Posterior Arm Research Articles

Maternal body mass index, maneuvers, and neonatal morbidity associated with shoulder dystocia

BackgroundShoulder dystocia is associated with neonatal morbidity. Higher maternal prepregnancy body mass index is an established risk factor for shoulder dystocia, yet the relationship between maternal prepregnancy body mass index and resulting neonatal morbidity after shoulder dystocia is not well studied. ObjectivesWe assessed the association between body mass index and neonatal adverse outcomes following shoulder dystocia. The frequency and type of maneuvers used to resolve shoulder dystocia by maternal body mass index was compared. Study DesignWe conducted a retrospective cohort study of pregnant individuals who experienced a shoulder dystocia at delivery from June 2012-July 2021 at a tertiary care center. We included singleton non-anomalous livebirths ≥36 weeks’ gestation at a single academic medical center in the Midwestern US. The primary exposure was prepregnancy body mass index categorized as: <30 kg/m2 [referent], 30-34.9 kg/m2, and ≥35 kg/m2. The primary outcome was a composite neonatal morbidity including birth injury (brachial plexus injury or fracture), seizures, hypoxic ischemic encephalopathy, and 5-minute Apgar < 7. Secondary outcomes were neonatal intensive care unit admission and neonatal acidemia (cord arterial pH < 7.10). Shoulder dystocia duration and the number and types of maneuvers were compared by body mass index group. Multivariable logistic regression was used and adjusted for nulliparity, diabetes, operative vaginal delivery, and gestational age. ResultsAmong 872 individuals who experienced a shoulder dystocia at delivery, 602 (69.0%) had a body mass index <30 kg/m2, 160 (18.3%) had a body mass index between 30-34.9 kg/m2, and 110 (12.6%) had a body mass index ≥35 kg/m2. The median duration of shoulder dystocia was 40 seconds (interquartile range 30, 60 seconds) and did not vary by maternal body mass index. Deliveries complicated by body mass index ≥35 kg/m2 required a greater number of maneuvers compared to those with lower maternal body mass index (p<0.01). McRoberts (96.0%), suprapubic pressure (90.2%) and delivery of the posterior arm (41.1%) were the most frequent maneuvers in all body mass index groups. Rubin’s maneuver was more frequently used with body mass index ≥35 kg/m2 compared with body mass index <30 kg/m2 (34.6% versus 22.4%, p = 0.02, adjusted odds ratio 1.63, 95% CI 1.04-2.57). Composite neonatal morbidity did not differ by body mass index. Neonatal injury was more frequent with body mass index ≥35 kg/m2 compared with body mass index <30 kg/m2 (adjusted odds ratio 1.97, 95% CI 1.06-3.68). Interaction between body mass index and number of maneuvers was not statistically significant (p=0.94). ConclusionsAmong pregnant individuals who experienced a shoulder dystocia, increased prepregnancy body mass index was associated with an increased number of maneuvers performed during a shoulder dystocia, but not longer duration. Risk of neonatal injury following shoulder dystocia, but not the composite neonatal adverse outcome, was increased with body mass index ≥35 kg/m2.

Efficacy of Liposuction of the Posterior Arm Fat Pad in Axillobrachioplasty after Massive Weigh Loss: A Pilot Study.

The topographic anatomical changes of the upper arms and axilla after massive weight loss (MWL) seem ill-described in the literature. The importance of the axilla in MWL brachioplasty and how the procedure differs from the postmenopausal "batwing" deformity of the upper arms is also unclear. Consideration of the underlying pathology seems imperative for a successful reconstruction. We aim to test a procedure specifically designed to mend the underlying pathology of obesity and MWL, liposuction-assisted axillobrachioplasty (LAAB). A prospective pilot study was designed to test the effect of LAAB on the axilla and evaluate the results comparative to patient's preoperative complaints and well-being and allow for adjustments for future trials. We measured the diameter of the arm and axilla at three specific points, A, B and C, and applied the arm module of BODY-Q regarding body perception and psychosocial well-being. Fifteen women, for a total of 30 arms, were included. Age average was 48 years (29-59) and showed a significant improvement in all measurements A-C, most significantly at point A in the axilla, where the reduction was associated with relief of preoperative ailments and great improvement on BODY-Q ratings. The procedure was uncomplicated, with high patient satisfaction. LAAB significantly improves the axilla and upper arm contour after MWL and correlates strongly with improvement of preoperative ailments. The study furthermore supports the clinical relevance of a posterior arm fat pad. The presented procedure seems to be uncomplicated and reproducible with a high patient satisfaction warranting a long-term clinical trial.

