Anterolateral keyhole transorbital routes to the skull base: a comparative anatomical study

OBJECTIVE

Although keyhole transorbital approaches are gaining traction, their indications have not been adequately studied comparatively. In this study the authors have defined them also as transwing approaches-meaning that they use the different facies of the sphenoid wing for cranial entry-and sought to compare the four major ones: 1) lateral orbitocraniotomy through a lateral canthal incision (LatOrb); 2) modified orbitozygomatic approach through a palpebral incision (ModOzPalp); 3) modified orbitozygomatic approach through an eyebrow incision (ModOzEyB); and 4) supraorbital craniotomy through an eyebrow incision (SupraOrb), coupled with its expanded version (SupraTransOrb).

METHODS

Cadaveric dissections were performed at the neuroanatomy lab. To delineate the skull base exposure, four formalin-fixed heads were used, with two sides dedicated to each approach. The outer limits were assessed via image guidance and were mapped and illustrated accordingly. A fifth head was dissected purely endoscopically, just to facilitate an overview of the transwing concept. Qualitative features were also rigorously examined.

RESULTS

The LatOrb proves to be more versatile in the middle cranial fossa (MCF), whereas the anterior cranial fossa (ACF) exposure is limited to a small area above the sphenoid ridge. An anterior clinoidectomy is possible; however, the exposure of the roof of the optic canal is suboptimal. The ModOzPalp adequately exposes both the ACF and MCF. Its lateral trajectory allows the inferior to superior view, yet there is restricted access to the medial anterior skull base (olfactory groove). The ModOzEyB also provides extensive exposure of the ACF and MCF, but has a more superior to inferior trajectory compared to the ModOzPalp, making it more appropriate for pathology reaching the medial anterior skull base or even the contralateral side. The anterior clinoidectomy is performed with improved visualization of the optic canal. The SupraOrb provides mainly anterior cranial base exposure, with minimal middle fossa. An anterior clinoidectomy can be performed, but without any direct observation of the superior orbital fissure. Some MCF access can be accomplished if the lateral sphenoid wing is drilled inferiorly, leading to its highly versatile variant, the SupraTransOrb.

CONCLUSIONS

All the aforementioned approaches use the sphenoid wing as skull base corridor from a specific orientation point; hence these are designated as transwing approaches. Their peculiarities mandate careful case selection for the effective and safe completion of the surgical goals.

Resection of the quadrangular lobule of the cerebellum to increase exposure of the cerebellomesencephalic fissure: an anatomical study with clinical correlation

OBJECTIVE

The lateral aspect of the cerebellomesencephalic fissure frequently harbors vascular pathology and is a common surgical corridor used to access the pons tegmentum, as well as the cerebellum and its superior and middle peduncles. The quadrangular lobule of the cerebellum (QLC) represents an obstacle to reach these structures. The authors sought to analyze and compare exposure of the cerebellar interpeduncular region (CIPR) before and after QLC resection and provide a case series to evaluate its clinical applicability.

METHODS

Forty-two sides of human brainstems were prepared with Klingler's method and dissected. The exposure area before and after resection of the QLC was measured and statistically studied. A case series of 59 patients who underwent QLC resection for the treatment of CIPR lesions was presented and clinical outcomes were evaluated at 1-year follow-up.

RESULTS

The anteroposterior surgical corridor of the CIPR increased by 10.3 mm after resection of the QLC. The mean exposure areas were 42 mm2 before resection of the QLC and 159.6 mm2 after resection. In this series, ataxia, extrapyramidal syndrome, and akinetic mutism were found after surgery. However, all these cases resolved within 1 year of follow-up. Modified Rankin Scale score improved by 1 grade, on average.

CONCLUSIONS

QLC resection significantly increased the exposure area, mainly in the anteroposterior axis. This surgical strategy appears to be safe and may help the neurosurgeon when operating on the lateral aspect of the cerebellomesencephalic fissure.

Unveiling the Journey: A Case Report of Managing an Impacted Central Incisor

Although impaction of the maxillary permanent central incisor is uncommon in dentistry due to its significance to facial aesthetics which are challenging to treat. To abstain from the consequences related to aesthetic and functional occlusion, early detection of an impacted central incisor is imperative. This case report describes a male patient, aged 22 years, who had an impacted central incisor tooth in the maxillary anterior region. A surgery was performed to remove the impacted supernumerary tooth that was preventing the eruption of the central incisor. Using a combination of surgical exposure and orthodontic force, the impacted right maxillary central incisor was relocated to its proper occlusion in the dental arch.

The Intriguing Case of Impacted Teeth 11, 12, and 13: Unveiling the Dental Dilemma

This case study offers a rare and difficult condition involving the impaction of teeth 11, 12, and 13, providing a severe dental challenge. A thorough examination was performed on the patient, which included clinical evaluations and radiographic examinations. Because the impacted teeth were causing discomfort and functional impairment, a multidisciplinary approach was required, which included surgical exposure followed by traction forces to level and align the impacted teeth. The abstract emphasizes the case's complexity, digging into the diagnosis process and the establishment of a personalized treatment strategy. The complexities of handling many impacted teeth are explored in length, including surgical intervention, orthodontic considerations, and postoperative care.

