Proximal Third Research Articles

Bone Mineral Density in the Scaphoid

Introduction: The scaphoid bone is essential for wrist stability and movement. While fractures commonly occur at the scaphoid's waist, those at the proximal pole, though rarer, tend to result in nonunion, potentially linked to variations in bone mineral density (BMD). Previous studies have shown an increase in BMD at the proximal pole in fractured scaphoids, but BMD distribution in intact scaphoids has not been well studied. This study aims to map the BMD distribution of the intact scaphoid to better understand the etiology of fractures and optimize treatment approaches. Methods: Conducted under ethical approval, this study included 100 individuals, using computed tomography to assess the BMD in distal, middle, and proximal thirds of the scaphoid. Measurements were performed in the defined regions and analyzed using SPSS software, with significance accepted at P < .05. Results: The study comprised 34 females and 66 males, with no significant BMD difference between the right and left wrists. The proximal third exhibited significantly higher BMD (542.2 HU) compared to the middle (293.1 HU) and distal thirds (298.4 HU). A statistically significant higher BMD was observed in males, particularly in the proximal and distal thirds. A weak negative correlation between age and BMD was noted across all sections. Conclusion: The proximal scaphoid shows significantly higher BMD, potentially explaining its lower fracture incidence but higher nonunion rate. This insight into the BMD distribution within an intact scaphoid may guide the clinical management of scaphoid fractures, highlighting the need for targeted treatment strategies based on BMD variations.

Inclisiran-containing low-density lipoprotein cholesterol reduction effectively stabilizes atherosclerotic plaques

Abstract Background/Introduction Near-infrared spectroscopy (NIRS) allows to quantify lipid composition of coronary artery lesions. High plaque lipid content has been associated with increased adverse cardiovascular event risk. Purpose Aim of this study was to evaluate atherosclerotic plaque lipid content reduction in association with low-density lipoprotein (LDL-C) lowering on the background of intensive hypolipidaemic therapy. Methods NIRS investigation was performed in stable coronary artery disease patients having 20-50% stenosis in the proximal or middle third of a coronary artery. Segment of interest was repeatedly evaluated after 15 months. Lipid-rich plaques (LRPs) were defined as lesions with maximum lipid-core burden index within 4 mm (maxLCBI4 mm) >250. Study participants were taking high-intensity statin (atorvastatin 40 or 80 mg and rosuvastatin 20 or 40 mg) with or without ezetimibe for a run-in period of 4-6 weeks. Afterwards, in patients not achieving LDL-C level <1.8 mmol/l, add-on inclisiran was started. Baseline LDL-C was defined as the level at the time of initiation of optimal lipid-lowering therapy. Statistical significance level of 0.05 was set. Results Data of 36 patients was analyzed. Mean baseline maxLCBI4 mm was 203.9, reduced by 39.8% (-81.1, 95%CI -129.2 to -33.0) at 15-month follow-up (P=0.003). In 15 patients LRPs were detected with mean baseline maxLCBI4 mm 363.5, which was decreased by 35.8% (-130.3, 95%CI -235.0 to -25.7) (P=0.020). Mean LDL-C level at baseline was 2.5 mmol/l among all participants, lowered by 32.0% (-0.8, 95%CI -1.1 to -0.5) after 15 months of treatment (P<0.001). 19 patients received inclisiran in addition to high-dose statin and optional ezetimibe therapy. In 24 patients achieving LDL-C target <1.8 mmol/l at 15-month follow-up, a significant maxLCBI4 mm reduction from 208.5 by 48.4% (-101.0, 95%CI -169.3 to -32.7) was established (P=0.010). Among those having LDL-C >1.8 mmol/l, maxLCBI4 mm reduction from 194.7 by 21.2% (-41.25, 95%CI -94.7 to 12.2) was observed, however the change was not statistically significant (P=0.114). Conclusion LDL-C lowering with high-intensity hypolipidaemic therapy, including escalation to proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibition, demonstrated atherosclerotic plaque stabilization by NIRS-detected lipid content decrease.

Partial agenesis of the pectoralis major and minor muscle: A cadaveric case report.

