Medial Border Research Articles

Meme Koruyucu Cerrahide İntraoperatif Ultrason ve Frozen Patoloji Kullanımının Güvenli Cerrahi Sınır Üzerindeki Etkinliği

Background: Breast cancer is the most common cancer in women over the age of 40. The lifetime risk is around 12%. Today, breast cancer patients are diagnosed at an early stage thanks to screening programs, and thus mortality has decreased to around 25-30%. The positivity or closeness of surgical margins in breast conserving surgery varies between 5-60%. Negativity of surgical margins is very important to prevent future recurrent breast cancer, to pre-vent recurrent surgeries, and to prevent additional treatments. In this study, we aimed to investigate the efficacy of intraoperative ultrasonography and frozen section use in breast cancers treated with breast conserving surgery in obtaining safe surgical margins and in postoperative cosmetic terms. Materials and Methods: This study includes 150 patients diagnosed with breast cancer and treated with breast con-serving surgery in between January 2015 and January 2019. The presence of distant metastases and multifocal or centrally located tumor involvement in the breasts were investigated. The localization of the tumor was marked anatomically by preoperative ultrasonography in all patients. The operation was started 15 minutes after the injec-tion. The tumor was completely excised, leaving at least 1 cm of intact tissue around the tumor, including the skin, on the preoperatively marked area, including the underlying muscle fascia. Medial and superior borders were marked with string. This excised tissue block was examined with intraoperative ultrasonography. Results: The mean age of the patients was 48,3± 9.7 years. While the tumor was located in the right breast in 83 (55.3%) of the patients, it was located in the left breast in 67 (44.7%) patients. The tumor was located in the upper outer quadrant in 67 (44.7%) patients, in the upper inner quadrant in 53 (35.3%) patients, and in the lower outer quadrant in 30 (20%) patients. Axillary dissection was performed in 21 (14 %) of the patients because sentinel lymph node was positive. In histological typing, 141 (94 %) patients were ductal carcinoma and 9 (6 %) patients were lobular carcinoma. Conclusions: As a result of our study and literature review, we think that frozen examination together with intraope-rative ultrasonography is a simple, easily applicable and cosmetically good method to determine the safe surgical margin in breast conserving surgery.

A CASE REPORT ON THE BILATERAL PSOAS MINOR MUSCLES WITH CLINICAL SIGNIFICANCE

The Psoas Minor is a thin paired muscle of the posterior abdominopelvic region, placed in front of the Psoas major.The psoas minor muscle is considered inconstant and is often absent, only being present in about 40% of human specimens studied.The psoas minor muscle originates from the vertical fascicles inserted on the last thoracic and first lumbar vertebrae. From there, it passes down onto the medial border of the psoas major and is inserted to the innominate line and the iliopectineal eminence. Additionally, it attaches to and stretches the deep surface of the iliac fascia and occasionally its lowermost fibers reach the inguinal ligament.

Anatomical Study of the Lateral Tibial Spine as a Landmark for Weight Bearing Line Assessment during High Tibial Osteotomy.

Background: Accurate pre-operative planning is essential for successful high tibial osteotomy (HTO). The lateral tibial spine is a commonly used anatomical landmark for weight-bearing line assessment. However, studies on the mediolateral (M-L) position of the lateral tibial spine on the tibial plateau and its variability are limited. Purpose: This study aimed to (1) analyze the M-L position of the lateral tibial spine on the tibial plateau and its variability, (2) investigate radiologic parameters that affect the position of the lateral tibial spine, and (3) determine whether the lateral tibial spine can be a useful anatomical landmark for weight-bearing line assessment during HTO. Materials and Methods: Radiological evaluation was performed on 200 participants (64% female, mean age 42.3 ± 13.2 years) who had standing anterior-posterior plain knee radiographs with a patellar facing forward orientation. The distances from the medial border of the tibial plateau to the lateral spine peak (dLSP) and lateral spine inflection point (dLSI) were measured using a picture archiving and communication system. The medial-lateral inter-spine distance (dISP) was also measured. All parameters were presented as percentages of the entire tibial plateau width. The relationships between the parameters were also investigated. Results: The mean value of dLSP was 56.9 ± 2.5 (52.4-64.5)%, which was 5% lower than the Fujisawa point (62%). The mean value of dLSI was 67.9 ± 2.2 (63.4-75.8)%, which was approximately 5% higher than the Fujisawa point. The values of the dLSP and dLSI were variable among patients, and the upper and lower 10% groups showed significantly higher and lower dLSP and dLSI, respectively, than the middle 10% group. The mean value of dISP was 16.5 ± 2.4%, and it was positively correlated with dLSP and dLSI. Conclusions: On average, the dLSP and dLSI were located -5% and +5% laterally from the conventional Fujisawa point, and they may be useful landmarks for correction amount adjustment during HTO. However, it should be noted that correction based on the lateral tibial spine can be affected by anatomical variations, especially in patients with small or large inter-spine distances.

