Reprint of: Female Urethral Carcinoma: A contemporary review of the clinicopathologic features, with emphasis on the histo-anatomic landmarks and potential staging issues.

Primary female urethral carcinoma (PUC-F) accounts for less than 1% of all genitourinary malignancies and comprises a histologically diverse group of tumors that are usually associated with poor prognosis. The carcinomas documented at this site include adenocarcinoma (clear cell adenocarcinoma, columnar cell carcinoma, and Skene gland adenocarcinoma), urothelial carcinoma (UCa), and squamous cell carcinoma (SCC). Recent studies have shown adenocarcinomas to be the most common type of primary urethral carcinoma in females. As most of the urethral carcinomas morphologically resemble carcinomas arising from surrounding pelvic organs or metastases, these should be ruled out before making the diagnosis of PUC-F. These tumors are currently staged according to the 8th edition of the American Joint Committee on Cancer (AJCC) staging system. However, the AJCC system has limitations, including the staging of tumors involving the anterior wall of the urethra. Staging systems like the recently proposed histology-based female urethral carcinoma staging system (UCS) takes into account the unique histological landmarks of the female urethra to better stratify pT2 and pT3 tumors into prognostic groups, that correlate with clinical outcomes including recurrence rates, disease-specific survival and overall survival. Further larger multi-institutional cohorts are however required to validate the results of this staging system. There is very limited information regarding the molecular profiling of PUC-F. Thirty-one percent of clear cell adenocarcinomas have been reported to show PIK3CA alterations, whereas 15% of adenocarcinomas show PTEN mutations. Higher tumor mutational burden and PD-L1 staining have been reported in UCa and SCC. Although multimodality treatment is usually recommended in locally advanced and metastatic disease, the role of immunotherapy and targeted therapy is promising in select PUC-F cases.

Ultrasound Evaluation of Retrocervical and Parametrial Deep Endometriosis on the Basis of Surgical Anatomic Landmarks.

STUDY OBJECTIVES: To assess the value of combined transvaginal/transabdominal ultrasonographic evaluation performed by experienced examiners for deep infiltrating endometriosis (DIE) lesions of the retrocervical (torus uterinus and uterosacral ligaments) and parametrial areas and summarize the features and anatomic criteria for identification of these lesions and their extent in the above-mentioned pelvic compartments. DESIGN: Retrospective study. SETTING: A specialized endometriosis center in Avellino, Italy. PATIENTS: A retrospective cohort of patients who underwent laparoscopic surgery for clinically suspected DIE between January 1, 2014, and December 31, 2018, with a dedicated ultrasound (US) evaluation performed no more than 1 month before the intervention. INTERVENTIONS: Preoperative US findings and surgical reports were reviewed. Using the findings of laparoscopic surgery as the gold standard, the sensitivity and specificity of preoperative US evaluation for retrocervical and parametrial endometriotic lesions were calculated with the corresponding 95% confidence intervals. MEASUREMENTS AND MAIN RESULTS: A total of 4983 patients were included. US evaluation showed high diagnostic accuracy for DIE detection in the examined pelvic compartments, with sensitivity and specificity of 97% to 98% and 98% to 100%, respectively, for both retrocervical (torus uterinus and uterosacral ligaments insertion) and parametrial lesions. CONCLUSION: Parametrial extension of DIE indicates major surgical technical difficulties and risk of complications, and urologic and nerve-sparing procedures may be required in such cases. Preoperative evaluation of such scenarios will allow proper counseling of patients and facilitate adequate surgical planning in referral centers; moreover, when necessary, it can guide the constitution of a dedicated multidisciplinary surgical team as an alternative to treatment by a pelvic surgeon alone. Detailed imaging evaluation of DIE lesions and their extension is crucial for clinical management of affected patients. It can facilitate optimization of surgical timing and strategies, thereby potentially preventing ineffective, or even harmful, repeated procedures.

Comparison of the sigmoid take-off with other definitions of the rectosigmoid junction: A retrospective comparative cohort analysis.