The pectoralis major and minor muscles, located in the anterior chest wall, are crucial for upper limb movements. Their nonsyndromic absence is rare but significant for surgical procedures involving the axillary and pectoral regions. Ultrasound can confirm the diagnosis and delimit the extent of the muscular abnormality, detect abnormalities of the costal cartilages, among others. This descriptive, cadaveric case report involves a formalin-fixed 57-year-old North American male, with no clinical or family history of similar conditions. The study was conducted at the Human Anatomy Laboratory of the School of Medicine of the Universidad Finis Terrae in Santiago, Chile, in August 2022. We present a cadaveric case of bilateral partial agenesis of the pectoralis muscles discovered during routine dissection. The pectoralis major muscle exhibited only the clavicular portion, with the sternocostal and abdominal portions absent and replaced by a thin layer of connective tissue bilaterally. The pectoralis minor muscle showed partial muscle fibers only in the most distal and inferior portions bilaterally. This case report is significant due to the rarity of this condition without accompanying anatomical variations. Understanding this variant is valuable for clinical situations involving the shoulder and thorax region, such as trauma to the proximal third of the humerus, clavicular region, suprascapular region, and anterior chest wall. It may complicate conservative and/or surgical treatments due to different functional and irrigation patterns in the area and is also important for educating future professionals.

The clinical characteristics of 497 children with congenital pseudarthrosis of the tibia

Objective: To investigate the clinical and radiologic characteristics of children with congenital pseudarthrosis of the tibia (CPT) in a single center. Methods: This is a retrospective case series study. According to inclusion and exclusion criteria, clinical data of 497 children(507 limbs) with CPT who were treated at Department of Orthopedics, the Children's Hospital Affiliated to Xiangya School of Medicine, Central South University from January 2011 to December 2020 were collected. Baseline data included gender, age at initial visit, age at onset of symptoms, accompanying symptoms, domicile, whether first treated at our hospital, and treatment-related information such as surgical or conservative treatment, surgical complications, etc., were extracted and analyzed using the health information system. Imaging data of the children, including Crawford classification, bilateral leg lengths, presence of fibular pseudarthrosis, and location of pseudarthrosis along the tibia segment, were analyzed using the Picture Archiving and Communication System. Data were compared using independent sample t test or χ2 tests. Results: Among 497 children with CPT, there were 305 males (61.4%) and 192 females (38.6%). The age at initial visit was (3.6±3.2) years (range: 0.1 to 16.2 years). Neurofibromatosis type 1 (NF1) symptoms were positive in 340 children (68.4%), and negative in 157 children (31.6%). Among NF1-positive children, those with symptoms onset before 1 year of age were significantly more than NF1-negative children (74.1%(252/340) vs. 66.2%(104/157);χ2=9.24, P=0.001), and the proportion of fractures (92.9%,316/340) was significantly higher than that in the NF1-negative group (84.7%,133/157) (χ2=8.33, P=0.004). According to imaging data, Crawford type Ⅳ was the most common type, with 321 limbs (63.3%), followed by type Ⅱ in 100 limbs (19.7%), type Ⅲ in 54 limbs (10.7%) and type Ⅰ in 32 limbs (6.3%). Pseudarthrosis occurred in the proximal third of the tibia in 14 limbs (2.8%), in the middle third in 185 limbs (36.5%), and in the distal third in 308 limbs (60.8%). Seventy-four children (14.9 %) had associated fibular pseudarthrosis. The lateral proximal tibial angle was 86.91°±5.21°(range: 72.17° to 102.08°), and the lateral distal tibial angle was 87.27°±10.73°(range: 51.07° to 128.17°). A total of 421 children (84.7%) underwent surgical treatment with (3.1±2.4) surgeries performed per child (range:0 to 12 surgeries); 76 children (15.3%) received conservative treatment. Postoperative complications mainly included ankle valgus (77 cases), leg length discrepancy (71 cases),refracture (48 cases), osteomyelitis (11 cases), and hardware failure (10 cases). NF1-positive children underwent more surgeries than NF1-negative children ((5.1±2.2)times vs.(2.1±1.8)times;t=14.93,P<0.01). Conclusions: Crawford type Ⅳ is the most common type of CPT in children in this study. CPT predominantly occurs in the middle or distal third of the tibia. The majority of children with CPT experienced symptoms and were seen at outpatient clinics before the age of 3 years. The main surgical complications currently associated with CPT treatment are ankle valgus and leg length discrepancy. Compared with CPT without NF1, children with NF1-positive CPT tend to have earlier symptom onset and may require more frequent treatments.