Anterolateral and Medial Locking Compression Plates for the Management of Distal Tibial Fractures: A Comparative Prospective Study.

Open/close reduction (OR/CR) and internal fixation (IF) of displaced fractures of distal tibia with either a medial or anterolateral plate is a commonly performed procedure. Anterolateral plating avoids an incision along the medial subcutaneous border of tibia and has been shown to have reduced risk of wound complications. The aim of our study was to determine the functional outcome of these fractures treated with anterolateral and medial distal tibial locking compression plates. This was a prospective study that included 60 patients with distal tibial fractures (close or grade I open injury)divided into two groups with 30 patients in each where one group was treated with OR/CR and IF using an anterolateral distal tibial locking plate (Group A) and the other using a medial distal tibial locking plate (Group B). The duration of surgery and intraoperative blood loss and time to union were recorded for all the patients. Functional evaluation was done at one year in terms of pain, function and alignment using theAmerican Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, and complications, if any, were noted. Both the groups were comparable in terms of age, gender, time of presentation, AO classification and presence of wound. The mean duration of surgery as well as the intraoperative blood loss were more in the anterolateral plate group than in the medial plate group, but the difference was statistically insignificant. Ten patients (33%) with medial plates had symptomatic hardware and 7 (23.3%) underwent removal while only 3 (10%) patients in the anterolateral plate group had similar complaints and none had to undergo removal. Two patients with anterolateral plate and one with medial plate had malunion. The mean time to fracture union as well as the rate of infection was less and the functional outcome at one year was better in the group treated with anterolateral plates as compared to the one with medial plates, but the difference again was not statistically significant for all the parameters. With reduced risk of soft tissue complications and by obviating the need for implant removal, anterolateral plates can prove to be a better alternative to the medial plates especially in elderly patients in the management of these fractures.

Minimally invasive plate osteosynthesis (MIPO) for scapular fractures.

Presentation of aminimally invasive surgical approach for the treatment of scapular fractures and the clinical outcome using this technique. Displaced extra-articular fractures of the scapula body and glenoid neck (AO 14B and 14F) and simple intra-articular fractures of the glenoid. Complex intra-articular fractures and isolated fractures of the coracoid base. Make astraight or slightly curved incision along the lateral margin of the scapula leaving the deltoid fascia intact. Identify the interval between the teres minor muscle and infraspinatus to visualize the lateral column, whilst retracting the deltoid to visualize the glenoid neck. Reduce and align the fracture using direct and indirect reduction tools. Asecond window on the medial border of the scapula can be made to aid reduction and/or to augment stability. Small (2.0-2.7 mm) plates in a90° configuration on the lateral border and, if required, on the medial border are used. Intra-operative imaging confirms adequate reduction and extra-articular screw placement. Direct postoperative free functional nonweight-bearing rehabilitation limited to 90° abduction for the first 6weeks. Sling for comfort. Free range of motion and permissive weight-bearing after 6weeks. We collected data from 35patients treated with minimally invasive plate osteosynthesis (MIPO) between 2011 and 2021. Average age was 53 ± 15.1years (range 21-71years); 17had atypeB and 18atypeF fracture according the AO classification. All patients suffered concomitant injuries of which thoracic (n = 33) and upper extremity (n = 25) injuries were most common. Double plating of the lateral border (n = 30) was most commonly performed as described in the surgical technique section. One patient underwent an additional osteosynthesis 3months after initial surgery due to pain and lack of radiological signs of healing of afracture extension into the spine of the scapula. In the same patient, the plate on the spine of scapula was later removed due to plate irritation. In 2patients postoperative images showed ascrew protruding into the glenohumeral joint requiring revision surgery. After standardisation of intra-operative imaging following these two cases, intra-articular screw placement did not occur anymore. No patient suffered from iatrogenic nerve injury and none developed awound infection.

