Posterior Opening Research Articles

Analysis of results of primary closure in fistula in ANO

Aim: Prospective analysis of results of primary closure in fistula in ano in terms of (a) Immediate- Bleeding, perianal haematoma, pain, suture line dehiscence and healingperiod. (b) Later - Incontinence & reccurence rate and Patient’s compliance & feasibility of technique in NSCBMC Jabalpur. Methods: Prospective study was conducted in Department of Surgery, NSCB Medical College, Jabalpurbetween Aug. 2012 to Sept. 2013. Total 60 patients were taken and divided in two groups, group-A (30 patients) taken as case study in which pimary closure was done and group-B (30 patients) taken as control group in which open fistulectomy was done. Results: Majority of patients were 31 to 60 years (80%). More number of males than females. (M=93.3%, F=6.7%). Perianal Discharge (90%), Pain (56.7%) and Swelling (33.3%) were the main complaints. Fistula-in-ano with a single opening (83.3%) was the commonest occurrence and posterior opening (70%) situation was more common. Bleeding was seen in open method (group-B=30%) whereas none of the patients shows bleeding in primary closure technique (group-A). Perianal haematoma was more seen in open method (group-B=20%) compare to primary closure method (group-A=6.6%).

Collision Pressure and Dissipated Power Dose in a Self-Oscillating Silicone Vocal Fold Model With a Posterior Glottal Opening.

The goal of this study was to experimentally evaluate how compensating for the adverse acoustic effects of a posterior glottal opening (PGO) by increasing subglottal pressure and changing supraglottal compression, as have been associated with vocal hyperfunction, influences the risk of vocal fold (VF) trauma. A self-oscillating synthetic silicone model of the VFs with an airflow bypass that modeled a PGO was investigated in a hemilaryngeal flow facility. The influence of compensatory mechanisms on collision pressure and dissipated collision power was investigated for different PGO areas and supraglottal compression. Compensatory behaviors were mimicked by increasing the subglottal pressure to achieve a target sound pressure level (SPL). Increasing the subglottal pressure to compensate for decreased SPL due to a PGO produced higher values for both collision pressure and dissipated collision power. Whereas a 10-mm2 PGO area produced a 12% increase in the peak collision pressure, the dissipated collision power increased by 122%, mainly due to an increase in the magnitude of the collision velocity. This suggests that the value of peak collision pressure may not fully capture the mechanisms by which phonotrauma occurs. It was also found that an optimal value of supraglottal compression exists that maximizes the radiated SPL, indicating the potential utility of supraglottal compression as a compensatory mechanism. Larger PGO areas are expected to increase the risk of phonotrauma due to the concomitant increase in dissipated collision power associated with maintaining SPL. Furthermore, the risk of VF damage may not be fully characterized by only the peak collision pressure.

A vidian neurectomy approach with the sphenoid process of the palatine bone as a landmark

Objective:To explore a safe and effective surgical approach to locate and cut the vidian nerves with the sphenoid process of the palatine bone as a landmark. Methods: The landmarks of locating the external opening of the vidian canal were confirmed by the dissection of the cadaveric heads, and the feasibility of locating the vidian nerves with the determined landmarks was verified during operation. Results:The anatomical landmarks, which are the anterior opening of palatovaginal canal, the posterior opening of palatovaginal canal, palatovaginal canal and the nasal pharyngeal crest of the root of the pterygoid process can be used as the important landmarks of locating vidian nerve. In the cases of 10 patients with refractory allergic rhinitis and vasomotor rhinitis, the vidian nerves were successfully located and sectioned, and one patient was complicated with short-term unilateral palatal numbness after surgery. Conclusion:The anterior opening of palatovaginal canal, the posterior opening of palatovaginal canal, palatovaginal canal and the nasal pharyngeal crest of the root of the pterygoid process can be used as surgical markers for vidian neurectomy with the sphenoid process of the palatine bone as landmarks.

