Medial Boundary Research Articles

Drivers of vessel progenitor fate define intermediate mesoderm dimensions by inhibiting kidney progenitor specification

Proper organ formation depends on the precise delineation of organ territories containing defined numbers of progenitor cells. Kidney progenitors reside in bilateral stripes of posterior mesoderm that are referred to as the intermediate mesoderm (IM). Previously, we showed that the transcription factors Hand2 and Osr1 act to strike a balance between the specification of the kidney progenitors in the IM and the vessel progenitors in the laterally adjacent territory. Recently, the transcription factor Npas4l – an early and essential driver of vessel and blood progenitor formation – was shown to inhibit kidney development. Here we demonstrate how kidney progenitor specification is coordinated by hand2, osr1, and npas4l. We find that npas4l and the IM marker pax2a are transiently co-expressed in the posterior lateral mesoderm, and npas4l is necessary to inhibit IM formation. Consistent with the expression of npas4l flanking the medial and lateral sides of the IM, our findings suggest roles for npas4l in defining the IM boundaries at each of these borders. At the lateral IM border, hand2 promotes and osr1 inhibits the formation of npas4l-expressing lateral vessel progenitors, and hand2 requires npas4l to inhibit IM formation and to promote vessel formation. Meanwhile, npas4l appears to have an additional role in suppressing IM fate at the medial border: npas4l loss-of-function enhances hand2 mutant IM defects and results in excess IM generated outside of the lateral hand2-expressing territory. Together, our findings reveal that establishment of the medial and lateral boundaries of the IM requires inhibition of kidney progenitor specification by the neighboring drivers of vessel progenitor fate.

Unravelling the Anatomy of the Anterior Tarsal Tunnel and Its Clinical Implications.

Anterior tarsal tunnel (ATT) syndrome is caused by the compression of the deep fibular nerve (DFN) within the ATT beneath the inferior extensor retinaculum, bounded by the tendons of the extensor hallucis longus (EHL) and extensor digitorum longus (EDL). Compression may result from direct trauma, repetitive mechanical irritation, and thrombosis of the dorsalis pedis artery. Injury to the contents of ATT could occur during ankle arthroscopy. Therefore,thisstudy was undertaken to provide a detailed description of the anatomy of the ATT and its clinical implications. Ten formalin-fixed cadavers were utilized for the study. The ATT was identified between the tendons of the EHL and EDL. The length at the medial and lateral boundaries and the width at the proximal end, middle, and distal end of the ATT were measured using a digital Vernier calliper. The mean length of the medial border of the tunnel was 31.42±8.44 mm, while the lateral border was 20.39±4.39 mm. The width of the ATT increased from the proximal to the distal end. DFN was related to the DPA laterally in 15 limbs and medially in five limbs within the tunnel. The present study not only describes the intricate anatomy of the ATT but also describes the patterns of DFN and DPA within the tunnel. Understanding the anatomy of ATT is crucial, as it paves the way for safe and efficient surgical interventions, thereby significantly reducing the risk of neurovascular damage during surgical procedures.

Anatomy of the Buccal Space: Surgical and Radiological Perspectives.

Among the anatomical spaces in the head and neck area, the buccal space has often been studied in dental/oral surgery and cosmetic surgery because it contains the facial vessels, mandibular and facial nerves, and adipose tissue called the buccal fat pad. In addition, as the space can communicate with other spaces, it can be significant in infections. Although the anatomy of the buccal space has been reported in several studies, there have been discrepancies concerning its boundaries, and its communications have often been overlooked. The aim of this review is to examine the anatomy of buccal space including its boundaries, contents, continuity with adjacent spaces, and clinical significance. A literature review was performed on Google Scholar and PubMed. The literature has depicted the anterior, medial, and lateral boundaries more or less consistently, but descriptions of the posterior, superior, and inferior borders are controversial. The buccal space includes the facial arteries, veins, facial nerves, parotid duct, and lymph nodes, which can be described differently depending on definitions and the extent of the space. As it communicates with other anatomical spaces including the masticatory space, it can be a reservoir and a channel for infections and tumors. Buccal fat pads have various clinical applications, from a candidate for flap reconstruction to a target for removal for cosmetic purposes. This review will help understand the anatomy of the buccal space including its boundaries, residing structures, and communication with other spaces from surgical and radiological perspectives.

