Improved early continence following laparoscopic radical prostatectomy: the urethral hammock technique.

PURPOSE: To introduce and illustrate a novel urethral reconstruction technique-the 'urethral hammock-technique'-and to assess its impact on early postoperative continence following laparoscopic radical prostatectomy (LRP). METHODS: 119 patients who underwent LRP between January 2020 and May 2022 (hammock group: n = 43, control group: n = 76) were included in the study. The primary outcome was continence (zero pads or max. one security pad) at 1, 3, and 6 months following surgery. Secondary outcomes were operative time, complications, and histological findings. Univariate and multivariate regression analyses were performed to reveal predictors for continence. p values < 0.05 with a two-sided 95%-confidence interval were considered statistically significant. RESULTS: Baseline characteristics were comparable among both groups. The number of patients achieving complete continence in both the hammock and control groups at various time intervals was: 4 weeks 37.2% (16/43) vs. 19.2% (14/73) (p = 0.047); 3 months 60.5% (26/43) vs. 37.3% (28/75) (p = 0.021) and 6 months 72.1% (31/43) vs. 60.3% (44/73) (p = 0.23), respectively. Adjusting for bladder neck preservation status and age, the hammock technique was a significant predictor for continence for the 4-week (OR 0.33, 95% CI 0.13-0.83, p = 0.019) and 3-month (OR 0.28, 95% CI 0.12-0.66, p = 0.004) interval but not for the 6-month interval (OR 0.64, 95% CI 0.27-1.5, p = 0.31). Operative time, complication rates, time till catheter extraction and histological findings were comparable between both groups (all p > 0.05). CONCLUSIONS: The hammock technique is a simple and reproducible technique to improve early postoperative continence for at least 3 months following surgery. However, these promising results warrant confirmation through a randomized controlled trial.

Intraoperative pelvic neuromonitoring based on bioimpedance signals: a new method analyzed on 30 patients.

PURPOSE: Increasing importance has been attributed in recent years to the preservation of the pelvic autonomic nerves during rectal resection to achieve better functional results. In addition to improved surgical techniques, intraoperative neuromonitoring may be useful. METHODS: This single-arm prospective study included 30 patients who underwent rectal resection performed with intraoperative neuromonitoring by recording the change in the tissue impedance of the urinary bladder and rectum after stimulation of the pelvic autonomic nerves. The International Prostate Symptom Score, the post-void residual urine volume and the Low Anterior Resection Syndrome Score (LARS score) were assessed during the 12-month follow-up period. RESULTS: A stimulation-induced change in tissue impedance was observed in 28/30 patients (93.3%). In the presence of risk factors such as low anastomosis, neoadjuvant radiotherapy and a deviation stoma, an average increase of the LARS score by 9 points was observed 12 months after surgery (p = 0,04). The function of the urinary bladder remained unaffected in the first week (p = 0,7) as well as 12 months after the procedure (p = 0,93). CONCLUSION: The clinical feasibility of the new method for pelvic intraoperative neuromonitoring could be verified. The benefits of intraoperative pelvic neuromonitoring were particularly evident in difficult intraoperative situations with challenging visualization of the pelvic nerves.

Infraorbital canal variants and its clinical and surgical implications. A systematic review.