Poster 145: Posterior Glenoid Osteotomy with Capsulolabral Repair Restores Force in a Critical Bone Loss Biomechanical Model

Objectives:Bone loss in posterior shoulder instability is an increasingly recognized clinical phenomenon. There is no widespread consensus on the surgical treatment of posterior shoulder instability with critical posterior glenoid bone loss. Here, we study the effect of opening posterior wedge osteotomy on resistance force of soft tissue repair alone in the setting of 20% critical bone loss.Methods:Native glenoid retroversion was measured on 9 cadavers. The humerus was potted in 90 degrees of forward flexion and 30 degrees of internal rotation relative to the scapula and a posterior dislocation was performed in order to create a posterior capsulolabral injury model. The specimens were each taken through a fixed sequence of testing: (1) posteroinferior capsulolabral tear, (2) no glenoid bone loss with posteroinferior capsulolabral repair, (3) 20% posterior glenoid bone loss with posteroinferior capsulolabral repair, (4) and 20% glenoid bone loss with posterior glenoid opening wedge osteotomy and posteroinferior capsulolabral repair. The resultant peak forces with 1 centimeter of posterior translation were measured. A one-way repeated-measures analysis of variance (RM-ANOVA) was used to compare mean force values.Results:Following the initial dislocation event, all shoulder had a resultant posterior capsulolabral injury. Repairing the capsulolabral complex in the 20% posterior glenoid bone loss group did not result in a statistically significant increase in resistance force compared to the labral deficient group, p = 0.068. When 20% posterior bone loss was created, the posterior glenoid osteotomy with capsulolabral repair was significantly stronger than the posterior repair alone both with and without bone loss, p = 0.008 and p = 0.045, respectively.Conclusions:In the setting of critical posterior glenoid bone loss, an opening wedge posterior glenoid osteotomy with capsulolabral repair significantly improved resistance to posterior humeral translation compared to capsulolabral repair alone.

A new specimen of pteranodontid pterosaur Bogolubovia orientalis from the upper cretaceous of Penza Province, Russia

ABSTRACT Bogolubovia orientalis, the first pterosaur taxon described from Russia, was known for more than a hundred years from a single specimen, the posterior fragment of the middle cervical vertebra from the Upper Cretaceous (upper Campanian) Rybushka Formation at Malaya Serdoba locality in Penza oblast, Russia. First classified as a pteranodontid, Bogolubovia was long thought to be an azhdarchid, and only very recently has it been again reclassified as a pteranodontid. Here, we describe the second pterosaur vertebra from the Malaya Serdoba locality, an atlantoaxis, which shows distinct pteranodontid characters, such as round cotyle, lack of hypapophysis, rudimentary diapophysis placed anterior to the lateral pneumatic foramen, and pair of posterior lateral pneumatic foramina. The pteranodontid characters of the holotype middle cervical vertebra include high neural arch, which is higher than the centrum and has the postzygapophyses placed well above the condyle, and the large posterior lateral foramina, similar in size with the posterior opening of the neural canal. Both vertebrae can be assigned to the same taxon, Bogolubovia orientalis. Bogolubovia can be distinguished from the pteranodontids Pteranodon and Volgadraco and thus is considered a valid taxon.

A Rare Case of Contained Chronic Rupture of Abdominal Aortic Aneurysm Associated With Vertebral Erosion: Pre- and Post-operative Findings on Computed Tomography and a Narrative Review.

Contained chronic rupture of aortic aneurysm (CCR-AA) is a rare condition that can be associated with vertebral body erosion (VBE) and is often a diagnostic challenge; in fact, CCR-AAs are in general hemodynamically stable and the patients tend to present with a non-specific low-back pain syndrome secondary to vertebral involvement. Furthermore, the differential diagnosis of a retroperitoneal mass can be difficult on medical imaging. We discuss the case of a 79-years-old man, heavy smoker without history of cardiovascular diseases, admitted to the emergency department with signs of left lower limb ischemia. The patient was hemodynamically stable and the medical examination revealed a pulsatile abdominal mass. Doppler ultrasound showed the presence of aneurysmal dilatation of infra-renal abdominal aorta and chronic femoropopliteal occlusion on the left side. The subsequent computed tomography angiography (CTA) demonstrated a voluminous retroperitoneal mass continuous with the infra-renal aorta, which infiltrated the psoas muscles and caused vertebral bodies erosion of the anterior wall in L2, L3 and L4 suspected for CCR-AA or mycotic aortic aneurysm. Furthermore, the examination confirmed the occlusion of the peripheral arterial circulation of the left lower limb. The patient underwent a successful open replacement of the infra-renal abdominal aorta through aorto-aortic prosthetic graft insertion; the visualization during the surgical procedure of a posterior vessel wall opening in continuity with the eroded vertebral bodies associated with negative microbiological culture of the thrombotic material sample, led to the definitive diagnosis of CCR-AA. The post-operative CTA showed successful open vascular treatment. A bypass surgery of the left lower limb was then performed with positioning saphenous graft between femoral common artery and posterior tibial artery. The patient was finally discharged in good clinical conditions.