Clinical and radiological outcome of proximal third tibia fractures treated with intramedullary nailing

Introduction. Extra articular proximal tibia fractures represent about 5-11% of all tibia fractures, and usually exhibit complex fracture patterns with moderate to severe soft tissue damage and deforming forces. No fracture arose more controversy regarding the best method of treatment, common methods of fixation of proximal tibia fractures with intramedullary nailing and minimally invasive plating widely in these fractures. The open reduction or minimally invasive plating of these fractures is widely used plates do not provide axial and varus stability and nail being load sharing device can provide both axial and varus stability, while the nail being a load sharing device can provide both axial and varus stability with minimal soft tissue handling. However, the nailing of extraarticular proximal tibia fractures is associated with malunion. This current study aims to analyse the outcome of proximal third fractures treated with nailing. Material and methods. Thirty consecutive patients with fracture of the proximal third of the tibia shaft underwent nailing and were followed for up to 2 years. The clinical and radiological outcome of these cases and the complications encountered were analysed according to modified Klemm and Borner scoring system. Results. Our study comprised of patients in the age group 19-80 years, average being 40.5 years. Average time of partial weight bearing in the present study was 7.9 weeks (range 6-18 weeks). The average time for full weight bearing was 13 weeks (range 10-24 weeks). The mean time for radiological union was 24.6 weeks (range 20-32 weeks). Fourteen had excellent result, 10 patients had good, 4 patients had fair results and 2 patients had poor results according to Klemm and Borner functional criteria. Conclusions. Intramedullary nailing of proximal third tibia fractures when used with proper reduction technique using reduction clamps, k-wires, poller screws or unicortical plating in semi extended position for nailing is an effective, stable and successful method of treatment for proximal third fractures of tibia.

The anatomical course of the sciatic nerve in relation to different approaches in total hip arthroplasty.

Although sciatic nerve (SN) injury is relatively rare, it is a devastating complication after primary and revision total hip arthroplasty (THA). Therefore, precise localization of the SN is essential for arthroplasty surgeons. We dissected 50 hemipelves from formalin-fixed cadavers. The course and location of the sciatic nerve were investigated in relation to different approaches for THA with the help of anatomical landmarks like the greater trochanter (GT), the iliac tubercle, the ischial tuberosity (IschT), the infrapiriform foramen, and the suprapiriform foramen. We found and exposed the sciatic nerve in all 50 specimens with no sex-specific differences. No SN was encountered up to 22mm posterior from the GT. The zone affording the highest probability of finding the nerve was posterior to the GT between 32 and 55mm in 39 (78%) cases, thus defining a danger zone for different approaches for the THA. Special care should be taken with posterior and deep instrument placement between the GT and IschT during THA. Moreover, manipulations in the proximal third of the posterior approach reaching deep and posteriorly should be performed with the utmost care.

Prenatal Diagnosis of Bilateral Meromelia Coexisting With Duodenal Atresia: Case Report of a Rare Anomalous Combination With Three-Dimensional Sonography

A rare case of bilateral fetal meromelia with duodenal atresia (DA) was diagnosed on three-dimensional (3D) sonography. A 32-year-old G3P2002 with a large for date uterus, was reviewed at 26 weeks’ gestation. The 3D sonogram confirmed the presence of the humerus, olecranon process, and only the proximal third of the ulna bone, bilaterally. The distal ulna, radius, metacarpals, and phalanges were absent on both upper limbs. The bones of the lower limbs were present and appropriate for gestational age. Further evaluation revealed the “double bubble” sign, which is characteristic of DA within the fetal abdomen. The patient was induced 2 weeks later, due to intrauterine fetal demise. The suspected fetal anomalies were confirmed at birth. A high index of suspicion and a detailed sonographic evaluation are essential for detecting rare fetal anomalies, such as meromelia.