BACKGROUND: Recent literature highlights anomalous cranial nerves in the sinonasal region, notably in the sphenoid and maxillary sinuses, linked to anatomical factors. However, data on the suspended infraorbital canal (IOC) variant is scarce in cross-sectional imaging. Anatomical variations in the sphenoid sinuses, including optic, maxillary, and vidian nerves, raise interest among specialists involved in advanced sinonasal procedures. The infraorbital nerve's (ION) course along the orbital floor and its abnormal positioning within the orbital and maxillary sinus region pose risks of iatrogenic complications. A comprehensive radiological assessment is crucial before sinonasal surgeries. Cone-beam computed tomography (CBCT) is preferred for its spatial resolution and reduced radiation exposure. OBJECTIVE: The aim of this study was to describe the prevalence of anatomical variants of the infraorbital canal (IOC) and report its association with clinical condition or surgical implication. METHODS: We searched Medline, Scopus, Web of Science, Google Scholar, CINAHL, and LILACS databases from their inception up to June 2023. Two authors independently performed the search, study selection, data extraction, and assessed the methodological quality with assurance tool for anatomical studies (AQUA). Finally, the pooled prevalence was estimated using a random effects model. RESULTS: Preliminary results show that three types are prevalent, type 1: the IOC does not bulge into the maxillary sinus (MS); therefore, the infraorbital foramen through the anterior wall of MS could be used for identification of the ION. Type 2: the IOC divided the orbital floor into medial and lateral aspects. Type 3: the IOC hangs in the MS and the entire orbital floor lying above the IOC. From which the clinical implications where mainly surgical, in type 1 the infraorbital foramen through the anterior wall of MS could be used for identification of the ION, while in type 2, since the lateral orbital floor could not be directly accessed an inferiorly transposition of ION is helpful to expose the lateral orbital wall directly with a 0 scope; or using angled endoscopes and instruments, however, the authors opinion is that direct exposure potentially facilitates the visualization and management in complex situations such as residual or recurrent mass, foreign body, and fracture located at the lateral aspect of the canal. Lastly, in type 3, the ION it's easily exposed with a 0° scope. CONCLUSIONS: This systematic review identified four IOC variants: Type 1, within or below the MS roof; Type 2, partially protruding into the sinus; Type 3, fully protruding into the sinus or suspended from the roof; and Type 4, in the orbital floor. Clinical recommendations aim to prevent nerve injuries and enhance preoperative assessments. However, the lack of consistent statistical methods limits robust associations between IOC variants and clinical outcomes. Data heterogeneity and the absence of standardized reporting impede meta-analysis. Future research should prioritize detailed reporting, objective measurements, and statistical approaches for a comprehensive understanding of IOC variants and their clinical implications. Open Science Framework (OSF): https://doi.org/10.17605/OSF.IO/UGYFZ .

Imaging of Anatomical Variants of the Lower Limb Nerves: Clinical and Preoperative Relevance.

Anatomical variants of peripheral nerves of the lower limb are relatively frequent and vulnerable to injury if not considered by the surgeon. Surgical procedures or percutaneous injections are often performed without knowing the anatomical situation. In a patient with normal anatomy, these procedures are mostly performed smoothly without major nerve complications. But in the case of anatomical variants, surgery may be challenging as "new" anatomical prerequisites complicate the procedure. In this context, high-resolution ultrasonography as the first-line imaging modality to depict peripheral nerves, has become a helpful adjunct in the preoperative setting. It is crucial, on the one hand, to gain knowledge of anatomical nerve variants and, on the other hand, to depict the anatomical situation preoperatively, to minimize the risk of surgical trauma to a nerve and make surgeries safer.

A marginal process of the zygomatic bone predicts a lateral exit of the zygomaticotemporal nerve: An anatomical study with application to surgery around the midface.

Previous studies have not verified the contents of accessory foramina of the zygomatic bone on dry skulls and thus could not conclude whether they carried accessory zygomaticofacial nerve branches or branches or the entire trunk of the zygomaticotemporal nerve (ZTN). Therefore, the aim of the current study is to present findings from cadaveric dissections to clarify this relationship. Fifty, fresh frozen, adult cadaveric sides underwent dissection of the ZTN. When identified, these nerves were quantified and their relationship to the zygomatic bone further documented by dissecting through the bone following the course of the nerve from a superficial to deep perspective. Additionally, 100 dry, adult, human skulls were analyzed looking for lateral foramina on the zygomatic bone. On three cadaveric sides (6%), the ZTN was found to pierce the zygomatic bone deeply and exit its superficial lateral surface. For dry skull specimens, a lateral zygomaticotemporal foramen (ZTF) was identified on nine sides (4.5%). For both groups, the presence of a strong marginal process of the zygomatic bone was strongly correlated to a ZTF exiting the lateral surface of the zygomatic bone. Although relatively uncommon, the ZTN can pierce the lateral aspect of the zygomatic bone and thus can be located superficial to the cheek. Such findings should be borne in mind during surgical or other invasive procedures in this area in order to minimize iatrogenic injury to the ZTN.

Connections between postparotid terminal branches of the facial nerve: An immunohistochemistry study.