Using Photogrammetry to Analyze Anatomical Changes in the Nipple in Juvenile and Adolescent Scoliosis Patients.

The need for an objective set of anterior trunk measurements, such as nipple and clavicular shoulder joints, is essential to quantify the anterior asymmetry present in scoliosis. This study aims to characterize breast asymmetry (BA) in young individuals with scoliosis using photogrammetry. Digital photographs of the anterior trunk of the 51 scoliosis patients aged 4-20years were taken from an anterior perspective. These images were then transferred to a computer. Ten parameters were measured using the ImageJ software. The positions of patients' nipples were classified into 6 types based on ratios on the x-axis. The majority of patients had a right breast that was larger, intensifying the apparent BA due to trunk rotation. The apical vertebra level in patients was found at T8 in 23.6% and T9 in 45.1%. In 92.5% of the patients, the right breast was consistently larger. The lengths between the lateral boundaries and nipples of the right and left breasts and between the medial boundary and nipple of the right breast were statistically significantly higher in males than in females (p < 0.05). Significant differences were found when comparing the values of the lengths between the medial boundaries and nipples of the right and left breasts, the difference in length between the right and left acromioclavicular joint lines, and the angles of the nipple and acromioclavicular joint with the degrees of scoliosis in juvenile and adolescents (p < 0.05). Pearson regression analysis revealed a significant correlation between BA differences and the Cobb angle with a correlation coefficient of 0.901. Factors related to breast aesthetics, like differences in the height of nipples and the distance from the sternal notch to the nipple, represent 30% of the overall score. The study concluded that there is a significant correlation between the severity of scoliosis and BA differences. Augmentation mammaplasty for BA not only decreased the breast difference but also leveled the nipple disparities. Photogrammetry is considered to be an alternative to other methods and is believed to contribute to the follow-up of BA. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Study of Morphometric Analysis of Foramen Transversarium and Uncinate Process and Clinical Relevance in Typical Cervical Vertebrae

The foramen transversarium differentiates the cervical vertebrae from the other vertebrae of the spinal column. From the first part of the subclavian artery, the vertebral artery arises and passes through the foramen transversarium. FT protects the vertebral artery. The medial boundary of the luschka joint is a safe sight to protect the vertebral artery. The Uncovertebral Joint, also known as the Luschka Joint, is a joint that was formed by the Uncinate Process between the cervical vertebra bodies. These joints form the medial border of an intervertebral foramen in the cervical area below C-2 and are rarely found on the first thoracic vertebra. The present study was carried out on 100 dry human typical cervical vertebrae of unknown age and sex to determine the morphometric dimensions of FT and Uncinate Process in typical cervical vertebrae. The dimensions were taken by the digital vernier caliper on the superior aspect of the FT and Uncinate Process. The length and width of the FT were more on the left side than on the right side which was statistically insignificant (p-value &gt;0.05). The narrow FTs were also observed in the present study. The mean difference between the Right and Left sides of the Uncinate Process was statistically not significant (p-value&gt;0.05).

Valuing sculpture: art, craft and industry, 1660–1860

Responding to the many useful and intriguing discussions that arose over the two days of the ‘Valuing Sculpture: Art, Craft and Industry, 1660–1860’ conference held in July 2021, this special issue explores new directions for scholarly research. This introduction considers the usefulness of the classifications of art, craft and industry, and in doing so presents this collection’s methodology of expanding dialogues by reaching across medial, dimensional, geographical and categorical boundaries.

A Radiation Therapy Contouring Atlas for Delineation of the Level I-II Axilla in the Prone Position