A new Late Miocene stem Octodontoid (Rodentia: Caviomorpha: Octochinchilloi) from the Solimões Formation (Brazil): paleobiogeographic implications

ABSTRACT Caviomorphs are the neotropical hystricognathous rodents (Ctenohystrica: Hystricognathi: Caviomorpha). Octodontoidea are today the richest and most speciose clade of caviomorphs. Their fossil record also reveals a wide array of extinct species, including Acarechimys, a taxon with a widespread South American distribution and extensive temporal range. This genus comprises at least five species documented in deposits ranging from the late Oligocene to the Middle Miocene. Here, we report the discovery of a new species of Acarechimys from Upper Miocene deposits of the Envira River (PRE06 outcrop), situated in the Acre State, western Brazilian Amazonia. The new species differs from the other species of the genus in having lower molars with a strong posterior arm of the metaconid, the presence of a mesostylid (usually prominent) and a neomesolophid forwardly directed and connected to the metalophulid I on m1 but not on m2–3, and the absence of posterior arm of the protoconid. This taxon represents the youngest known species of the Acarechimys lineage to date. Its occurrence in Western Amazonia strengthens support for the hypothesis that South American rodent lineages survived longer during the Neogene at low latitudes than in the southern regions of the continent.

Stratification of outcome of shoulder dystocia according to maneuver used for delivery, retrospective cohort and meta-analysis.

Shoulder dystocia is an unpredictable obstetric condition with potential long-term neonatal complications. The risk of neonatal injury might be related to the condition itself as well as to the obstetrics maneuvers used for its release. To examine the available evidence to assess current management and possible improvement of outcomes. A comprehensive search of MEDLINE, EMBASE, EMCARE, and The Cochrane Library database was performed, all studies reporting on neonatal outcomes in cases of shoulder dystocia stratified by obstetric maneuvers used for delivery were included. Data abstraction was performed and checked by two independent reviewers. McRoberts maneuver was the least associated with risk of neonatal injury (odds ratio 0.6, 95% confidence interval 0.4-0.9), followed by delivery of posterior arm. Delivery of posterior arm might be prioritized in cases of shoulder dystocia after failed McRoberts. Neonatal hypoxic injury correlates with the duration of dystocia rather than the maneuver used.

Preliminary Application of Infrared Thermography to Monitoring of Skin Temperature Asymmetries in Professional Padel Players.

The aim of the present study was to evaluate skin temperature (Tsk) asymmetries, using infrared thermography, in professional padel players before (PRE), after (POST) and 10 min after training (POST10), and their relationship with perceptual variables and training characteristics. Thermal images were taken of 10 players before, after and 10 min after a standardized technical training. After training, Tsk of the dominant side was higher than before training in the anterior forearm (30.8 ± 0.4 °C vs. 29.1 ± 1.2 °C, p < 0.01; ES = 1.9), anterior shoulder (31.6 ± 0.6 °C vs. 30.9 ± 0.6 °C, p < 0.05; ES = 1.0) posterior arm (29.5 ± 1.0 °C vs. 28.3 ± 1.2 °C, p < 0.05; ES = 1.0), and posterior forearm (30.8 ± 0.9 °C vs. 29.3 ± 1.6 °C, p < 0.05; ES = 1.1). Likewise, these differences were significant POST10 in the anterior arm, anterior forearm, anterior shoulder, posterior arm and posterior forearm. Comparing the different moments of measurement (PRE, POST and POST10), the temperature was higher POST10 in all the regions analyzed except for the shoulder, abdominals, and lower back. Also, correlations were found between fatigue variation and temperature variation between limbs (Tsk dominance), and no correlation was found except between age and posterior thigh (|r| = 0.69; p < 0.05), and between the racket mass and anterior knee (|r| = 0.81; p < 0.01). In conclusion, infrared thermography allows monitoring of skin asymmetries between limbs in professional padel players, but these asymmetries were not related to overall fatigue variation, overall pain variation, years of experience and training hours.

Complete encasement of the radial nerve by a giant lipoma: illustrative case.

Among the spectrum of adipose lesions associated with peripheral nerves, complete circumferential encasement of the nerve by the lesion is a very rare entity. The authors report the first case of a giant lipoma that completely and circumferentially encased the radial nerve. A 57-year-old woman presented with a large left-arm mass that she had noticed over a year following significant weight loss. She had hypersensitivity and dysesthesias in the left posterior arm but no weakness or other symptoms. Magnetic resonance imaging of the left upper limb demonstrated a large lipoma completely encasing the radial nerve, originating at the level of the spiral grove proximally and extending distally to the lateral epicondyle. The lesion was completely resected at surgery with total preservation of radial nerve function. Lipomas encasing peripheral nerves can be difficult to manage while preserving function. This case adds to the intriguing spectrum of adipose lesions associated with peripheral nerves. https://thejns.org/doi/10.3171/CASE24148.