Fingertip amputations in children: Atasoy flap’s indications and limitations

IntroductionThe Atasoy flap is considered simple and reliable for covering distal digital defects in adults. Various studies in children have shown more contrasting results, particularly in terms of aesthetics and function. The aim of this study is to evaluate the long-term results of this flap specifically in children, in order to determine its limitations and indications. HypothesisThe Atasoy flap is reliable and reproducible for coverage of distal digital substance loss up to zone 2 in children. Materials and methodsFifty-six children who benefited from an Atasoy flap operated on between January 2017 and January 2020 were included. Lesion area, operative technique, postoperative complications (infection, healing difficulties, necrosis), and ultimately nail appearance, cold intolerance or finger pain, finger eviction, extension defect, and final parental satisfaction were analyzed. ResultsForty-nine children were evaluated with a mean follow-up of 18 months (min = 3 months, max = 38 months, SD = 11.3 months). Eighteen children had a hook nail, resulting in 6 of them having their finger excluded. The majority of hook nails were found in zone III and in proximal zone II lesions (12 cases). Eighty-nine percent of children with distal suture fixation to the nail bed (8 children) had this complication. Cold intolerance was present in 9 children. There were no cases of extension failure or early post-operative complications. Final parent satisfaction was 9.1/10 (min = 5, max = 10, SD = 1.3). ConclusionThe Atasoy flap in children appears reliable for covering loss of distal digital substance. The main complication is the occurrence of hook nails. Compliance with its indications (transverse substance loss not exceeding the proximal third of zone II) and a precise surgical technique (distal needle fixation without suturing to the nail bed, deep flap lift, non-closure of the donor site) help limit this risk. Level of evidenceIV; retrospective study.

Osteometric analysis of human adult dry tibia at a Medical College in South India: A cross-sectional study

Abstract Background: In the domains of forensic science, anatomy, archaeology, and sports medicine, morphometric data of long bones are important. The morphometry of the tibia is essential for the successful outcome of total knee arthroplasty. The lower end of the tibia, which forms the ankle joint, is commonly impacted in accidents and sports injuries. Objective: The present study aims to reappraise the morphometry of the adult dry tibia in South India. Materials and Methods: A cross-sectional observational study was conducted on 60 bones of adult human dry tibia obtained from the bone collection of the department of anatomy. Various parameters of the upper end, shaft, and lower end of the tibia were measured using a digital Vernier caliper. Results: The tibial length varied from 32.7 to 42.7 cm, with a mean length of 36.79 ± 2.24. The Cnemic index, Foraminal index, Length–thickness index, and Cross-section index were 72.57 ± 11, 32.1 ± 3.3, 75.7 ± 11.1, and 22.95 ± 1.53, respectively. According to the foraminal index, 75% of the bones belonged to Type-1 and 25% to Type-2, where the nutrient foramen was in the proximal and middle third of the bone, respectively. Conclusions: The present study gives observational morphometric data of the tibia, which will be helpful in clinical as well as in medicolegal cases. These parameters will help in the selection of the correct prosthesis for a successful surgery, and we hope this morphometric analysis will have substantial significance across various disciplines.

Profile of Cases of Death Due to Coronary Artery Disease: An Autopsy Based Descriptive Study

Background: Most common cause of sudden cardiac death is coronary artery disease, which contributes to 75 to 90%. The present study is undertaken to describe the profile of autopsy cases of coronary artery disease. Methods:Descriptive cross-sectional study was conducted in all cases of sudden and unexpected death brought for autopsy a tertiary level centre in southern Kerala during a period of one year. Gross and microscopical examination of heart and coronary arteries were studied and in cases with coronary artery disease, associated factors like previous history of illness, personal habits, family history of illness, body mass index, abdominal circumference, horizontal earlobe crease were described in detail. Categorical variables were represented as frequency and percentage, continuous variables as mean and standard deviation and association was tested using Chi square test. Conclusions: Statistically significant association (p value = 0.001) was observed between the horizontal earlobe crease and occlusive coronary artery disease. No significant association was obtained between the obesity parameters like body mass index, waist to hip ratio and occlusive coronary artery disease. Majority of the cases with significant occlusion was observed in the left anterior descending artery.The most common site of thrombus was in the proximal third of left anterior descending artery.

Endovascular Stent-Graft Repair of True and False Aneurysms of the Splenic Artery.