When patients are treated prone for whole breast irradiation (WBI), the axilla typically receives less dose than when patients are treated with WBI in the supine position. There are situations, however, where the axilla is a target as in a situation where the physician intends to treat with "high tangents" to provide good coverage of both the breast and level I-II axilla. In these scenarios, ideal target delineation when the patient is in the prone position is not well-defined. While different consensus guidelines exist for delineation of the nodal areas in the supine position, to our knowledge there are no contouring guidelines for the regional nodes in the prone position based on bone, skin, vascular and muscle landmarks. Forty-three patients treated with high tangents in the prone position from 2012-2018 were identified as representative cases. The level I and II regional nodal contours from the Radiation Therapy Oncology Group (RTOG) breast cancer atlas were adapted for prone position by a radiation oncologist and a breast radiologist based on anatomic considerations and changes observed from supine to prone positioning on diagnostic imaging. The revised nodal contours were reviewed by an expanded expert multidisciplinary panel including additional breast radiation oncologists and surgical oncologists to delineate the level I and II axilla on noncontrast computed tomography (CT) scans. We adapted the RTOG breast cancer atlas, supported by detailed figures, in order to create a CT based atlas of the level I and II axillary lymph node stations in the prone position. For the level I axilla, the cranial and caudal anatomic boundaries remain unchanged. With transition to the prone position from supine, tenting of the pectoralis major occurs displacing the muscle from the chest wall and shifting the axillary space anteromedial to the lateral border of the pectoralis major. Therefore, the anterior boundary is now defined by the plane of the anterior extent of the pectoralis major to skin. The medial boundary is defined by the plane of the lateral border of the pectoralis major and pectoralis minor including to ribs and intercostal muscles. The lateral boundary is defined by the skin, cropped by 5mm. The posterior boundary is defined by the plane of the anterior surface of the latissimus dorsi and subscapularis muscle to skin. For the level II axilla, the cranial, posterior, medial and lateral boundaries remain unchanged. With transition from supine to prone, the axilla exhibits an anterolateral shift, now laterally abutting the lateral border of the pectoralis minor. The anterior boundary is now defined as the posterior aspect of the pectoralis major muscle. The caudal boundary is where the pectoralis minor inserts into ribs. The adaptations to the RTOG breast cancer atlas for prone positioning will enable radiation oncologists to more accurately target the level I and II axilla when treating patients prone in whom the axilla is a target in addition to the breast.

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.

The novel traction-suturing technique in correction of caudal end deviation of the nasal septum.

Caudal end correction is one of the main challenges during septoplasty that needs extra steps and skills. This complex area affects the shape of the nose. Moreover, the caudal end represents the medial boundary of the internal nasal valve. Thus, any deviation may disturb this critical area causing nasal obstruction. This study aimed to evaluate the novel traction-suture technique to correct septal caudal end deviation and its postoperative impact. This prospective case-series study. It was held in a tertiary referral university institute between January 2019 to February 2022. We included 95 cases who suffered from nasal obstruction and a cosmetic problem because of mild or moderate caudal end deviation. Under general anesthesia, the caudal end was corrected by the novel traction-suturing technique (TST). To evaluate the surgical outcomes and patients' related quality of life, we used two validated questionnaires; the Nasal Obstruction Symptom Evaluation and the Rhinoplasty Outcome Evaluation before the surgery and 1 year after the surgery. NOSE and ROE questionnaires showed statistically significant improvements after the surgery (P value was < 0.001). Complications occurred in seven patients (7.3%), all of which were minor complications. Traction-suturing technique (TST) improved nasal breathing and patients' satisfaction with their nasal configuration. Traction-suturing is a simple short maneuver that junior doctors can easily learn without distinct complications or recurrence.

P-085 MANAGEMENT OF LATERAL ABDOMINAL WALL HERNIAS

Abstract Lateral abdominal wall hernias are rare and inconsistently defined, which is why the use of the EHS classification makes sense, not least for the purpose of comparing the quality of surgical results. A distinction must be made between true fascial defects and denervation atrophy. Based on the available literature, there is generally a low level of evidence with no consensus on the best operative strategy. The proximity to bony structures and the complex anatomy of the three-layer abdominal wall make lateral hernias difficult to care for. The surgical variability include laparo-endoscopic, robotic, minimally- invasive, open or hybrid approaches with different mesh positions in relation to the layers of the abdominal wall. The extensive preperitoneal mesh reinforcement open, transperitoneally laparoscopic (TAPP) or endoscopic extraperitoneally (TEP, TES) has met with the greatest approval. The extent of the required medial mesh- overlap is determined by the distance between the medial defect boundary and the lateral edge of the straight rectus-abdominal muscles. The lateral pre- and retroperitoneal dissection can be extended into the homolateral retrorectus compartment by laterally incising the posterior rectus sheath or can even be expanded by crossing the midline behind the intact linea alba into the contralateral retrorectus compartment. The “intraperitoneal onlay meshplasty” (IPOM) is only a suitable procedure for smaller and closable defects, but it is also important as an “exit strategy” in the case of a defective peritoneum. All procedures are explained using clear illustrations which are protected by copyright and were exclusively published in German in “der Chirurg”.