It has been assumed that connections between the postparotid terminal branches of the facial nerve are purely motor. However, the nature of their fibers remains unexplored. The aim of this study is to determine whether these connections comprise motor fibers exclusively. In total 17 connections between terminal facial nerve branches were obtained from 13 different facial nerves. Choline acetyltransferase antibody (ChAT) was used to stain the fibers in the connections and determine whether or not all of them were motor. All connections contained ChAT positive and negative fibers. The average number of fibers overall was 287 (84-587) and the average proportion of positive fibers was 63% (37.7%-91.5%). In 29% of the nerves, >75% of the fibers were ChAT+ (strongly positive); in 52.94%, 50%-75% were ChAT+ (intermediately positive); and in 17.65%, <50% were ChAT+ (weakly positive). Fibers traveling inside the postparotid terminal cranial nerve VII branch connections are not exclusively motor.

Morphological variations of the brachial artery and their clinical significance: a systematic review.

PURPOSE: Morphological variations of the brachial artery are quite commonly discovered in routine dissection and have been the subject of many studies. However, there is a need for a clear classification. This work presents morphological variations of the brachial artery, based on numerous case reports and studies created for the appropriate classification and interpretation among surgeons and radiologists. It also discusses the most important clinical aspects of the given varieties. METHODS: The research method is based on the combined interpretation of the researches based on numerous publications concerning both the principles of correctly classifying the described morphological variations of the brachial artery and the resulting clinical implications. This work considers atypical variations such as the presence of the superficial brachial artery, brachoradial artery, accessory brachial artery and absence of the brachial artery. Variations of the brachial artery in relation to the external and internal diameter of the vessel have also been discussed. RESULTS: After conducting a complex analysis of the collected data, the fundamental principles for classifying such variability as superficial brachial artery, brachioradial artery and accessory brachial artery were defined. Additionally, clinical implications resulting from the above like the impact of the superficial brachial artery on the median nerve neuropathy and the positive correlation between the brachioradial artery and increased danger of incorrect transradial catheterization were demonstrated. CONCLUSIONS: The clinical implications of the atypical arterial pattern within the upper limb are crucial during the angiography and surgical procedures so the variations affect the appropriate diagnosis and surgical intervention. Hence, the knowledge about the morphological variations of the brachial artery should be constantly broadened by radiologists and surgeons to improve the accuracy and effectiveness of the treatment process.

Case report of unusual insertion of the fibularis brevis muscle.

The fibularis brevis and fibularis longus muscles belong to the lateral compartment of the leg. The fibularis brevis is morphologically variable, especially in the number of tendons and place of insertion. Its type of insertion is correlated with the presence of a fibularis digiti quinti, which is also anatomically variable. We present a case study based on dissection of a seventy-three-year-old female cadaver with an unusual insertion of the fibularis brevis muscle. The tendon had three bands inserting into the fifth metatarsal bone. There was a coexisting fibularis digiti quinti, which was fused with the fibularis tertius muscle. Awareness of such anatomical variation could be useful during reconstructive surgery and planning rehabilitation protocols.

A proposal for a new classification of the long head of the biceps brachii.

INTRODUCTION: The anterior compartment of the arm consists of three muscles: the biceps brachii, brachialis and coracobrachialis. The aim of the present study was to characterize possible variations in the morphology of the proximal attachments of the long head of the biceps brachii and to propose an accurate classification of the area which can be useful for planning surgical procedures and planning rehabilitation in the region. MATERIALS AND METHODS: Eighty (40 left and 40 right, 40 female, 40 male) upper limbs fixed in 10% formalin solution were examined. RESULTS: The main tendon of the long head of the biceps brachii demonstrated three types of attachment. The most common type, Type I (53.75%), was characterized by a single attachment only for the supraglenoid tubercle. Type III (33.75%) was characterized by a single attachment to the glenoid labrum. Type II (12.5%) was characterized by a double attachment to the glenoid labrum and the supraglenoid tubercle. Additionally, two types of the accessory tendon of the long head of the biceps brachii were identified (Type A-B). Type A (14 cases) was attached to the capsule of the humeral joint, and Type B (six cases) was attached to the greater tubercle of the humerus. CONCLUSION: The long head of the biceps brachii is characterized by high morphological variability. The new classification proposes three types of proximal attachment (I-III), with two types of accessory long head of the biceps brachii (A-B) tendon. A thorough understanding of the morphological variability of the long head of the biceps brachii is necessary when planning arthroscopic procedures or even planning rehabilitation procedures.

Anatomic basis for a new ultrasound-guided, mini-invasive technique for release of the deep transverse metatarsal ligament.