A Muscle-Preserving Short Transverse Incision for Unicompartmental Knee Arthroplasty: A Technical Note.

We describe the use of a short transverse incision technique with muscle retention for unicompartmental knee arthroplasty (UKA). The incision is made transversely just above the joint line, followed by a detachment of subcutaneous soft tissue from the underlying capsule and fascia to create a mobile window. The fascia is incised along the medial border of the vastus medialis and the capsule of the suprapatellar pouch is incised laterally, preserving vastus medialis muscle. All procedures are performed within the mobile window while controlling the knee flexion angle. Following implantation, the capsule and fascia are anatomically repaired. This approach was used in 30 consecutive patients who underwent Oxford UKA, including one bi-unicompartmental knee arthroplasty without complications. Importantly, no patients had any disturbances of the infrapatellar branch of the saphenous nerve disturbancessuch as numbness, hyperesthesia, hypoesthesia, or neuroma pain. The transverse approach is thought to be a safe and feasible method for UKA.

Evaluation of Medial Meniscal Extrusion Using Radiography.

Recently, there has been increasing interest in medial meniscal extrusion (MME), but few reports have evaluated MME via X-ray. In this study, the amount of MME and meniscal height at the medial border of the tibia were measured via X-ray with gradation processing. The extrusion length divided by the meniscal height yields the meniscal extrusion ratio, which was used as an index. In addition, the medial meniscal length of the part protruding from the medial border of the tibia on MRI was measured as an absolute value. Then, the correlation between the meniscal extrusion ratio and the amount of MME on MRI was examined, and there was a strong correlation between the meniscal extrusion ratio via X-ray and the amount of MME on MRI (correlation coefficient 0.860, p < 0.0001). The cut-off value of the meniscal extrusion ratio via X-ray for positive meniscal extrusion on MRI was 0.50, with an AUC of 0.9825, sensitivity of 0.9063, and specificity of 0.8663. From the present study, it was possible to measure the extrusion length and meniscal height via gradation processing, with X-ray and without MRI, and to calculate the meniscal extrusion ratio, which strongly correlates with the amount of MME on MRI.

Sequential Release and Muscle Slide of Irreparable Rotator Cuff Tears Results in Linear Gains in Tendon Mobility

The purposes of this study were to examine the technique of the supraspinatus and infraspinatus muscle slide for the treatment of rotator cuff tears and to quantify the amount of release and resultant tendon excursion at their insertion sites in cadavers. Twelve shoulders in 6 human cadavers were dissected. Their average age at time of death was 84 years. Though a large open posterior incision, artificial rotator cuff tears were created, if not already present. Standard arthroscopic release was completed. Muscle slide technique was then performed for the supraspinatus and infraspinatus muscles in quartiles, with tendon excursion measured at each interval. The average muscle length from its most medial border to the tendinous insertion was 130 mm and 145.8 mm for the supraspinatus and infraspinatus, respectively. Progressive release of the muscle origin from lateral to medial in 25% increments corresponded to a 6.47-mm lateral shift of the tendon to a maximum of 25.8 mm before complete release of the supraspinatus muscle was achieved. For the infraspinatus, it was an average of 5.38 mm at each 25% interval to a maximum of 21.5 mm. The only restraint to mobility were the motor branches attached to the undersurface of each muscle belly. An additional 25.8 mm (supraspinatus) and 21.5 mm (infraspinatus) of tendon excursion was produced when 100% of the muscle was released from its underlying fossa. At that juncture, tendon excursion was limited by tension placed on each muscle's respective neurovascular supply. Furthermore, sequential release of each muscle resulted in a predictable and consistent gain in tendon mobility, with an average of 6.47 mm and 5.38 mm for each quartile of muscle release in the supraspinatus and infraspinatus from lateral to medial. Tension at the repair site is a contributing factor to poor outcomes after arthroscopic rotator cuff repair of massive rotator cuff tears. This study quantifies the tendon mobility that may be gained following additional muscle slide techniques, and the addition of this technique may contribute to a tension-free repair.