A combined microinvasive trans-submandibular and nasendoscopy surgical approach to dissect recurrent or radiotherapy-insensitive nasopharyngeal carcinoma.

ObjectiveTo investigate a novel combined microinvasive trans-submandibular and nasendoscopy surgical approach for nasopharyngeal carcinoma involving the parapharyngeal space.MethodsSeven patients diagnosed with nasopharyngeal carcinoma involving the parapharyngeal space between May 2018 and April 2021, two males and five females, aged 37–63 years.Six of the 7 patients underwent submental flap preparation and dissection of the lymph nodes in the upper neck and parapharyngeal space on the lesion side. The nasopharynx lesions and tumor margins were dissected under nasal endoscopy. The medial boundary of internal carotid artery separated by open cervical approach was used as the lateral boundary of the tumor to realize en bloc resection of the tumor.ResultsThe patients were preoperatively diagnosed with T2~3N0M0 nasopharyngeal carcinoma, including mucoepidermoid carcinoma (n=2), papillary adenocarcinoma (n=1), and nonkeratinizing squamous cell carcinoma (n=4). The tumors were removed completely, and patients achieved primary healing of the incision. No recurrence and no serious complications were recorded during the 13–48 month follow-up.ConclusionComplete resection of the tumor was obtained in the 7 patients without recurrence and serious complications during the follow-up. The findings of this cohort study suggest that, patients with recurrent nasopharyngeal carcinoma after radiotherapy and radiotherapy-insensitive types of nasopharyngeal carcinoma, the combined microinvasive trans-submandibular and nasendoscopy surgical approach may be considered as an surgical options. The results of this study provide an additional option for surgical treatment of NPC in the clinic.

Gender differences affect the location of the patellar tendon attachment site for tibial rotational alignment in total knee arthroplasty

PurposeThis study was carried out to investigate the accuracy of referring different locations of the patellar tendon attachment site and the geometrical center of the osteotomy surface for tibial rotational alignment and observe the influences of gender differences on the results.MethodsComputed tomography scans of 135 osteoarthritis patients (82 females and 53 males) with varus deformity was obtained to reconstruct three-dimensional (3D) models preoperatively. The medial boundary, medial one-sixth, and medial one-third of the patellar tendon attachment site were marked on the tibia. These points were projected on the tibial osteotomy plane and connected to the geometrical center (GC) of the osteotomy plane or the middle of the posterior cruciate ligament (PCL) to construct six tibial rotational axes (Akagi line, MBPT, MSPT1, MSPT2, MTPT1 and MTPT2). The mismatch angle between the vertical line of the SEA projected on the proximal tibial osteotomy surface and six different reference axes was measured. In additional, the effect of gender differences on rotational alignment for tibial component were assessed.ResultsRelative to the SEA, rotational mismatch angles were − 1.8° ± 5.1° (Akagi line), − 2.5° ± 5.3° (MBPT), 2.8° ± 5.3° (MSPT1), 4.5° ± 5.4° (MSPT2), 7.3° ± 5.4° (MTPT1), and 11.6° ± 5.8° (MTPT2) for different tibial rotational axes in all patients. All measurements differed significantly between the male and female. The tibial rotational axes with the least mean absolute deviation for the female or male were Akagi line or MSPT, respectively. There was no significant difference in whether the GC of the osteotomy surface or the midpoint of PCL termination was chosen as the posterior anatomical landmark when the medial boundary or medial one-sixth point of the patellar tendon attachment site was selected as the anterior anatomical landmark.ConclusionWhen referring patellar tendon attachment site as anterior anatomical landmarks for tibial rotational alignment, the influence of gender difference on the accuracy needs to be taken into account. The geometric center of the tibial osteotomy plane can be used as a substitute for the middle of the PCL termination when reference the medial boundary or medial one-sixth of the patellar tendon attachment site.

