Anatomical Variations of the Upper Lateral Cartilages and Their Implications in Rhinoplasty

Background

Upper lateral cartilage manipulation is often associated with compromise of the middle-third vault. Although the anatomical details of the upper lateral cartilages are of great importance for the maintenance or even the creation of an aesthetically pleasing dorsum with proper respiratory function, the literature includes few studies related to these themes. Thus, this study aimed to evaluate the total length of the upper lateral cartilages and their extension under the nasal bones and caudally, and examine the anatomical variations of the upper lateral cartilages and their implications in rhinoplasty.

Method

An anatomical study was performed on 32 upper lateral cartilages of 16 fresh adult cadavers. The upper lateral cartilages were measured for total length, cephalad length (overlapped by the nasal bones), and caudal length (caudally to the nasal bones) using a millimeter ruler. The measurements were recorded and analyzed by BioEstat 5.0 software. The statistical tests were performed at the significance level of 0.05.

Results

A total of 13 male specimens and 3 female specimens with ages ranging between 20 and 60 years were analyzed. The length of the upper lateral cartilage portion under the nasal bones on the right side ranged from 3 to 7 mm (4.62 ± 1.20 mm). On the left side, it ranged from 2 to 7 mm (4.56 ± 1.26 mm). The total length of the upper lateral cartilages ranged from 16 to 28 mm (20.44 ± 3.26 mm) on the right side and 17 to 30 mm (20.75 ± 3.71 mm) on the left side.

Conclusion

Data from this study confirmed the anatomical variations of the upper lateral cartilages, including the portion lying under the nasal bones. This has important surgical implications given the attention required during spreader graft fabrication in order to maintain dorsal aesthetic lines and proper respiratory function.

     

Lateral deviation of four types of epidural catheters from the lumbar epidural space into the intervertebral foramen

Background

During epidural anesthesia, the catheter tip occasionally deviates from the epidural space into the intervertebral foramen, resulting in inadequate anesthesia.

Methods

During postoperative plain radiography, iohexol was injected via the epidural catheter to determine its position and to observe the spread of the material. After exclusion of seven patients with catheters that migrated into the subcutaneous area and 25 patients with no evidence of the contrast medium, 415 patients were evaluated. We retrospectively compared patients to determine whether the incidence of deviation into the intervertebral foramen differed between four types of epidural catheters. We also investigated the load applied to the catheter tip using a Shimadzu Autograph AG-X-500 N-111 universal testing machine.

Results

Deviation of the epidural catheter into the intervertebral foramen was observed in eight and 33 patients in the Hakko and Perifix Soft tip catheter groups, respectively. The incidence of deviation was higher in the Perifix Soft tip catheter group, and lower in the FlexTip Plus and Perifix FX catheter groups. A rapid increase was observed in the force exerted on the tips of the Hakko and Perifix Soft tip catheters, while the force transmitted to the tips of the FlexTip Plus and Perifix FX catheters gradually increased and then reached a plateau at a low level.

Conclusions

The incidence of deviation was significantly lower with spiral-type catheters than with other types of catheters. This might be attributable to the gradual transmission of a lower level of force to the tip in spiral-type catheters.

     

A Novel Lateral Approach to the Assessment of Vocal Cord Movement by Ultrasonography

Background

Ultrasonography is a non-invasive technique that is commonly used by endocrinologists and endocrine surgeons to examine the thyroid region and could be useful for the assessment of vocal cord movement by these specialists. However, previous studies reported a low rate of successful visualization of vocal cord movement by ultrasonography. To address this issue, we devised a novel ultrasonographic procedure for assessing vocal cord movement indirectly by observing the arytenoid movement from a lateral view.

Methods

Subjects were 188 individuals, including 23 patients with vocal cord paralysis and 13 with vocal cord paresis. We performed ultrasonographic assessment of vocal cord movement using two different procedures: the conventional middle transverse procedure and the novel lateral vertical procedure.

