in the female pelvis focusing on surgically identifiable nerve bundles to the urinary bladder. MethodsSurgical videos of transabdominal nerve-sparing radical hysterectomy for 10 patients with cervical cancer at International Federation of Gynecology and Obstetrics (FIGO 2009) stage IB1–IIB were retrospectively analyzed. The paracervical tissue dorsal to the ureter was separated into the lateral component (dorsal layer of the vesicouterine ligament) and medial component (paracolpium) using Okabayashi’s technique. Any bundle-like structures in the paracervical area were isolated and divided using cold scissors, and each cut edge was inspected to determine whether the bundle was a blood vessel or a nerve. ResultsIn all cases, the surgically identifiable nerve bundle of the bladder branch was identified on the rectovaginal ligament running parallel and dorsal to the vaginal vein of the paracolpium. The bladder branch was revealed only after complete division of the vesical veins in the dorsal layer of the vesicouterine ligament where no definitive nerve bundles were observed. The bladder branch was derived laterally from the pelvic splanchnic nerve and medially from the inferior hypogastric plexus. ConclusionsThe surgical identification of the nerve bundle of the bladder branch is essential for a safe and secure nerve-sparing radical hysterectomy. The preservation of the surgically identifiable bladder branch from the pelvic splanchnic nerve as well as from the inferior hypogastric plexus can provide satisfactory postoperative voiding function.

Fracture of the lateral process of the talus with associated deltoid ligament injury: a report of 2 cases

BackgroundFractures of the lateral process of the talus (LTPF) are rare and only rarely are associated ligamentous injuries. The injury mechanism is commonly considered to be similar with ankle sprains, where excessive varus of the hindfoot leads to avulsion fractures of the lateral process of the talus. However, previous cadaveric studies have suggested that LTPF was more likely to be caused by eversion or external rotation force with dorsiflexion of the ankle. But no clinical evidence has been provided.Case presentationTwo patients presented to the emergency department with ankle pain after ankle eversion or external rotation. Physical examination revealed tenderness and swelling on both medial and lateral sides of the ankles. Plain radiographs and computed tomography revealed LTPF and medial soft tissue swelling, and magnetic resonance imaging confirmed a discontinuity of the deltoid ligament in Case 1. Surgical exploration revealed rupture of the superficial layer of the deltoid ligaments with intact deep layer in both patients. Treatment included fixation of the lateral process of the talus with headless compression screws and repair of deltoid ligaments. Both patients achieved excellent clinical outcomes 1 year post injury.ConclusionThere are many possibilities of the injury mechanism of LTPF. These two cases provided clinical evidence that eversion or external rotation force, in addition to inversion, was also an important mechanism of LTPF.

AcidoCEST-UTE MRI Reveals an Acidic Microenvironment in Knee Osteoarthritis.

A relationship between an acidic pH in the joints, osteoarthritis (OA), and pain has been previously demonstrated. Acidosis Chemical Exchange Saturation Transfer (acidoCEST) indirectly measures the extracellular pH through the assessment of the exchange of protons between amide groups on iodinated contrast agents and bulk water. It is possible to estimate the extracellular pH in the osteoarthritic joint using acidoCEST MRI. However, conventional MR sequences cannot image deep layers of cartilage, meniscus, ligaments, and other musculoskeletal tissues that present with short echo time and fast signal decay. Ultrashort echo time (UTE) MRI, on the other hand, has been used successfully to image those joint tissues. Here, our goal is to compare the pH measured in the knee joints of volunteers without OA and patients with severe OA using acidoCEST-UTE MRI. Patients without knee OA and patients with severe OA were examined using acidoCEST-UTE MRI and the mean pH of cartilage, meniscus, and fluid was calculated. Additionally, the relationship between the pH measurements and the Knee Injury and Osteoarthritis Outcome Score (KOOS) was investigated. AcidoCEST-UTE MRI can detect significant differences in the pH of knee cartilage, meniscus, and fluid between joints without and with OA, with OA showing lower pH values. In addition, symptoms and knee-joint function become worse at lower pH measurements.