INTRODUCTION: Morton's neuroma is an entrapment neuropathy of the third common plantar digital nerve, caused by the deep transverse metatarsal ligament (DTML). Minimally invasive or percutaneous surgery is a very common procedure, but surgical effectivity of this technique remains controversial. The goal of our study was to prove the effectiveness and safety of a new ultrasound-guided technique for DTML-release in a cadaver model. MATERIALS, METHODS, AND RESULTS: The DTML was visualized in 10 fresh frozen donated body to science-feet (eight male and two females, five left and five right) using an US device (GE Logic R7; 13 MHz linear probe, Madrid, Spain). Consecutively, minimally invasive ultrasound-guided surgery was performed. Exclusion criteria of the donated bodies to science were previous history of forefoot surgery and space occupying mass lesions. The complete release of the ligament was achieved in all specimens without damage of any important anatomical structures as proven by anatomical dissection. CONCLUSIONS: The results of this study indicate that our novel approach of an ultrasound-guided release of the DTML is safer and more effective compared to blind techniques. The DTML could reliably be visualized and securely cut through a dorsal, minimally invasive surgical incision of only 2 mm.

The anconeus muscle revisited: double innervation pattern and its clinical implications.

PURPOSE: The aim of the present study is to describe in detail the morphology and innervation pattern of the anconeus muscle, bearing in mind clinical implications such as iatrogenic injuries during surgical elbow approaches. METHODS: A cadaveric study was performed; 56 elbows from 28 formalin-fixed cadavers belonging to the Anatomy Department of Universidad Complutense of Madrid were dissected. The triceps-anconeus nerve was located and dissected. A second innervation to the anconeus muscle from a branch of the posterior interosseous nerve (PIN) was occasionally detected. Taking the lateral epicondyle as a landmark, the entry points of both nerves in the muscle were referenced, the triceps-anconeus nerve was referenced at 0°, 30°, 45°, 70° and 90° of elbow flexion, and the PIN branch at 0°. RESULTS: Anconeus muscle was present in all specimens. The triceps-anconeus nerve was present in all of the dissected elbows. A branch from PIN to the anconeus muscle was present in 38 of the 54 elbows (70.4%). There were statistically significant differences in all measurements regarding the specimens' gender, being higher for men. CONCLUSIONS: There is evidence of a high frequency of a double innervation pattern for the anconeus muscle: the main branch of triceps-anconeus muscle depending on the radial nerve, which is liable to being damaged during posterior elbow approaches, and a secondary branch depending on the PIN. There are very few references to this finding in Anatomical literature and none with such a large sample size.

Anatomical basis of a safe mini-invasive technique for lengthening of the anterior gastrocnemius aponeurosis.

BACKGROUND: The surgical procedure itself of lengthening the gastrocnemius muscle aponeurosis is performed to treat multiple musculoskeletal, neurological and metabolical pathologies related to a gastro-soleus unit contracture such as plantar fasciitis, Achilles tendinopathy, metatarsalgia, cerebral palsy, or diabetic foot ulcerations. Therefore, the aim of our research was to prove the effectiveness and safety of a new ultrasound-guided surgery-technique for the lengthening of the anterior gastrocnemius muscle aponeurosis, the "GIAR"- technique: the gastrocnemius-intramuscular aponeurosis release. METHODS AND RESULTS: An ultrasound-guided surgical GIAR on ten fresh-frozen specimens (10 donors, 8 male, 2 females, 5 left and 5 right) was performed. Exclusion criteria of the donated bodies to science were BMI above 35 (impaired ultrasound echogenicity), signs of traumas in the ankle and crural region, a history of ankle or foot ischemic vascular disorder, surgery or space-occupying mass lesions. The surgical procedures were performed by two podiatric surgeons with more than 6 years of experience in ultrasound-guided procedures. The anterior gastrocnemius muscle aponeurosis was entirely transected in 10 over 10 specimens, with a mean portal length of 2 mm (± 1 mm). The mean gain at the ankle joint ROM after the GIAR was 7.9° (± 1.1°). No damages of important anatomical structures could be found. CONCLUSION: Results of this study indicate that our novel ultrasound-guided surgery for the lengthening of the anterior gastrocnemius muscle aponeurosis (GIAR) might be an effective and safe procedure.

Derotational femoral osteotomy changes patella tilt, patella engagement and tibial tuberosity trochlear groove distance.