Methodology for vNOTES Sacrocolpopexy with Transvaginal Mesh Retroperitonealization and Tensioning

Background: Laparoscopy has the potential of making procedures less invasive with a lower complication profile while being more appealing to patients due to ease of recovery and cosmesis. Sacrocolpopexy has traditionally been performed through the abdominal route with limited reports of transvaginal applications. Methods: Our study aims to provide a step-by-step approach to performing a vNOTES sacrocolpopexy with appropriate tensioning and peritoneal coverage of the mesh used based on both cadaveric and live patient experience. This systematic description of a fully laparoscopic transvaginal apical suspension with mesh attachment to the sacrum being completely retroperitoneal and the mesh retroperitoneal and covered at the conclusion of the case. Results: Successful vNOTES Sacrocolpopexy is performed and reproduced, with transvaginal complete peritoneal coverage and tensioning of the mesh. Total vaginal length (TVL) of 9 cm in both live and cadaveric patients. The steps of the procedure include 1. A vNOTES laparoscopic-assisted vaginal hysterectomy is completed. 2. A 0-Prolene suture is attached longitudinally to the sacral arm of a precut (Y) mesh or any single layer Type I polypropylene mesh piece, placed from the sacral arm to the distal edge of the mesh forming a “U” shape with the bottom of the “U” ultimately attaching to the anterior longitudinal ligament. 3. To begin the SCP procedure after completion of the vaginal hysterectomy, dissection of the presacral mesh attachment site begins by entering the retroperitoneal space, slightly right of midline at the level of the ischial spine, lateral to the rectum and medial to the uterosacral ligament. 4. Once the dissection is completed with appropriate exposure of the anterior longitudinal ligament at the sacral promontory, the sacral mesh is attached to the anterior longitudinal ligament at the S1-2 level, ideally with a tacker under direct visualization. 5. Two sutures, one on each side of the tunnel, are placed on the cephalad edge of the sacral peritoneal incision and labeled. After removing the Gelport, two more absorbable sutures are attached to the anterior peritoneum of the anterior vaginal wall in the proximity of the bladder, around 3 cm on each side of the midline. These peritoneal sutures in each of the above two steps will later be tied together to help cover the arms of the mesh. 6. Before mesh arm attachment, each area on the anterior and posterior vaginal walls is dissected off respective tissue (bladder and perineal body/rectovaginal fascia) and then everted for mesh attachment. 7. Both anterior and posterior mesh pieces are sutured to their respective vaginal walls with six interrupted sutures. Each mesh arm will have several centimeters of mesh freely hanging off both anterior and posterior cuff edges. These edges can be trimmed to 2 cm past the vaginal cuff edge. 8. All three pieces of mesh are stacked together and serially threaded from anterior mesh to posterior mesh, ensuring each mesh piece remains aligned (Figure 1). Each U suture is then passed through the free ends of the anterior and posterior mesh pieces and then secured with a hemostat. The cut edges of the suture can either be aligned at the back of the posterior arm to permit retroperitonealization of the knot or placement at the vaginal apex abutting the vaginal cuff. 9. Peritoneal closure is achieved by tying a posterior tunnel suture to each respective anterior vaginal wall suture at each lateral edge of the tunnel incision. 10. The vaginal cuff closure begins with a Vicryl suture anchored at the patient’s right forniceal edge running it to midline while anchoring another suture at the left forniceal edge to permit the surgeon to tension the vaginal apex appropriately. 11. Mesh tensioning is achieved by placing a single digit through the remaining space left in the tunnel incision. A knot using the Prolene suture securing the overlapping mesh is tied extracorporeally and pushed through the vaginal cuff to mobilize the mesh crux cephalad, thus elevating the vaginal apex towards the sacrum. The elevation of this knot guides the vaginal length. 12. The remainder of the vaginal cuff is then closed while avoiding incorporation of the mesh into the suture line (the ideal distance from mesh Y-junction to cuff is 1-2cm). Conclusion: By describing an innovative and reproducible technique to perform vNOTES sacrocolpopexy based on cadaveric and live patient experience, we successfully demonstrate how to perform a laparoscopic transvaginal apical suspension with mesh attachment to the sacrum through retroperitoneal placement. The vNOTES approach for sacrocolpopexy may offer a viable alternative to the transabdominal approach for candidates with difficult transabdominal access while avoiding trocar injuries and reducing surgical costs.