Posterior Capsular Outcomes of Pediatric Cataract Surgery With In-The-Bag Intraocular Lens Implantation.

AimTo investigate the change of posterior capsular outcomes of pediatric cataract surgery with primary in-the-bag intraocular lens (IOL) implantation.MethodsWe conducted a case series of pediatric cataract children who underwent cataract extraction with primary in-the-bag IOL implantation, posterior capsulorhexis or vitrectorhexis, and limited anterior vitrectomy at the Eye Hospital of Wenzhou Medical University between 2016 and 2019. Digital retro-illumination photographs of pediatric eyes were obtained at baseline and 6 months, 12 months, and the last visit postoperatively. Capsular outcomes of the posterior capsular opening area (PCOA) and lens reprolifration area at those time points were compared. Correlations between the PCOA and influential factors, such as age at surgery, axial growth, and follow-up duration, were analyzed. The study was registered at register.clinicaltrials.gov (NCT04803097).ResultsData of 23 patients (27 eyes) were used in the final analysis. During follow-up, the PCOA enlarged at a rate of 0.29–0.32 mm2/month during the first six months postoperatively and 0.05–0.08 mm2/month over the next 1–2 years. Six months postoperatively, the PCOA enlargement statistically and positively correlated with the follow-up duration and axial growth. The area of lens reprolifration was 0.46 ± 1.00 mm2 at six months postoperatively and then remained stable.ConclusionThe PCOA enlarged rapidly within the first six months after the pediatric cataract surgery with primary IOL implantation. Six months postoperatively, the enlargement of PCOA was positively correlated with follow-up duration and axial growth. Posterior capsulorhexis or capsulectomy should be performed with a diameter of 3.0 to 4.0 mm for good visual axis transparency and the protection of in-the-bag IOL.

Posterior Glenoid Osteotomy With Capsulolabral Repair Improves Resistance Forces in a Critical Glenoid Bone Loss Model.

Background:There is no widespread consensus on the surgical treatment of posterior shoulder instability with critical posterior glenoid bone loss.Hypothesis:That opening posterior glenoid wedge osteotomy with soft tissue repair would improve the resistance forces of instability when compared with soft tissue repair alone in the setting of 20% critical bone lose.Study Design:Controlled laboratory study.Methods:Native glenoid retroversion was measured on 9 shoulders using computed tomography (CT) scans. The humerus was potted in 90° of forward flexion and 30° of internal rotation relative to the scapula, and a posterior dislocation was performed to create a posterior capsulolabral injury model. The specimens were each taken through a fixed sequence of testing: (1) posteroinferior capsulolabral tear, (2) no glenoid bone loss with posteroinferior capsulolabral repair, (3) 20% posterior glenoid bone loss with posteroinferior capsulolabral repair, and (4) 20% glenoid bone loss with posterior glenoid opening wedge osteotomy and posteroinferior capsulolabral repair. Bone loss was created using a sagittal saw. The resultant peak forces with 1 cm of posterior translation were measured. A 1-way repeated-measures analysis of variance was used to compare mean force values.Results:After the initial dislocation event, all shoulders had a resultant posterior capsulolabral injury. The resulting labral injury was extended from 6- to 9-o’clock in all specimens to homogenize the extent of injury. Repairing the capsulolabral complex in the 20% posterior glenoid bone loss group did not result in a statistically significant increase in resistance force compared with the labral deficient group (34.1 vs 22.2 N; P = .068). When 20% posterior bone loss was created, the posterior glenoid osteotomy with capsulolabral repair was significantly stronger (43.8 N) than the posterior repair alone both with (34.1 N) and without (31.8 N) bone loss (P = .008 and .045, respectively).Conclusion:In the setting of critical posterior glenoid bone loss, an opening wedge posterior glenoid osteotomy with capsulolabral repair improved resistance to posterior humeral translation significantly compared with capsulolabral repair alone.Clinical Relevance:The results of this biomechanical cadaveric study may aid in surgical planning for this complex patient population.

An anatomical pathogenesis of lower urinary tract definitions from the 2002 ICS report symptoms, conditions, syndromes, urodynamics.

