Nuevo índice aterogénico para la predicción de aterosclerosis carotídea basado en la ratio proteína C reactiva no ultrasensible/HDL / New atherogenic index for the prediction of carotid atherosclerosis based on the non-ultrasensitive c-reactive protein/HDL ratio

Introducción La valoración del riesgo cardiovascular aparece en las guías clínicas como medida de prevención de enfermedades cardiovasculares, cuya etiología fundamental es la arteriosclerosis. Una de las herramientas que se utiliza para estimar el riesgo en práctica clínica son los índices aterogénicos (IA), cocientes entre fracciones lipídicas con rangos de referencia bien establecidos. A pesar de su uso extendido, existe todavía información limitada sobre su utilidad clínica. En los últimos años, algunas investigaciones han reforzado el papel de la inflamación en la etiología y cronicidad del proceso aterosclerótico. La inclusión de parámetros inflamatorios en el cálculo de IA podría mejorar su rendimiento diagnóstico en la detección de arteriosclerosis. Nos propusimos evaluar un nuevo IA en forma de ratio entre los valores de proteína C reactiva (PCR) no ultrasensible y las cifras de colesterol unido a lipoproteínas de alta densidad (HDL). Métodos Se incluyeron en el estudio 282 pacientes, asintomáticos, y sin historia de enfermedad cardiovascular. Se realizó en todos ellos analítica con perfil lipídico y PCR, y en el plazo inferior a un mes, ecografía carotídea para evaluar la presencia de ateromatosis. El nuevo IA se estableció como el cociente entre el valor de PCR no ultrasensible en mg/dL (multiplicado por 100) y el valor de HDL en mg/dL. Se comparó con los índices de Castelli I y II, y el índice aterogénico del plasma. La curva ROC determinó que el punto de corte óptimo del nuevo IA fue valor=1, con un área bajo la curva de 0,678 (IC 95% 0,60-0,75; p<0,001). ResultadosLa edad media de la muestra fue 60,4±14,5 años. Un total de 118 pacientes (41,8% del total) tenían arteriosclerosis carotídea. Al evaluar el rendimiento diagnóstico de los IA, encontramos que la ratio PCR·100/HDL mostró los valores más elevados de sensibilidad y valor predictivo positivo (0,73 y 0,68, respectivamente) ... Conclusiones... (AU)

Introduction Current guidelines recommend cardiovascular risk assessment as a preventive measure for cardiovascular diseases, whose fundamental etiology is arteriosclerosis. One of the tools used to estimate risk in clinical practice are atherogenic indices (AI), ratios between lipid fractions with well-established reference ranges. Despite its widespread use, there is still limited information on its clinical utility. In recent years, some research has reinforced the role of inflammation in the etiology and chronicity of the atherosclerotic process. The inclusion of inflammatory parameters in the AI calculation could improve its diagnostic performance in the detection of arteriosclerosis. We sought to evaluate a new AI as a ratio between C-reactive protein (CRP) values and high-density lipoprotein cholesterol (HDL) values. Methods A total of 282 asymptomatic patients with no history of cardiovascular disease were included in the study. Laboratory tests with lipid profile and CRP, and carotid ultrasound to assess the presence of atheromatosis were performed in all of them. The new AI is established as the ratio between non-ultrasensitive CRP value in mg/dL (multiplied by 100) and HDL value in mg/dL. It was compared with the Castelli I and II indices, and the plasma atherogenic index. The optimal cut-off point of the new AI was value=1 as determined by ROC curve, with an area under the curve of 0.678 (95% CI 0.60-0.75; p<0.001).Results Mean age of patients was 60.4±14.5 years. A total of 118 patients (41.8% of total) had carotid arteriosclerosis. When evaluating the diagnostic performance of different AIs, we found that CRP·100/HDL ratio showed the highest values of sensitivity and positive predictive value (0.73 and 0.68, respectively) compared to the Castelli I and II indices, and the plasma atherogenic index. ... Conclusions ... (AU)

New atherogenic index for the prediction of carotid atherosclerosis based on the non-ultrasensitive c-reactive protein/HDL ratio. / Nuevo índice aterogénico para la predicción de aterosclerosis carotídea basado en la ratio proteína C reactiva no ultrasensible/HDL.