A RARE CASE OF TYPE A AORTIC DISSECTION PRESENTING AS ACUTE STROKE: A DIAGNOSTIC CHALLENGE

Abstract A 60–year–old woman presented to the emergency department with acute left hemiplegia, not chest pains. Past medical history was significant for family history of aortic aneurysm, arterial hypertension. At brain–CT was reported hypodensity areas in posterior arm of the right internal capsule and in right tempero–polar lobe, confirmed on brain–MRI, and compatible with acute ischemic injury. Echocolor–dopper of epiaortic vessels documentated ulcerated plaque into the right common carotid artery (CCA). Selective catheterization found focal dissection obstructing the flow, treated with self–expanding stent. On echocardiography evalutation for suspiction of TAAD: dilatation of ascending aorta with flap oscillation, severe arotic regurgitation, pericardial effusion (Fig. 1). CT–Angiography was performed with evidence of type A dissection extending superiorly to the right CCA and inferiorly to the iliac bifurcation. For coma state, the patient was mechanically ventilated, and seriate CTs showed new ischemic lesions and hemorrhagic infarction of previous. Because of contraindication for cardiac surgery due neurological state, the patient was referred at medical therapy as bridge to hybrid aortic arc substitution at resolution of intracranial hemorrhages. In the next days there was progressive improvement neurological status with restoration of sensory and autonomic breathing with hemodynamic stability. Aortic dissection (AD) is defined as a disruption of the medial layer leading to the formation of two lumens separated by an intimomedial flap. AD is a critical diagnosis to make due to life–threatening outcomes and its non–specific presentation as in the case of our patient where the management of AD was delayed due to an unusual initial clinical presentation. Multimodality imaging approach has been fundamental for correct diagnosis and risk stratification. A limited number of studies have reported cases with stroke as the first symptom with concomitant TAAD. Concomitant intracerebral hemorrhage and TAAD is a very rare presentation and the optimal timing of surgery in these patients is unknown. In our opinion, patients who presents acute stroke should be carefully evaluated using multimodal imaging to exclude TAAD before administering reperfusion therapy. In addition, performing CAS before surgery for TAAD is challenging but might be a valid treatment option to maintain good brain perfusion and improve prognosis, but further investigations are needed.

Reliability and validity of the medial standing overhead arm reach (SOAR) test as a measure of functional hip adduction motion

Objective The Posterior Standing Overhead Arm Reach (SOAR) test has been previously reported as a reliable clinical measure of closed chain hip extension motion. The proposed Medial SOAR test expands on that testing approach to provide a similar measure of functional hip adduction motion. This was a preliminary intrarater and interrater reliability and validity study of the Medial SOAR test as a measure of functional hip adduction. Design Cross-sectional. Setting University motion analysis laboratory. Participants Fifty hips were assessed in 25 (22 female) asymptomatic participants (mean age = 23.4 years, SD = 0.8). Main measures Maximum hip adduction during the Medial SOAR test was measured with a standard goniometer independently by two examiners. The test was also performed using three-dimensional motion capture. The intrarater and interrater reliability of the goniometric measure was determined using intraclass correlation coefficients, and the relationship between measures obtained via goniometry and three-dimensional motion capture was assessed with Pearson correlations and Bland–Altman analysis. Results Intrarater reliability (ICC2,3) was 0.88 (95% CI = 0.80–0.92) for Examiner 1 and 0.87 (95% CI = 0.79–0.92) for Examiner 2. The standard error of measurement and minimal detectable change were less than 3.0°. Interrater reliability demonstrated an intraclass correlation coefficient = 0.62 (95% CI = 0.28–0.79). Pearson correlations were significant with low-to-moderate associations (r = 0.49, P < 0.001; r = 0.24, P = 0.045). Conclusions Similar to the previously reported Posterior SOAR test, the Medial SOAR test demonstrated acceptable intrarater and interrater reliability, along with low-to-moderate associations with three-dimensional motion capture. The Medial SOAR test has the potential to provide a reliable and accurate assessment of closed chain hip adduction.

Sagittal Abdominal Diameter as the Best Predictor of Metabolic Syndrome in HIV-Infected Men on Antiretroviral Therapy.

The interaction of human immunodeficiency virus (HIV), host and antiretroviral therapy (ART) causes a range of metabolic disorders that can be characterized as a metabolic syndrome (MetS) that increases the cardiovascular risk. MetS involves central obesity, which can be detected using different anthropometric parameters. To assess the abilities of different anthropometric parameters in the prediction of MetS in HIV-infected men on ART. The study involved 92 male participants (mean age 44.46±10.38 years), divided into two groups: with and without MetS. All subjects underwent biochemical evaluation (triglycerides, HDL-cholesterol, fasting glucose), blood pressure measurement and anthropometric assessment: body mass, body height, body mass index (BMI), body fat mass, body circumferences (chest, upper arm, forearm, waist, hip, proximal and middle thigh and calf), sagittal abdominal diameter (SAD), skinfold thicknesses (subscapular, anterior and posterior upper arm, anterior and lateral forearm, abdominal, supraspinal, thigh and calf), waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), waist-to-thigh ratio (WTR), sagittal abdominal diameter-to-body height ratio (SADH), body adiposity index (BAI) and conicity index. MetS was specified according to IDF criteria. Subjects with MetS had statistically significant higher values of all anthropometric parameters except middle thigh circumference, calf skinfold and body height. According to ROC analysis and Binary Logistic Regression, SAD has been shown as the best predictor of MetS with a predictive value of 21.40 cm (AUC:0.91), followed by WHR with a predictive value of 0.93. Sagittal abdominal diameter is the strongest anthropometric indicator of MetS in HIV-infected patients on ART.