AimTo present an anatomical pathogenesis parallel with the 2002 International Continence Society Lower Urinary Tract (LUTS) definitions standardization Report 2002.MethodsEach LUTS section is discussed using the same numbers as the Report.Results Normal function Bladder control is binary, with two reflexes alternating, either closure (dominant) or open (micturition), with the same cortical and peripheral components: three directional muscle forces contracting against pubourethral (PUL) and uterosacral (USL) ligaments for closure, two against uterosacral ligaments for micturition. Dysfunction OAB symptoms reflect a prematurely activated micturition; PUL/USL weakness prevents muscle forces from controlling afferent urothelial emptying signals. Stress urinary incontinence is a consequence of weak PULs allowing posterior muscle forces to open the urethra during effort. Lax USLs weaken contractile force of the posterior urethral opening vectors, so detrusor has to contract against an unopened urethra. This is experienced as “obstructive micturition.”ConclusionsAnatomical analysis indicates the ICS definitions are fundamentally sound, except for “OAB” which implies detrusor causation. Minor changes, OAB to “overactivated” bladder allow causation outside of bladder. This construct supports OAB and its component symptoms as a syndrome, as intuited by the Committee, (albeit as a prematurely activated micturition), retains the acronym, explains OAB cure by ligament repair, and incontinence pathogenesis from two post‐2002 syndromes which need an addition to the definitions, Posterior Fornix Syndrome (of which OAB is a component) and Tethered Vagina Syndrome, which is the basis for skin‐grafting cure of the 30%–50% of women who continue leaking urine massively after successful obstetric fistula closure.

Extended spinal dysraphism: Rachischisis or myeloschisis

Myeloschisis (rachischisis) is a rare congenital malformation linked to incomplete development of the spine and characterized by posterior opening of the vertebrae [1,2]. It is spread over more than one floor or even the entire spine and incompatible with life. Its diagnosis is clinical, confirmed by ultrasound and cross-sectional imaging [2]. This anomaly in its thoracic location is rare. There are two types: Segmentation and development defects [4]. Developmental defects include hemi vertebrae and failure of neural tube fusion which in turn includes the simple cleft of the posterior arch of the vertebrae (spina bifida) [3]. It can involve one or more vertebral arches, determining extensive spinal dysraphism. Certain factors favor their appearance. According to the literature, only one article published in 1972 by Levy et al, which reported an incidence of 0.01% of thoracic spina bifida [3]. We report the case of a 33-day-old female infant born at term in breech presentation, with a pregnancy that was not well followed. There was a notion of taking fenugreek during pregnancy. Hospitalized for meningitis, with a dysmorphic face, clinically presented a dorsolumbar spina bifida (Figure 1). She had received antibiotic therapy and regular dressings since her admission. A cerebral-medullary scan was performed and showed a progressive opening of the spinous processes from the cervical and dorsal spine, more marked at the height of the spinous process of the fourth dorsal vertebra to distality, with issue of meningeal structures and spinal cord. Conflicts of interest: The authors declare that they have no conflicts of interest.

Dentoskeletal changes and their correlations after micro-implant-assisted palatal expansion (MARPE) in adults with advanced midpalatal suture ossification.

To evaluate and correlate the dentoskeletal changes of adult patients after miniscrew-assisted rapid palatal expander (MARPE) in the two final stages of midpalatal suture ossification. This interventional pre-post clinical study consisted of 20 adults (24.9±1.8 years), with transverse maxillary atresia, divided into two subgroups (n=10) based on the ossification degree of the midpalatal suture: stage D, fusion completed in the palatine bone; and stage E, fusion anteriorly in the maxilla. Cone beam computed tomography (CBCT) in the pre- (T0) and post-treatment (T1) time intervals were used to evaluate the anterior and posterior sutural opening, activation of the expander screw, vestibular-lingual inclinations, and widths of first premolars and first molars. Maxillary interincisor diastema was measured on patients' plaster models in the same timepoints. The Wilcoxon-Mann-Whitney test, generalized linear models (GLM), and chi-square (χ2) test were employed. All variables significantly increased after MARPE therapy regardless of the ossification degree (P<0.05). Patients with stage D suture presented wider interincisal diastema and maxillary suture opening (on both regions, anterior and posterior) when compared with patients with stage E (P<0.05). Maxillary interincisor diastema was positively associated with anterior and posterior suture opening for all subjects (P<0.05). MARPE therapy was unsuccessful in six patients, mostly presented by individuals with E maturation stage of the midpalatal suture. After MARPE, a significant correction in the transverse defect of the maxillary basal bone was achieved for adults in the last two midpalatal suture maturation stages. Adult patients in stage D of maxillary suture ossification are more susceptible to dentoskeletal changes following MARPE therapy as compared to patients with stage E.