INTRODUCTION: Current guidelines recommend cardiovascular risk assessment as a preventive measure for cardiovascular diseases, whose fundamental etiology is arteriosclerosis. One of the tools used to estimate risk in clinical practice are atherogenic indices (AI), ratios between lipid fractions with well-established reference ranges. Despite its widespread use, there is still limited information on its clinical utility. In recent years, some research has reinforced the role of inflammation in the etiology and chronicity of the atherosclerotic process. The inclusion of inflammatory parameters in the AI calculation could improve its diagnostic performance in the detection of arteriosclerosis. We sought to evaluate a new AI as a ratio between C-reactive protein (CRP) values and high-density lipoprotein cholesterol (HDL) values. METHODS: A total of 282 asymptomatic patients with no history of cardiovascular disease were included in the study. Laboratory tests with lipid profile and CRP, and carotid ultrasound to assess the presence of atheromatosis were performed in all of them. The new AI is established as the ratio between non-ultrasensitive CRP value in mg/dL (multiplied by 100) and HDL value in mg/dL. It was compared with the Castelli I and II indices, and the plasma atherogenic index. The optimal cut-off point of the new AI was value=1 as determined by ROC curve, with an area under the curve of 0.678 (95% CI 0.60-0.75; p<0.001). RESULTS: Mean age of patients was 60.4±14.5 years. A total of 118 patients (41.8% of total) had carotid arteriosclerosis. When evaluating the diagnostic performance of different AIs, we found that CRP·100/HDL ratio showed the highest values of sensitivity and positive predictive value (0.73 and 0.68, respectively) compared to the Castelli I and II indices, and the plasma atherogenic index. It was also the only predictor of carotid atheromatosis both when considering its values quantitatively (with OR 1.4 [95% CI 1.1-1.7]; p=0.005), and qualitatively (with OR 2.9 [95% CI 1.5-5.5]; p<0.001) in patients with a CRP·100/HDL ratio>1. CONCLUSIONS: The new PCR·100/HDL index showed the best diagnostic performance in the detection of carotid atheromatosis compared to other classic AIs in this Spanish population of asymptomatic patients.

Lateral pterygoid muscle ultrasound-guided injection: A technical note.

BACKGROUND: Temporomandibular disorders (TMDs) are a frequent cause of orofacial pain, causing functional disability and a negative impact on quality of life. Botulinum toxin (BTX-A) injection in lateral pterygoid muscle (LPM) is one of the treatment modalities proposed, but the blind puncture guided by EMG carries a risk of vascular puncture or diffusion of the toxin to nearby muscles. We describe an ultrasound-guided approach and evaluate the spread of the injection in a fresh human cadaver. METHODS: A fresh human cadaver was injected. An out-of-plane approach was performed using a convex probe, injecting 1.0 ml of 0.25% methylene blue dye into the LPM. After, a dissection was performed to isolate the lateral pterygoid muscle and assess the spread of the dye. RESULTS: Ultrasound-guided injection allowed to visualize in real-time the spread of the dye within the LPM. The deep and superficial muscles nearby to LPM were not stained by the dye, but upper and lower head of LPM was heavily stained. CONCLUSION: Ultrasound-guided approach for the injection of BTX-A into the LPM could be considered a successful and safe treatment for myofascial pain related to TMD. Therefore, further clinical studies are needed to study the reproducibility of ultrasound guided LPM injection and to evaluate the clinical results.

Comparison of vertical and extended vertical rectus abdominis myocutaneous flaps. An anatomical study.