In treatment of aneurysms (SAAs) and pseudoaneurysms (SAPs) of the splenic artery, endovascular coil embolization is the approach most commonly used as it is minimally invasive and safe. However, it carries a significant rate of primary failure (up to 30%) and might be complicated by splenic infarction. The use of stent grafts might represent a valuable alternative when specific anatomical criteria are respected. We report a comprehensive review on technical and clinical outcomes achieved in this setting. Methods: We performed a comprehensive review of the literature through the MedLine and Cochrane databases (from January 2000 to December 2023) on reported cases of stenting for SAAs and SAPs. Outcomes of interest were clinical and technical success and related complications. The durability of the procedure in the long-term was also investigated. Results: Eighteen papers were included in the analysis, totalling 41 patients (n = 20 male 48.8%, mean age 55.5, range 32-82 years; n = 31, 75.6% SAAs). Mean aneurysm diameter in non-ruptured cases was 35 mm (range 20-67 mm), and most lesions were detected at the proximal third of the splenic artery. Stent grafting was performed in an emergent setting in n = 10 (24.3%) cases, achieving immediate clinical and technical success rate in 90.2% (n = 37) of patients regardless of the type of stent-graft used. There were no procedure-related deaths, but one patient died in-hospital from septic shock and n = 2 (4.9%) patients experienced splenic infarction. At the last available follow-up, the complete exclusion of the aneurysm was confirmed in 87.8% of cases (n = 36/41), while no cases of aneurysm growing nor endoleak were reported. None of the patients required re-intervention during follow-up. Conclusions: When specific anatomical criteria are respected, endovascular repair of SAAs and SAAPs using stent grafts appears to be safe and effective, and seems to display a potential advantage in respect to simple coil embolization, preserving the patient from the risk of end-organ ischemia.

Basilar Artery, Anterior Inferior Cerebellar Artery, Superior Cerebellar Artery

The basilar artery(BA)is formed by the fusion of two longitudinal arteries, and incomplete development may lead to BA fenestration. The BA provides many short perforating arteries and long lateral pontine arteries to the brain stem. The anterior inferior cerebellar artery(AICA)usually branches from the proximal third of the BA and primarily perfuses the ventral, inferior and lateral aspect of the cerebellum and inner ear organ. However, there are many variations to the AICA that depend on the degree of posterior inferior cerebellar artery development. The superior cerebellar artery(SCA)branches into not only to the rostral, ventral aspect of the cerebellar hemisphere, but also to the deeper cerebellar nucleus and brain stem. Duplications within this vessel are frequently identified, but it is not missing.

Pseudo-tunneling procedure for PICC-ports catheters insertion in patients with small veins at the middle third of the arm.

Axillary vein in the brachial tract or Basilic vein in the proximal third of the arm usually present a diameter wide enough to receive a catheter of 5 Fr. Therefore, a peripherally inserted central catheters with port (PICC-Ports) cannot be positioned in these areas. Pseudo-tunneling procedure allows the positioning of the Port in the middle part of the arm without using tunnelers during insertion of PICC with Port in patients who present deep veins of the arm too small to receive a PICC-Port catheter. The aim of this study was to present our experience with pseudo-tunneling procedure during the positioning of the PICC-Port, while using a particular variation of the technique already described for PICCs and midline. From January to December 2023, 103 PICC-Ports were placed in adult patients. Ninety catheters were tunneled from the puncture of the axillary vein at the proximal arm point, while we used this new technique in 42 patients by the same trained team of Vascular Access Unit at ASST Spedali Civili Hospital of Brescia. All procedures were successfully performed at the first attempt. No insertion related complications were observed. Our data suggest pseudo-tunnelling is a safe and effective technique for PICC-Ports insertion avoiding central venous catheterization, even in patient with small vein at the arms.

An Outcome Analysis of Pediatric Diaphyseal Fractures Treated Surgically With the Titanium Elastic Nailing System.