The prophylactic effect of betaxolol 0.5% versus brimonidine 0.2% on IOP elevation after Nd:YAG laser posterior capsulotomy

ABSTRACT Clinical relevance Posterior capsule opacification is a common late complication of cataract surgery. Posterior capsule opening with Nd:YAG laser, which is the standard treatment, may cause transient elevation of intraocular pressure (IOP). Background To evaluate the efficacy of betaxolol 0.‌5% compared to brimonidine 0.2%, in prevention of intraocular pressure increase after Nd:YAG Laser posterior capsulotomy. Methods In a double masked randomised clinical trial, 38 eyes from 38 pseudophakic patients over 21 years of age who had significant posterior capsule opacification after phacoemulsification were randomly assigned to receive either betaxolol 0.‌5% (18 eyes) or brimonidine 0.‌2% (20 eyes) one hour before Nd:YAG Laser posterior capsulotomy.‌ Exclusion criteria were: glaucoma or history of glaucoma surgery, active uveitis, active ocular infection, pregnancy, unstable cardiovascular condition and severe asthma and lung diseases. Intraocular pressure was measured by Goldmann applanation tonometry, 1 hour before applying the laser and 4 hours after the laser application. Results There was no statistically significant difference between the two groups regarding the baseline mean IOP and the 4-hour post-laser mean IOP. There was a statistically significant decrease in the 4-hour post-laser mean IOP as compared to the baseline mean IOP in each group. The mean IOP change in the betaxolol group, was −2.39 ± 1.79 mm Hg and in the brimonidine group was −4.25 ± 2.20 mm Hg. The difference was statistically significant (P = 0.007). None of the patients experienced clinically significant IOP increase (≥5 mm Hg) in either group. Conclusion Use of a single topical dose of betaxolol 0.5% and brimonidine 0.2%, 1 hour before laser treatment, can prevent significant acute IOP increase after Nd:YAG laser posterior capsulotomy, and betaxolol may provide a new alternative for prophylactic use.

Incidence and Factors Affecting the Occurrence of Lateral Hinge Fracture After Medial Opening-Wedge High Tibial Osteotomy

Background:Few clinical studies have reported the predictors of lateral hinge fracture (LHF) after medial opening-wedge high tibial osteotomy (MOWHTO).Purpose/Hypothesis:The purpose was to compare the incidence of LHF on plain radiographs versus computed tomography (CT) scans and to investigate the factors related to the development of LHF after MOWHTO. We hypothesized that (1) a higher LHF detection rate would be seen on CT scans versus plain radiographs and (2) LHF incidence would be related to opening gap width and hinge position.Study Design:Cohort study (diagnosis); Level of evidence, 3.Methods:A total of 97 MOWHTO cases were included. The presence and types of LHF were determined from plain radiographs and CT scans. Radiographic parameters were measured on plain radiographs taken 6 weeks postoperatively. Anterior and posterior opening gap widths, coronal and sagittal osteotomy slopes, and fibular height were calculated from CT scans. The wedge-hinge relationship and the zone of hinge position were assessed, and the patient and radiographic factors related to LHF occurrence were evaluated.Results:Seventeen LHF cases (20.5%) were detected on plain radiographs, while significantly more (37 cases; 44.6%) were found on CT scans (P = .001). Based on Takeuchi classification, 28 LHF cases were considered type 1, 7 were type 2, and 2 were type 3. Logistic regression analysis revealed that opening gap width (odds ratio, 1.615; 95% confidence interval, 1.232-2.118; P = .001) and posterior opening gap width (odds ratio, 3.731; 95% confidence interval, 1.642-4.351; P = .008,) differed significantly between patients with versus without LHF. Other patient and radiographic factors were not significantly related to LHF occurrence. Receiver operating characteristic curve analysis identified the opening gap width cutoff values for LHF as 11.0 mm (area under the curve, 0.81; sensitivity, 78.4%; specificity, 73.9%).Conclusion:The incidence of LHF after MOWHTO can be underestimated on plain radiographs compared with CT scans. Only large opening gap width, especially posterior gap width, was found to have a statistically significant relationship with occurrence of LHF. Therefore, special caution for possible LHF may be needed if a large correction is planned.

A unique yet technically simple type of joint allows for the high mobility of scorpion tails.