The extended vertical rectus abdominis myocutaneous (eVRAM) flap has been proposed for reconstruction of large pelviperineal defects where traditional VRAM flap could be insufficient. To compare the dimensions of VRAM and eVRAM flaps an anatomical study was performed. Ten VRAM and ten eVRAM flaps were dissected in ten fresh adult cadavers. Length, width and volume of all the flaps were measured. Length and volume were significantly larger in eVRAM flap compared to VRAM flap (36.55 cm vs. 30.15, p=.005; and 315.5 vs. 244 mL, p=.012, respectively). No differences were observed in flap width. The eVRAM flap could be a better option than traditional VRAM for reconstruction of big pelviperineal defects when bulkier tissue, larger skin paddle and/or longer arch of rotation are needed for reconstruction.

Bilateral vertebral arteries arising distal to the left subclavian artery: embryological and anatomical description.

Abnormalities in the origin of vertebral arteries are relatively uncommon, but extremely rare when this abnormality happens on both sides. We present an anatomic variation in which both vertebral arteries came from the proximal descending thoracic aorta beyond the left subclavian artery with no other supra-aortic vessels accompanying the abnormality. The right vertebral artery took a retro-oesophageal course (lusoria artery), while the right and the left vertebral arteries enter the transverse foramina at the 7th cervical vertebra. From an embryological point of view, and overall controversial, this anomaly can be explained by the bilateral persistence of the 8th intersegmental artery as the origin of vertebral artery, instead of the dorsal segment of the 7th intersegmental artery being the origin, which is normally the case. The adequate identification of vertebral artery anomalies in complementary explorations is very important to avoid misdiagnosed vertebral occlusions or unexpected vertebral artery injuries during supra-aortic trunks, thyroid, and oesophagus open surgeries, among others, or even over the course of endovascular procedures.

Prevalence and morphometric analysis of the retromolar canal in a Spanish population sample: a helical CT scan study

Background: The retromolar canal (RMC) is an anatomical variation of the mandibular canal (MC) whose identification and study should be considered given its implication in the surgical procedures of the retromolar area. The prevalence of the RMC widely varies according to previous studies and may be influenced by the followed study method. This work aimed to evaluate the prevalence of the RMC in a Spanish population sample. Material and Methods: For this purpose, 225 CT scan images (with a higher resolution than the cone beam CT used in other previous studies) from the Hospital Clínico Universitario de Valencia were analyzed. The Osirix MD® radiological image analysis system was applied to analyse the dimensions, location in the retromolar area and morphologic characteristics of the RMC by classifying them according to their typology. Furthermore, the relations between the RMC and gender, age and laterality were studied. Results: RMC prevalence was 23.1%. No significant relation between the presence of the canal and gender, age or laterality was found. Type Ia was the commonest type with a prevalence of 40.8%. Conclusions: Based on the results of this study, the RMC should be considered a frequent anatomical variation whose complete study is very important in daily clinical practice.(AU)

Anatomía quirúrgica aplicada a abordajes transperitoneales de la aorta abdominal y los troncos viscerales. Artículo dinámico / Surgical anatomy applied to transperitoneal approaches of the abdominal aorta and visceral trunks. Dynamic article

Los cirujanos cardiovasculares y del aparato digestivo deberían estar al corriente de las múltiples alternativas de abordaje de la aorta abdominal y sus troncos viscerales. Artículo narrativo, ilustrado y dinámico de las diferentes maniobras quirúrgicas descritas con este objetivo. Disección de 5 cadáveres realizadas durante tres cursos nacionales de Anatomía Quirúrgica aplicada a aorta integral, Cirugía hepatobiliopancreática y Cirugía abdominal digestiva. Maniobras quirúrgicas descritas: abordaje aórtico inframesocólico longitudinal, abordaje aórtico supracelíaco, abordaje del tronco celíaco, tres tipos de abordaje de la arteria mesentérica superior: retroperitoneal tras maniobra de Kocher, supramesocólico e inframesocólico, maniobra de Cattell-Braasch y dos tipos de maniobra de Mattox: retrorrenal y prerrenal. El conocimiento profundo de la anatomía intraabdominal es fundamental para la actuación quirúrgica sobre la aorta abdominal y el entrenamiento en cadáver a partir de la anatomía quirúrgica vascular y del tubo digestivo podría ayudar a desarrollar las habilidades quirúrgicas de los cirujanos en formación. (AU)