Results

The rate of visualization of vocal cords with the middle transverse procedure was 70.2% and that of the arytenoid cartilage with the lateral vertical procedure was 98.4%. The lateral vertical procedure enabled visualization of all patients with vocal cord paresis/paralysis and detected all 23 patients with vocal paralysis; only one of 13 patients with vocal cord paresis was positively identified. The conventional procedure enabled visualization of 21 of 36 patients with vocal cord paresis/paralysis with high accuracy. There was no false-positive case in either procedure.

Conclusion

The proposed lateral vertical procedure improved the rate of visualization of vocal cord movement by ultrasonography, suggesting that it is a useful technique to screen for vocal cord paralysis by ultrasonography.

     

Arthroskopische subakromiale Dekompression

Objective

Coracoacromial ligament release to widen the subacromial space, resection of the anterior undersurface of the acromion and, if needed, caudal exophytes at the acromioclavicular joint.

Indications

All types of outlet impingement after 3 months of conservative treatment.

Contraindications

Impingement syndrome with instability/muscular imbalance, massive rotator cuff tear, unstable os acromionale, posterior–superior impingement, joint infection, freezing phase of a secondary frozen shoulder.

Surgical technique

Lateral decubitus position with traction device for the arm. Diagnostic arthroscopy of the glenohumeral joint via standard portals. With arthroscope moved to the subacromial space, bursectomy, electrosurgical release of coracoacromial ligament, resection of acromial hook through standard posterior portal.

Postoperative management

Physiotherapy or self-exercises on postoperative day 1, pain-adapted analgesia to avoid shoulder stiffness.

Results

Several studies present positive long-term results compared to conservative treatment (and open acromioplasty) for partial rotator cuff tears and for elderly patients. With a 20-year follow-up, successful results have been achieved for all patients with isolated impingement syndrome.

     

Characteristics and treatment strategies of mitral regurgitation associated with undifferentiated papillary muscle

Purpose

In this report we review our experience of operations on mitral regurgitation associated with abnormal papillary muscles/chordae tendineae of the mitral valves and discussed the clinical characteristics, operative findings, and treatment strategies.

Methods

Undifferentiated papillary muscle was defined as a hypoplastic chordae tendineae with anomalous formation of papillary muscles attached to the mitral valves directly. Consecutive 87 patients undergoing surgery for mitral regurgitation at our institution were reviewed and 6 of them had undifferentiated papillary muscle.

Results

The underlying mechanism of regurgitation was prolapse at the center of the anterior leaflet in 3 cases and tethering, a wide area of myxomatous degeneration, and annular dilatation in one case, respectively. Five patients underwent mitral valve plasty and 1 patient received replacement. Anomalous formation of chordae tendineae was corrected by resection and suture with transplantation at the tip of the leaflet to which abnormal chordae were attached in 2 cases, while resection and suture with chordal shortening was performed in 1 case, and chordal reconstruction using artificial chordae was employed in 2 cases. There was no operative death, and postoperative echocardiography showed no residual regurgitation in any of the cases.

Conclusions

Mitral regurgitation associated with undifferentiated papillary muscle resulted from prolapse or tethering and impaired flexibility of leaflets. It was possible to successfully treat the patients by mitral valve plasty unless complex congenital cardiac malformation coexisted. Detailed examinations of attached papillary muscle by echocardiography and intraoperative inspection are necessary and surgical techniques should be selected appropriately in each case.

     

Lateral internal sphincterotomy under local and spinal anaesthesia for chronic anal fissure: A randomised control trial

Introduction

Anal fissure is described as a linear defect, or laceration, in the anoderm, located between the dentate line and the anal verge. An acute fissure is a simple laceration, whereas a chronic anal fissure is an ulceration with built-up scarred edges and exposed internal anal sphincter muscle fibers at its base. Additional findings may include a perianal skin tag at the external margin of the fissure and a hypertrophied papilla at the dentate.