Membrane anatomy in right colon cancer: definition and identification of mesocolic completeness

Complete mesocolic excision (CME) and D3 resection of right colon cancer have been widely implemented, but the definition and identification of the completeness of the mesentery have not been fully agreed, especially the dorsal and medial borders. In this paper, we proposed the dorsal fascia of the colonic mesentery as the dorsal border of the mesocolon and the line connecting the roots of the ileocolic artery and the middle colic artery (ICA-MCA line) as the medial border of the CME by systematically studying the relationship between the mesentery and the mesenteric bed from the theory of membrane anatomy, combined with surgical experience and in-depth review of ontogenetic anatomy. We also proposed the visible "superior mesenteric vein notch" and "middle colic artery triangle" on surgical specimens as identifiers of mesocolic completeness.

Subthalamic deep brain stimulation for primary dystonia: defining an optimal location using the medial subthalamic nucleus border as anatomical reference.

Although the subthalamic nucleus (STN) has proven to be a safe and effective target for deep brain stimulation (DBS) in the treatment of primary dystonia, the rates of individual improvement vary considerably. On the premise of selecting appropriate patients, the location of the stimulation contacts in the dorsolateral sensorimotor area of the STN may be an important factor affecting therapeutic effects, but the optimal location remains unclear. This study aimed to define an optimal location using the medial subthalamic nucleus border as an anatomical reference and to explore the influence of the location of active contacts on outcomes and programming strategies in a series of patients with primary dystonia. Data from 18 patients who underwent bilateral STN-DBS were retrospectively acquired and analyzed. Patients were assessed preoperatively and postoperatively (1 month, 3 months, 6 months, 1 year, 2 years, and last follow-up after neurostimulator initiation) using the Toronto Western Spasmodic Torticollis Rating Scale (for cervical dystonia) and the Burke-Fahn-Marsden Dystonia Rating Scale (for other types). Optimal parameters and active contact locations were determined during clinical follow-up. The position of the active contacts relative to the medial STN border was determined using postoperative stereotactic MRI. The clinical improvement showed a significant negative correlation with the y-axis position (anterior-posterior; A+, P-). The more posterior the electrode contacts were positioned in the dorsolateral sensorimotor area of the STN, the better the therapeutic effects. Cluster analysis of the improvement rates delineated optimal and sub-optimal groups. The optimal contact coordinates from the optimal group were 2.56 mm lateral, 0.15 mm anterior, and 1.34 mm superior relative to the medial STN border. STN-DBS was effective for primary dystonia, but outcomes were dependent on the active contact location. Bilateral stimulation contacts located behind or adjacent to Bejjani's line were most likely to produce ideal therapeutic effects. These findings may help guide STN-DBS preoperative planning, stimulation programming, and prognosis for optimal therapeutic efficacy in primary dystonia.

Rubrospinal activation during asleep subthalamic nucleus deep brain stimulation: a false localizing sign. Illustrative case.

Deep brain stimulation (DBS) can be a life-changing intervention for patients with Parkinson's disease (PD), but its success is largely dependent on precise lead placement. The subthalamic nucleus (STN) is one of the most common surgical targets of DBS, but the close anatomical and physiological resemblance of the STN to the mediocaudal red nucleus renders these landmarks difficult to distinguish. We present an atypical case in which targeted localization of the STN resulted in symptoms pathognomonic of rubrospinal tract (RST) stimulation. A 79-year-old female with a 12-year history of right-hand resting tremor due to medically refractory PD presented for asleep bilateral STN-DBS surgery. Right STN intraoperative testing revealed left hand and elbow flexion contractures, initially suggestive of corticospinal tract activation, despite imaging studies demonstrating reasonable lead placement in the central dorsolateral STN. The lead was moved anteromedially near the medial border of the STN, but stimulation at this location revealed similar but more robust flexor hand and arm contractures, without any extraocular muscle involvement. Thus, activation of the RST was suspected. Isolated activation of the RST is possible during STN-DBS surgery. Its identification can help avoid false localization and suboptimal lead placement.