Introduction Pediatric fractures account for one-fourthof all pediatric injuries. Stabilizing the fracture, regulating the length and alignment, encouraging bone healing, and minimizing morbidity and problems for the child and family are the objectives of treatment for diaphyseal fractures of long bones in children. Our goal is to investigate how pediatric diaphyseal long bone fractures are treated with a titanium elastic nailing system (TENS). Methods A prospective interventional study was conducted on 24 children who had displaced diaphyseal fractures of major long bones, involving 31 diaphyseal fractures of long bones. Utilizing Flynn's grading standards, the result was examined. Results The mean age was 12.20 years. The youngest child was seven years old and the eldest child was 16 years old. There were 20 boys (83.33%) and four girls (16.67%). The male-to-female ratio was noted to be 5:1. The commonest mode of injury was road traffic accidents (12 cases, 50%), followed by falls while playing (10 cases, 41.67%). Other causes included falls from height (one case, 4.17%)and blunt trauma (one case, 4.17%). The commonest bone to get fractured was the femur (37.50%), followed by both bones of the forearm (29.17%), tibia (20.83%), humerus (8.33%), and ulna alone (4.17%). The middle third (21 fractures, 67.74%) was the most prevalent location for fractures. Five fractures each (16.13%) accounted for in the proximal and distal thirds. Twelve fractures (38.71%) were detected on the left side, while the majority of fractures (19 fractures, 61.29%) were seen on the right side. Most of the fractures in this group were transverse fractures (18 fractures, 58.06%) followed by oblique fractures (eightfractures, 25.81%). Comminuted fractures accounted for five fractures (16.13%). Of the 31 fractures, open reduction had to be done in two fractures, after unsuccessful attempts at closed reduction. Closed reduction was done in 29 fractures. There were 15.12 weeks in the average union term. The range is six weeks to 39 weeks. The most frequent side effect was discovered to be skin irritation at the entry site. The extraosseous portion of nails caused irritation at two entry sites (6.45%). A case had delayed union (3.23%) and restricted knee range of movements. Conclusion For the treatment of juvenile diaphyseal fractures of the long bones, the TENSis the best option. It is a quick, straightforward, safe, dependable, and efficient way to treat pediatric long-bone fractures in patients aged five to 16 years. The healing process takes a fair amount of time, while the surgery takes less time. It does away with the necessity for extended bed rest and significantly shortens hospital stays. It provides stability and elastic mobility, which is perfect for early mobilization and quick union at the fracture site. It has a low rate of complications and produces excellent functional results.

The study of outcome in fractures of proximal third of tibia in adults treated by expert tibia nail

This study aims to evaluate the clinical, functional outcome and complications of fracture proximal third of tibia treated with expert tibia nail in terms of radiological union, functional outcomes by short form -36 (SF-36) score, Johner and Wruhs criteria, visual analogue score and patient satisfaction score. Twenty-five patients with fracture proximal third of tibia treated with expert tibia nail in SNMC and HSK hospital and research centre, Bagalkot were enrolled in this study. The radiological union was assessed by plain radiograph and functional outcome by SF-36 score, Johner and Wruhs criteria, visual analogue score and patient satisfaction score. The radiological union was achieved in all the patients between 14 to 26 weeks duration (mean of 19.6±2.82 weeks). The mean SF-36 score was 84.9±4.06 and the mean visual analogue score was 2±1.78 at the 22nd week of follow-up. Results based on Johner and Wruhs criteria, 17 patients had excellent, 6 had good, 1 had fair and 1 had poor results. The average patient satisfaction score was 8.88 out of 10. There were 8 cases of post-operative knee pain, 5 cases of infection, 2 cases of malunion, 1 case of shortening and 1 case of the delayed union in our study. Intramedullary fixation with expert tibia nail for fracture proximal third tibia is a safe and less invasive technique. The radiological union was achieved in all the cases. This technique ensures excellent functional outcomes and a low incidence of complications.

A selective anatomically based lymph node sampling can replace a side specific pelvic lymphadenectomy in endometrial cancer with failed sentinel node mapping

AimTo evaluate the locations of metastatic pelvic sentinel nodes (SLN) and the proportion of SLNs outside and within defined typical anatomical positions along the upper paracervical lymphatic pathway (UPP). Patients and methodsConsecutive women with endometrial cancer (EC) of all risk groups underwent pelvic SLN-detection using cervically injected indocyanine green (ICG). A strict anatomically based algorithm and definitions of SLNs was adhered to. The positions of ICG-defined SLNs were intraoperatively depicted on an anatomical chart. All SLNs were examined using ultrastaging and immunohistochemistry. The proximal third of the obturator fossa and the interiliac area were defined as typical positions. The parauterine lymphovascular tissue (PULT) was separately removed. The proportions of metastatic SLNs, overall and isolated, typically, and atypically positioned were analyzed per woman. ResultsA median of two (range 1–12) SLN metastases along the UPP including the PULT were found in 162 women. 41 of 162 women (25.3 %) had isolated metastases in the obturator fossa harboring 49.1 % of all SLN metastases. Three women (1,9 %) had isolated PULT metastases. SLN metastases outside typical positions were identified in 28/162 women (17.3 %); isolated metastases were seen in seven women (4.3 %), so 95.7 % of pelvic node positive women had at least one metastatic SLN located at a typical position. ConclusionA selective removal of lymph nodes at typical proximal obturator and interiliac positions and the PULT can replace a full side specific pelvic LND when SLN mapping is unsuccessful. The obturator fossa is the predominant location for metastatic disease.