PURPOSE: The aim was to assess the influence of femoral derotational osteotomy on patella tilt (PT), axial patella engagement (AEI) and tibial tuberosity trochlear groove distance (TTTG). METHODS: Derotational femoral osteotomy was performed on ten lower limbs of body donors embalmed with alcohol-glycerine. Femoral torsion, tibial torsion, knee torsion, PT, AEI and TTTG were evaluated on axial CT slices for an absolute femoral torsion of 15°, 20°, 25°, 30°, 35° and 40°. A linear mixed model analysis was used to estimate the effect of femoral torsion on PT, AEI, TTTG and knee torsion adjusted for correlation due to repeated observations. Estimates with 95% confidence intervals were used to represent the mean change in the dependent variables for one unit of change (degree, mm or AEI) in the predictor variable. RESULTS: A significant correlation was observed between femoral torsion and AEI (p < 0.001), PT (p < 0.001) and TTTG distance (p = 0.002). In cases of increased internal femoral torsion, a significant decreased AEI (estimate - 0.003, 95% CI - 0.003 to - 0.002), an increased PT (estimate 0.3, 95% CI 0.2-0.4) and an increased TTTG distance (estimate 0.1, 95% CI 0.1-0.2) were observed. No correlation was seen between change in femoral torsion and knee torsion (n.s.). CONCLUSIONS: Derotational femoral osteotomy has a significant impact on patella tilt and axial patella engagement. Moreover, TTTG distance is slightly changed by a derotational femoral osteotomy, which has to be taken into account preoperatively when considering surgical procedures. LEVEL OF EVIDENCE: Level V.

Clinical-anatomic mapping of the tarsal tunnel with regard to Baxter's neuropathy in recalcitrant heel pain syndrome: part I.

PURPOSE: Neuropathy of the Baxter nerve (BN) seems to be the first cause of the heel pain syndrome (HPS) of neurological origin. METHODS: 41 alcohol-glycerol embalmed feet were dissected. We documented the pattern of the branches of the tibial nerve (TN) and describe all relevant osteofibrous structures. Measurements for the TN branches were related to the Dellon-McKinnon malleolar-calcaneal line also called DM line (DML) for the proximal TT and the Heimkes Triangle for the distal TT. Additionally, we performed an ultrasound-guided injection procedure of the BN and provide an algorithm for clinical usage. RESULTS: The division of the TN was 16.4 mm proximal to the DML. The BN branches off 20 mm above the DML center or 30 mm distally to it. In most of the cases, the medial calcaneal branch (MCB) originated from the TN proximal to the bifurcation. Possible entrapment spots for the medial and lateral plantar nerve (MPN, LPN), the BN and the MCB are found within a circle of 5 mm radius with a probability of 80%, 83%, and 84%, respectively. In ten out of ten feet, the US-guided injection was precisely allocated around the BN. CONCLUSIONS: Our detailed mapping of the TN branches and their osteofibrous tubes at the TT might be of importance for foot and ankle surgeons during minimally invasive procedures in HPS such as ultrasound-guided ankle and foot decompression surgery (UGAFDS).

Ultrasound-guided decompression surgery of the distal tarsal tunnel: a novel technique for the distal tarsal tunnel syndrome-part III.

BACKGROUND: The aim of this study was to provide a safe ultrasound-guided minimally invasive surgical approach for a distal tarsal tunnel release concerning nerve entrapments. METHODS AND RESULTS: The study was carried out on ten fresh-frozen feet. All of them have been examined by high-resolution ultrasound at the distal tarsal tunnel. The surgical approach has been marked throughout the course of the medial intermuscular septum (MIS, the lateral fascia of the abductor hallucis muscle). After the previous steps, nerve decompression was carried out through a MIS release through a 2.5 mm (± 0.5 mm) surgical portal. As a result, an effective release of the MIS has been obtained in all fresh-frozen feet. CONCLUSION: The results of our anatomic study indicate that this novel ultrasound-guided minimally invasive surgical approach for the release of the MIS might be an effective, safe and quick decompression technique treating selected patients with a distal tarsal tunnel syndrome.

Ultrasound-guided decompression surgery of the tarsal tunnel: a novel technique for the proximal tarsal tunnel syndrome-Part II.