Poster 265: The Risk of Iatrogenic Posterior Neurovascular Injury in Lateral Meniscal Repair Based on Real Arthroscopic Position: An MRI Study

Objectives: Posterior horn of lateral meniscal repair using an all-inside meniscal repair device involves a risk of iatrogenic posterior neurovascular injury. Some studies have evaluating the injury risk in this area but most were based on preoperative MRIs and landmarks which are difficult to clearly see under actual arthroscopic surgery. To our knowledge, there have been no studies to date evaluating the risk of injury based on MRIs with the knee in the standard operational figure-of-4 position with joint dilatation in arthroscopic lateral meniscal repair related to the lateral border of the lateral meniscal root which is easy to identify during surgery. The objective of this study was to evaluate and compare the risk of posterior neurovascular injury and establish the safe and danger zones in repairing the lateral meniscus through the anterolateral and anteromedial portals in relation to the medial and lateral borders of the lateral meniscal root (LMR) using standard operational figure-of-4 position with joint dilatation MRIs. Methods: This study was descriptive laboratory study. Using 29 axial magnetic resonance imaging (MRI) studies 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 anteromedial and anterolateral portals to the medial and lateral borders of the LMR extending 14 mm beyond the joint capsule. If the line passed through or touched the posterior neurovascular structure, a risk of iatrogenic injury was noted, and measurements were made to determine the safe zones in relation to the medial or lateral border of the LMR. Results: Repairing the lateral meniscus through the anterolateral portal in relation to the lateral border of the LMR had a significantly greater risk of posterior neurovascular injury than repairing through the anteromedial portal, of which the incidences were 68.97% and 10.35%, respectively (p-value = 0.001). The “safe zones” of lateral meniscal repair in relation to the lateral border of the LMR through the anterolateral and anteromedial portals were 4.15 ± 1.87 mm and 6.57 ± 0.98 mm lateral to the lateral border of the LMR, respectively. Conclusions: Our study found a risk of iatrogenic posterior neurovascular injury when repairing the posterior lateral meniscus tissue through both the anterolateral and anteromedial portals in relation to both the lateral and medial borders of the LMR, with repairs through the anterolateral portal having greater risk than through the anteromedial portal. To reduce this risk, the surgeon can use the “safe zones” as described in this study to decrease the potential risk of iatrogenic posterior neurovascular injury during arthroscopic lateral meniscal repair. Clinical Relevance: Iatrogenic injury is always a concern in any surgery, and the results of this study can be a guide to reducing iatrogenic posterior neurovascular injury during posterior horn of lateral meniscal repair.

Poster 276: Assessment of Trochlear Cartilage Thickness and Volume Using Sagittal Magnetic Resonance Images to Quantify Trochlear Dysplasia: A Matched-Cohort Study

Objectives: Trochlear dysplasia is considered a major contributing factor for patellar instability. More recently, trochleoplasty procedures have become popularized to address this morphological abnormality. Both thick and thin flap trochleoplasty techniques exist, with the goal to deepen the trochlea while avoiding perforation of the trochlear cartilage during the procedure. However, the relative cartilage thickness in the dysplastic trochlea has not been well described. This study aimed to assess trochlear cartilage thickness and volume in knees with and without patellar instability and the relationship to measurements of trochlear dysplasia. Methods: 25 knees with symptomatic patellar instability were compared with 25 gender-matched knees. Retrospective chart review was performed to obtain demographic data. On sagittal images, trochlear cartilage thickness (TCT) and trochlear cartilage volume (TCV) were analyzed at the center, medial border, and lateral border of the trochlea. TCT was defined as the cartilage thickness halfway along the trochlear length at its maximum dimension. TCV was defined by total area of cartilage proximal to the plane of the intercondylar midpoint. Symptomatic and control values were compared using paired sample t-test. Stepwise multivariate linear regression was performed to assess for associations with standard radiographic parameters of trochlear dysplasia. Results: TCT was significantly different between the medial, central and lateral trochlea in both the symptomatic and control groups (p&lt;0.001). Only lateral TCT demonstrated a significant difference between groups, which was 20.3% (p=0.035) thicker in the symptomatic cohort compared to controls. No significant differences existed in TCV between symptomatic and control groups. In females, central TCT was 28.3% thicker in the symptomatic cohort (p=0.024), while medial TCV was 2.3x greater (p = 0.019). Males failed to demonstrate gender specific differences. Regression analysis demonstrated that patient height showed a significant relationship with all measurements except for medial TCV. Central TCT demonstrated a significant, independent relationship with trochlear depth (Coefficient 0.38, p = 0.011), while central TCV demonstrated a significant, independent relationship with trochlear depth (Coefficient 9.9, p &lt;0.001), sulcus angle (Coefficient 1.1, p &lt;0.001), and lateral trochlear inclination (Coefficient -1.1, p &lt;0.001). Conclusions: While trochlear dysplasia typically refers to abnormal bony morphology, this study demonstrates the role of differential contributions of chondral thickness and volume between knees with and without patellar instability, and that these measurements correlated with severity of dysplasia. Future studies should further investigate the relationship between TCT and TCV with other dysplasia parameters to better inform the surgical considerations of performing trochleoplasty in the treatment of patellar instability. [Table: see text]