Methods

This is a randomised control study that included 50 patients, divided in two groups, who were treated with lateral internal sphincterotomyunder local anaesthesia (group A) and spinal anaesthesia (group B) in Dr. Ram Manohar Lohia Hospital, New Delhi, India, from May 2014 to November 2015. The follow-up period ranged from 2- 6 months.

Results

Fissure persistence or recurrence was found in 1 patient (4.16%) after 2 months in group B, and none in patients of group A. Wound healed by epithelization with mean of 1 week in group A, while it required 2 to 3 weeks for group B wounds to heal. There was wound infection in 5 out of 24 patients in group B (20.8%). There was no incontinence of flatus or stool in any of the patients in both groups.

Conclusions

Lateral internal sphincterotomy is now considered the treatment of choice for anal fissure, because it is a day care surgery, it causes less pain, it has negligible chances of recurrence and wound infection and is more effective in management of chronic anal fissure.

     

First carpometacarpal arthroplasty with ligamentous reconstruction: a long-term follow-up

Background

The purpose of the present study is to evaluate a single surgeon’s short, intermediate, and long-term clinical, functional, and radiographic outcomes with a trapeziectomy with flexor carpi radialis (FCR) suspension arthroplasty without tendon interposition (LRSA).

Methods

Twenty-one patients underwent 26 FCR suspension arthroplasties without tendon interposition by a single senior surgeon. All patients had Eaton stage III and IV carpometacarpal (CMC) osteoarthritis. The Patient-Rated Wrist and Hand Evaluation (PRWHE) and Quick Disabilities of Arm, Shoulder, and Hand (QuickDASH) were used to evaluate functional outcomes. A comprehensive strength and range of motion evaluation was performed to evaluate clinical outcomes. Plain radiographs at rest and with maximal pinch were performed to evaluate for arthroplasty space subsidence.

Results

The LRSA exhibited consistent clinical and functional outcomes throughout postoperative follow-up. As the average patient age and time from surgery increased, range of motion (ROM) and PRWHE scores stayed relatively constant, while lateral tip and tip pinch strength deteriorated with time. The LRSA prevented the proximal migration of the first metacarpal in all but one patient. No patients required revision arthroplasty following LRSA.

Conclusions

This study demonstrates the consistent short, intermediate, and long-term clinical, functional, and radiographic outcomes following a trapeziectomy with FCR suspension arthroplasty.

     

Combined posterolateral corner and acute anterior cruciate ligament injuries in an adolescent cohort: a magnetic resonance imaging analysis

Purpose

Failure of a reconstructed anterior cruciate ligament (ACL) has significant morbidity in the paediatric and adolescent patient population. Untreated concomitant posterolateral corner (PLC) injury is an identified cause of failed ACL reconstruction; however, the injury pattern has yet to be defined for the paediatric population.

Methods

Magnetic resonance imaging (MRI) studies of the knee performed between 1 January 2009 and 1 January 2013 were retrospectively reviewed. Imaging reports indicating an intra-substance injury of the ACL were reviewed, and all associated injured structures were recorded. Injury patterns were categorised by age, gender, physis status and associated injuries. Logistic regression and chi-square analyses compared ACL disruptions with and without concomitant PLC injuries.

Results

One hundred and twenty-eight patients (74 boys and 54 girls, average age 15.27 years) sustained an ACL disruption. Concomitant injury to the PLC was seen in 13.3 % of injuries. Associated PLC injuries were significantly associated with lateral meniscus injury and Segond fractures. Lateral meniscus injury was predictive of PLC injury (p?=?0.05) upon logistic regression analysis.

Conclusion

Concomitant PLC injuries were found in 13.3 % of all ACL disruptions on MRI analysis. Lateral meniscus injuries associated with an ACL disruption were predictive of concomitant PLC injury. Combined injury of the ACL and lateral meniscus should prompt close scrutiny to PLC structures.

     

The learning curve of lateral access lumbar interbody fusion in an Asian population: a prospective study

Purpose

Lateral access lumbar interbody fusion (LLIF) is a minimally invasive technique that has an increasing popularity. It offers unique advantages and circumvents risk of certain serious complications encountered in other conventional spinal approaches. This study provides a statistical analysis defining the lateral access learning curve in the Asian population.