Although being one of the most well-known animal groups, functional and constructional aspects of scorpions and especially of their tail (metasoma) have so far been overlooked. This tail represents a special construction, as it consists of five tube-shaped segments made up of strong cuticle, which are movable against each other and thus manoeuvre the notorious stinger both quickly and very precisely in space. This high mobility of an exoskeletal structure can be attributed to the connection between the segments described here for the first time. This joint allows for the twisting and bending at the same time in a single, simple construction: adjoining metasomal segments each possess an almost circular opening posteriorly, where the next segment is lodged. Anteriorly, these segments possess two saddle-like protrusions laterally, which are able to rotate in two directions on the rim of the posterior circular opening of the previous segment allowing for twisting and bending. The metasomal joint is particularly noteworthy since its mechanism can be compared to that of arthropod appendages. The scorpion metasoma is actually the only known case in Chelicerata, in which an entire body section has been modified to perform tasks similar to that of an appendage while containing digestive organs. The joint mechanism can also inspire technical applications, for instance in robotics.

Short Communication: Morphological study of the scales of Barbodes cf. binotatus (Cyprinidae) from Toba Lake, Indonesia by using Scanning Electron Microscopy-Energy Dispersive Spectroscopy (SEM-EDS)

Abstract. Lubis K, Sudibyo M, Siregar EH, Laili N. 2021. Short Communication: Morphological study of the scales of Barbodes cf. binotatus (Cyprinidae) from Toba Lake, Indonesia by using Scanning Electron Microscopy-Energy Dispersive Spectroscopy (SEM-EDS). Biodiversitas 22: 3821-3828. Spotted barb (Barbodes cf binotatus) is a freshwater fish of Sumatra Island, especially found in the Toba. The study of morphological characteristics of the scales of Spotted barb (B. cf binotatus) is necessary in fish taxonomy. Therefore, the present study investigated the morphology and the chemical elements of the scales located between the dorsal fin and lateral line and those on the lateral line using SEM-EDS (Scanning Electron Microscope (SEM)- Energy Dispersive X-ray Spectroscopy (EDS). We found that the scales of Spotted barb (B. cf binotatus) have the general morphological characteristics of cycloid scales. The morphologies of the scales between the dorsal fin and lateral line and those on the lateral line are slightly different. Lateral line scales of Spotted barb (B. cf binotatus) have no focus area, replaced by a lateral line canal located along the anterior-posterior axis of the scales with two openings. The anterior opening is bigger and wider in compared to the posterior opening. The circuli of the dorsal fin scale is orientated towards the focus. However, the circuli of the lateral scale faces the lateral line canal. The scales contain some elements such as Ca, K, O, Mg, Na, and P.

Posterior Open-wedge Osteotomy and Glenoid Concavity Reconstruction Using an Implant-free, J-shaped Iliac Crest Bone Graft in Atraumatic Posterior Instability with Pathologic Glenoid Retroversion and Dysplasia: A Preliminary Report.

