Specific Anatomical Landmarks Research Articles

Glioma-induced neural functional remodeling in the hand motor cortex: precise mapping with ECoG grids during awake craniotomy—experimental research

Background: The dilemma of achieving ‘onco-functional balance’ in gliomas affecting the motor cortex highlights the importance of functionally-guided resection strategies. While accurate mapping of eloquent areas often requires frequent electrical stimulation, this practice can lead to side effects like seizures and postoperative deficits. To enhance safety in functional mapping, we studied how gliomas impact hand movement areas and assessed the effectiveness of cortical electrical activity for functional mapping in this setting. Materials and Methods: We recruited patients with gliomas affecting the motor cortex and individuals with an unaffected motor cortex for awake craniotomy. During the procedures, electrocorticography (ECoG) grids were employed to record signals under three conditions: resting state, finger movements, and wrist movements. We then quantified the distances from the positively stimulated sites to the specific anatomical landmarks. Additionally, we analyzed the relationship between the ECoG power features and the stimulation responses. Results: The cortical layout for finger activity in the MCG group was more dispersed and overlapped, typically clustering near the central sulcus and Sylvian fissure. The predictive performance of ECoG mapping exhibited significant variability across different frequency bands and clinical scenarios. Specifically, the area under the curve (AUC) for the Non-MCG group during the resting state reached its peak, with a value of 0.802 for Gamma3 (95% CI = 0.729-0.875) and 0.865 for broadband (95% CI = 0.804-0.926). In contrast, the MCG group achieved the highest AUC during wrist movements, with Gamma3 at 0.785 (95% CI = 0.719-0.849) and broadband at 0.824 (95% CI = 0.753-0.890). Conclusion: Gliomas in the motor cortex disrupt the distribution of hand activity, complicating intraoperative functional mapping. As a novel and reliable approach, ECoG technique can complement and guide direct cortical stimulation for precise mapping, potentially reducing its frequency, minimizing the risk of functional deficits, and achieving a balance between maximal tumor resection and neurological preservation.

Arthroscopic foveal reattachment of triangular fibrocartilage complex: Inside-out technique at specific ulnocarpal anatomical landmarks.

This study evaluates the outcomes of arthroscopic triangular fibrocartilage complex (TFCC) foveal reattachment using an inside-out suture passing through the TFCC at specific ulnocarpal anatomical landmarks to grasp the radioulnar ligaments. Thirty-eight patients with a mean age of 36 years (range 19-54), diagnosed with TFCC injury with distal radioulnar joint (DRUJ) instability, underwent arthroscopic inside-out TFCC foveal reattachment using designated suture sites. At a mean follow-up of 32 months (range 26-44), pain score, range of motion, grip strength, Disabilities of the Arm, Shoulder and Hand (DASH) score, and Modified Mayo Wrist Score all showed significant improvement after surgery. The DRUJ stability was restored and the minimal clinically important difference threshold for the DASH score was achieved in all patients. Arthroscopic TFCC foveal reattachment using the inside-out technique at specific ulnocarpal anatomical landmarks provided reliable outcomes and could be considered as another straightforward procedure for treating TFCC injuries with DRUJ instability.Level of evidence: IV.

Ankle fractures reduction under direct visualization. Superiority of anatomical landmarks versus radiological evaluation- A randomised control trial.

Distal tibiofibular joint injury is quite common in rotational ankle fractures, with high malreduction rates reported. Although several intraoperative techniques evaluate the optimal tibiofibular reduction, they are critically debated due to high error rates and subjective interpretation of the results. We attempted to describe specific anatomical landmarks and anatomical relationships of the ankle joint through capsulotomy and inspection of the anterior incisura fibularis corner and evaluate their reliability regarding optimal tibiofibular reduction. Sixty patients with malleolar fractures and concomitant distal tibiofibular joint disruption were randomized into two groups. Patients of Group A were treated with a standard approach. In Group B, the reduction was performed following specific anatomical landmarks of the anterolateral ankle joint through capsulotomy. Reduction quality was evaluated with postoperative bilateral ankle CT. Distal tibiofibular joint reduction after direct visualization resulted in significantly better rotation and fibula length values than patients treated with the standard approach. In addition, clinical scores were better in the 3rd and 6th postoperative months. Direct visualization of the anterolateral ankle joint can provide trustworthy anatomical landmarks to achieve high-quality reduction of the distal tibiofibular joint in ankle fractures. Additional repair of the ligamentocapsular structures of the corner enhances joint stability and provides better clinical outcomes in 12 months.