Access to the abdominal aorta and its visceral trunks is possible through several approaches. Dissections of five cadavers performed during three National Surgical Anatomy courses applied to Aorta, Hepatobiliopancreatic and Digestive Surgery. Videos and pictures were taken throughout the dissections and showed different abdominal aorta approaches. Abdominal aorta and visceral trunks approaches: longitudinal inframesocolic access, supraceliac clamping, celiac trunk dissection, superior mesenteric artery approaches (retroperitoneal after Kocher menoeuvre, supramesocolic or inframesocolic), Cattell-Braasch manoeuvre and mattox manoeuvre: retrorenal and prerenal. Correct knowledge of the intraabdominal anatomy is necessary to perform all the abdominal aorta surgical approaches. Cadaveric dissection could help to achieve this objective. Cardiovascular and digestive surgeons need to know the possible strategies in order to choose the one which is best suited for each patient. (AU)

Surgical anatomy applied to transperitoneal approaches of the abdominal aorta and visceral trunks. Dynamic article.

Access to the abdominal aorta and its visceral trunks is possible through several approaches. Dissections of five cadavers performed during three National Surgical Anatomy courses applied to Aorta, Hepatobiliopancreatic and Digestive Surgery. Videos and pictures were taken throughout the dissections and showed different abdominal aorta approaches. Abdominal aorta and visceral trunks approaches: longitudinal inframesocolic access, supraceliac clamping, celiac trunk dissection, superior mesenteric artery approaches (retroperitoneal after Kocher menoeuvre, supramesocolic or inframesocolic), Cattell-Braasch manoeuvre and mattox manoeuvre: retrorenal and prerenal. Correct knowledge of the intraabdominal anatomy is necessary to perform all the abdominal aorta surgical approaches. Cadaveric dissection could help to achieve this objective. Cardiovascular and digestive surgeons need to know the possible strategies in order to choose the one which is best suited for each patient.

Improving the cementation of the tibial component in knee arthroplasty : a study of four techniques in the cadaver.

AIMS: The main objective of this study is to analyze the penetration of bone cement in four different full cementation techniques of the tibial tray. METHODS: In order to determine the best tibial tray cementation technique, we applied cement to 40 cryopreserved donor tibiae by four different techniques: 1) double-layer cementation of the tibial component and tibial bone with bone restrictor; 2) metallic cementation of the tibial component without bone restrictor; 3) bone cementation of the tibia with bone restrictor; and 4) superficial bone cementation of the tibia and metallic keel cementation of the tibial component without bone restrictor. We performed CT exams of all 40 subjects, and measured cement layer thickness at both levels of the resected surface of the epiphysis and the endomedular metaphyseal level. RESULTS: At the epiphyseal level, Technique 2 gave the greatest depth compared to the other investigated techniques. At the endomedular metaphyseal level, Technique 1 showed greater cement penetration than the other techniques. CONCLUSION: The best metaphyseal cementation technique of the tibial component is bone cementation with cement restrictor. Additionally, if full tibial component cementation is to be done, the cement volume used should be about 40 g of cement, and not the usual 20 g. Cite this article: Bone Joint Res 2021;10(8):467-473.

Surgical anatomy applied to transperitoneal approaches of the abdominal aorta and visceral trunks. Dynamic article. / Anatomía quirúrgica aplicada a abordajes transperitoneales de la aorta abdominal y los troncos viscerales. Artículo dinámico.