Extensile Exposures in Revision and Complex Primary Total Knee Arthroplasty: A Review of Anatomy, Biomechanics, and Techniques

Developing adequate exposure when performing a revision total knee arthroplasty is critical to an efficient and safe intraoperative course. Proper planning and knowledge of the relevant anatomy are important when dissecting scar tissue associated with previous trauma or surgery and navigating bone loss. We present a review of the different total knee arthroplasty extensile exposure techniques that have been described in the literature. Specific exposures discussed include the femoral peel, banana peel, medial epicondylar osteotomy, quadriceps snip, tibial tubercle osteotomy, wandering resident, and the V-Y quadricepsplasty with patella turndown. Furthermore, we review the histological healing potential, biomechanical principles that drive post-operative expectations, post-operative rehabilitation protocols, and reported functional outcomes of each technique.

Surgical exposure for vitrectomy in retinopathy of prematurity

Our purpose was to evaluate the efficacy of lateral canthotomy, sub-tenon anesthesia injection, and the use of modified speculum for gaining adequate surgical exposure during surgery for retinopathy of prematurity (ROP). Fourteen eyes of 10 consecutive patients undergoing microincisional vitrectomy surgery (MIVS) for stage 4 and stage 5 ROP were included. There was a significant widening of the palpebral fissure height and length using this technique. No patient developed a lens injury during the surgery. All the canthotomy incisions completely healed at a four-week follow-up visit. This is a safe and effective technique for increasing surgical exposure in cases of ROP requiring vitrectomy.

Periodontal outcomes associated with impacted maxillary central incisor and canine teeth following surgical exposure and orthodontic alignment: a systematic review and meta-analysis

BACKGROUND

Maxillary incisor and canine teeth are commonly impacted and require multidisciplinary treatment to accommodate them in the dental arch.

OBJECTIVES

To assess the periodontal outcomes of impacted maxillary central incisor and canine teeth, which have been successfully aligned in the arch following surgical exposure and orthodontic traction with fixed appliance therapy.

SEARCH METHODS

Systematic literature searches without restrictions were undertaken in eight databases.

SELECTION CRITERIA

Studies reporting surgical interventions in combination with orthodontic traction with fixed appliance therapy to align impacted maxillary incisors or canines published up to January 2023.

DATA COLLECTION

Duplicate independent study selection, data extraction, and risk of bias assessment.

ANALYSIS

Random-effects meta-analyses of aggregate data.

RESULTS

Twenty-three studies (21 retrospective and 2 prospective) were included in the final analysis. Three studies reported outcomes for maxillary central incisors and 20 reported outcomes for maxillary canines. For maxillary central incisors, all three studies were rated as being at moderate risk of bias. For maxillary canines, 17 studies and 1 study were rated at moderate and high risk of bias, respectively. Both prospective studies were rated at a low risk of bias. Meta-analyses comparing aligned impacted maxillary canines to their non-impacted contralateral counterparts found the former had increased Plaque Index scores (mean difference [MD] 0.19; 95% confidence interval [CI] 0.03, 0.35; P = 0.03), increased clinical attachment loss (MD 0.40 mm; 95% CI 0.17, 0.63; P = 0.01), increased pocket probing depth (MD 0.18 mm; 95% CI 0.07, 0.28; P = 0.001), increased bone loss (MD 0.51 mm; 95% CI 0.31, 0.72; P < 0.001), and reduced keratinized gingival width (MD -0.31 mm; 95% CI -0.61, -0.01; P = 0.04).

CONCLUSIONS

Limited evidence suggests that surgical exposure and orthodontic alignment of impacted maxillary central incisor or canine teeth, results in modest adverse effects in the periodontium. These findings should be viewed with caution as our certainty for these outcomes is very low to low due to the bias and heterogeneity. Further well-conducted studies reporting patient centred outcomes are required.

REGISTRATION

PROSPERO (CRD42020225639).

Effect of dental follicles in minimally invasive open-eruption technique of labially impacted maxillary central incisors

OBJECTIVES

To summarize the open-eruption technique of impacted anterior maxillary teeth, this study reports a technically improved operation on surgical exposure based on dental follicles and evaluates post-treatment periodontal health considering the effect of dental follicles.

METHODS

Patients who underwent open-eruption technique with unilateral labially impacted maxillary central incisors were selected. The impacted teeth were assigned to the experimental group, and the contralateral unimpacted maxillary central incisors were assigned to the control group. In the surgical exposure, the new technique makes use of dental follicles to manage the soft tissue, so as to preserve soft tissue for better aesthetic results and healthier periodontal tissue. Tooth length, root length, alveolar bone loss, and alveolar bone thickness were recorded after the therapy.