Surgically Treated Hind-Limb Fibromyxochondroma in a Cranwell’s Horned Frog (Ceratophrys cranwelli)

Ceratophrys cranwelli, commonly known as the Cranwell’s horned frog or Pacman frog, is an amphibian species native to South America. This species has gained interest both as a pet among hobbyists and as a subject of scientific inquiry in veterinary medicine. A two-year-old pet male albino Ceratophrys cranwelli was presented exhibiting lethargy, weight loss, and anorexia, persisting for two months. Clinical examination revealed a fracture localized to the proximal third of the left femur accompanied by an osteolytic process. The patient was discharged with a treatment regimen for suspected secondary nutritional hyperparathyroidism and an ulcerative skin lesion. Nevertheless, due to the progressive deterioration of the left thigh, amputation of the affected limb was proposed and performed at the coxofemoral joint. Histopathological analysis of the excised mass revealed an atypical mesenchymal mass consistent with a fibromyxochondroma. The surgical procedure was conducted under anesthesia induced by a combination of alfaxalone, ketamine, medetomidine, and butorphanol, with postoperative treatment consisting of enrofloxacin, meloxicam, and butorphanol. The patient showed good post-surgical recovery, exhibiting normal physiological and behavioral activities. This report highlights the management and the diagnostic challenges of a progressive limb lesion in a Ceratophrys cranwelli, offering insights into potential therapeutic approaches for similar cases in amphibians.

Is Fibular Fixation Necessary with Increasing Proximity in Ankle Fractures: A Survey of OTA and AOFAS Surgeons

Introduction/Purpose: Ankle fractures are one of the most common fractures encountered in orthopedics. The Maisonneuve fracture pattern is described as a pronation, external rotation injury involving the medial ankle structures, the syndesmosis, and the proximal third of the fibula. However, the actual distance from the proximal fibula has not been defined in what distinguishes a Maisonneuve fracture. With Weber C fractures, most surgeons tend to provide fixation to the fibula and reassess the syndesmosis afterwards. When dealing with the proximal fibula “Maisonneuve” fracture pattern, most surgeons would tend to ignore the fibula fracture and focus on syndesmotic reduction. Orthopaedic Trauma Association and American Orthopaedic Foot &amp; Ankle Society provided their opinion via survey in treating increasing proximity of fibula fractures associated with unstable ankle fracture patterns. Methods: A survey was provided to eight OTA and AOFAS orthopedic surgeons. A powerpoint was provided to the surgeons that contained non-weightbearing injury films of eighteen patients. A questionnaire was provided giving two answer choices, address the fibular or syndesmosis primarily. The eighteen ankle fractures were selected based on increasing proximity of the fibula fracture, which ranged from 4.5cm to 32.3cm. The ankle fractures were grouped into four categories to include the Maisonneuve variant based on distance. These fracture radiographs were randomized in order to not influence the surgeon’s opinion during the study. The four groups were as follows: 1. 4.5cm – 7.4cm to include six ankle fracture radiographs 2. 8cm – 10.4cm to include four ankle fracture radiographs 3. 14.6cm to 23.3cm to include five ankle fracture radiographs 4. 30.7cm to 32.3 cm to include three Maisonneuve variant ankle fracture radiographs Results: Regarding section 1, the majority of surgeons responded with open reduction, internal fixation of the fibula as their initial reduction. Section 2, the responses remained consistent with a majority of surgeons choosing to address fibular fixation followed by syndesmotic evaluation. The total number of responses in this section scored 43 answer A selections to 5 answer B selections. Section 3 (14.6-23.3cm) provided the most variability in the responses provided. With 60 possible answer choices, the polled surgeons responded with answer choice A seventeen times and answer choice B 43 times. Section 4 (30.7-32.2cm) or the Maisonneuve produced a steady response of answer choice B. Syndesmotic reduction was performed 34 times compared to only two fibular fixation choices – or answer choice A. Conclusion: The purpose of this study was to evaluate expert opinion on differing treatment as the proximity of the fibular fracture increased in connection with an unstable ankle fracture pattern. General consensus under 10,4cm was to address fibular fixation. However, once the fibular fracture exceeded 14cm, significant variability was noted. These results prove that further biomechanical studies are needed to determine the effect fibular stability in increasing proximity has on the syndesmosis. Chart 1 shows answer selections across the four categories. Chart 2 shows answer selections across the highest variability group 3.