Atraumatic posterior shoulder instability in patients with pathologic glenoid retroversion and dysplasia is an unsolved problem in shoulder surgery. In a preliminary study of a small group of patients with atraumatic posterior shoulder instability associated with glenoid retroversion ≥ 15° and glenoid dysplasia who underwent posterior open-wedge osteotomy and glenoid concavity reconstruction using an implant-free, J-shaped iliac crest bone graft, we asked: (1) What proportion of the patients had persistent apprehension? (2) What were the improvements in patient-reported shoulder scores? (3) What were the radiographic findings at short-term follow-up? Between 2016 and 2018, we treated seven patients for atraumatic posterior shoulder instability. We performed this intervention when posterior shoulder instability symptoms were unresponsive to physiotherapy for at least 6 months and when it was associated with glenoid retroversion ≥ 15° and dysplasia of the posteroinferior glenoid. All seven patients had a follow-up examination at a minimum of 2 years. The median (range) age at surgery was 27 years (16 to 45) and the median follow-up was 2.3 years (2 to 3). Apprehension was assessed by a positive posterior apprehension and/or posterior jerk test. Patient-reported shoulder scores were obtained and included the subjective shoulder value, obtained by chart review (and scored with 100% representing a normal shoulder; minimum clinically important difference [MCID] 12%), and the Constant pain scale score (with 15 points representing no pain; MCID 1.5 points). Radiographic measurements included glenohumeral arthropathy and posterior humeral head subluxation, bone graft union, correction of glenoid retroversion and glenoid concavity depth, as well as augmentation of glenoid surface area. All endpoints were assessed by individuals not involved in patient care. In four of seven patients, posterior apprehension was positive, but none reported resubluxation. The preoperative subjective shoulder value (median [range] 40% [30% to 80%]) and Constant pain scale score (median 7 points [3 to 13]) were improved at latest follow-up (median subjective shoulder value 90% [70% to 100%]; p = 0.02; median Constant pain scale score 15 points [10 to 15]; p = 0.03). Posterior glenoid cartilage erosion was present in four patients (all four had Walch Type B1 glenoids) preoperatively and showed no progression until the final follow-up examination. The median (range) humeral head subluxation index decreased from 69% (54% to 85%) preoperatively to 55% (46% to 67%) postoperatively (p = 0.02), and in two of four patients with preoperative humeral head subluxation (> 65% subluxation), it was reversed to a centered humeral head. CT images showed union in all implant-free, J-shaped iliac crest bone grafts. The median preoperative retroversion was corrected from 16° (15° to 25°) to 0° postoperatively (-5° to 6°; p = 0.02), the median glenoid concavity depth was reconstructed from 0.3 mm (-0.7 to 1.6) preoperatively to 1.2 mm (1.1 to 3.1) postoperatively (p = 0.02), and the median preoperative glenoid surface area was increased by 20% (p = 0.02). No intraoperative or postoperative complications were recorded, and no reoperation was performed or is planned. In this small, retrospective series of patients treated by experienced shoulder surgeons, a posterior J-bone graft procedure was able to reconstruct posterior glenoid morphology, correct glenoid retroversion, and improve posterior shoulder instability associated with pathologic glenoid retroversion and dysplasia, although four of seven patients had persistent posterior apprehension. Although no patients in this small series experienced complications, the size and complexity of this procedure make it likely that as more patients have it, some will develop complications; future studies will need to characterize the frequency and severity of those complications, and we recommend that this procedure be done only by experienced shoulder surgeons. The early results in these seven patients justify further study of this procedure for the proposed indication, but longer term follow-up is necessary to continue to assess whether it is advantageous to combine the reconstruction of posterior glenoid concavity with correction of pathological glenoid retroversion and increasing glenoid surface compared with traditional surgical techniques such as the posterior opening wedge osteotomy or simple posterior bone block procedures. Level IV, therapeutic study.

EVALUATION OF TRANS-NASAL ENDOSCOPIC CROSS-OVER FLAP TECHNIQUE IN THE REPAIR OF CHOANAL ATRESIA

Background: Choanal atresia (CA) is a widely recognized craniofacial disorder characterized by the obliteration of the posterior nasal opening, due to the imperforation of the oronasal membrane and overgrowth of the horizontal and vertical process of the palatine bone during weeks 4-11 of the gestation process. Objective: To evaluate the efficacy of trans-nasal endoscopic cross-over flap technique in the repair of choanal atresia with long-term follow-up. Patients and methods: This study was conducted on 20 choanal atresia cases that were managed by the endoscopic transnasal approach using cross-over flap technique at the Department of Otorhinolaryngology, Bab EL-Sharia and AL-Hussein Hospitals, Faculty of Medicine, AL-Azhar University from December 2018 to January 2020. Results: The study included 20 cases: 13 females and 7 males, 5 cases were bilateral, 15 cases were unilateral. Four cases were bony atretic plate, and 16 cases were mixed atretic plate. Four cases (20%) needed post-operative revision repair due to restenosis of the choana. Revision was more common in bilateral cases than unilateral cases and in bony type than mixed type. Also, revision was common in patients with associated malformations, and in patients done before 10 days. Conclusion: Transnasal endoscopic surgery using cross-over flap technique is one of the best choices in the management of the choanal atresia. Endoscopy and CT are the methods of choice for diagnosis.

Working classification and the quest for an effective, reconstructive management strategy in Y duplication of male urethra