Dynamic stability in runners with and without plantar fasciitis

BackgroundPlantar fasciitis (PF) is a common overuse injury experienced by runners. PF may decrease the ability of the plantar fascia to create tension and reduce stability of the foot. Stability of the foot is necessary for whole-body dynamic stability during running which consists of cyclical periods of single leg stance. Given that a major risk factor for running-related injury is previous injury, evaluating dynamic stability in runners with PF, runners with resolved PF, and healthy runners may elucidate differences between these individuals and clarify risk for secondary injury in these groups. Research questionIs dynamic stability reduced in runners with PF and runners with resolved PF compared to healthy runners? MethodsThirty runners were recruited for this retrospective comparative study based on mileage and injury status: current PF (PF), resolved PF (RPF), or healthy (CON). Kinematic and kinetic data were collected during running and dynamic stability was determined by time-to-contact (TtC) analysis for early, mid, and late stance to the anterior, posterior, medial, and lateral boundary of the foot. Dynamic stability was compared between groups one-way ANOVAs (α = 0.05) and Tukey post-hoc tests conducted when appropriate. Cohen’s d effect sizes (d) were reported for all TtC comparisons (small = 0.20, medium = 0.50, large = 0.80). ResultsTtC values were shorter in PF compared to the other groups to all boundaries during mid-stance. TtC was significantly greater in PF compared to RPF to the anterior boundary during late stance. SignificanceShorter TtC observed in PF compared to the other groups during midstance may indicate reduced dynamic stability during the most stable portion of running which may lead to increased injury risk.

Lateral Harvest of an Osseous-Based Quadriceps Tendon Autograft Results in Thinner Remaining Patellar Bone.

Background:Patellar fracture after quadriceps tendon (QT) autograft harvest for anterior cruciate ligament reconstruction (ACLR) has been reported in up to 8.8% of patients.Purpose:To determine the thickness of the remaining patellar bone across the QT graft harvest location while providing clinical guidance for safely harvesting a patellar bone block when using a QT graft in ACLR.Study Design:Descriptive laboratory study.Methods:Medial and lateral QT graft boundaries were marked using a bone saw on 13 cadaveric patellae, and 3-dimensional computed tomography models were created. After the harvest of a virtual bone block with a maximum depth of 10 mm, the thickness of the remaining bone was measured across the graft harvest location in 9 zones. The thickness of the remaining bone was analyzed according to zone, graft harvest location, and patellar facet length. Risk zones were defined as <50% total patellar depth remaining.Results:We observed substantial variability in QT bone block harvest location, in which the distance between the lateral boundary of the harvest location and the lateral patellar cortex was from 21.2% to 49.2% of the axial patellar width. There was significantly less bone remaining in the lateral columns (mean ± SD, 7.56 ± 2.19 mm) compared with the medial columns (9.83 ± 2.10 mm) of the graft harvest location (P = .028). The number of risk zones was significantly associated with distance to the lateral cortical edge, with an increase in 0.59 zones with every 1-mm decrease in distance to the lateral cortex edge (b = -0.585; R 2 = 0.620; P = .001). With every 1-mm increase in the distance of the lateral cortex to the lateral graft boundary, the thickness of bone remaining in the lateral column increased by 0.412 mm (P < .001). No risk zones were encountered when the lateral boundary of the harvest location was created 18.9 mm from the lateral edge of the patella or 43% of the total patellar width from the lateral edge.Conclusion:Harvest of a more laterally based QT autograft bone block resulted in thinner remaining patellar thickness, increasing the potential of encountering a risk zone for fracture.Clinical Relevance:Care should be taken to avoid harvesting the patellar bone block too laterally during ACLR.

Medial border of D3 lymphadenectomy for right colon cancer

The extent of D3 lymphadenectomy for right colon cancer, especially the medial border of central lymph node dissection remains controversial. D3 lymphadenectomy and complete mesocolon excision (CME) are two standard procedures for locally advanced right colon carcinoma. D3 lymphadenectomy determines the medial border according to the distribution of the lymph nodes. The mainstream medial border should be the left side of superior mesenteric vein (SMV) according to the definition of D3, but there are also some reports that regards the left side of superior mesenteric artery (SMA) as the medial border. In contrast, the CME procedure emphasizes the beginning of the colonic mesentery and the left side of SMA should be considered as the medial border. Combined with the anatomical basis, oncological efficacy and technical feasibility of D3 lymph node dissection, we think that it is safe and feasible to take the left side of SMA as the medial boundary of D3 lymph node dissection. This procedure not only takes into account the integrity of mesangial and regional lymph node dissection, but also dissects more distant lymph nodes at risk of metastasis. It has its anatomical basis and potential oncological advantages. However, at present, this technical concept is still in the exploratory stage in practice, and the related clinical evidence is not sufficient.

Postural Control Differences between Patients with Posterior Tibial Tendon Dysfunction and Healthy People during Gait.