Access to the abdominal aorta and its visceral trunks is possible through several approaches. Dissections of five cadavers performed during three National Surgical Anatomy courses applied to Aorta, Hepatobiliopancreatic and Digestive Surgery. Videos and pictures were taken throughout the dissections and showed different abdominal aorta approaches. Abdominal aorta and visceral trunks approaches: longitudinal inframesocolic access, supraceliac clamping, celiac trunk dissection, superior mesenteric artery approaches (retroperitoneal after Kocher menoeuvre, supramesocolic or inframesocolic), Cattell-Braasch manoeuvre and mattox manoeuvre: retrorenal and prerenal. Correct knowledge of the intraabdominal anatomy is necessary to perform all the abdominal aorta surgical approaches. Cadaveric dissection could help to achieve this objective. Cardiovascular and digestive surgeons need to know the possible strategies in order to choose the one which is best suited for each patient.

A Randomized Controlled Trial of Three Noninvasive Analgesic Techniques for the Prevention of Pain During Facial Injections.

BACKGROUND: Injections are associated with a certain amount of pain, the tolerance of which can vary between individuals. With regard to noninvasive pain control techniques in subcutaneous injections, few studies with adequate levels of evidence and design quality exist to support any specific analgesic method. OBJECTIVES: In this study, we evaluated the efficacy of 3 noninvasive analgesic techniques (cold, anesthetic cream, and vibration) during subcutaneous forehead injections in 100 healthy volunteers. METHODS: This randomized, single-blind, controlled trial comprised 100 healthy volunteers. Every patient received 4 forehead injections of 0.1 mL physiological saline through 29G needles after 1 of 3 noninvasive analgesic techniques (cold, vibration, or anesthetic cream) or control treatment was applied to each injection site. The results were evaluated through a survey that included a visual analog scale for pain measurements. RESULTS: All analgesic methods demonstrated better pain control than the no-treatment arm (P < 0.001), of which vibration performed better than the other analgesic techniques (P < 0.015 vs cold and P < 0.015 vs anesthetic cream). No differences were observed between cold and anesthetic cream. The average amount of pain per injection in males was higher than in females (P < 0.014). CONCLUSIONS: Vibration analgesia effected significantly better pain control than cold and anesthetic cream. Nevertheless, the choice of anesthetic method should be adapted to the preferences and experiences of each patient to optimize pain control in procedures that involve subcutaneous injections.

Chronic Pregabalin Treatment Ameliorates Pain, but not Depressive-Like Behaviors, in a Reserpine-Induced Myalgia Model in Rats.

BACKGROUND: Anticonvulsants are often prescribed as coanalgesics for pathologies presenting chronic pain, such as chronic neuropathic pain and fibromyalgia. These pathologies are associated with a wide range of comorbidities: chronic fatigue, cognitive impairment, sleep disturbances, and mood disorders. Pregabalin, an anticonvulsant used to treat fibromyalgia syndrome, has been proven to improve pain and fatigue symptoms. However, most studies have not considered the analytic effect of this drug on comorbid depressive-like symptoms in this syndrome. OBJECTIVES: The main study objective was to examine the role of pregabalin in depressive symptomatology comorbid to chronic widespread pain using a reserpine-induced myalgia model. STUDY DESIGN: A randomized, controlled, animal study. SETTING: Research and data analyses were performed at the GESADA laboratory, Department of Human Anatomy and Embryology, University of Valencia, Spain. METHODS: Forty-six Sprague-Dawley male rats were used. Acute chronic pregabalin administration was tested for depressive-like behaviors (Forced Swimming and Novelty-Suppressed Feeding Tests) and for alteration of pain thresholds (tactile allodynia, Electronic Von Frey test; and mechanical hyperalgesia, Randall and Selitto test). The same procedures were followed with duloxetine as a positive control. RESULTS: Pregabalin significantly improved depressive-like behaviors in acute, but not chronic treatment, and significantly ameliorated pain thresholds. LIMITATIONS: Lack of histological and electrophysiological tests. CONCLUSIONS: Pregabalin is not effective in depressive-like symptoms associated with chronic pain but might play an acute antidepressive-like role given its antinociceptive effect.