BACKGROUND: The aim of this study is to provide a safe ultrasound-guided minimally invasive surgical approach for a proximal tarsal tunnel release concerning nerve entrapments. METHODS AND RESULTS: The study was carried out on ten fresh-frozen feet. All of them were examined by high resolution ultrasound at the medial ankle region. The surgical approach was marked throughout the course of the flexor retinaculum (laciniate ligament). Once the previous steps were done, the flexor retinaculum release technique was carried out with a 2-mm entry only. As a result, an effective and safe release of the flexor retinaculum was obtained in all fresh-frozen feet. CONCLUSION: The results of our anatomic study indicate that our novel ultrasound-guided minimally invasive surgical approach for the release of the flexor retinaculum might be an effective, safe and quick decompression technique treating selected patients with a proximal tarsal tunnel syndrome.

Pedicle screw anchorage of carbon fiber-reinforced PEEK screws under cyclic loading.

PURPOSE: Pedicle screw loosening is a common and significant complication after posterior spinal instrumentation, particularly in osteoporosis. Radiolucent carbon fiber-reinforced polyetheretherketone (CF/PEEK) pedicle screws have been developed recently to overcome drawbacks of conventional metallic screws, such as metal-induced imaging artifacts and interference with postoperative radiotherapy. Beyond radiolucency, CF/PEEK may also be advantageous over standard titanium in terms of pedicle screw loosening due to its unique material properties. However, screw anchorage and loosening of CF/PEEK pedicle screws have not been evaluated yet. The aim of this biomechanical study therefore was to evaluate whether the use of this alternative nonmetallic pedicle screw material affects screw loosening. The hypotheses tested were that (1) nonmetallic CF/PEEK pedicle screws resist an equal or higher number of load cycles until loosening than standard titanium screws and that (2) PMMA cement augmentation further increases the number of load cycles until loosening of CF/PEEK screws. METHODS: In the first part of the study, left and right pedicles of ten cadaveric lumbar vertebrae (BMD 70.8 mg/cm3 ± 14.5) were randomly instrumented with either CF/PEEK or standard titanium pedicle screws. In the second part, left and right pedicles of ten vertebrae (BMD 56.3 mg/cm3 ± 15.8) were randomly instrumented with either PMMA-augmented or nonaugmented CF/PEEK pedicle screws. Each pedicle screw was subjected to cyclic cranio-caudal loading (initial load ranging from - 50 N to + 50 N) with stepwise increasing compressive loads (5 N every 100 cycles) until loosening or a maximum of 10,000 cycles. Angular screw motion ("screw toggling") within the vertebra was measured with a 3D motion analysis system every 100 cycles and by stress fluoroscopy every 500 cycles. RESULTS: The nonmetallic CF/PEEK pedicle screws resisted a similar number of load cycles until loosening as the contralateral standard titanium screws (3701 ± 1228 vs. 3751 ± 1614 load cycles, p = 0.89). PMMA cement augmentation of CF/PEEK pedicle screws furthermore significantly increased the mean number of load cycles until loosening by 1.63-fold (5100 ± 1933 in augmented vs. 3130 ± 2132 in nonaugmented CF/PEEK screws, p = 0.015). In addition, angular screw motion assessed by stress fluoroscopy was significantly smaller in augmented than in nonaugmented CF/PEEK screws before as well as after failure. CONCLUSIONS: Using nonmetallic CF/PEEK instead of standard titanium as pedicle screw material did not affect screw loosening in the chosen test setup, whereas cement augmentation enhanced screw anchorage of CF/PEEK screws. While comparable to titanium screws in terms of screw loosening, radiolucent CF/PEEK pedicle screws offer the significant advantage of not interfering with postoperative imaging and radiotherapy. These slides can be retrieved under Electronic Supplementary Material.

Biomechanical evaluation of cable and suture cerclages for tuberosity reattachment in a 4-part proximal humeral fracture model treated with reverse shoulder arthroplasty.