RESULTS

A total of 17 patients with unilateral maxillary central incisor impaction were successfully treated. The tooth length and root length of the two groups showed a statistically significant difference between the impacted and homonym teeth, with a shorter length in the impacted tooth (P<0.05). More labial alveolar bone loss was found in the experimental group compared with that in the control group (P<0.05). The outcomes of the cementoenamel junction width, pa- latal alveolar bone loss, and alveolar bone thickness did not indicate statistical significance between the experimental and control groups (P>0.05).

CONCLUSIONS

In the surgical exposure, the new technique uses dental follicles to manage the soft tissue and preserve it for better aesthetic results and healthier periodontal tissues.

Anterior deltoid muscle reflection using a deltopectoral approach is safe and does not influence outcome of reverse shoulder arthroplasty

BACKGROUND

The deltopectoral approach is well accepted for shoulder arthroplasty procedures. The extended deltopectoral approach with detachment of the anterior deltoid from the clavicle allows increased joint exposure and can protect the anterior deltoid from traction injury. The efficacy of this extended approach has been demonstrated in anatomical total shoulder replacement surgery. However, this has not been shown in reverse shoulder arthroplasty (RSA). The primary aim of this study was to evaluate the safety of the extended deltopectoral approach in RSA. The secondary aim was to evaluate the performance of the deltoid reflection approach in terms of complications, surgical, functional and radiological outcomes up to 24 months post-surgery.

METHODS

A prospective non-randomized comparative study was performed between January 2012 and October 2020 including 77 patients in the deltoid reflection group and 73 patients in the comparative group. Decision for inclusion was based on patient and surgeon factors. Complications were recorded. Patients were followed up for at least 24 months to evaluate their shoulder function and ultrasound evaluation. Functional outcome measures included the Oxford Shoulder Score (OSS), Disabilities of the Arm, Shoulder and Hand (DASH) score, American Shoulder Elbow Surgeons score (ASES), pain intensity (VAS 0-100), range of motion (forward flexion (FF), abduction (AD), and external rotation (ER)). A regression analysis was performed to evaluate any factors of influence on the VAS.

RESULTS

There were no significant differences in the rate of complications between the two groups (14.5% in the deltoid reflection group and 13.8% in the comparative group, p=0.915). Ultrasound evaluation was available in 64 (83.1%) patients, and no proximal detachment was observed. In addition, there were no significant differences in functional outcome measures both preoperatively and at 24 months post-surgery between the groups on Mean VAS pain, OSS, DASH, ASES, FF, ABD, and ER. Adjustment for possible confounders in a regression model indicated that only prior surgery significantly influenced the VAS pain (p=0.031, 95%CI 0.574 - 11.67) after surgery. Deltoid reflection (p=0.068), age (p=0.466), sex (p=0.936), glenoid graft (p=0.091), prosthesis manufacturer (p=0.382) and preop VAS score (p=0.362) were not of influence.

DISCUSSION

Results of this study show an extended deltopectoral approach for RSA is safe. Selected reflection of the anterior deltoid muscle improved exposure and prevents anterior deltoid muscle injury followed by re-attachment. Patients had similar functional scores preop and at 24 months compared to a comparative group. Furthermore, ultrasound evaluation showed intact re-attachments.

Positional factors affecting the surgical management of impacted permanent mandibular canines

OBJECTIVE

To assess which positional factors influence the decision to surgically remove or expose an impacted mandibular canine. Clinical and radiographic assessment are important considerations when treatment planning for the management of impacted mandibular canines.

DESIGN

A cross-sectional study.

SETTING

The Royal Surrey County Hospital, Guildford, UK.

METHODS

The clinical notes and orthopantomogram radiographs were assessed for all patients aged 21 years or under who underwent surgical management of impacted mandibular canine teeth between 2017 and 2019. The following variables were recorded: angulation, horizontal position, vertical height, overlap of the adjacent tooth and bucco-lingual position of the canine.

RESULTS

From the 67 patients and 77 canines included, surgical extraction was performed for 48 canines (62%) and surgical exposure was performed for 29 canines (38%). Chi-square and multivariable logistic regression revealed canine angulation to the midline, horizontal position of the canine root apex, vertical height of the canine crown and canine overlap of the adjacent tooth to be associated with the decision to remove or expose an impacted permanent mandibular canine (P < 0.001). The bucco-lingual position of the canine did not influence the decision to remove or expose an impacted permanent mandibular canine (P = 0.159).

CONCLUSION

The decision to expose or remove an impacted mandibular canine is guided by its angulation, horizontal position and vertical position, and by the degree of overlap of the adjacent tooth. However, the bucco-lingual position is not related to the decision to surgically remove or expose an impacted permanent mandibular canine.