Maternal and neonatal complications of shoulder dystocia with a focus on obstetric maneuvers: A case-control study of 1103 deliveries.

Shoulder dystocia is a severe obstetric emergency that can cause substantial neonatal and maternal complications. This study aims to assess the performed obstetric maneuvers and their frequency, success, and association with maternal and neonatal complication rates. The study population was collected among all deliveries in the Hospital District of Helsinki and Uusimaa between 2006 and 2015 (n = 181 352) by searching for ICD-10 codes for shoulder dystocia, brachial plexus injury and clavicle fracture. Shoulder dystocia cases (n = 537) were identified by reviewing the medical records. Shoulder dystocia cases treated with one or two maneuvers were compared with those treated with at least three. Medical records of a matched control group constituting of 566 parturients without any of the forementioned ICD-10 codes were also scrutinized. Using the four most common obstetric maneuvers (McRoberts maneuver, suprapubic pressure, rotational maneuvers, the delivery of the posterior arm) significantly increased during the study period with individual success rates of 61.0%, 71.9%, 68.1% and 84.8%, respectively. Concurrently, the rate of brachial plexus injury and combined neonatal morbidity significantly declined from 50% to 24.2% (p = 0.02) and from 91.4% to 48.5% (p < 0.001). Approximately 75% of shoulder dystocia cases treated with maneuvers were resolved by the McRoberts maneuver and/or suprapubic pressure, but each of the four most performed maneuvers significantly increased the cumulative success rate individually and statistically (p < 0.001). The rates of brachial plexus injury and combined neonatal morbidity were at their highest (52.9% and 97.8%) when none of the maneuvers were performed and at their lowest when two maneuvers were performed (43.0% and 65.4%). The increasing number (≥3) of maneuvers did not affect the combined maternal or neonatal morbidity or brachial plexus injury but increased the risk for third- or fourth-degree lacerations (odds ratio 2.91, 95% confidence interval 1.17 to 7.24). The increased use of obstetric maneuvers during the study period was associated with decreasing rates of neonatal complications; conversely, the lack of obstetric maneuvers was associated with the highest rate of neonatal complications. These emphasize the importance of education, maneuver training and urgently performing shoulder dystocia maneuvers according to the international protocol guidelines.

Determinants of Dissatisfaction After Laparoscopic Cure of Vaginal and/or Rectal Prolapse using Mesh: a Comprehensive Retrospective Cohort Study.

The primary objective is to identify determinants of dissatisfaction after surgical treatment of vaginal prolapse ± rectal prolapse, using laparoscopic mesh sacrohysteropexy (LSH) or sacrocolpopexy (LSC) ± ventral mesh rectopexy (VMR). The secondary objective is the evaluation of complications and objective/subjective recurrence rates. The study performed was a single-surgeon retrospective review of prospectively collected data. LSH/LSC ± VMR were performed between July 2005 and September 2022. Primary investigated outcome was patients' satisfaction, assessed using the Patient Global Impression of Improvement (PGI-I) score and the bother visual analog scale (VAS) obtained postoperatively (at a 1-month interval and on a 6-month/yearly basis thereafter). We looked for a correlation between the level of satisfaction (as reflected by the VAS) and potential determinants. There were 355 patients with a mean age of 62 ±12 years. Nearly all the patients (94.3%) had a stage 3 or 4 prolapse according to the POP-Q classification. The mean postoperative bother VAS was 1.8, with only 12.7% of patients reporting a bother VAS score ≥ 3/10, indicating a dissatisfaction. PGI-I showed improvement in the vast majority of patients (96.4% scoring 1 to 3). Patients with anal incontinence preoperatively scored higher on the bother VAS postoperatively (r=0.175, p < 0.05). The use of a posterior arm mesh (for posterior vaginal prolapse) correlated with better satisfaction overall (r= -0.178, p = 0.001), whereas the performance of VMR was associated with a bothering sensation (r = 0.232, p < 0.001). A regression analysis confirmed the impact of posterior mesh and VMR on satisfaction levels, with odds of dissatisfaction being 2.18 higher when VMR was combined with LSH/LSC. Posterior mesh use improves patient satisfaction when the posterior compartment is affected. In patients with concomitant vaginal and rectal prolapse, combining VMR with anterior LSC/LSH appears to negatively impact patients' satisfaction. Preoperative anal incontinence was demonstrated to be a risk factor for postoperative dissatisfaction.