BACKGROUND: The diversity in definitions for the rectosigmoid junction is becoming a major obstacle in standardizing optimal treatment of rectal cancers. The study aimed to determine the average distance of the sigmoid take-off from the anal verge and its association with individual factors. MATERIALS AND METHODS: Patients diagnosed with rectal and sigmoid colon cancer in our centre from January 2010 to December 2018 were retrospectively enrolled in the cancer group. The results of 200 controls without colorectal disease were also reviewed (normal group). The distance of different landmarks and margins of cancer from the anal verge were retrieved from computed tomography (CT), magnetic resonance imaging (MRI), and endoscopy findings. RESULTS: The cancer group comprised 635 patients (381 men, median age: 64 years). The average distances of the sigmoid take-off from the anal verge measured in CT and MRI were comparable (P = 0.483). On MRI, the average distance of the sigmoid take-off from the anal verge in the cancer group was comparable with that of the normal group (P = 0.070). Multivariate regression revealed that the distance of the sigmoid take-off from the anal verge was associated with the distances of the sacral promontory (P < 0.001) and peritoneal reflection (P < 0.001) from the anal verge. CONCLUSION: The cancer distributions of patients varied widely with the application of different definitions. The point of sigmoid take-off is an intuitive landmark influenced by individual factors. The measurement of the sigmoid take-off by different researchers in both CT and MRI revealed good consistency. Further studies regarding the clinical significance of this definition are still needed.

A landmark-based 3D analysis reveals a narrower tibial plateau and patella in trochlear dysplastic knees.

PURPOSE: The trochlear dysplastic femur has a specific morphotype previously characterised by not only dysplastic features of the trochlea but also by specific features of the notch and posterior femur. In this study the morphology of the tibia and patella was investigated to gain further insight in the complete geometrical complexity of the trochlear dysplastic knee. METHODS: Arthro-CT scan-based 3D models of 20 trochlear dysplastic and 20 normal knees were uniformly scaled and landmarks and landmark-based reference planes were created to quantify a series of morphometric characteristics of the tibia and patella. RESULTS: In the mediolateral direction, the 3D-analysis revealed a 3% smaller medial tibial plateau (30.4 ± 1.6 mm vs 31.5 ± 1.6 mm), a 3% smaller overall width of the tibial plateau (73.6 ± 2.0 mm vs 75.7 ± 2.0 mm), a 16% smaller medial facet (17.3 ± 2.2 mm vs 20.1 ± 1.3 mm) and a 4% smaller overall width of the patella (41.7 ± 2.5 mm vs 43.4 ± 2.3 mm) in trochlear dysplastic knees. In the anteroposterior direction, the lateral tibial plateau of trochlear dysplastic knees was 5% larger (37.2 ± 2.3 mm vs 35.5 ± 3.1 mm). A correlation test between the width of the femur and the width of the tibia revealed that trochlear dysplastic knees show less correspondence between the femur and tibia compared to normal knees. CONCLUSION: Significant differences in the morphology of the tibial plateau and patella were detected between trochlear dysplastic and normal knees. Both in the trochlear dysplastic tibial plateau and patella a narrower medial compartment leads to a significant smaller overall mediolateral width. These findings are important for the understanding of knee biomechanics and the design of total knee arthroplasty components. LEVEL OF EVIDENCE: III.

MAPGI: Accurate identification of anatomical landmarks and diseased tissue in gastrointestinal tract using deep learning.