Successful surgery of neuroendocrine carcinoma infiltrating right ventricle and pulmonary artery.

We present the clinical case of a 60-year-old woman complained of dyspnea on exertion. Echocardiogram showed a giant mass in the right ventricle (RV) with obstruction to the outflow tract. Thorax computed tomography confirmed a mass of greater than 60 mm infiltrating RV and causing severe stenosis in the pulmonary artery, with severe pericardial effusion. Cardiac surgery was performed for tumor resection and pulmonary root replacement with a biological valved conduit. Histological analysis diagnosed a poorly differentiated large-cell neuroendocrine carcinoma. The patient had no immediate postoperative complications and has completed radiotherapy at a 9-month follow-up.

Feasibility and diagnostic performance of including point-of-care ultrasound (POCUS) in preparticipation screening of young competitive athletes.

Optimal pre-participative screening in young athletes is still controversial. We sought to evaluate the strategy of including point-of-care ultrasound to electrocardiogram. In total, 1188 young competitive athletes were screened in different sports institutions. This proved to be a useful strategy by improving diagnostic performance primarily with respect to detect structural abnormalities and also by minimising positive false cases of electrocardiogram alone.

Microscopic Study of Injectable Steroids: Effects of Postmixing Time on Particle Aggregation.

BACKGROUND: Epidural steroid injection (ESI) is a common practice for pain treatment since 1953. In 2014, the FDA issued a warning about ESI. Studies have focused on the effect of the particle size and their ability to generate harmful aggregates. Although steroid aggregates provide longer times for reabsorption, therefore a longer anti-inflammatory effect, they are potentially harmful to the central nervous system via embolic mechanisms.Previous studies have established that steroidal aggregates with asizes over 100 mu m are potentially able to occlude blood vessels. Studies by Tiso et al and Benzon et al addressed the role of steroids on CNS adverse events, with similar outcomes. The main difference was on the role of aggregates with a size over 100 mu m, which Benzon et al. attributed to the ability of certain steroid preparations to rapidly precipitate and form large aggregates. OBJECTIVES: Studying the effect of the time elapsed between mixing the steroid preparation and injection on the number and size of aggregates with sizes above 100 mu m. STUDY DESIGN: Original study in basic science. SETTING: Basic scienceMETHODS: Steroids evaluated are commonly used in Spain for ESI: betamethasone, triamcinolone, and dexamethasone. The size and number of the aggregates was determined for undiluted commercial steroid preparations in the usual amount for a single and double dosage used for ESI.Samples were examined with a Leica TCS-SP2 microscope at the first, the fifth and the 30th minute after shaking the preparations. Aggregates observed in the different preparations were manually counted and grouped in the following size range: 0-20, 20-50, 50-100, 100-300, 300-500 and > 500 mu m.Statistical analysis was carried out using the R software. Nonparametric techniques were used in the comparison of aggregate size. Global comparison of the groups using the Kruskal-Wallis test and post-hoc comparisons using the Wilcoxon test, adjusting P-values by the Holm method for multiple comparisonsRESULTS: Aggregates present in triamcinolone and betamethasone samples were statistically larger than in dexamethasone samples. Triamcinolone suspensions produced significantly larger aggregates than betamethasone five minutes after mixing. Triamcinolone preparations produced greater particle aggregates (> 500 mu m), which were not present in dexamethasone and betamethasone preparations. LIMITATIONS: Study how the human internal factors like blood elements and spinal fluid could interact with steroids and influence the size of the aggregates formed. CONCLUSIONS: This study demonstrates that the size of the particles injected depends on the type of steroid and the time allowed between mixing and injecting. The results demonstrate that waiting longer than 5 minutes between mixing and injecting can predispose the formation of potentially harmful aggregates in triamcinolone and betamethasone samples. The presence of greater particle aggregates (> 500 mu m) may occlude some important vessels and arteries with serious adverse results. Vigorous shaking of the injectable could prevent such events. KEY WORDS: Epidural steroid injection, triamcinolone, betamethasone, dexamethasone, steroid aggregates.