Feasibility of robotic posterior fossa skull base surgery.

Despite its potential advantages, robotic surgery has yet to be applied to skull base procedures. Complex anatomy and restricted access have limited the development of robotic skull base surgery. The authors' aim was to conduct a feasibility study of robotic surgery for posterior fossa skull base lesions. Six silicone-injected postmortem human heads were prepared for the robotic surgery. Because there was no drilling tool with the robot, specimens were dissected in advance using an endoscope and microscope. The following approaches were investigated: 1) supracerebellar-infratentorial; 2) retromastoid; and 3) posterior occipitocervical junction surgeries. For each approach specific anatomical landmarks were identified, and the surgical freedom (vertical distance angle between the tools) was measured. In the case of the supracerebellar-infratentorial approach, the authors used 3 burrs with 1.5 cm of diameter: 1 paramedian and 2 laterally. The view of the pineal region was visualized, and sufficient surgical freedom of both tools was secured. The median vertical distance was 1.2 cm (range 1.1-1.8 cm), and the median angle between the tools was 105° (range 92°-110°). On the other hand, in the retromastoid approach, with a single burr 2.5 cm in diameter, the root exit zone of the facial nerve was barely visible, and a space for tools to access was not secured. The median vertical distance was 0.8 cm (range 0.6-1.0 cm), and the median angle between the tools was 10° (range 6°-12°). In the case of the posterior occipitocervical junction approach, the authors used the 3 tubular retractors, 1 in the middle and 2 laterally. Even though the space was narrow, the medulla and adjacent nerves could be identified, and a moderate level of surgical freedom could be obtained for tool mobilization. The median vertical distance was 1.6 cm (range 1.2-2.5 cm), and the median angle between the tools was 90° (range 88°-95°). Although robotic surgery has yet to be applied to neurosurgery, it is expected to be helpful in posterior fossa skull base surgery if appropriate tools can be developed.

How many is enough? Measuring the number of FAST exams needed by emergency medicine trainees to reach competence

BackgroundFor patients with blunt abdominal trauma, the Focused Assessment with Sonography in Trauma (FAST) exam is the initial imaging modality employed to diagnose and risk stratify. A positive FAST exam in this patient population denotes intraperitoneal hemorrhage. In a hemodynamically unstable patient, it necessitates rapid surgical intervention. Ultrasound is highly dependent on the operator’s ability to obtain quality images for interpretation. Failure to obtain adequate images prevents accurate interpretation and reduce its diagnostic accuracy. Previous studies evaluating whether the FAST exam can be improved solely by experience had conflicting results. None of those studies used an objective method to evaluate the FAST exam’s quality. Our study aimed to objectively determine the number of FAST exams required by an emergency medicine (EM) resident to reach sufficient quality for independent scanning.Methods59 first-year EM residents from a single site were included in this study. All FAST exams that were saved in the Qpath archival system by the 59 EM residents, whether the exam was performed for educational or clinical purposes, were reviewed, and scored using a Task-Specific Checklist (TSC) score. This score is an objective way to assess the proficiency and quality of the FAST scan. The TSC was based on whether the imaging of 24 specific anatomic landmarks, split into four anatomic regions, was completed successfully or not. The AEMUS (Advanced EM Ultrasonography) faculty provided feedback to trainees wither electronically via Qpath or at the bedside. According to the quality of ultrasound imaging and competence (QUICK Score), if the average TSC score for the first 10 exams was 18 or higher, the resident was considered an expert. However, if the resident failed to achieve that score, we skipped the first exam performed by the resident and the average score for the second through eleventh exams was then calculated. If the resident did not achieve the desired result, the first and second exams were skipped and the average score for the remaining 10 exams was determined. This sequence was repeated until the resident achieved an average score of 18 or higher on their TSC score.ResultsIn total, 663 FAST scans performed by EM residents were scored. The average number of FAST exams needed for independent scanning is 11.23 (95% CI, 10.6-11.85). 66.1% of enrolled residents achieved an average score of 18 or higher in their first 10 FAST exams, and 33.8% of residents required more than 10 scans. The average scores for the right upper quadrant (RUQ), left upper quadrant (LUQ), pelvic, and subxiphoid views were 5 (95% CI, 4.88–5.1), 4.7 (95% CI, 4.59–4.8), 5.1 (95% CI, 4.96–5.24), and 3.7 (95% CI 3.6–3.8) respectively.ConclusionThis study demonstrated that when constructive feedback on each FAST exam was given, the average first-year emergency medicine resident achieves competency in performing FAST exams independently after completing 10–12 (average of 11.23) FAST exams. Further research is required to validate the findings.