Anatomic Repair of Deltoid Ligaments in Acute Injury With Suture Anchor Technique.

Acute disruption of the deltoid ligament usually occurs in rotational ankle fracture. If left untreated, its instability may contribute to ankle arthritis. We have designed a suture technique to repair all deltoid ligament layers. It provides anatomic ligament-to-bone repair of the superficial and deep deltoid ligaments and anchor suture reinforcement. This technique may protect the horizontally oriented fibers of the deep deltoid ligaments and allow them to heal with sufficient rest while providing immediate stability of the construct. The superficial ligaments are then repaired with residual anchor sutures. [Orthopedics. 2022;45(3):e168-e173.].

Prevalence and Pattern of Lateral Impingements in the Progressive Collapsing Foot Deformity

Category:Hindfoot; Midfoot/ForefootIntroduction/Purpose:Lateral impingements, subdivided into Sinus Tarsi (STI), Talo-Fibular (TFI), and Calcaneo-Fibular (CFI) impingements, appear to be associated with the Peritalar Subluxation (PTS) component of the Progressive Collapsing Foot Deformity (PCFD). This is not yet confirmed, as the chronological place of the different types of lateral impingements in PTS is unknown. It is also unclear whether STI are associated with PTS or Midfoot Abduction. Our primary objective was to assess the amount of PTS in STI, TFI and CFI. Our secondary objective was to determine the position of STI among the PTS and Midfoot Abduction deformities. We hypothesized that STI and TFI will be associated with a lower amount of PTS than CFI and that STI will be part involved in both PTS and Midfoot Abduction deformities.Methods:A retrospective study including 72 PCFD assessed with Weight Bearing Computed Tomography (WBCT) was realized. Patients under 15 or with a previous history of surgery were excluded. Lateral impingements were assessed on WBCT images and subdivided as STI, TFI and CFI. Both direct and indirect signs of impingement were considered positive. The amount of PTS was assessed by the percentage of uncoverage and the incongruence angle of the Middle Facet (MF). Midfoot-Abduction was assessed by Talonavicular coverage angle and global foot deformity by Foot and Ankle Offset (FAO). These data were collected by two independent observers and one performed a blinded second assessment. Interobserver and Intraobserver reliabilities were determined using unweighted Cohen's kappa values for lateral impingements and using intraclass correlation coefficients for the measurements. Impingement groups were compared using Student's T-tests for normal, and Mann-Whitney for non-normal variables.Results:Interobserver and Intraobserver reliabilities ranged from substantial to almost perfect for all assessments. STI was present in 84.7%, TFI in 65.2% and CFI in 19.4% of PCFD cases. PCFD with STI showed significant increases of MF uncoverage (p=0.0001), FAO (p=0.0008) and Talonavicular coverage angle (p=0.0197) compared to PCFD without STI. PCFD with TFI did not show significant difference on measurements compared to PCFD without TFI. PCFD with CFI had associated STI in 100% and TFI in 64.2% of cases. PCFD with CFI showed significant decreases of MF incongruence (p=0.0398) and significant higher FAO (p=0.0058) compared to PCFD without CFI. PCFD with both STI and CFI showed significant decreases of MF incongruence (p=0.032) and significant higher FAO (p=0.028) compared to PCFD with isolated STI.Conclusion:Our hypotheses have not been confirmed. STI was associated with both PTS and Midfoot Abduction deformities but neither TFI nor CFI were associated with PTS considering MF subluxation. Conversely, CFI was associated with a reduction of the MF incongruence angle despite being associated with a higher global deformity. STI may be associated with earlier PCFD with a concentration of the malignment forces in the subtalar joint whereas CFI may occur later and be associated with a failure of the deep layer of the deltoid ligament and a talar tilt. This could explain the relative reduction of the PTS in CFI.

Nerve-Sparing Radical Hysterectomy: Kobayashi's Method.