Methods

This prospective study included 32 consecutive patients who underwent LLIF from April 2012 to August 2014. The surgeries were performed by two senior spine surgeons and follow-up was conducted at 6 weeks, 3, 6, 9 months and 1 year post-operation.

Results

The breakpoint in operating time occurred at the 22nd level operated, from a mean of 71 min in the early phase group to a mean of 42 min in the steady state group. LLIF at L4/5 level is technically more demanding but technically feasible as competency is achieved.

Conclusions

During the learning process, there was no compromise of perioperative or clinical outcomes. It should be feasibly incorporated into a spine surgeon’s repertoire of procedures for the lumbar spine.

     

Die Arthrodese des Subtalargelenks

Objective

Realignment and stabilization of the hindfoot by subtalar joint arthrodesis.

Indications

Idiopathic/posttraumatic arthritis, inflammatory arthritis of the subtalar joint with/without hindfoot malalignment. Optional flatfoot/cavovarus foot reconstruction.

Contraindications

Inflammation, vascular disturbances, nicotine abuse.

Surgical technique

Approach dependent on assessment. Lateral approach: Supine position. Incision above the sinus tarsi. Exposure of subtalar joint. Removal of cartilage and breakage of the subchondral sclerosis. In valgus malalignment, interposition of corticocancellous bone segment; in varus malalignment resection of bone segment from the calcaneus. Reposition and temporarily stabilization with Kirschner wires. Imaging of hindfoot alignment. Stabilization with cannulated screws. Posterolateral approach: Prone position. Incision parallel to the lateral Achilles tendon border. Removal of cartilage and breakage of subchondral sclerosis. Medial approach: Supine position. Incision just above and parallel to the posterior tibial tendon. Removal of cartilage and breakage of subchondral sclerosis. Stabilization with screws.

Postoperative management

Lower leg walker with partial weightbearing. Active exercises of the ankle. After a 6?week X?ray, increase of weightbearing. Full weightbearing not before 8 weeks; with interpositioning bone grafts not before 10–12 weeks. Stable walking shoes. Active mobilization of the ankle.

Results

Of 43 isolated subtalar arthrodesis procedures, 5 wound healing disorders and no infections developed. Significantly improved AOFAS hindfood score. Well-aligned heel observed in 34 patients; 5 varus and 2 valgus malalignments. Sensory disturbances in 8 patients; minor ankle flexion limitations. Full bone healing in 36 subtalar joints, pseudarthrosis in 4 patients.

     

Lateral subvastus approach with tibial tubercle osteotomy for primary total knee arthroplasty: clinical outcome and complications compared to medial parapatellar approach

Purpose

The lateral subvastus approach (LSVA) with tibial tubercle osteotomy (TTO) is an alternative approach for total knee arthroplasty (TKA) in selected patients. The aim of this study was to compare clinical outcomes between LSV and medial parapatellar approaches for primary TKA and to investigate incidence of complications related to TTO.

Methods

A total of 580 patients with primary TKA, meeting the inclusion criteria, were treated at our hospital from February 2006 until February 2013. All patients’ data were included in the local arthroplasty register and were followed up 12 months postoperatively. The data set contains: demographic data, the WOMAC score, the KSS as well as knee flexion and complications related to tibial tubercle osteotomy.

Results

The clinical outcome after TKA using the LSVA combined with TTO was comparable with those using the medial standard approach 1 year postoperatively. Four patients (3.8 %) needed a revision due to complications related to tubercle osteotomy.

Conclusions

The LSVA is thus a viable alternative in cases of primary TKA if technical difficulties with the medial approach are anticipated. Applying precise surgical technique, the LSVA seems to be a safe and reproducible procedure.