Total Hilar Exposure Maneuver for Repair of Complex Bile Duct Injury

The reconstruction of high-level bile duct injury is challenging because exposure of the hilar area is limited and sometimes inaccessible by the Hepp-Couinaud approach. We describe a maneuver for total hilar exposure to perform complex bile duct injury reconstruction. After adhesions surrounding the liver are divided, intraoperative ultrasonography is used to delineate the hilar and intrahepatic biliary anatomy. Surgical exposure of the biliary system is achieved by our maneuver, which consists of four steps: (1) identification of landmark structures, such as the base of the umbilical fissure, the inferior edge of segment 4b, the cystic-hilar plate junction, and the right anterior portal pedicle; (2) lowering of the hilar plate; (3) hepatotomy along the right anterior pedicle; and (4) connection of the hepatotomy to the base of segment 4b. This maneuver allows the liver to be flipped upward, which facilitates clear exposure of the hilar duct and preserves the liver parenchyma. The anterior parts of the right and left hepatic duct are then opened, a wide-hepaticojejunostomy anastomosis is achieved for biliary reconstruction, and a jejunal subcutaneous limb is created. We used this maneuver for treating complex bile duct injury in six cases; none of the patients has died, and two had Clavien-Dindo grade III complications, including surgical site infection and intra-abdominal collection. The total hilar exposure maneuver is thus feasible and safe. It provides excellent exposure of both hepatic ducts and is a good surgical alternative to the Hepp-Couinaud approach in cases of high-level injury.

Study of comparative surgical exposure to the petroclival region using patient-specific, petroclival meningioma virtual reality models

OBJECTIVE

Despite advancement of surgical techniques, the attachments of petroclival meningiomas near the central clival depression (CCD) remain difficult to visualize. With existing methods, the amount of tumor near the CCD that is inaccessible through various approaches cannot be compared. Tumors distort the brainstem, changing the size of the operative corridor for some but not all approaches; therefore, using cadavers with normal posterior fossae makes it impossible to compare different approaches to the tumor. The authors used virtual reality (VR) models created from the imaging data of patients to compare various surgical approaches that have otherwise been incomparable in previous studies.

METHODS

CT and MRI data obtained in 15 patients with petroclival meningiomas were used to create anatomically accurate 3D VR models. For each model, various surgical approaches were performed, and the surgical freedom to 6 targets of the regions were measured. Furthermore, portions of the tumor that were visually blocked by the brainstem or bony structures were segmented and recorded as blinded volumes for comparison.

RESULTS

The extended retrosigmoid approach generated excellent exposure of the petroclival region, but for most specimens, there was inaccessible tumor volume adjacent to the brainstem (mean 641.3 mm3, SE 161.8). In contrast, the brainstem sides of the tumors were well-visualized by all the transpetrosal approaches. The blinded volume of the tumor was largest for the retrolabyrinthine approach, and this was statistically significant compared with all other approaches (mean 2381.3 mm3, SE 185.4).

CONCLUSIONS

The authors performed a novel laboratory study by using patient CT and MRI data to generate 3D virtual models to compare surgical approaches. Since it is impossible to perform various approaches in separate surgeries in patients for comparison, VR represents a viable alternative for such comparative investigations.

Comparative Evaluation of Periodontal Osseous Defects Using Direct Digital Radiography and Cone-Beam Computed Tomography

OBJECTIVES

To evaluate and compare the accuracy of Direct Digital Radiography (DDR) and cone-beam computed tomography (CBCT) in determination and diagnosis of periodontal osseous defects.

METHODS

A nonrandomized in vivo study was conducted to compare the two imaging modalities, DDR and CBCT, for the diagnosis of periodontal osseous defects. Comparison was made between the linear measurements of DDR and CBCT images with the actual measurements of various osseous defects during surgical exposure (Gold standard).

RESULTS

The results of the present study demonstrated the difference in the mean values of the DDR and surgical exposure measurements of periodontal osseous defects, whereas comparable mean values were found between the CBCT and surgical exposure measurements, with no statistically significant difference (P > 0.05) being found between each modality.

CONCLUSION

CBCT proved to be an indispensable imaging tool in detecting and quantifying periodontal defects and furcation involvement more precisely and could provide additional benefits over the traditional radiography for clinical and postsurgical evaluation.

Safety, Feasibility, and Radiographic Outcomes of the Anterior Meniscal Takedown Technique to Approach Chondral Defects on the Tibia and Posterior Femoral Condyle: A Matched Control Study

OBJECTIVE

Takedown of the anterior meniscus to facilitate exposure of the cartilage defects located on the tibial plateau and/or posterior femoral condyle with subsequent reattachment is being performed clinically; however, clinical evidence is lacking to support the safety of this technique. The aim of this study was therefore to investigate whether meniscal extrusion develops after patients undergo meniscus takedown and transosseous refixation during autologous chondrocyte implantation (ACI).

DESIGN

We analyzed data from 124 patients with a mean follow-up of 6.8 ± 2.5 years. Sixty-two patients who underwent (ACI) with anterior meniscus takedown and refixation by the senior surgeon (TM), were compared with a matched control group of patients who underwent ACI without meniscus takedown. Meniscal extrusion was investigated by measuring the absolute value and the relative percentage of extrusion (RPE) on 1.5-T magnetic resonance images (MRI) at final follow-up. The number of menisci with radial displacement greater or lesser than 3 mm was determined. In cases where a preoperative MRI was available, both pre- and postoperative meniscal extrusion was evaluated (n = 30) in those patients undergoing meniscal takedown.