Lrrn1 Regulates Medial Boundary Formation in the Developing Mouse Organ of Corti.

One of the most striking aspects of the sensory epithelium of the mammalian cochlea, the organ of Corti (OC), is the presence of precise boundaries between sensory and nonsensory cells at its medial and lateral edges. A particular example of this precision is the single row of inner hair cells (IHCs) and associated supporting cells along the medial (neural) boundary. Despite the regularity of this boundary, the developmental processes and genetic factors that contribute to its specification are poorly understood. In this study we demonstrate that Leucine Rich Repeat Neuronal 1 (Lrrn1), which codes for a single-pass, transmembrane protein, is expressed before the development of the mouse organ of Corti in the row of cells that will form its medial border. Deletion of Lrrn1 in mice of mixed sex leads to disruptions in boundary formation that manifest as ectopic inner hair cells and supporting cells. Genetic and pharmacological manipulations demonstrate that Lrrn1 interacts with the Notch signaling pathway and strongly suggest that Lrrn1 normally acts to enhance Notch signaling across the medial boundary. This interaction is required to promote formation of the row of inner hair cells and suppress the conversion of adjacent nonsensory cells into hair cells and supporting cells. These results identify Lrrn1 as an important regulator of boundary formation and cellular patterning during development of the organ of Corti.SIGNIFICANCE STATEMENT Patterning of the developing mammalian cochlea into distinct sensory and nonsensory regions and the specification of multiple different cell fates within those regions are critical for proper auditory function. Here, we report that the transmembrane protein Leucine Rich Repeat Neuronal 1 (LRRN1) is expressed along the sharp medial boundary between the single row of mechanosensory inner hair cells (IHCs) and adjacent nonsensory cells. Formation of this boundary is mediated in part by Notch signaling, and loss of Lrrn1 leads to disruptions in boundary formation similar to those caused by a reduction in Notch activity, suggesting that LRRN1 likely acts to enhance Notch signaling. Greater understanding of sensory/nonsensory cell fate decisions in the cochlea will help inform the development of regenerative strategies aimed at restoring auditory function.

Avoiding Pretarsal Denervation in Lower Blepharoplasty Incisions: Refined Pretarsal Motor Nerve Anatomy.

Pretarsal atrophy is not uncommonly found in patients who have undergone a transcutaneous or transconjunctival lower blepharoplasty because of intraoperative denervation of the pretarsal orbicularis oculi. The motor-supplying concept to the lower eyelid was recently updated; however, there have not yet been any guidelines to preserve motor nerves in lower blepharoplasty incisions based on the refined knowledge. Forty-six fresh cadaveric hemifaces were examined to find a safe zone for a lower blepharoplasty muscle incision and a danger zone for an infraorbital incision in the transblepharoplasty midface approach. In addition, practical anatomy about the pretarsal motor supply was also investigated in detail. The medial, lateral, superior, and inferior borders of the safe zone for a lower blepharoplasty muscle incision were 9.4 mm from the medial canthus line, 3 mm from the lateral canthal crease, and 6.0 and 6.5 mm from the eyelid margin, respectively. The danger zone for an infraorbital incision ranged from 9.4 mm medial to the midpupillary line to 9.7 mm lateral to the midpupillary line. The motor nerve in the danger zone abutted the distal roof of the preseptal pocket, making it vulnerable to electrocautery heat. Motor nerve distribution of the lower pretarsal orbicularis oculi was fully identified. There is a safe zone for the lower blepharoplasty muscle incision which, if adhered to, will preserve the pretarsal motor supply and prevent muscle atrophy. There is an infraorbital danger zone, where surgeons should pay special attention to avoid electrocautery heat injury.