A video guide of five access methods to the splenic flexure: the concept of the splenic flexure box.

AIM: The aim of this study was to describe all the possible approaches for laparoscopic splenic flexure mobilization (SFM), each suitable for specific situations, and create an illustrated system to show SFM approaches in an easy and practical way to make it easy to learn and teach. METHODS: Two different phases. First part: Cadaver-based study of the colonic splenic flexure anatomy. In order to demonstrate the different approaches, a balloon was placed through the colonic hepatic flexure in the lesser sac without sectioning any of the fixing ligaments of the splenic flexure. Second part: A real case series of laparoscopic SFM. RESULTS: First part: 11 cadavers were dissected. Five potential approaches to SFM were found: anterior, trans-omentum, lateral, medial infra-mesocolic, and medial trans-mesocolic. The illustrative system developed was named: Splenic Flexure "Box"(SFBox). Second part: One of the types of SFM described in first part was used in five patients with colorectal cancer. Each laparoscopic approach to the splenic flexure was illustrated in a video accompanied by illustration aids delineating the access. CONCLUSION: With the cadaver dissection and subsequent demonstration in real-life laparoscopic surgery, we have shown five types of laparoscopic splenic flexure mobilization. The Splenic Flexure "Box" is a useful way to learn and teach this surgical maneuver.

A Proposal for Novel Standards of Histopathology Reporting for D3 Lymphadenectomy in Right Colon Cancer: The Mesocolic Sail and Superior Right Colic Vein Landmarks.