TRANSMETACARPAL REPLANTATION. ELEVEN YEARS LATER

A case in a series of nine transmetacarpal replantations was presented at the combined meeting of the 7th European congress on Prevention of Hand Traumas and the 7th congress of the Bulgarian Society for Surgery of the Hand, 19-21 October 2023, Plovdiv, Bulgaria.&#x0D; A male patient aged 42, a heavy truck driver, was an ideal candidate for replantation. In February 2012 he sustained transmetacarpal amputation by circular saw through the proximal third of the left hand, with local crush of the tissues. During replantation enormous tissue edema appeared, caused by long ischemia time with cryopreservation of the amputated part for three hours. Restoration of the common digital nerves was postponed and performed 4 months later (Millesi procedure).&#x0D; Eleven years later the following outcome is registered. TAM: 110 (good), ab-adduction of 2nd and 4th fingers is restored in limited range. The effect is attributed to reinnervation of some spared interosseous muscles by the motor branch of the ulnar nerve, restored during the autoplastic of the common digital nerves. The lateral pinch between the thumb and second finger is useful.&#x0D; The skin sensitivity is examined by Weber static two-point discrimination test (2pdt):12 mm for 2nd and 3rd fingers, 15 mm for the 4th finger and one point for the pulps of the 5th finger and the thumb; 2pdt, carried out on the palm, in the base of the fingers, is 10 mm.&#x0D; The gained useful function of the hand is 50%. Original working ability is restored, but it is forbidden for the patient to work as a professional driver. He can drive his own car.&#x0D; In transmetacarpal replantations with level through the proximal part of the palm some interosseous muscles are preserved, and repair of the motor branch of the ulnar nerve is with favorable prognosis regarding functional recovery.

(171) Tunical Incision and Grafting for Severe Peyronie’s Disease Using Human Fascia Lata: Surgical Technique

Abstract Introduction Management of Peyronie’s disease is challenging for patients and can present with deformed penile angulation, pain, and reduction in erectile function. This video demonstrates the usage of cadaveric fascia lata grafting to rectify severe ventral penile curvature symptomatic of advanced Peyronie’s disease. Objective We outline a surgical technique to use fascia lata allografting for the correction of excessive ventral penile curvature caused by Peyronie’s disease if non-surgical treatments are insufficient. Methods A 65 year-old African-American male patient with severe Peyronie’s disease and a history of hypertension presented with a ventral penile curvature of 110 degrees at the proximal third of the shaft. Consequently, he was unable to engage in penetrative sexual intercourse. An artificial hydraulic erection confirmed the curvature, and the areas of fibrotic plaque were palpated. A degloving incision was made proximal to the glans, and a 6 cm segment of Buck’s fascia was elevated ventrally. The neurovascular bundle and urethra were separated from the corporae. A second hydraulic erection was induced, exposing a 6 cm by 3.5 cm rectangular tunical defect which was marked for excision. Bovie electrocautery was utilized to excise the fibrotic section of tunica albuginea. A rectangular section of Biosure human cadaveric fascia lata graft was soaked in saline solution and trimmed to 6 cm by 4 cm. The graft was sutured to the excised region of the tunica albuginea with 4–0 Maxon in a watertight fashion with a running stitch. A final hydraulic erection confirmed the mitigation of the penile curvature, and Buck’s fascia and the shaft skin were re-approximated to the subcoronal skin with 3–0 Vycril suture. Results This grafting procedure resulted in a near complete resolution of the ventral penile curvature with no complications. The patient was admitted overnight for observation and discharged POD 1 with a 3-layer dressing and mesh underwear. The postoperative penile length increased to 17.5cm from 16cm preoperatively as a result of the grafting and mitigation of the penile curvature. Conclusions Fascia lata allografts are robust and easily obtainable, which is ideal for the corporal reconstruction of fibrotic tunica albuginea in patients with Peyronie’s disease. This procedure demonstrates the utility of cadaveric fascia lata as an alternative surgical grafting material for the surgical correction of penile curvature associated with severe Peyronie’s disease. Disclosure No.