RESULTS

There was no significant difference in either absolute meniscus extrusion, RPE, or extrusion rate in patients with and without meniscus takedown. Among patients with meniscal takedown and both pre- and postoperative MRI scans, absolute meniscus extrusion, RPE, and extrusion rate showed no significant differences.

CONCLUSION

Meniscal takedown and subsequent transosseous refixation is a safe and effective technique for exposure of the tibial plateau and posterior femoral condyle.

Efficacy of Operculectomy in the Treatment of 145 Cases with Unerupted Second Molars: A Retrospective Case-Control Study

The aim of this study is to assess whether operculectomy in patients with retained second molars eases spontaneous tooth eruption in respect to untreated controls. Two hundred and twenty-two patients with delayed eruption of at least one second molar were selected from the archives of the Department of Orthodontics, Milan, Italy. Eighty-eight patients, 40 males and 48 females (mean age 14.8 ± 1.3 years), met the inclusion criteria. Records were then divided into case and control groups. The case group consisted of patients that underwent removal of the overlaying mucosa over second molars (i.e., operculectomy) and the control group consisted of subjects who retained their operculum over an unerupted second molar and were followed for one year without performing any treatment. A total of 145 impacted second molars were considered (75 cases, 70 controls). A risk ratio with 95% confidence interval was used to compare the prevalence of eruption in the two groups. Spontaneous eruption occurred in 93.3% of cases in the operculectomy group (70/75), while in the control group, 10% teeth erupted spontaneously (7/70). Spontaneous eruption in the upper arch occurred in 95.2% of cases among treated patients (40 out of 42), while in the lower arch, spontaneous eruption occurred in 90.9% of cases (30 out of 33). Spontaneous eruption of the upper second molars in the control group occurred in 8.5% of cases (3 out of 35), while in the lower arch, it occurred in 8.5% (3 out of 35). Operculectomy can ease the spontaneous eruption of retained second molars and reduce the chances of inclusion.

Glenoid exposure in shoulder arthroplasty: the role of soft tissue releases

Background

The deltopectoral approach is commonly used in shoulder arthroplasty. Various soft tissue releases can be performed to obtain adequate glenoid exposure, but their effectiveness is not known. The purpose of this study was to (1) quantify the effects of various releases on the amount of glenoid surface area exposure and (2) determine if common soft tissue releases performed about the shoulder significantly improve exposure of the glenoid.

Methods

A standard deltopectoral approach was used on cadaveric shoulders (n=8) in the beach chair position. The releases performed were as follows: long head of biceps, pectoralis major tendon, inferior capsule, and posterior capsule. Following each release, a custom-designed jig was used to mark the exposed glenoid surface. The glenoid was then digitized using a 3D surface scanner to quantify the exposed surface area with each release.

Results

The mean glenoid surface area exposure prior to any releases was 57% (SD 8%). Following release of the long head of biceps, exposure increased to 69% (SD 10%). The exposed area was increased to 83% (SD 6%) with release of the pectoralis major, and 93% (SD 2%) with inferior capsule. The entire glenoid was exposed following posterior capsule release.

Conclusions

Release of the long head of biceps, pectoralis major, and inferior and posterior capsule all independently led to significant increases in glenoid surface exposure in the deltopectoral approach. Mean surface area exposed with all 3 releases was 93%. Although posterior capsular release improved exposure, the results of this study suggest that this is rarely necessary.

Persistent Enlarged Occipital Sinus with Absent Unilateral Transverse Sinus

The occipital sinus may occasionally remain patent, but the incidence is extremely low and observed in less than 10% of cases. A persistent patent occipital sinus (POS) may be associated with other venous sinus abnormality. The absence of transverse sinus in association with POS is an extremely rare condition and not reported yet. The neuroradiologist, neurosurgeons, otolaryngologist, and neurologist must be aware of the possible existence of POS and other associated venous sinus anomaly, as its warrants very crucial modification of surgical planning, selection of appropriate approaches, and, additionally, may also critically limit the extent of surgical exposure of target, and may hinder intended extent of surgical excision of tumor and associated possibility of injury to POS, which may produce catastrophic hemorrhage, brain swelling, and neurosurgical morbidity. The authors report a 35-year-old male who underwent suboccipital craniotomy for right-side giant acoustic schwannoma. Following the raising bone flap, a markedly prominent, turgid, occipital sinus was observed, not placed exactly in the midline but deviated to the right side, causing further restraining of dural opening. Surgical nuances and intraoperative difficulty encountered along with pertinent literature is reviewed briefly.

Are age and radiographic features effective on orthodontic alignment of palatally impacted maxillary canines? a retrospective study

Purpose:

The purpose of the study was to evaluate the effects of age and radiographic parameters on success of orthodontic alignment of impacted maxillary canines.