BACKGROUND: Strong agreement exists concerning the standards of pathologic reporting for total mesorectal excision and complete mesocolic excision. It represents a quality standard that correlates with survival. However, no agreed standards of reporting are available to define D3 lymphadenectomy for right colectomy. OBJECTIVE: The purpose of this study was to define anatomopathological standards of specimen quality obtained from the surgical specimen when an oncologic right hemicolectomy with D3 lymphadenectomy has been correctly performed. DESIGN: This study was conducted in 2 different phases. The first part consisted of a cadaver-based study of right colon anatomy, and the second part consisted of a prospective assessment of a series of surgical specimens obtained after right hemicolectomy for cancer. SETTINGS: The anatomic phase of the study was performed in collaboration with the University of Valencia Department of Anatomy and Embryology. The second part was performed at a colorectal unit of a tertiary hospital. PATIENTS: Seventeen cadavers were used for the first phase, and 65 surgical specimens were examined for the second part of the study. MAIN OUTCOME MEASURES: In each specimen, the pathologists looked for anatomic structures defined as markers of quality standards of the D3 lymphadenectomy during the first phase. Specimens were classified as complete, partial, and incomplete D3 lymphadenectomy. RESULTS: Twenty percent of specimens were classified as incomplete D3 lymphadenectomy, 31% as partial, and 49% as complete. A median number of 14 (6-64), 22 (11-47), and 29 (14-55) lymph nodes were isolated (p = 0.01). Similarly, the median numbers of lymph nodes isolated in the area of D3 lymphadenectomy were 0 in incomplete, 1 (0-5) in Partial, and 3 (0-8) in Complete D3 lymphadenectomy specimens (p = 0.0001). LIMITATIONS: A large multicenter study with adequate power is needed. CONCLUSIONS: We propose the right mesocolic sail and trunk of superior right colic vein as new and reproducible anatomopathologic standards of D3 lymphadenectomy in oncologic right hemicolectomy. See Video Abstract at http://links.lww.com/DCR/B149. PROPUESTA PARA NUEVOS ESTÁNDARES HISTOPATOLÓGICOS EN LA LINFADENECTOMÍA D3 EN EL CÁNCER DE COLON DERECHO: LA VELA MESOCÓLICA Y LA VENA CÓLICA DERECHA SUPERIOR: Existe un claro acuerdo sobre los estándares de calidad patológicos para la escisión total del mesorrecto y la escisión completa del mesocolon. Son considerados "estándar de calidad" que se correlaciona con la supervivencia. Sin embargo, no se dispone de estándares de calidad para definir la linfadenectomía D3, en la colectomía derecha.Definir los estándares anatomopatológicos de calidad obtenidos de una muestra quirúrgica, cuando se ha realizado correctamente una hemicolectomía derecha oncológica, con linfadenectomía D3.Dos fases diferentes. La primera parte consistió en un estudio basado en la anatomía del colon derecho, realizado en cadáveres, y la segunda parte consistió en una evaluación prospectiva de una serie de muestras quirúrgicas obtenidas después de la hemicolectomía derecha para cáncer.La fase anatómica del estudio se realizó en colaboración con el Departamento de Anatomía y Embriología de la Universidad de Valencia. La segunda parte se realizó en la Unidad Colorrectal de un hospital terciario.Se utilizaron diecisiete cadáveres para la primera fase y se examinaron 65 muestras quirúrgicas para la segunda parte del estudio.En cada muestra, los patólogos buscaron estructuras anatómicas definidas, como marcadores de los estándares de calidad de la linfadenectomía D3, durante la primera fase. Las muestras se clasificaron como linfadenectomía D3 completa, parcial e incompleta.El veinte por ciento de las muestras se clasificaron como "Linfadenectomía D3 Incompleta", el 31% como "Parcial" y el 49% como "Completa." Se aisló una media de 14 (6-64), 22 (11-47) y 29 (14-55) ganglios linfáticos respectivamente (p = 0,01). Del mismo modo, el número medio de ganglios linfáticos aislados en el área de la linfadenectomía D3 fue 0 en "Incompleta", 1 (0-5) en "Parcial" y 3 (0-8) en muestras de "Linfadenectomía D3 Completa" (p = 0,0001).Se necesita un estudio multicéntrico con potencia adecuada.Proponemos la vela mesocólica derecha y el tronco de la vena cólica derecha superior, como estándares anatomopatológicos nuevos y reproducibles de linfadenectomía D3, en hemicolectomía derecha oncológica. Consulte Video Resumen en http://links.lww.com/DCR/B149.

Autologous Patellar Tendon Reconstruction after Total Knee Arthroplasty Infection with Skin Loss: Anatomical Study and Case Report.

Disruption of patellar tendon after total knee arthroplasty (TKA) is a devastating complication. If associated with infection or soft tissue defect, knee arthrodesis is usually indicated. The purpose of this study is to analyze, by means of an anatomical study, the feasibility of our novel technique for reconstruction of extensor apparatus after TKA infections with skin defects, combining gracilis (G) and semitendinosus (ST) tendon autografts and chimeric medial gastrocnemius-sural artery perforator (SAP) flap. In addition, to report on the use of this reconstruction, we described an illustrative clinical case. Ten fresh cadaver lower limbs were dissected. The width of the gastrocnemius, number of medial SAP, length of hamstrings tendons, and distance from the lower pole of the patella to anterior tibial tuberosity (ATT) were measured. A mean of 1.37 perforator branches (range 1-3) was found. In all cases, the tendon length for gracilis and ST, and the width in the middle third of gastrocnemius related to the patella-ATT distance were enough to make the reconstruction. We performed this technique in a 78-year-old man with an infected TKA with skin defect. After 1 year and two-stage procedure, the patient achieved full active knee extension and was able to ambulate without aids. Extensor apparatus reconstruction combining tendon autografts and chimeric medial gastrocnemius-SAP flap is an available technique and may be considered as an alternative to arthrodesis in extensor mechanism ruptures after infection in TKA.