67 Precision identification and weight assessment of cattle using supervised machine learning on body surface keypoints

Abstract Computer vision systems (CVS) offer identification solutions for animals with distinct coat patterns, but are less effective for solid-colored herds. In addition, they can be used to measure critical phenotypes, such as body weight (BW). Providing both BW and identification for solid-colored animals can help farmers make decisions. This study aimed to 1) develop an automatic CVS capable of identifying using the Euclidean distance between keypoints located at specific anatomical landmarks (e.g., bony prominences), and 2) predict the BW using features extracted from these keypoints. The keypoint model was trained to identify seven keypoints per cow, located at the left and right hips, left and right pin bones, tail head, sacral, and cervical vertebrae. These locations remain constant as body condition score of a cow changes. The Euclidean distance between these keypoints was used to generate biometric features for each cow. The keypoint detection model was trained using 3,928 images over 900 epochs with a batch size of 14 and validated using 391 images. This trained model was used to predict keypoints on a different set of 41 cows over 5 d, resulting in a total of 6,944 images which correspond to the dataset for cow identification. The Random Forest (RF) algorithm for cow identification was trained with the first 4 d (5,376 images), and the last day served as the test set (1,568 images). For the cow identification, a RF algorithm was employed on the Euclidean distance of the keypoints. The hyperparameters were determined through a grid search on the training set, utilizing 5-fold cross-validation. The hyperparameters ‘mtry’ (which ranged from 1 to 10) and ‘ntree’ (which ranged from 250 to 500, in increments of 50) were optimized. For the second objective, due to the completely new environment, the keypoint model was fine-tuned using transfer learning for 240 epochs with a batch size of 14, utilizing 310 images. The model predicted keypoints in 1,593 images from different beef-on-dairy animals. This dataset was used to train the BW prediction model. The Euclidean distances from the predicted images and sex were used as features. A RF model was trained using a leave-one-animal-out cross-validation approach. The hyperparameters were determined through a grid search on the training set, using 10-fold cross-validation. The ‘mtry’ parameter ranged from 2 to 16, in increments of 2. For animal identification, the model achieved an accuracy, precision, recall, and F1-score of 92.7%, 89.0%, 90.2%, and 92.7%, respectively. To predict BW, the RF model achieved an R² of 0.86 and a root mean squared prediction error of 36.9 kg, representing 6.7% of the observed values average. These results suggest that keypoints located on the dorsal body surface can identify and weigh individual animals, even those lacking distinct coat color patterns.

A new technique of monsplasty as an adjunctive procedure in cases of abdominoplasty: A prospective clinical trial

A new technique of monsplasty as an adjunctive procedure in cases of abdominoplasty: A prospective clinical trial

Measurement of Nasal Contour Landmarks in Septorhinoplasties with Special Regard to the Course of Postoperative Swelling Using a Three-Dimensional Camera.