Materials and methods:

The retrospective records of 50 patients (mean age 20.44 years) who had impacted maxillary canines in palatal position were included. The patients was requiring surgical exposure and mechanical orthodontic treatment were divided into two groups as adolescent (age≤18; n=24) and adult (age>18; n=26). In both groups, the treatment time and success were evaluated clinically and radiographically.

Results:

Fifty patients between the ages of 13 to 42 (12 males and 38 females) with palatally impacted canines were treated with combined surgical-orthodontic approach. Forty-seven teeth (94%) had reacted to surgical exposure and orthodontic alignment within 16 to 36 months with a mean of 24.81 months. Three of the impacted canines (6%) were surgically removed because no movement was observed following 10 months of traction forces.

Conclusion:

The distance of the canine tip to the occlusal plane on the lateral cephalometric radiographs have found to be related with the total orthodontic treatment time. Neither the age of the patient nor other clinic and radiographic parameters had influence on the treatment results of alignment of maxillary canines following surgical exposure.

The PreOp Program: Intensive Preclinical Surgical Exposure is Associated With Increased Medical Student Surgical Interest and Competency

OBJECTIVE

As medical students' interest in surgical fields wanes, we investigated the impact of a preclinical surgical exposure program on students' attitudes toward pursuing surgical careers.

DESIGN

This is a prospective longitudinal study of PreOp, a preclinical rotation-based surgical exposure program for first-year medical students, from 2013 to 2017. Surveys assessed PreOp rotation quality, students' surgical interest, and students' self-reported preparedness for the surgical clerkship. Surgery clerkship grades were obtained as a measure of surgical competency and compared to class-wide peers. Match data was collected and compared to class-wide peers as well as historical norms.

SETTING

NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York, NY; tertiary care center.

PARTICIPANTS

Fifty-four PreOp students from 2013 to 2017.

RESULTS

Fifty-four PreOp participants were recruited. After completing the PreOp program, 66.7% of PreOp students reported being very likely to apply into a surgical field compared to 29.4% when they started medical school. Ultimately, 71.4% of PreOp students versus 21.7% of non-PreOp class-wide peers matched into surgical fields (p < 0.001). From the preceding 5 match years before PreOp implementation, 21.4% of all students matched into surgical fields compared to 25.6% of all students after PreOp was started (p = 0.26). In terms of preparedness, 75% of PreOp students reported feeling more prepared for the third-year surgery clerkship than their non-PreOp peers after the second year of medical school. PreOp students were significantly more likely than non-PreOp class-wide peers to receive honors in the surgery clerkship when controlling for cumulative clerkship GPA (p = 0.012, adjusted odds ratio = 5.5 [95% confidence interval 1.5-22.1]).

CONCLUSIONS

Hands-on preclinical surgical exposure was associated with student-reported increased surgical interest that was maintained longitudinally and reflected in significantly increased surgical matches relative to non-PreOp class-wide peers. This study uniquely demonstrates that participation in PreOp was also associated with increased self-reported surgical preparedness and significantly higher surgery clerkship grades relative to overall academic performance.

Characterization of an anatomic safe zone surrounding the lower subscapular nerve during an open deltopectoral approach

BACKGROUND

Due to anatomic variance in subscapular nerve innervation patterns, it is theorized that the dysfunction of the subscapularis could be the result of iatrogenic denervation during mobilization of the subscapularis while exposing the anterior glenohumeral joint in anterior surgical approaches. The purpose of this study was to describe innervation patterns of the subscapularis and to characterize a safe zone when conducting an anterior surgical approach.

METHODS

The study used 6 human cadaveric shoulder specimens (12 shoulders total). A deltopectoral approach was used to expose the axillary nerve back to the posterior cord of the brachial plexus and reveal the origins of the upper and lower subscapularis nerves. An anatomic safe zone was characterized by measuring distances from both the upper and lower subscapularis nerve insertions with respect to that of the lateral border of the conjoint tendon, the bicipital groove, superior border of the subscapularis, and the axillary nerve (for the lower subscapular nerve only) with the arm in 30° abduction.

RESULTS

The anatomic safe zone of the subscapular nerves medial to the conjoint tendon is less than 32 mm. In relation to the axillary nerve, the safe zone is less than 10 mm inferiorly and 15 mm medially.

CONCLUSIONS

This described safe zone with respect to the lateral border of the conjoint tendon and axillary nerve is aimed to provide guidance to reduce iatrogenic injury of the subscapular nerves during anterior shoulder exposure. Extra care should be undertaken while dissecting past this safe zone to prevent iatrogenic subscapular nerve injury.

Hydrodissection of Wiltse's Plane to Facilitate Exposure During Minimally Invasive Transforaminal Lumbar Interbody Fusion

Traditional posterior lumbar approaches in a transforaminal lumbar interbody fusion (TLIF) require subperiosteal dissection of bilateral paraspinal muscles to provide adequate exposure. This may traumatize the multifidus muscle and its afferent innervations leading to postoperative paraspinal muscle atrophy. Minimizing such intraoperative trauma has been identified as an important factor in the reduction of postoperative lumbar pain. An approach via a blunt dissection through Wiltse’s plane, which lies between the longissimus and multifidus muscles, may minimize postoperative pain. Definition of this plane may be facilitated by local injection of 1% lidocaine within the plane itself, as well as in the musculature defining its borders.