Studying the Effects of Shoulder Dystocia and Neonate-Focused Delivery Maneuvers on Brachial Plexus Strain: A Computational Study.

The purpose of this computational study was to investigate the effects of neonate-focused clinical delivery maneuvers on brachial plexus (BP) during shoulder dystocia. During shoulder dystocia, the anterior shoulder of the neonate is obstructed behind the symphysis pubis of the maternal pelvis, postdelivery of the neonate's head. This is managed by a series of clinical delivery maneuvers. The goal of this study was to simulate these delivery maneuvers and study their effects on neonatal BP strain. Using madymo models of a maternal pelvis and a 90th-percentile neonate, various delivery maneuvers and positions were simulated including the lithotomy position alone of the maternal pelvis, delivery with the application of various suprapubic pressures (SPPs), neonate in an oblique position, and during posterior arm delivery maneuver. The resulting BP strain (%) along with the required maternal delivery force was reported in these independently simulated scenarios. The lithotomy position alone served as the baseline. Each of the successive maneuvers reported a decrease in the required delivery force and resulting neonatal BP strain. As the applied SPP force increased (three scenarios simulated), the required maternal delivery force and neonatal BP strain decreased. A further decrease in both delivery force and neonatal BP strain was observed in the oblique position, with the lowest delivery force and neonatal BP strain reported during the posterior arm delivery maneuver. Data obtained from the improved computational models in this study enhance our understanding of the effects of clinical maneuvers on neonatal BP strain during complicated birthing scenarios such as shoulder dystocia.

Impact of Introducing PROMPT on Permanent Brachial Plexus Injury and Tears III°/IV° in Shoulder Dystocia: The Hanover Cohort Study.

To test the hypothesis that PROMPT reduces permanent brachial plexus palsy and perineal tears. A prospective/retrospective cohort study. Setting. Hanover Medical School, Germany. Population/Sample. A self-selected population. The training period is from November 9th, 2017, until December 31st, 2019; control: January 1st, 2004, until November 8th, 2017. Main Outcome Measures. Shoulder dystocia, nonpermanent and permanent brachial plexus injuries (BPIs), perineal tears III°/IV°, manual manoeuvres, and asphyxia. There was a total of 22,640 births, and shoulder dystocia increased from 48/18,031 (0.27%) to 23/4,609 (0.50%) ((p=0.017), OR: 1.88, 95% CI: (1.14; 3.09)), whereas BPIs decreased from 7/48 (14.6%) to 1/23 (4.3%) (p=0.261). There was 1/7 (14.2%) of permanent BPI before and 0/1 (0%) case after. Perinatal asphyxia increased from 3/48 (6.3%) to 4/23 (17.4%) (p=0.23). However, adverse outcomes after one year were zero. McRoberts' manoeuvre increased from 37/48 (77.1%) to 23/23 (100%) ((p=0.013), OR: 1.62, 95% CI: (1.33; 1.98)), and internal rotation manoeuvres and manual extraction of the posterior arm from 6/48 (12.5%) to 5/23 (21.7%) (p=0.319). Episiotomies decreased from 5,267/18,031 (29.2%) to 836/4,609 (18.1%) ((p < 0.001), OR: 0.54, 95% CI: (0.49, 0.58)), whereas perineal tears III°/IV° associated with shoulder dystocia increased from 1/48 (2.1%) to 1/23 (4.8%) (p=0.546). Vaginal operative deliveries remained constant (6.5% vs. 7%). PROMPT significantly improves the management of shoulder dystocia and decreases permanent brachial plexus injuries but not perineal tears III°/IV°.

The effectiveness of the modified Epley maneuver for the treatment of posterior semicircular canal benign paroxysmal positional vertigo.

To compare the repositioning effect of the modified Epley maneuver and the traditional Epley maneuver for posterior semicircular canal benign paroxysmal positional vertigo (PC-BPPV). Sixty-five patients with unilateral PC-BPPV were randomly divided into two groups. The control group received the traditional Epley maneuver, while the experimental group received the modified Epley maneuver, which prolonged the time in the healthy side lying position and the final bowing position. The number of successful repositions after one, two, and three attempts and the total number of successful repositions were recorded and compared between the two groups. A BPPV virtual simulation model was used to analyze the mechanism of the modified Epley maneuver. The first repositioning success rate of the experimental group was significantly higher than that of the control group (85% vs. 63%, p = 0.040). The experimental group achieved 100% repositioning success rate after two attempts, while the control group needed three attempts to reach 86% repositioning success rate. Four cases in the control group experienced canal switching during the repositioning process, while none in the experimental group did. The BPPV virtual simulation model showed that the modified Epley maneuver could facilitate the passage of otoliths through the posterior arm of the posterior semicircular canal, especially through the location of obstruction. The modified Epley maneuver is more effective than the traditional Epley maneuver in improving the single repositioning success rate and reducing the canal switching rate for PC-BPPV. This study provides a new option for the treatment of BPPV.