     

Experimental study of the installation acetabular component with uncoverage in arthroplasty patients with severe developmental hip dysplasia

Purpose

The purpose of this study was stimation of optimal percentage of lateral uncoverage of the acetabular component during total hip arthroplasty for patients with severe developmental hip dysplasia.

Methods

Mathematical computer modeling based on the finite element technique and the mechanical experiment were performed. Critical values of uncoverage enabling safe primary fixation of acetabular component were estimated in designed models.

Results

Using the finite element technique and the mechanical experiment on pelvis models, a possibility of mounting an acetabular component with moderate uncoverage within 25% without screws and with significant uncoverage to 35% with an additional two-screw fixation was demonstrated.

Conclusions

This study provides additional guidance on optimal acetabular uncoverage assessment and fixation methods of surgeons performing THA on patients with DDH.

     

Reliability of anterior medial collateral ligament plication of the elbow

Purpose

The aim of this study is to describe a new surgical procedure to plicate the anterior bundle medial collateral ligament (aMCL) into its humeral footprint using a suture anchor, and to present the results of a preliminary clinical series.

Methods

Eight patients with posttraumatic medial elbow pain and signs of medial elbow instability underwent aMCL plication with suture anchors and decompression of ulnar nerve. Arthroscopic evaluation permitted to define signs of minor medial elbow instability; 70°-scope was used to document from an intra-articular point of view of the aMCL status. The patients were then retrospectively evaluated with the Oxford Elbow Score (OES), Mayo Elbow Performance Score (MEPI) and single-assessment numeric evaluation (SANE) by an independent examiner.

Results

In all cases, the 70°-scope allowed direct visualization of the aMCL. Lateral subluxation of the coronoid process into the trochlea was observed in all patients. Postoperative median SANE was 50 [35–74.5] points; postoperative median OES was 17 [15.5–31.5] points; postoperative median MEPI was 65 [57.5–72.5] points. None of the patients reported further episodes of medial elbow instability or pain and all patients returned to normal daily activities.

Conclusions

The 70°-scope arthroscopic evaluation of the joint allows a direct evaluation of the inner aMCL status. Lateral subluxation of the coronoid process into the trochlea was observed and can be considered a sign of minor medial elbow instability. Mini-open suture anchor aMCL plication is an original technique that enables an anatomic and minimally invasive ligament retension.

Clinical relevance

The authors introduce a valid and safe treatment of posttraumatic medial elbow laxity.

     

No differences between direct anterior and lateral approach for primary total hip arthroplasty related to muscle damage or functional outcome

Purpose

The aim was to compare the muscle damage and functional outcomes between patients who underwent total hip arthroplasty through a direct anterior (49 patients) or a lateral approach (50 patients).

Methods

A randomized, controlled, prospective study. The study variables were muscle damage based on post-operative levels of serum markers (citokynes and acute phase reactants) and MRI, and Harris hip score.

Results

Post-operatively, there were significantly higher mean levels in the lateral group related to interleukin 6 and 8, and tumor necrosis factor-alpha up to fourth postoperative day. By MRI at six post-operative months, the fatty atrophy in the gluteus muscles was more in the lateral group, but similar in the other muscles. The mean thickness of the tensor fasciae latae was significantly lower in the anterior group. Functional outcome was similar between groups at three and 12 post-operative months.

Conclusions

Muscle damage due to the surgical approach had no influence on functional outcome after three post-operative months. Both anterior and lateral approaches for THA are similarly safe and feasible, so the choice depends only on the preference and experience of the surgeon.

     

Komplikationsmanagement im Internet Marketing

Background

New patients come more and more often over the internet; therefore internet marketing plays an increasingly important role.

Question

How can physicians build an effective internet marketing strategy and avoid complications?

Method

Selection and authorization of a reputable agency.

Results

New customer acquisition through high visibility in the internet, at the same time increasing the image and awareness.

Conclusions

In the overall “marketing mix” internet marketing has become indispensable to physicians who want to be successful. Those who are well positioned in Google are well known by their target audience and thus receive a higher response.