In this paper, we demonstrate this technique with a 55-year-old female patient who presented with left-sided radicular leg pain in an L5 distribution. Wiltse plane hydrodissection was utilized in performing an L4-5 TLIF. Ultrasound images of the patient’s sub-fascial musculature were obtained pre- and posthydrodissection to assess the elucidation of this plane through this technique. Intraoperative images were obtained following dissection of Wiltse’s plane to further illustrate the facilitation of exposure of Wiltse’s plane through hydrodissection. Postoperatively the patient did well citing a complete resolution of her radicular pain. She did not require intravenous (IV) pain medication, as her postoperative pain was well controlled with oral pain medication. She was mobilized on post-op day one, and discharged home on post-op day two with minimal back pain.

Our initial experience supports the feasibility, safety, and effectiveness of hydrodissection of Wiltse’s plane to facilitate exposure during a minimally invasive TLIF and thereby reducing postoperative pain.

Commissurotomy

This step-by-step feature provides a pictorial description of the commissurotomy procedure. Commissurotomy can be performed to increase surgical access to the caudal oral cavity for procedures such as total mandibulectomy, caudal mandibulectomy, and surgical access to the mandibular ramus.

Surgical considerations and management of bilateral labially impacted canines

Canines are among the most commonly impacted teeth. When a canine is positioned labially, the untoward soft-tissue responses following surgical exposure may cause unfavorable esthetic outcomes. Therefore, decision making as to the choice of a proper surgical technique to uncover labially impacted teeth is critical. This case presentation describes two different surgical approaches for two maxillary impacted canines in a 12-year-old girl. A sequential approach included a first stage of surgical exposure using apically positioned flaps and orthodontic extrusion of both impacted teeth. A successive laterally positioned flap was used for the left maxillary canine to achieve a harmonious soft-tissue contour. In this case, close monitoring and cooperation during the various treatment phases led to proper canine positioning and a successful esthetic result, with good periodontal health and functional occlusion.

Curved incision under the costal margin in retroperitoneal tumor surgery

This study was conducted to investigate the value of using a curved incision under the costal margin in retroperitoneal tumor surgery. Data on 68 patients with retroperitoneal tumors were reviewed. Of the 68 patients, 32 underwent tumor removal via a curved incision under the costal margin (group A) and the remaining 36 patients underwent a mid-abdominal oblique incision at the waist (group B). The patient outcomes were compared between the two groups to analyze the effects of the different types of incision on the completeness of resection, duration of operation, intraoperative blood loss, postoperative recovery time and surgical complications. The tumors from the 32 patients in group A were all successfully removed and the outcomes of the patients in group A, regarding tumor removal, duration of operation, amount of blood lost and surgical complications, were superior to those of the patients in group B. A route of incision is required that adequately exposes the internal limit or lower boundary of the tumor and ensures adequate surgical field visualization. The 32 patients underwent retroperitoneal tumor removal via a curved incision under the costal margin, plus a longitudinal incision along the lower boundary of the tumor at the midline of the abdomen. All the patients underwent complete tumor resection and recovered well after surgery, without necrosis at the incision site. In terms of duration of the operation, blood transfusion volume, mean length of hospital stay, weight of tumor removed, perioperative mortality, postoperative intestinal fistulas and rate of complete surgical resection, the outcomes of the patients in group A were superior to those of group B.

The extended medial elbow approach-a cadaveric study

BACKGROUND

The two most commonly used approaches to expose medial elbow structures are the flexor carpi ulnaris split and the Hotchkiss over-the-top approach. The aim of this study was to define the extended medial approach to the elbow, featuring advantages of over-the-top (proximal exposure) and additional complete exposure of the coronoid and proximal medial ulna, while respecting the internervous plane between the flexor pronator mass and flexor carpi ulnaris muscle.

METHODS

In this comparative anatomic study, 12 fresh frozen cadaveric elbows were dissected alternately to study the distal limitation and exposed area of the extended medial elbow approach compared with splitting the flexor carpi ulnaris.

RESULTS

Proximal ulna exposure area was comparable between the extended medial elbow approach (average, 840 mm(2)) and the flexor carpi ulnaris split (average, 810 mm(2); P = .44). The extended medial approach was limited distally by the posterior recurrent ulnar artery (mean 68 mm from medial epicondyle), whereas the first motor branch for the flexor carpi ulnaris muscle limited the second approach in 75% of the specimens (mean 29 mm from medial epicondyle, P < .001).

CONCLUSIONS

The extended medial elbow approach is a single approach allowing full exposure of the medial elbow and combining the advantages of the over-the-top approach with a safe distal extension to the medial ulna. In contrast to the flexor carpi ulnaris split, our approach respects the internervous plane.