The integration of three-dimensional (3D) cameras into clinical practice for pre-operative planning and post-operative monitoring of rhinoplasties remains controversial. However, this technology offers the advantage of capturing the 3D surface without exposing patients to potentially harmful radiation. Continuous assessment allows the follow-up of swelling patterns, cartilage alignment, and bone remodeling. The primary objective of our study was to quantify changes in nasal structure before and after rhinoplasty by using 3D photography. Our study cohort consisted of 29 patients who underwent open structural rhinoplasty. We used the Artec Space Spider camera to acquire a total of 103 3D images. We collected pre-operative and at least two or three post-operative follow-up scans, which were taken one, three, and six months after surgery. We evaluated paired scans that included various time intervals to improve our understanding of swelling behavior and to ensure an objective analysis of changes. Eleven specific anatomical landmarks were identified for measurement. Two independent raters determined the distances between these landmarks over time. The calculation of intraclass correlation coefficients showed low inter-rater variability. Statistically significant changes over time (p < 0.05) were observed for various anatomical landmarks, including soft tissue nasion, soft tissue orbitale right, soft tissue maxillofrontale left, soft tissue maxillofrontale right, nasal bridge, and nasal break point. Conversely, no significant changes (p > 0.05) were observed in the measurements of soft tissue orbitale left, pronasale, subnasale, alare right, or alare left. A visual assessment was conducted using surface distance maps. The results indicate that the complete decrease in swelling takes at least 6 months or even longer. Additionally, 3D photography can provide an objectively comparable analysis of the face and external contours. Furthermore, it allows for a comparison of external contours and therefore pre- and post-operative differences.

FetalBrainAwareNet: Bridging GANs with anatomical insight for fetal ultrasound brain plane synthesis

Over the past decade, deep-learning (DL) algorithms have become a promising tool to aid clinicians in identifying fetal head standard planes (FHSPs) during ultrasound (US) examination. However, the adoption of these algorithms in clinical settings is still hindered by the lack of large annotated datasets. To overcome this barrier, we introduce FetalBrainAwareNet, an innovative framework designed to synthesize anatomically accurate images of FHSPs. FetalBrainAwareNet introduces a cutting-edge approach that utilizes class activation maps as a prior in its conditional adversarial training process. This approach fosters the presence of the specific anatomical landmarks in the synthesized images. Additionally, we investigate specialized regularization terms within the adversarial training loss function to control the morphology of the fetal skull and foster the differentiation between the standard planes, ensuring that the synthetic images faithfully represent real US scans in both structure and overall appearance. The versatility of our FetalBrainAwareNet framework is highlighted by its ability to generate high-quality images of three predominant FHSPs using a singular, integrated framework. Quantitative (Fréchet inception distance of 88.52) and qualitative (t-SNE) results suggest that our framework generates US images with greater variability compared to state-of-the-art methods. By using the synthetic images generated with our framework, we increase the accuracy of FHSP classifiers by 3.2% compared to training the same classifiers solely with real acquisitions. These achievements suggest that using our synthetic images to increase the training set could provide benefits to enhance the performance of DL algorithms for FHSPs classification that could be integrated in real clinical scenarios.

Evaluation of the arterial kink point during flexion of the hip: A dynamic angiographic study in iliac endofibrosis patients.

The aim of the study was to determine the flexion point's location of the ilio-femoral arterial axis and its angulation. Thirty-seven dynamic digital subtraction angiographies were analyzed and were included in the current study. Different lengths were measured, based on specific anatomical landmarks: the origin of the external iliac artery, the inguinal ligament and the bifurcation of the femoral artery. These lengths were measured in extension and during flexion of the hip in order to determine the flexion point of the artery. In extension, some physiological angulations of the external iliac artery were measured. During flexion of the hip joint, the distance from the kink point to the bifurcation of the common iliac artery was respectively 82 ± 21mm (range 48-116) on the right side and 95 ± 20mm (range 59-132) on the left side. The distance from the kink point to the inguinal ligament was respectively 38 ± 40mm (range 12-138) on the right side and 26 ± 23mm (range 8-136) on the left side. The distance from the kink point to the bifurcation of the femoral artery was respectively 45 ± 29mm (range 15-107) on the right side and 27 ± 12mm (range 10-66) on the left side. During flexion, the angulation of the flexion point of the ilio-femoral axis was 114 ± 18° (range 81-136°). The flexion point was located cranially to the inguinal ligament and below the departure of the external iliac artery.