Y-duplication is a rare subtype of urethral duplication whose surgical correction has traditionally yielded less than satisfactory results. Herein we report 18 patients, 17 of whom have completed successful urethral reconstruction. A retrospective analysis was done on 18 children who have undergone repair of Y-duplication urethra in two tertiary care institutes from 2013 to 2020. The various subtypes encountered were classified in order to develop a rationale for reconstruction based on the underlying pathology. The various modalities used for reconstruction and the outcomes of the repair were studied. All but one boy voided mainly via the posterior (ventral) channel opening in the ano-rectum or perineum. These boys had the urethral reconstruction incorporating the healthy proximal ventral urethra at its origin. Further reconstruction up to the glans tip depended on the degree of dorsal (orthotropic) urethral patency, which forms the basis of our classification into Types I (completely stenotic), II (penile urethra patent), III (penile and bulbar urethra patent) and IV (fully patent dorsal urethra). Reconstruction resulting in voiding via a glanular or coronal meatus was completed in 17 boys. One boy is awaiting further surgery while being dependent on Mitrofanoff CIC. While urethral continuity could be achieved using patent segments of native urethra alone into two boys (Types II and III), all other children needed a neo-urethral segment to replace (Type I) or supplement (Type II) the dorsal urethra. Neo urethra was constructed from a tubularized preputial island flap (n=11), Monti tube constructed from ileum (n=3) or sigmoid colon (n=4). A perineal operative exposure alone sufficed in 9, while the rest required an additional trans pubic approach. The only boy with Type IV anomaly underwent excision of the ventral urethral limb. Three boys with initially elevated serum creatinine have normal levels after reconstruction. Successful reconstruction of boys with Y- duplication of the urethra entailed elucidation of anatomical variations, adequate operative exposure (trans pubic and/or perineal) and innovative utilisation of local and/or distant tissues (preputial island flap, ileal/sigmoid Monti tubes).

Management of Obstructive Hydrocephalus Associated with Pineal Region Cysts and Tumors and Its Implication in Long-Term Outcome

Different treatment options have been proposed for obstructive hydrocephalus associated with pineal lesions. We discuss the obstructive hydrocephalus management associated with pineal region tumors and cysts in Helsinki Neurosurgery. In this article, hydrocephalus treatment by tumor-cyst removal (n= 40), shunt surgery (n= 25), and endoscopic ventriculostomies (n= 3) is evaluated in 68 patients with obstructive hydrocephalus among 136 patients with pineal region tumor and cyst. Multivariate statistical analysis was followed by univariate and multivariate regression models of last functional status, last tumor-free imaging, and disease-specific mortality of the study population. Preoperative hydrocephalus was linked to higher World Health Organization tumor grades, poor functional status, higher mortality, and incomplete resection of pineal region cysts and tumors. Preoperative hydrocephalus remained a predictor of poor last functional status after multivariate regression. Pineal lesion removal with the posterior third ventricle opening as primary hydrocephalus treatment resulted in better last functional status, fewer postoperative shunts, fewer hydrocephalus-related procedures, and fewer postoperative infections than in the shunt-treatment group. Multivariate regression analysis linked higher World Health Organization tumor grade, poor immediate functional status, postoperative complications, and incomplete surgical resection as independent predictors of disease mortality in patients with hydrocephalus. Same variables (except immediate modified Rankin Scale score) and higher number of shunt surgeries became independent predictors of poor last functional status at multivariate analysis. Incomplete resection was the only independent predictor of tumor-free magnetic resonance imaging at the last evaluation. Direct removal of pineal lesions with the opening of the posterior third ventricle could represent effective and reliable management of the associated obstructive hydrocephalus. Further research is required to generalize our inferences.

Goodsall’s rule– its predictive accuracy in tracing the tract of fistula in ano

Background: Despite being one of the oldest reported medical conditions, the management and treatment of fistula in ano are still in the evolving phase. The management of fistula-in-ano requires confirmation of the diagnosis, identifying the fistulous tract and inner opening. In majority of patients a single primary fistula tract exists and the anatomy can be determined by examination under anaesthesia adhering to the principles described by Goodsall. A thorough clinical examination of the patient is essential in the assessment of fistula-in-ano, sometimes helped by imaging such as magnetic resonance imaging and endoanal ultrasonography. Although Goodsall’s rule was accepted in the past, as a method to determine the course of the fistula, recent studies showed poor conflicting results. Thus, this study attempts to scrutinize the predictive accuracy of Goodsall’s rule. Methods: After approval from ethical committee and obtaining informed consent from each patient, prospective analysis of 188 patients who has fistula-in-ano were included in the study. They were grouped according to Goodsall’s rule and its predictive accuracy was checked with intraoperative findings. Data was entered in excel sheet and analysed by SPSS version 20.0. For all statistical interpretations, p&lt;0.05 was considered the threshold for statistical significance.Results: Predictive accuracy of Goodsall’s rule found to be 84.6% in case of fistula with an anterior external opening. While in case of fistula with posterior external opening this found to be 69.1%. Overall predictive accuracy of Goodsall’s rule is 77%. Conclusions: Goodsall’s rule can be used as guide in predicting the tract.