Case report: Posterior arm perforator flap for reconstruction of axillary defect after infected radiation-induced ulcer

Axillary soft tisue defects are uncommon in Vietnam. We report a case of an 81-year-old female patient had an infected axillary skin ulcer after going through a radical surgery and radiation therapy 30 years ago. In this case, a CT scanner was used to evaluate the fundus of the lesion and biopsy to rule out malignancy. The treatment procedure was eliminating infection based on the antibiogram, wound care, debridement, negative pressure wound therapy and reconstruction of defect. The optimal choice in this case was to use posterior arm perforator flap. After the surgery, the flap had a good vitality and the wound healed after 3 weeks. The case affirmed that the posterior arm perforator flap is suitable for axillary coverage and should be considered as one of the main options for axillary reconstruction.

Weave Technique for Reconstruction of Medial Collateral Ligament and Posterior Oblique Ligament: A Functional Percutaneous Approach Using Gracilis Tendon

Background: Injury to the medial collateral ligament (MCL) is common. MCL injuries, with impairment of its superficial portion, associated with the deep portion, lead to valgus instability and extrusion of the medial meniscus, resulting in instability and increased pressure in the medial compartment, with consequent damage to the cartilage. We can synthesize this set of structures as the medial meniscocapsular complex. Treating medial, superficial, and deep capsular meniscal complex together aims to restore the normal anatomy, stability, and function of the medial meniscus. Indications: • Anterior cruciate ligament with MCL grade III or MCL grade II • MCL grade III or grade II with clinical instability Technique Description: An arthroscopic examination was performed to assess the “floating meniscus” sign and to confirm a tear of the MCL. The gracilis tendon is harvested in a usual fashion, leaving its distal insertion pedicle fixed to the tibial bone. An incision over the medial epicondyle is made, and a 6-mm drill is used to create a 2.5-cm bone tunnel. The passage of the medial subfascial graft is made toward the medial epicondyle. At this point, its fixation is performed with an interference screw. After fixing the anterior arm, we will return with the free portion of the graft in the most posterior portion and also percutaneously. This posterior arm is biologically fixed, closing the sartorius fascia over the 2 arms of the reconstruction with periosteal stitches. Results: Reconstruction tests were performed on cadaver models, obtaining a graft tension without compromising the range of motion (ROM) and a good result in their final analysis. We ended up publishing our results in a clinical study, with good functional results in both the Lysholm and Tegner scores, at a follow-up of 2 years. Discussion/Conclusion: We present an arthroscopic-assisted technique for a medial, percutaneous, aesthetic, and extremely functional approach. A technical limitation of our procedure is the absence of a biomechanical test for the gracilis double reconstruction: a strong point is that we performed some reconstruction tests on cadaver models, obtained good visual results and graft tension without compromising the ROM, and performed a positive clinical study with a minimum follow-up of 2 years. In conclusion, a simple and inexpensive technique that uses known anatomic principles of graft placement, without compromising ROM was performed. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Wedgeless V-Shaped Osteotomy of the Distal Medial Femur with Locking Plate Fixation for Correction of Genu Valgum in Adolescents and Young Adults.