Unsupervised machine learning for clustering forward head posture, protraction and retraction movement patterns based on craniocervical angle data in individuals with nonspecific neck pain

ObjectivesThe traditional understanding of craniocervical alignment emphasizes specific anatomical landmarks. However, recent research has challenged the reliance on forward head posture as the primary diagnostic criterion for neck pain. An advanced relationship exists between neck pain and craniocervical alignment, which requires a deeper exploration of diverse postures and movement patterns using advanced techniques, such as clustering analysis. We aimed to explore the complex relationship between craniocervical alignment, and neck pain and to categorize alignment patterns in individuals with nonspecific neck pain using the K-means algorithm.MethodsThis study included 229 office workers with nonspecific neck pain who applied unsupervised machine learning techniques. The craniocervical angles (CCA) during rest, protraction, and retraction were measured using two-dimensional video analysis, and neck pain severity was assessed using the Northwick Park Neck Pain Questionnaire (NPQ). CCA during sitting upright in a comfortable position was assessed to evaluate the resting CCA. The average of midpoints between repeated protraction and retraction measures was considered as the midpoint CCA. The K-means algorithm helped categorize participants into alignment clusters based on age, sex and CCA data.ResultsWe found no significant correlation between NPQ scores and CCA data, challenging the traditional understanding of neck pain and alignment. We observed a significant difference in age (F = 140.14, p < 0.001), NPQ total score (F = 115.83, p < 0.001), resting CCA (F = 79.22, p < 0.001), CCA during protraction (F = 33.98, p < 0.001), CCA during retraction (F = 40.40, p < 0.001), and midpoint CCA (F = 66.92, p < 0.001) among the three clusters and healthy controls. Cluster 1 was characterized by the lowest resting and midpoint CCA, and CCA during pro- and -retraction, indicating a significant forward head posture and a pattern of retraction restriction. Cluster 2, the oldest group, showed CCA measurements similar to healthy controls, yet reported the highest NPQ scores. Cluster 3 exhibited the highest CCA during protraction and retraction, suggesting a limitation in protraction movement.DiscussionAnalyzing 229 office workers, three distinct alignment patterns were identified, each with unique postural characteristics; therefore, treatments addressing posture should be individualized and not generalized across the population.

3-Dimensional pose estimation to detect posture transition in freestall-housed dairy cows

Freestall comfort is reflected in various indicators, including the ability for dairy cattle to display unhindered posture transition movements in the cubicles. To ensure farm animal welfare, it is instrumental for the farm management to be able to continuously monitor occurrences of abnormal motions. Advances in computer vision have enabled accurate kinematic measurements in several fields, such as human, equine, and bovine biomechanics. An important step upstream to measuring displacement during posture transitions is determining that the behavior is accurately detected. In this study, we propose a framework for detecting lying-to-standing posture transitions from 3-dimensional (3D) pose estimation data. A multiview computer vision system recorded posture transitions between December 2021 and April 2022 in a Swedish stall housing 183 individual cows. The output data consisted of the 3D coordinates of specific anatomical landmarks. The sensitivity of posture transition detection was 88.2%, and precision reached 99.5%. In analyzing those transition movements, breakpoints detected the timestamp of onset of the rising motion, which was compared with that annotated by observers. Agreement between observers, measured by intraclass correlation, was 0.85 between 3 human observers and 0.81 when adding the automated detection. The intra-observer mean absolute difference in annotated timestamps ranged from 0.4 s to 0.7 s. The mean absolute difference between each observer and the automated detection ranged from 1.0 s to 1.3 s. We found a significant difference in annotated timestamps between all observer pairs, but not between the observers and the automated detection, leading to the conclusion that the automated detection does not introduce a distinct bias. We conclude that the model is able to accurately detect the phenomenon of interest and that it is equitable to an observer.

Transvaginal Sonography for the Preoperative Assessment of Parametrial Deep Infiltrating Endometriosis: A Diagnostic Accuracy Study