Background: Patients with posterior tibial tendon dysfunction (PTTD) may exhibit postural instability during walking likely due to a loss of medial longitudinal arch, abnormal foot alignment, and pain. While many studies have investigated gait alterations in PTTD, there is no understanding of dynamic postural control mechanisms in this population during gait, which will help guide rehabilitation and gait training programs for patients with PTTD. The purpose of the study was to assess dynamic postural control mechanisms in patients with stage II PTTD as compared to age and gender matched healthy controls. Methods: Eleven patients with stage II PTTD (4 males and 7 females; age 59 ± 1 years; height 1.66 ± 0.12 m; mass 84.2 ± 16.0 kg) and ten gender and age matched controls were recruited in this study. Participants were asked to walk along a 10 m walkway. Ten Vicon cameras and four AMTI force platforms were used to collect kinematic and center of pressure (COP) data while participants performed gait. To test differences between PTTD vs. control groups, independent t-tests (set at α < 0.05) were performed. Results: Patients with PTTD had significantly higher double stance ratio (+23%) and anterior-posterior (AP) time to contact (TTC) percentage (+16%) as compared to healthy control. However, PTTD had lower AP COP excursion (−19%), AP COP velocity (−30%), and medial-lateral (ML) COP velocity (−40%) as compared to healthy controls. Mean ML COP trace values for PTTD were significantly decreased (−23%) as compared to controls, indicating COP trace for PTTD tends to be closer to the medial boundary than controls during single-support phase of walking. Conclusion: PTTD patients showed more conservative and cautious postural strategies which may help maintain balance and reduce the need for postural adjustment during PTTD gait. They also showed more medially shifted COP patterns than healthy controls during single-support phase of walking. Dynamic postural control outcomes could be used to develop effective gait training programs aimed at alleviating a medial shift of COP (everted foot) for individuals with PTTD in order to improve their functionality and gait efficiency.

Textual Transformations: Iain Sinclair’s Black Apples of Gower and the Merlin Legend

This paper explores the connections between Iain Sinclair’s 2015 travelogue Black Apples of Gower and the Merlin legend. Despite the fact that, on the surface, Sinclair does not refer to the early Welsh merlinistic tradition, on closer inspection both share what M. Wynn Thomas has described as “hidden attachments” – cross cultural connections and experiences between the two literatures of modern Wales. The archaic bedrock of the Merlin legend and the alchemical imagery in Sinclair’s book are both rooted in the mythico-ritualistic complex of symbolic regeneration based on the repetition of the act of original creation. Both Merlin and the alchemical process involve an ontological transformation which is mirrored in Black Apples of Gower by the transcendence of textual and medial boundaries: a complex network of intertextual allusions and word-image relationships (ekphrases, reproductions and illustrations). By exploring these relationships, along with the merlinistic and alchemical imagery present in the text, I argue that the work employs the strategy of what I call textual nigredo – a process of intertextual and intermedial transformation. The affinities identified between the Merlin legend and Sinclair’s travelogue provide an argument for seeing Iain Sinclair as a Welsh writer and shed new light on the links between the Welsh-language literary tradition and English-language Welsh writing which may be pursued further in the future.

Management of lateral abdominal wall hernias

Lateral abdominal wall hernias are rare and inconsistently defined, which is why the use of the European Hernia Society classification makes sense, not least for the purpose of comparing the quality of surgical results. Adistinction must be made between true fascial defects and denervation atrophy. Based on the available literature, there is generally alow level of evidence with no consensus on the best operative strategy. The proximity to bony structures and the complex anatomy of the three-layer abdominal wall make the technical treatment of lateral hernias difficult. The surgical variations include laparoendoscopic, robotic, minimally invasive, open or hybrid approaches with different mesh positions in relation to the layers of the abdominal wall. The extensive preperitoneal mesh reinforcement open, transabdominal peritoneal (TAPP) laparoscopic repair or total extraperitoneal (TEP) endoscopic repair has met with the greatest approval. The extent of the required medial mesh overlap is determined by the distance between the medial defect boundary and the lateral edge of the straight rectus abdominus muscles. The medially directed preperitoneal and retroperitoneal dissection can be extended into the homolateral retrorectus compartment by laterally incising the posterior rectus sheath or by crossing the midline behind the intact linea alba into the contralateral retrorectus compartment. The intraperitoneal onlay mesh (IPOM) technique is asuitable procedure only for smaller defects with possible defect closure but it is also important as an exit strategy in the case of adefective peritoneum. Individualized prehabilitative and preconditioning measures are just as important as the assessment of preoperative anamnestic and clinical findings and risks with radiographic cross-sectional imaging diagnostics.