Genu valgum is a common disorder affecting adolescents and young adults. Treatment of this disorder requires restoration of normal mechanical axis alignment and joint orientation, for which it is important to assess whether the deformity arises from the distal femur, knee joint, or proximal tibia. Most commonly, the deformity originates from the distal femur, and various osteotomies of the distal femur have been described1-6. The presently described wedgeless V-shaped osteotomy7,8 is a good option among the various alternative procedures listed below. The anesthetized patient is placed in the supine position on a radiolucent operating table. A bolster is placed beneath the knee to relax the posterior structures. A medial longitudinal skin incision is made that extends from the level of the medial joint line to 5 cm proximal to the adductor tubercle. The vastus medialis is identified and elevated anteriorly by detaching it from its distal and posterior aspects. The leash of vessels underneath the vastus medialis is identified, and the apex of the V-shaped osteotomy is kept just proximal to it. The anterior arm of the V is kept longer than the posterior one, both of them are kept perpendicular to each other, and the apex of the V is made to point distally. The osteotomy is performed on the medial cortex with use of an oscillating saw or multiple drill holes that are then connected using a thin osteotome. Care is taken not to utilize a saw or drill on the lateral cortex. A gentle valgus thrust is applied to break the lateral cortex without periosteal disruption. The apex of the V osteotomy on the proximal fragment is trimmed, and the deformity is corrected with varus force. The osteotomy site is stabilized with use of an anatomically contoured distal medial femoral locking plate or a medial proximal tibial L-shaped buttress plate (of the contralateral side). The implant position is verified under a C-arm image intensifier. The wound is closed in layers over a suction drain in a standard manner. Various types of corrective osteotomies of the distal femur have been described in the literature, including the lateral opening wedge, medial closing wedge, dome, and spike osteotomies1-6. All of these procedures have certain limitations and shortcomings. The wedgeless V-shaped osteotomy is another described procedure that is inherently stable7,8. It is a safe procedure and yields good clinical outcomes8,9. The posterior arm of the V-shaped osteotomy is kept smaller than the anterior arm. The proximal cortical bone is allowed to dig into the cancellous bone of the wider distal metaphysis during deformity correction. Trimming the apex of proximal bone end after making the osteotomy facilitates the process. In a study of 46 patients with a mean age of 16.9 years (range, 15 years to 23 years), Gupta et al.8 reported that the mean radiographic tibiofemoral angle improved from 22.2° (range, 16° to 29°) preoperatively to 5.1° (range, 0° to 10°) postoperatively (p < 0.001). Similarly, the mean lateral distal femoral angle improved from 79.2° preoperatively to 89.1° postoperatively (p < 0.001) and the mean mechanical axis deviation improved from 19.6 mm preoperatively to 3.7 mm postoperatively (p < 0.001). A total of 44 of 46 cases had an excellent functional outcome, with the other 2 having good outcomes. None of the patients in the study had an unsatisfactory outcome. It is important to keep the whole lower limb accessible to the image intensifier intraoperatively.Identification of the leash of vessels underneath the vastus medialis is important to decide the level of the osteotomy.It is important to preserve the periosteal sleeve on the lateral aspect of the femur. CORA = center of rotation of angulationECG = electrocardiogramLDFA = lateral distal femoral angleMAD = mechanical axis deviationMPTA = medial proximal tibial angle.

Long-term trends in the incidence and management of shoulder dystocia in a tertiary obstetric unit in Hong Kong.

Because there have been changes in the management of macrosomic pregnancies and shoulder dystocia in the past decade, this study was conducted to compare the incidences of shoulder dystocia and perinatal outcomes between the periods of 2000-2009 and 2010-2019. This retrospective study was conducted in a tertiary obstetric unit. All cases of shoulder dystocia were identified using the hospital's electronic database. The incidences, maternal and fetal characteristics, obstetric management methods, and perinatal outcomes were compared between the two study periods. The overall incidence of shoulder dystocia decreased from 0.23% (134/58 326) in 2000-2009 to 0.16% (108/65 683) in 2010-2019 (P=0.009), mainly because of the overall decline in the proportion of babies with macrosomia (from 3.3% to 2.3%; P<0.001). The improved success rates of the McRoberts' manoeuvre (from 31.3% to 47.2%; P=0.012) and posterior arm extraction (from 52.9% to 92.3%; P=0.042) allowed a greater proportion of affected babies to be delivered within 2 minutes (from 59.0% to 79.6%; P=0.003). These changes led to a significant reduction in the proportion of fetuses with low Apgar scores: <5 at 1 minute of life (from 13.4% to 5.6%; P=0.042) and <7 at 5 minutes of life (from 11.9% to 4.6%; P=0.045). More proactive management of macrosomic pregnancies and enhanced training in the acute management of shoulder dystocia led to significant improvements in shoulder dystocia incidence and perinatal outcomes from 2000-2009 to 2010-2019.

Muscle interconnections in the anterior and posterior arm compartment: a cadaveric case series with possible clinical implications

PurposeThe report describes four cases of accessory bundles (ABs) or fibers connecting the muscles of the anterior with the posterior arm compartment. The ABs morphology (pure muscular or musculofascial or musculoaponeurotic) is described emphasizing their attachment points, characterized as muscles’ interconnections.Materials and methodsFour formalin-embalmed donated male cadavers were dissected.ResultsThe muscles’ interconnections were unilaterally identified. In the first case, the two ABs originated from the coracobrachialis muscle (CB), received fibers from the biceps brachii (BB), and were inserted into the triceps brachii (TB) medial head. The ABs created an arch over the brachial vessels and the median nerve (MN). In the second case, an accessory musculoaponeurotic structure was identified between CB and TB medial head and extended over the brachial vessels. In the third case, the myofascial ABs between the BB short head and the upper arm fascia, coursed anterior to the MN, the brachial artery, and the ulnar nerve, with direction to the TB medial head. In the fourth case, the three muscular ABs originating from the CB superficial and deep heads, in common with the BB short head, joined the upper arm fascia and the TB medial head and possibly entrapped the musculocutaneous nerve, the MN, and the brachial artery.ConclusionABs or musculoaponeurotic extensions may predispose to complications due to their potential compression on nerves and vessels. Clinicians should consider the possible existence of such bridging variants between muscles, in the differential diagnosis of a patient presenting with ischemia, edema, or MN palsy symptoms.