After Prof. S. Okabayashi introduced Okabayashi Operation in 1921, several surgeons introduced numerous improvements in Japan. One of them is so-called the Tokyo Method which was improved and revised by Dr. Kyusaku Ogino (1950), Prof. Takashi Kobayashi, University of Tokyo (1961, 1970), and Prof. Shoichi Sakamoto, University of Tokyo (1981). The nerve-sparing radical hysterectomy without sacrificing radicality was introduced in 1961 1 and improved in 1970 by Prof. Kobayashi. 2 The autonomic nerve pathway including hypogastric nerve (sympathetic nerve), pelvic splanchnic nerve (parasympathetic nerve), and pelvic nerve plexus as a junction of the two nerves and the branch of the plexus to the bladder (vesical nerve branch) are preserved except in advanced cases. He divided the process of nerve-sparing surgery into four steps for separating the autonomic nerve pathway from adjacent tissues along the pathway consisting of cardinal, sacrouterine, rectouterine/vaginal, and vesicouterine ligaments. The first step is separation of the cardinal ligament (deep uterine vessels) from the pelvic splanchnic nerve. The second step is separation of the medial side of severed cardinal ligament from the pelvic nerve plexus. The first and second steps are performed in the lateral side of the autonomic nerve system. The third step is separation of sacrouterine and rectouterine/vaginal ligaments from hypogastric nerve and pelvic nerve plexus. The third step is necessary for achieving high radicality, namely, for severing the sacrouterine and rectouterine/vaginal ligaments near the rectum without damage to the pelvic nerve plexus. The fourth step is separation of paravaginal tissues and posterior (deep) layer of the vesicouterine ligament from the vesical nerve branches of the plexus. The third and fourth steps are performed in the medial side of the autonomic nerve system.

Effects of Sulcus Vocalis Depth on Phonation in Three-Dimensional Fluid-Structure Interaction Laryngeal Models.

Sulcus vocalis is an indentation parallel to the edge of vocal fold, which may extend into the cover and ligament layer of the vocal fold or deeper. The effects of sulcus vocalis depth d on phonation and the vocal cord vibrations are investigated in this study. The three-dimensional laryngeal models were established for healthy vocal folds (0 mm) and different types of sulcus vocalis with the typical depth of 1 mm, 2 mm, and 3 mm. These models with fluid-structure interaction (FSI) are computed numerically by sequential coupling method, which includes an immersed boundary method (IBM) for modelling the glottal airflow, a finite-element method (FEM) for modelling vocal fold tissue. The results show that a deeper sulcus vocalis in the cover layer decreases the vibrating frequency of vocal folds and expands the prephonatory glottal half-width which increases the phonation threshold pressure. The larger sulcus vocalis depth makes vocal folds difficult to vibrate and phonate. The effects of sulcus vocalis depth suggest that the feature such as phonation threshold pressure could assist in the detection of healthy vocal folds and different types of sulcus vocalis.

Effectiveness of repairing the deep layer of deltoid ligament by suture anchor repair method in treatment of mixed medial injury associated with ankle fractures

To explore the necessity of repairing the deep layer of deltoid ligament in the treatment of mixed medial injury associated with ankle fractures. Between January 2016 and December 2018, 12 patients with mixed medial injury associated with ankle fractures were treated with the fixation of the lateral malleolus by bone plates, the fixation of the anterior colliculus of medial malleolus by cannulated screws, and the repair of the deltoid ligament by suture anchors. There were 8 males and 4 females, with an average age of 42 years (range, 18-56 years). According to the Lauge-Hansen classification criteria, there were 11 cases of supination-external rotation type and 1 case of pronation-external rotation type. According to the Weber classification criteria, all cases were type B. The time from injury to operation was 3-6 days, with an average of 4.7 days. In each patient, X-ray films of anteroposterior and lateral views and mortise view of ankle were taken postoperatively. The motion range of ankle joints was observed. The function of the ankle and the outcome of the treatment were evaluated according to the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system, Olerud-Molander scoring system, and the visual analogue scale (VAS) score. All cases were followed up 12-42 months (mean, 28 months). The 12 patients returned to their pre-injury jobs. Five patients with sports injury completely recovered to their pre-injury motor function. No patient experienced persistent medial ankle pain or ankle instability. At last follow-up, the ankle range of motion in dorsiflexion was 9°-25° (mean, 17.96°), which was 0°-11° (mean, 4.02°) less than that in normal side; the range of motion in plantar flexion was 38°-50° (mean, 43.90°), which was 0°-7° (mean, 2.53°) less than that in normal side. The AOFAS score was 88-100 (mean, 96.7); the Olerud-Molander score was 90-100 (mean, 96.5); the VAS score was 0-3 (mean, 1.1). It is necessary to repair the deep layer of deltoid ligament in the mixed medial injuries associated with ankle fracture, which include anterior colliculus fracture and deep deltoid ligament injury. A better outcome can be achieved by employing the suture anchor repair method.