BACKGROUND: Sufficient tuberosity fixation in proximal humeral fractures treated with shoulder arthroplasty is essential to gain a good clinical outcome. This biomechanical study evaluated the strength of the reattached tuberosities in reverse total shoulder arthroplasty fixed with cables or with sutures in a cerclage-like technique. Considering the mechanical advantages of flexible titanium alloy cables compared with conventional sutures for cerclage-like fixations, we hypothesized that titanium alloy cables would achieve higher fixation strengths of the tuberosities compared with heavy nonabsorbable sutures. METHODS: A 4-part fracture was created on 8-paired proximal human humeri. The tuberosities were reduced anatomically and fixed by 2 heavy nonabsorbable sutures (suture group) or by two 1-mm titanium alloy cables (cable group) in a cerclage-like technique around the neck of the prosthesis. The humeri were placed in a custom-made test setup enabling internal and external rotation. Cyclic loading with a stepwise increasing load magnitude was applied with a material testing machine, starting with 1 Nm and increasing the load by 0.25 Nm after each 100th cycle until failure of the fixation occurred (>15° rotation of the tuberosities). Any motion of the tuberosities was measured with a 3-dimensional ultrasound motion analysis system. RESULTS: Overall, the cable group reached 1414 ± 372 cycles, and the suture group reached 1257 ± 230 cycles until the fixations failed (P = .313). The suture group showed a significantly higher rotation of the lesser tuberosity relative to the humerus shaft axis after 200, 400, and 600 cycles compared with the cable group (P = .018-.043). CONCLUSIONS: Tuberosities reattached with cable cerclages showed higher fixation strength and therefore less rotation compared with suture cerclages in a 4-part proximal humeral fracture model treated with reverse total shoulder arthroplasty. Whether this higher fixation strength results in higher bony ingrowth rates of the tuberosities and thus leads to a better clinical outcome needs to be investigated in further clinical studies.

Contemporary CBCT diagnostics-discovery of a new artery with possible impact on surgical planning: the anterior superior palatal alveolar artery.

PURPOSE: An ongoing clinical trial regarding intra- and post-surgical morbidity in maxillary apicoectomies showed significant higher morbidity for upper canines and palatal roots of upper 1st premolars. Analysis of available presurgical cone beam computed tomography (CBCT)-scans revealed the existence of an unknown bone-canal branching off from the bone-canal or groove of the anterior superior alveolar artery (asaa). Aim of the study was the determination of the contents of this newly found bone canal in human cadaver heads, its prevalence as possible standard anatomical structure and its automatized detection with a contemporary high-resolution TRIUM-CBCT-device in vivo. METHODS: 35 human cadaver heads were dissected, the prevalence of the bone-canal determined and its contents analyzed by histology. 835 consecutive routine high-resolution TRIUM-CBCT-scans from routine patients were analyzed by an automatized detection- and tracing-algorithm for in vivo-determination of prevalence of this bone canal. Automatized detection and additional manual tracing were statistically evaluated by SSPS 20.0 software. RESULTS: The bone-canal was found in 96% of the anatomical specimens, its content identified as artery not described until now and named after the first finder "Arteria Kurrekii". Automatized tracing of TRIUM-CBCT-scans with additional manual tracing revealed an in vivo prevalence of this newly found artery of 95% (p ≤ 0.05). CONCLUSIONS: The newly found anterior superior palatal alveolar artery (aspaa-"Arteria Kurrekii") might have the same clinical impact for surgical procedures in the maxilla as the posterior superior alveolar artery (psaa). Its first detection was enabled by high-resolution TRIUM-CBCT devices and prevalence as standard anatomical structure proven in vivo by automatized CBCT-scan analysis.

New laparoscopic approach to the pudendal nerve for neuromodulation based on an anatomic study.

AIMS: The aim was to develop a new laparoscopic technique for placement of a pudendal lead. METHODS: Development of a direct, feasible and reliable minimal-invasive laparoscopic approach to the pudendal nerve (PN). Thirty-one embalmed human specimens were dissected for the relevant anatomic structures of the pelvis. Step-by-step documentation and analysis of the laparoscopic approach in order to locate the PN directly in its course around the medial part of the sacrospinous ligament and test this approach for feasibility. Landmarks for intraoperative navigation towards the PN as well as the possible position of an lead were selected and demonstrated. RESULTS: The visible medial umbilical fold, the intrapelvine part of the internal pudendal artery, the coccygeus muscle and the sacrospinous ligament are the main landmarks. The PN traverses the medial part of the sacrospinous ligament dorsally, medially to the internal pudendal artery. The medial part of the sacrospinous ligament has to be exposed in order to display the nerve. An lead can be placed ventrally on the nerve or around it, depending on the lead type or shape. CONCLUSIONS: A precise and reliable identification of the PN by means of laparoscopy is feasible with an easy four-step approach: (1) identification of the medial umbilical fold; (2) identification of the internal iliac artery; (3) identification of the internal pudendal artery and incision of the coccygeus muscle ('white line', arcuated line); and (4) exposition of the medial part of the sacrospinous ligament to display the PN.