Quantitative comparison of exposure for the posterior Judet approach to the scapula with and without deltoid takedown

BACKGROUND

The purposes of this study are to quantify the extent of the scapula exposed and to describe the osseous landmarks within the dissection of a posterior Judet approach with and without takedown of the posterior deltoid muscle.

METHODS

The posterior Judet approach using the muscular interval between the teres minor and infraspinatus muscle with and without takedown of the deltoid muscle was performed on 10 fresh-frozen cadaveric shoulders. Retractors with 2 kg of force were used at the wound margins for retraction. Upon completion of the exposure, a calibrated digital image was taken from the surgeon's perspective and specific anatomic landmarks were identified. The digital images were then analyzed with a computer software program, ImageJ (National Institutes of Health, Bethesda, MD, USA), to calculate the area (in square centimeters) of bone exposed.

RESULTS

The mean area of posterior scapula exposed by the traditional Judet approach with takedown of the deltoid muscle was 30.2 cm(2) (95% confidence interval, 27.7-32.7 cm(2)) compared with 27.3 cm(2) (95% confidence interval, 24.8-29.9 cm(2)) when the deltoid was not detached (P < .0001). In all 10 cadaveric shoulders, the posterior Judet approach without takedown of the deltoid muscle allowed access to the posterior glenoid, lateral scapula border, and spinoglenoid notch.

CONCLUSIONS

Although takedown of the deltoid muscle improves exposure, the posterior Judet approach without takedown of the posterior deltoid muscle allows for safe exposure to 91% of the bony scapula obtained by removing the deltoid muscle and access to the critical osseous fixation points of the posterior scapula.

An extensive posterior approach of the elbow with osteotomy of the medial epicondyle

BACKGROUND

This study describes a posterior approach to the elbow for placement of a total elbow prosthesis.

METHODS

Release of the medial collateral ligament is achieved by performing an osteotomy of the medial epicondyle. This allows anatomic refixation of the origin of the medial collateral ligament. A description of the posterior approach is given. Standard radiographs were used to analyze the bone-to-bone refixation of the osteotomy of the medial epicondyle in 13 elbows.

RESULTS

Radiographs showed proper bone healing in all elbows, with restoration of the anatomic origin of the medial collateral ligament.

DISCUSSION

The described approach provides a good exposure of the elbow necessary for the placement of modern total elbow prostheses, without compromising the stability of the elbow. Refixation of stabilizing structures is relatively easy and results in an anatomic position of the ligaments.

Protruded and nonprotruded subungual exostosis: Differences in surgical approach

BACKGROUND

In subungual exostosis surgery, repair of the damaged nail bed and surgical excision of the mass without damaging the nail bed is important. The ideal method of surgery is still unclear. This study is done to qualify the effects of different surgical methods on outcome measures in different types of subungual exostosis.

MATERIALS AND METHODS

Fifteen patients, operated with a diagnosis of subungual exostosis between January 2008 and June 2012, were evaluated. Protruded masses were excised with a dorsal surgical approach after the removal of the nail bed and nonprotruded masses were excised through a"fish-mouth" type of incision.

RESULTS

The mean age of the patients in protruded subungual exostosis group was 17.3 years (range 13-22 years) and this group consisting of seven female and two male patients. The patients were followed up for a mean of 14.1 ± 4.8 months. The mean age of the patients in the nonprotruded subungual exostosis group was 14.6 years (range 13-16 years) and consisting of six female patients. The patients were followed up for a mean of 11.6 ± 2.9 months. The results were positively affected by changing the surgical approach depending on whether or not the exostosis is protruded from the nail bed. All patients had healthy toe nails in the postoperative period without any signs of recurrence.

CONCLUSIONS

In patients with a protruded subungual exostosis, the mass should be removed by a dorsal approach with the removal of the nail and injury to the nail bed should be repaired. In patients with a nonprotruded subungual exostosis, the mass should be excised through a "fish-mouth" type incision at the toe tip without an iatrogenic damage.

A case of impacted maxillary central incisor and its management

Impaction of maxillary permanent central incisor is not a frequently reported case in dental practice, but its treatment is challenging because of its importance to facial esthetics. Early detection of such teeth is most important if complications are to be avoided. We report a case of a 14-year-old female with an impacted central incisor tooth in the maxillary anterior region. The impacted supernumerary tooth which was preventing the eruption of permanent incisor was surgically removed. Combined approach with surgical exposure and the application of an orthodontic force brought the impacted left maxillary central incisor down to its proper position in the dental arch.

Management of impacted dilacerated maxillary central incisor: A clinical case report

The impacted maxillary incisor is detrimental for problems related to esthetics and occlusion in permanent dentition stage. A case with an unerupted maxillary central incisor was diagnosed radiographically with impacted dilacerated maxillary central incisor. The management of the case was carried out surgically and orthodontically. By combining two stages of surgical exposure, orthodontic traction and alignment, the impacted dilacerated incisor was successfully moved into desired position. A two-year follow-up of the stability and periodontal health showed that the tooth placed in the occlusion maintained both esthetics and function.