Objective: The aim of the study was to evaluate the diagnostic accuracy for parametria endometriosis (PE) of transvaginal sonography (TVS) performed following a systematic approach for the assessment of the lateral parametria. Design: A diagnostic accuracy study was employed based on a prospective observational design. Participants: All consecutive patients who underwent laparoscopic surgery for endometriosis between January 2016 and December 2020 were considered. Setting: The study was conducted at endometriosis referral hospitals. Methods: We prospectively collected clinical, imaging, and surgical data of all consecutive patients who underwent laparoscopic surgery for endometriosis between January 2016 and December 2020. A standardized technique with a systematic approach for the assessment of the lateral parametria following specific anatomic landmarks was used for the TVS. The diagnostic accuracy for PE in TVS was assessed using the intraoperative and pathologic diagnosis of PE as the gold standard. Results: In 476 patients who underwent surgery, PE was identified in 114 out of 476 patients (23.95%): 91 left and 54 right PE out of 476 surgical procedures were identified (19.12% vs. 11.34%; p = 0.001); bilateral involvement in 27.19% (31/114 patients) cases. The sensitivity of TVS for PE was 90.74% (79.70–96.92%, 95% CI) for the right side and 87.91% (79.40–93.81%, 95% CI) for the left side. The specificity was almost identical for both sides (98.58% vs. 98.18%). For the right parametrium, the positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 63.82 (28.70–141.90, 95% CI) and 0.09 (0.04–0.22, 95% CI), respectively. On the left parametrium, the PLR and NLR were 48.35 (23.12–101.4, 95% CI) and 0.12 (0.07–0.21, 95% CI), respectively. The diagnostic accuracy for right and left PE was 97.69% (95.90–98.84%, 95% CI) and 96.22% (94.04–97.74%, 95% CI), respectively. Limitations: The principal limit is the high dependence of TVS on the operator experience. Therefore, although a standardized approach following precise definitions of anatomical landmarks was used, we cannot conclude that the observed accuracy of TVS for PE is the same for all sonographers. In this regard, the learning curve was not assessed. In the case of negative TVS for parametrial involvement with an absent intraoperative suspect, a complete dissection of the parametrium was not performed to avoid surgical complications; therefore, cases of minor PE may be missed, underestimating false negatives. Conclusions: TVS performed following a systematic approach for assessing the lateral parametria seems to have good diagnostic accuracy for PE with large changes in the posttest probability of parametrial involvement based on the TVS evaluation. Considering the clinical and surgical implications of PE, further studies implementing a standardized approach for assessing the parametrium by TVS are recommended to confirm our observations and implement a standardized protocol in clinical practice.

A new classification of parasagittal bridging veins based on their configurations and drainage routes pertinent to interhemispheric approaches: a surgical anatomical study.

Opening the roof of the interhemispheric microsurgical corridor to access various neurooncological or neurovascular lesions can be demanding because of the multiple bridging veins that drain into the sinus with their highly variable, location-specific anatomy. The objective of this study was to propose a new classification system for these parasagittal bridging veins, which are herein described as being arranged in 3 configurations with 4 drainage routes. Twenty adult cadaveric heads (40 hemispheres) were examined. From this examination, the authors describe 3 types of configurations of the parasagittal bridging veins relative to specific anatomical landmarks (coronal suture, postcentral sulcus) and their drainage routes into the superior sagittal sinus, convexity dura, lacunae, and falx. They also quantify the relative incidence and extension of these anatomical variations and provide several preoperative, postoperative, and microneurosurgical clinical case study examples. The authors describe 3 anatomical configurations for venous drainage, which improves on the 2 types that have been previously described. In type 1, a single vein joins; in type 2, 2 or more contiguous veins join; and in type 3, a venous complex joins at the same point. Anterior to the coronal suture, the most common configuration was type 1 dural drainage, occurring in 57% of hemispheres. Between the coronal suture and the postcentral sulcus, most veins (including 73% of superior anastomotic veins of Trolard) drain first into a venous lacuna, which are larger and more numerous in this region. Posterior to the postcentral sulcus, the most common drainage route was through the falx. The authors propose a systematic classification for the parasagittal venous network. Using anatomical landmarks, they define 3 venous configurations and 4 drainage routes. Analysis of these configurations with respect to surgical routes indicates 2 highly risky interhemispheric surgical fissure routes. The risks are attributable to the presence of large lacunae that receive multiple veins (type 2) or venous complex (type 3) configurations that negatively impact a surgeon's working space and degree of movement and thus are predisposed to inadvertent avulsions, bleeding, and venous thrombosis.

Anterior Incisura Fibularis Corner Landmarks Can Safely Validate the Optimal Distal Tibiofibular Reduction in Malleolar Fractures-Prospective CT Study.

Distal tibiofibular injuries are common in patients with malleolar fractures. Malreduction is frequently reported in the literature and is mainly caused by insufficient intraoperative radiological evaluation. In this direction, we performed a prospective observational study to validate the efficacy of the anatomical landmarks of the anterior incisura corner. Patients with malleolar fractures and syndesmotic instability were reduced according to specific anatomic landmarks and had a postoperative bilateral ankle CT. The quality of the reduction was compared to the healthy ankles. None of the controlled parameters differed significantly between the operated and healthy ankles. Minor deviations were correlated to the normal incisura morphology rather than the reduction technique. The anterior incisura anatomical landmarks can be an efficient way of reducing the distal tibiofibular joint without the need for intraoperative radiological evaluation.