The influence of first ray instability and hindfoot valgus in the development of hallux rigidus: state of art.

Hallux rigidus (HR) is a painful condition associated with degenerative arthritis of the first metatarsophalangeal (MTP1) joint, leading to a progressive loss of dorsiflexion. The etiological factors leading to the development of the condition are not yet fully understood in the literature. When the hindfoot is aligned in excessive valgus, the medial border of the foot tends to roll over, which brings to increased stress on the medial side of the MTP1 joint, and consequently on the first ray (FR), thus potentially influencing the development of HR deformity. This state of art aims to analyze the influence of FR instability and hindfoot valgus in HR development. From the results of the analyzed studies, it appears that a FR instability may predispose the big toe to increased stress and to narrow the proximal phalanx motion on the first metatarsal, which brings to compression and ultimately degeneration of the MTP1 joint, mostly in advanced stages of disease, less in mild or moderate HR patients. A strong correlation between a pronated foot and MTP1 joint pain was found; forefoot hypermobility during the propulsion phase may promote MTP1 joint instability and increase pain. Thus, the increased moment of pronation of the foot with the overload of the medial column, when present, should be corrected conservatively or surgically; this, most likely, would be useful not only to eliminate or at least limit the painful symptoms but above all to prevent the worsening of the condition, also after the surgical treatment of HR.

The Direct Anterior Approach (DAA) as a Standard Approach for Total Hip Arthroplasty (THA) in Coxa Profunda and Protrusio Acetabuli? A Radiographic Analysis of 188 Cases.

The direct anterior approach (DAA) represents a well-recognized soft tissue sparing technique for primary total hip arthroplasty (THA). The feasibility and suitability of the DAA in cases of complex acetabular deformities, namely coxa profunda (CP) and protrusio acetabuli (PA), remain to be determined. A total of 188 cases of CP (100 cases) and PA (88 cases) hips undergoing primary THA via the DAA were retrospectively analyzed. Surgical and radiographic parameters were evaluated and potential complications were assessed. Finally, successful implantation was defined if surgical and radiographic parameters were well within established values of non-complex primary THA. In 159 hips, the medial border of the acetabular component was transferred laterally to the ilioischial line, corresponding to a fully treated acetabular protrusion. In 23 (12.23%) cases, mild, and in 5 (2.66%) cases, moderate residual acetabular protrusion remained after THA. Postoperatively, 11.40% (PA group) and 9.00% (CP group) had a leg length discrepancy (LLD) greater than 10 mm. The mean operative time was significantly less than 60 min. A linear relationship between the BMI and operative time was observed, with an additional 0.9 min of operative time per BMI unit. Overall, complications were rare and did not differ between the two groups. The results of this study suggest that the DAA is a suitable approach for primary THA in patients with coxa profunda and acetabular protrusion if performed by experienced surgeons familiar with the DAA. Obese patients with acetabular protrusion may pose a significant limitation to the DAA and caution should be advised in cases of obesity.

Diagnostic imaging for elbow TRASH lesions in children and usefulness of ultrasonography using standard planes.