Morphology of the temporalis muscle focusing on the tendinous attachment onto the coronoid process.

The temporalis muscle is usually described as a single layer originating at the temporal line, converging to a tendon, and inserting onto a narrow site of the coronoid process. However, recent studies have shown that the temporalis muscle can be divided into two or three separate segments and the distal attachment continues inferiorly beyond the coronoid process. Therefore, the aims of this study were to analyze the morphology of the temporalis muscle focusing on the tendinous attachment onto the coronoid process and to provide educational values. The temporalis muscle was carefully dissected in 26 cadavers and classified based on the muscle fascicle direction. Each divided part was sketched and measured based on bony landmarks to elucidate its tendinous insertion site onto the coronoid process, and the results obtained were reviewed through the literature. The temporalis muscle ends at two distinct terminal tendons with wider insertion sites than usually presented in textbooks and atlases and separates into two parts that combine to act as a single structural unit. The superficial part is a large fan-shaped muscle commonly recognized as the temporalis muscle. This converges infero-medially to form the superficial tendon and the lateral boundary of the retromolar triangle. Meanwhile, the deep part is a narrow vertically oriented rectangular muscle that converges postero-laterally to form the deep tendon and the medial boundary of the retromolar triangle. These results indicate that understanding the temporalis muscle’s insertion site onto the coronoid process will be useful clinically with educational values during surgical procedures.

Anatomical study and clinical application of in situ reduction and fixation of anterior medial fenestration approach of femoral head fracture

Objectives: To explore the feasibility of anterior medial fenestration approach in situ reduction and fixation in the treatment of PipkinⅠ and Ⅱ femoral head fractures,and to explore the clinical effect of this operation. Methods: Hips of two anti-corrosion adult specimens treated with formalin were dissected, then anatomical structures and directional characteristics of anterior medial main muscles,ligaments,blood vessels and nerves were observed.The anterior medial fenestration approach was performed on bilateral hips of four fresh frozen specimens to determine pulling direction of stripped muscles and ligaments required during operation,and to observe and analyze vascular and nerve traction protection directions exposed in the approach.Determine extent of exposure to the approach and assess feasibility of this approach.The clinical data of 12 patients with Pipkin Ⅰ and Ⅱ femoral head fractures who underwent in situ reduction and fixation of anterior medial fenestration at Department of Orthopaedics,Affiliated Hospital of Chengdu University from February 2016 to April 2018 were retrospectively analyzed.There were 3 males and 9 females with an age of 48.5 years(range:37 to 59 years).There were 8 cases of Pipkin type Ⅰ and 4 cases of Pipkin type Ⅱ.The operation time,blood loss,fracture healing time,last Thompson-Epstein evaluation and Harris score were observed. Results: Anterior medial fenestration approach to expose the femoral head in 4 bilateral hips with a total of 8 sides of fresh frozen specimens.The upper boundary of observation fenestration was pubic body (anterior acetabulum),and the outer upper boundary was iliacus and psoas muscle.The lateral boundary is rectus femoris and femoral vessels,the lower boundary was transverse branch of the medial femoral circumflex artery and vein.The medial boundary was pubis muscle,short adductor muscle and long adductor muscle.Pubofemoral and iliofemoral ligament were seen in fenestration. Four quadrants in front of femoral head in fenestration can be seen after cutting switch capsule active hip joint. In 12 patients with femoral head fracture,the operation time was 107.5 minutes(range:90 to 135 minutes),and the intraoperative bleeding volume was 115.0 ml(range:85 to 150 ml).The patients were followed up for 18.6 months(range:12 to 28 months).The fracture healing time of 12 patients was 144.2 days(range:120 to 180 days).The curative effect was evaluated according to Thompson-Epstein standard at the last follow-up:excellent in 6 cases,good in 4 cases and fair in 2 cases.At the last follow-up,the Harris score of hip joints was 85.1(range:75 to 93). Conclusions: Anterior medial fenestration in situ reduction and fixation surgery is feasible for the treatment of Pipkin Ⅰ and Ⅱ femoral head fractures. The short and midterm follow-up reveal satisfactory effect.