Probing real-world Central European population midfacial skeleton symmetry for maxillofacial surgery.

Symmetry is essential for computer-aided surgical (CAS) procedures in oral and maxillofacial surgery (OMFS). A critical step for successful CAS is mirroring the unaffected side to create a template for the virtual reconstruction of the injured anatomical structure. The aim was to identify specific anatomical landmarks of the midfacial skeleton, to evaluate the symmetry in a group of the real-world Central European population, and to use these landmarks to assess midfacial symmetry in CT scans. The retrospective cross-sectional study defined landmarks of the midface's bony contour using viscerocranial CT data. The distances of the skeletal landmarks (e.g., the frontozygomatic suture and temporozygomatic suture) of the left and right sides from the midline were measured and statistically compared. Midfacial symmetry for reference points was defined as a difference within 0mm and their mean difference plus one standard deviation. We examined a total of 101 CT scans. 75% of our population shows symmetrical proportions of the midface. The means of the differences for the left and right sides ranged from 0.8 to 1.3mm, averaging 1.1 ± 0.2mm for all skeletal landmarks. The standard deviations ranged from 0.6 to 1.4mm, with a computed mean of 0.9 ± 0.3mm. We established a methodology to assess the symmetry of the bony midface. If the determined differences were equal to or lower than 2.5mm in the mentioned midfacial skeletal landmarks, then the symmetry of the bony midface was considered present, and symmetry-based methods for CAS procedures are applicable. Many CAS procedures require facial symmetry. We provide an easy-to-apply method to probe for symmetry of the midface. The method may be used for population-based research, to check for proper reduction of fractures after reposition or to screen for symmetry prior to CAS planning.

Assessing the Impact of Maxillomandibular Difference on the Success of Orthodontic Decompensation Preparation in Orthognathic Surgical Skeletal Class-III Patients

Background: Combined orthodontic-surgical treatment includes a thorough diagnosis and analysis of dental and facial deformities. Cephalometric analysis is a common tool for this, in which measurements of specific anatomical landmarks are performed. In order to achieve a successful surgery, orthodontic teeth preparation is mandatory, including dental decompensation before surgery. This should be planned and adequately executed to allow the surgeon to move the jaws to the correct ideal position. Aim: The current study aimed to check if the orthodontic decompensation amount is influenced and compromised by the maxillomandibular difference and if there is a correlation between the deformity’s severity and the orthodontist’s difficulty in achieving an accurate result in the orthodontic decompensation preparation. Methods: The study consisted of 50 pre-operational cephalometric radiographs of patients with Class-III (prognathic) deformity. The measurements included the angles of the upper incisor (U1) longitudinal axis to the Frankfort plane (FH) and palatal plane (PP), lower incisor (L1) longitudinal axis to the lower mandibular plane (MP), overjet (OJ), effective maxillary length, effective mandibular length, and the maxilla–mandibular difference (Diff); Pearson correlation coefficient was applied. Results: There was a significant correlation between the maxilla–mandibular difference and U1 to FH angle (r = 0.254, p = 0.037), U1 to PP angle (r = 0.447, p &lt; 0.001), OJ (r = (−0.426), p &lt; 0.001). There was no statistical significance for Diff and L1 to MP angle (p = 0.342). Conclusions: In Class-III patients, achieving adequate decompensation is more challenging with the maxillary incisors rather than with the mandibular incisors, especially in more severe cases.

A comparison of quantitative and qualitative shoulder range of motion with patient-reported outcomes.