Effect of medial collateral ligament release and osteophyte resection on medial laxity in total knee arthroplasty.

The concept of medial stabilizing technique total knee arthroplasty (MST-TKA) is to minimize the medial release without the superficial layer of medial collateral ligament (MCL). However, it is unclear at what stage the proper medial laxity is obtained during surgery. The purpose of this study was to investigate the implication of deep layer of MCL (dMCL) and osteophyte resection on medial laxity during MST-TKA. A total of 103 consecutive patients who underwent cruciate-retaining TKA using the navigation system were included. The intraoperative hip-knee-ankle (HKA) angle was recorded under three conditions (no stress, valgus, and varus stress) at four time points after the resection of the anterior cruciate ligament (ACL) and meniscus (1st evaluation), after the dMCL release (2nd evaluation), and after osteophyte resection on both the femoral and tibial side (3rd evaluation). To assess valgus laxity, the differences in intraoperative HKA angle between 1st and 2nd evaluation (stage 1) and between 2nd and 3rd evaluation (stage 2) were calculated. Under the valgus stress condition, the intraoperative HKA angle change in stage 2 was significantly larger than that in stage 1 in full extension (stage 1; -0.5 ± 1.0°, stage 2; -2.0 ± 1.3°, p < 0.001) and 30° flexion (stage 1; -0.8 ± 1.4°, stage 2; -1.5 ± 2.0°, p = 0.008). There were no significant differences at 60° and 90° of knee flexion. Under the no stress and varus stress conditions, there were no significant differences in knee flexion at all angles. The medial laxity during MST-TKA increased significantly more after dMCL release and osteophyte resection than after just dMCL release at full extension and 30° flexion, and it was, therefore, considered that osteophyte resection is a key procedure for a successful MST-TKA. Level II, therapeutic prospective cohort study.

A new genus Turneroconcha (Bivalvia: Vesicomyidae: Pliocardiinae) for the giant hydrothermal vent clam 'Calyptogena' magnifica.

A new monotypic genus, Turneroconcha, is established for T. magnifica (Boss Turner) which was originally assigned to the genus Calyptogena Dall. The distinguishing morphological characters of the new genus are the combination of both conchological and anatomical features including: the presence of only two tooth elements in the right valve; submerged location of the posterior part of the posterior lamellar ligament layer; the absence of a subumbonal pit, lunular incision, escutcheon and pallial sinus; the presence of both pairs of demibranchs; the tubular structure of marginal parts of the interlamellar septa in gills; an inner valve of the inhalant siphon without processes; tentaculate inner mantle fold 3 and a Z-shaped digestive tract. Analysis of morphological data on Recent and fossil pliocardiines shows that Turneroconcha gen. nov. can be presently considered as a monotypic genus. The comparative morphological analysis of the new genus with described pliocardiine genera is consistent with available molecular results. Turneroconcha gen. nov. is endemic to the East-Pacific Rise and Galapagos Rift and occurs at water depths of 2251 to 2791 m. It is the only pliocardiine genus known so far with a mainly epifaunal life habit. No fossils of Turneroconcha gen. nov. are known.