     

In-hospital cost comparison between the standard lateral and supercapsular percutaneously-assisted total hip surgical techniques for total hip replacement

Purpose

The purpose of this study was to compare the in-hospital costs associated with the tissue-sparing supercapsular percutaneously-assisted total hip (SuperPath) and traditional Lateral surgical techniques for total hip replacement (THR).

Methods

Between April 2013 and January 2014, in-hospital costs were reviewed for all THRs performed using the SuperPath technique by a single surgeon and all THRs performed using the Lateral technique by another surgeon at the same institution.

Results

Overall, costs were 28.4 % higher in the Lateral group. This was largely attributable to increased costs associated with transfusion (+92.5 %), patient rooms (+60.4 %), patient food (+62.8 %), narcotics (+42.5 %), physical therapy (+52.5 %), occupational therapy (+88.6 %), and social work (+92.9 %). The only costs noticeably increased for SuperPath were for imaging (+105.9 %), and this was because the SuperPath surgeon performed intraoperative radiographs on all patients while the Lateral surgeon did not.

Conclusions

The use of the SuperPath technique resulted in in-hospital cost reductions of over 28 %, suggesting that this tissue-sparing surgical technique can be cost-effective primarily by facilitating early mobilisation and patient discharge even during a surgeon’s initial experience with the approach.

     

Offene Double-row-Rotatorenmanschettenrekonstruktion mit der LASA-DR-Screw

Objective

Safe and cost-effective rotator-cuff repair.

Indication

All types of rotator cuff lesions.

Contraindications

Frozen shoulder, rotator cuff mass defect, defect arthropathy.

Surgical technique

Extensive four-point fixation on the bony footprint is performed using the double-row lateral augmentation screw anchor (LASA-DR) with high biomechanical stability. Following mobilization of the tendons, these are refixed in the desired configuration first medially and then laterally. To this end, two drilling channels (footprint and lateral tubercle) are created for each screw. Using the shuttle technique, a suture anchor screw is reinforced with up to four pairs of threads. The medial row is then pierced and tied, and the sutures that have been left long are tied laterally around the screw heads (double row).

Postoperative management

4 Weeks abduction pillow, resulting in passive physiotherapy, followed by initiation of active assisted physiotherapy. Full weight-bearing after 4–6 months.

Results

Prospective analysis of 35 consecutive Bateman-III lesions with excellent results and low rerupture rate (6?%).

     

A prospective randomized study in 20 patients undergoing bilateral TKA comparing midline incision to anterolateral incision

Background

Lateral flap numbness is a known side-effect of midline skin incision in total knee arthroplasty (TKA) and a cause of patient dissatisfaction. Anterolateral incision is an alternative approach which preserves the infrapatellar branches of the saphenous nerve and avoids numbness. Studies have compared both incisions, but in different patients. However, different patients may assess the same sensory deficit dissimilarly, because of individual variations in anatomy and healing responses. We compared the two incisions in the same patient at the same time, using an anterolateral incision on one knee and a midline incision on the other knee in simultaneous bilateral TKA. Other surgical steps including medial arthrotomy were idential. We also correlated subjective and objective findings.

Materials and methods

Twenty patients were prospectively randomized. Sensory loss and skin healing were assessed at 6, 12 and 52 weeks. Subjective preference for the knee with less numbness was charted on Wald’s Sequential Probability Ratio Test. Sensation scores for touch, vibration, static and moving two-point discrimination were measured. Scar healing was evaluated using the Patient and Observer Scar Assessment Scale (POSAS). Functional scores were measured.

Results

A statistically significant difference favoring knees with anterolateral incision was observed in patient preference at all assessment points and this correlated with sensation scores. A statistically significant difference was observed in POSAS score favoring knees with anterolateral incision at 6 and 12 weeks which became statistically insignificant at 1 year. Functional scores remained comparable.

Conclusion

We recommend anterolateral incision as a safe and effective method to circumvent the problem of lateral flap numbness with midline incision.

Level of evidence

I.