The evaluation of shoulder function requires a combination of physical examination of shoulder range of motion and measures of functional outcome measures. Although efforts have been made to define range of motion for clinical evaluation with respect to functional outcomes, a disconnect still exists when defining a successful outcome. We aim to compare quantitative and qualitative measures of shoulder range of motion with patient-reported outcome measures. Data from 100 patients who presented to the office of a single surgeon with a chief complaint of shoulder pain were evaluated for this study. Evaluation included American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Single Assessment Numeric Evaluation relative to the shoulder of interest, demographic information, and range of motion in the shoulder of interest. Internal rotation angle did not correlate with patient-reported outcomes, whereas external rotation and forward flexion angles did. Qualitative internal rotation as measured by hand-behind-back reach demonstrated a weak to moderate correlation with patient-reported outcomes, and a significant difference in global range of motion and functional outcome measures were identified in patients who can or cannot reach above the belt line or to the thoracic spine. Qualitative assessment of forward flexion demonstrated that patients who can reach specific anatomic landmarks have significantly improved functional outcome measures, and the same is true when comparing patients who can externally rotate past neutral. Hand-behind-back reach can be used as a clinical marker of global range of motion and functional outcome measures for patients with shoulder pain. Goniometer measurement of internal rotation has no relationship with patient-reported outcomes. Forward flexion and external rotation assessment with qualitative cutoffs can additionally be used clinically to determine functional outcome for patients with shoulder pain.

Advantages of ultrasound identification of the distal insertion of the calcaneofibular ligament during ligament reconstructions.

In lateral ankle instability, anatomical ligament reconstructions are generally performed using arthroscopy. The ligament graft is passed through the talar, fibular and calcaneal tunnels, reconstructing the anterior talofibular and calcaneofibular (CFL) bundles. However, the calcaneal insertion of the CFL needs to be performed in an extra-articular fashion, and cannot be carried out under arthroscopy, thus requiring specific anatomical landmarks. For obtaining these landmarks, methods based on radiography or surface anatomy have already been described but can only offer an approximate identification of the actual CFL anatomical insertion point. In contrast, an ultrasound technique allows direct visualization of the insertion point and of the sural nerve that may be injured during surgery. Our study aimed to assess the reliability and accuracy of ultrasound visualization when performing calcaneal insertion of the CFL with specific monitoring of the sural nerve. Our anatomical study was carried out on 15 ankles available from a body donation program. Ultrasound identification of the sural nerve was obtained first with injection of dye. A needle was positioned at the level of the calcaneal insertion of the CFL. After dissection, in all the ankles, the dye was in contact with the sural nerve and the needle was located in the calcaneal insertion area of the CFL. The mean distance between the sural nerve and the needle was 4.8mm (range 3-7mm). A pre- or intra-operative ultrasound technique is a simple and reliable means for obtaining anatomical landmarks when drilling the calcaneal tunnel for ligament reconstruction of the lateral plane of the ankle. This tunnel should preferably be drilled obliquely from the heel towards the subtalar joint (1h-3h direction on an ultrasound cross section), which preserves a maximum distance from the sural nerve for safety purposes, while allowing an accurate anatomical positioning of the osseous tunnel.

Anatomical landmarks for localisation of the anterior ethmoidal artery: a combined radiological and cadaveric (endoscopic) study

PurposeThe anterior ethmoidal artery is a major surgical landmark that is susceptible to iatrogenic injury during surgery of the anterior ethmoidal sinus, frontal sinus, and skull base. The present study aimed to define the location of the anterior ethmoidal artery in relation to specific anatomical landmarks using radiological imaging and endoscopic dissection.MethodsEighty-six anterior ethmoidal arteries were assessed using computed tomography scans (bilateral analyses) and forty anterior ethmoidal arteries were assessed using cadaveric specimens (bilateral analyses). The skull base, anterior nasal spine, anterior axilla of the middle turbinate, and nasal axilla were morphometrically analysed to determine their reliability as anterior ethmoidal artery landmarks.ResultsDistances to the skull base, anterior nasal spine, and nasal axilla displayed statistically significant differences between sexes and sides (p < 0.05). All landmarks demonstrated excellent reliability as anatomical landmarks for the localisation of the anterior ethmoidal artery, radiologically and endoscopically (ICC values ranged from 0.94 to 0.99).ConclusionThe middle turbinate axilla was the most reliable landmark, due to the lack of statistically significant differences according to sex and laterality, and the high inter-rater agreement between measurements. Anatomical knowledge of variations and relationships observed in the present study can be applied to surgeries of the anterior ethmoidal sinus, frontal sinus, and skull base to improve localisation of the anterior ethmoidal artery, preoperatively and intraoperatively, and avoid iatrogenic injury of the vessel.