Fractures around the elbow in children should be carefully evaluated because the main portion is cartilaginous, and radiographs are not completely reliable. This study aimed to assess the diagnostic imaging for pediatric elbow fractures that require special attention and consider the usefulness of ultrasonography with seven standard planes for the diagnosis. Patients diagnosed with elbow fractures wherein TRASH (The Radiographic Appearance Seemed Harmless) lesions were evaluated retrospectively. The diagnoses on initial radiographs, final diagnoses, additional imaging excluding radiographs, and the treatments were investigated. The standard planes for ultrasonography to detect elbow fractures included an anterior transverse scan at the level of the capitellum and proximal radioulnar joint, an anterior longitudinal scan at the level of the humeroradial and humeroulnar joints, a longitudinal scan along the lateral and medial border of the distal humerus, and a posterior longitudinal scan at the level of the distal humerus. A total of 107 patients with an average age of 5.8 years (range, 0-12 years) at the time of diagnosis were included. Of 46 (43.0%) patients misdiagnosed at the initial radiograph, 19 (17.8%) needed additional treatments due to inappropriate initial management. Ultrasonography using the standard planes was useful for prompt diagnosis and appropriate treatment. Prompt and appropriate evaluation with ultrasonography can prevent the mismanagement of pediatric elbow injuries. Level of evidence: Level IV-retrospective case series.

The Occipitalis Muscle as an Adjunct Superficial Landmark for the Transverse Sinus and Transverse-Sigmoid Junction: An Anatomical Study With Application to Posterior Cranial Fossa Surgery.

Although neuronavigation systems are widely used for identifying deep intracranial structures, additional superficial anatomical landmarks can be useful when this technology is not available or is not working properly. Herein, we investigate the potential of the occipitalis muscle (OM), rarely mentioned in neurosurgical literature, as a superficial landmark for the transverse sinus (TS) and transverse-sigmoid sinus junction (TSJ). Eighteen adult cadaveric heads underwent dissection. The borders of the OM were identified and measured. The muscle was then removed and the bone underlying the muscle was drilled. The relationships between the OM and the underlying dural venous sinuses were then investigated by using a surgical microscope. The OM is a quadrangular-shaped muscle, that invariably crosses the lambdoid suture, showing relationships with the TS inferiorly and the TSJ laterally. The medial border was located a mean of 2.7 cm from the midline and its lower edge was a mean of 1.6 cm above the TS. The inferior border was found between the lambdoid suture and the superior nuchal line in all the specimens. The medial half of the inferior margin was placed on average 1.1 cm superiorly to the TS while the lateral margin ran just above or over the TS. The lateral border was located a mean of 1.1 cm medially to the asterion and approximated the mastoid notch, being within 1-2 cm from it. The TSJ was between 2.1 and 3.4 cm lateral to OM lateral border. A combination of superficial anatomical landmarks can be useful for surgical planning. We found that the OM represents a valuable aide for neurosurgeons and is a reliable landmark for the deeper-lying TS and TSJ.

Differentiation of strains in the lateral and medial bands of the iliofemoral ligament: A segmental approach.

Iliofemoral ligament strains have been assessed in a circumscribed portion, limiting the information regarding the strains in the proximal, mid and distal portions. The purpose of this study is to describe the longitudinal and transversal strain within the proximal, mid and distal portions of the lateral and medial bands of the iliofemoral ligament. Ten fresh cadaveric specimens were assessed. The iliofemoral ligaments were divided into medial and lateral bands. Hemispherical beads (2.6 mm) were placed on the lateral and medial borders of each band. Four positions were assessed: abduction, extension, internal and external rotations combined with extension. The hemispherical beads were scanned at the end range of motion using a laser scanner. The three-dimensional position of each bead was used to estimate longitudinal and transversal strains. A three-factor ANOVA was used to compare movements, borders, and portions within each ligament for longitudinal strains. A one-way ANOVA was used to compare transversal strains between portions. This technique showed mean reliability (ICC: 2, 1) of 0.90 ± 0.06. The external rotation showed the highest strains in both ligaments (p < 0.05). Abduction showed a significant difference between the lateral and medial borders in both bands (p = 0.001). Eight movement-border combinations showed a significant difference between proximal, medial, and lateral portions (p < 0.005). According to our results, there is a clear effect of portions (proximal, mid and distal) within the ligament and movements. Abduction shows the lowest strains longitudinally but the largest strains transversally. Although we do not know the impact of this phenomenon, future studies should assess the strains following hip arthroscopies. The latter might improve the impact of this procedure on hip biomechanics. Lastly, the iliofemoral ligament should be assessed using a segmental approach rather than as a complete unit.