Automatic detection of anatomical landmarks and diseases in medical images is a challenging task which could greatly aid medical diagnosis and reduce the cost and time of investigational procedures. Also, two particular challenges of digital image processing in medical applications are the sparsity of annotated medical images and the lack of uniformity across images and image classes. This paper presents methodologies for maximizing classification accuracy on a small medical image dataset, the Kvasir dataset, by performing robust image preprocessing and applying state-of-the-art deep learning. Images are classified as being or involving an anatomical landmark (pylorus, z-line, cecum), a diseased state (esophagitis, ulcerative colitis, polyps), or a medical procedure (dyed lifted polyps, dyed resection margins). A framework for modular and automatic preprocessing of gastrointestinal tract images (MAPGI) is proposed, which applies edge removal, contrast enhancement, filtering, color mapping and scaling to each image in the dataset. Gamma correction values are automatically calculated for individual images such that the mean pixel value for each image is normalized to 90 ±â€¯1 in a 0-255 pixel value range. Three state-of-the-art neural networks architectures, Inception-ResNet-v2, Inception-v4, and NASNet, are trained on the Kvasir dataset, and their classification performance is juxtaposed on validation data. In each case, 85% of the images from the Kvasir dataset are used for training, while the other 15% are reserved for validation. The resulting accuracies achieved using Inception-v4, Inception-ResNet-v2, and NASNet were 0.9845, 0.9848, and 0.9735, respectively. In addition, Inception-v4 achieved an average of 0.938 precision, 0.939 recall, 0.991 specificity, 0.938 F1 score, and 0.929 Matthews correlation coefficient (MCC). Bootstrapping provided NASNet, the worst performing model, a lower bound of 0.9723 accuracy on the 95% confidence interval.

Anatomical study of the innervation of posterior knee joint capsule: implication for image-guided intervention.

BACKGROUND AND OBJECTIVES: Peripheral nerve block is an important component of the multimodal analgesia for total knee arthroplasty. Novel interventional techniques of ultrasound-guided nerve block supplying the posterior knee joint capsule require knowledge of the innervation of the posterior capsule. The objectives of this cadaveric study were to determine the course, frequency, and distribution of the articular branches innervating the posterior knee joint capsule and their relationships to anatomical landmarks. METHODS: Fifteen lightly embalmed specimens were meticulously dissected. The origin of articular branches was identified, their frequency recorded, and the course documented in relation to anatomical landmarks. The capsular distribution of articular branches was documented and a frequency map generated. RESULTS: In all specimens, articular branches from the posterior division of the obturator and tibial nerves were found to supply the posterior capsule. Additionally, articular branches from common fibular nerve and sciatic nerve were found in eight (53%) and three (20%) specimens, respectively. The capsular distribution of tibial nerve spanned the entire posterior capsule. The posterior division of obturator nerve supplied the superomedial aspect of the posterior capsule overlapping with the tibial nerve. The superolateral aspect of the posterior capsule was innervated by the tibial nerve and, when present, the common fibular/sciatic nerves. CONCLUSIONS: Frequency map of the course and distribution of the articular branches and their relationship to anatomical landmarks form an anatomical basis for peripheral nerve block approaches that provide analgesia to the posterior knee joint capsule.

Three-dimensional analyses of nasolabial forms and upper lip surface symmetry after primary lip repair in patients with complete unilateral cleft lip and palate.

PURPOSE: To analyze three-dimensional (3D) nasolabial forms and upper lip surface symmetry after primary lip repair in children with unilateral cleft lip and palate (UCLP). METHODS: Subjects were 22 Japanese children with complete UCLP who underwent primary lip repair and were followed-up for 4-6 years. The 3D coordinates of facial landmarks and the angle and radius of the approximate nasal alar circle were calculated. Upper lip surface symmetry was analyzed using histogram intersection. RESULTS: The nasal tip and columella base were slightly dislocated to the cleft side, and the midpoint of Cupid's bow shifted to the non-cleft side. The nasal alar and the top of Cupid's bow were reconstructed at the same height, while the approximate nasal alar circle was smaller on the cleft side. The mean value of similarity for upper lip surface symmetry was 0.82; a subject with a higher value had more symmetrical contour lines in the visualized surface image. CONCLUSIONS: Postoperative nasolabial forms were almost restored to symmetrical levels, while retaining a small nasal alar. Histogram intersection is applicable as a method for the quantitative evaluation of upper lip surface symmetry in UCLP.

Urethral mobility and Point Aa of the Pelvic Organ Prolapse Quantification (POP-Q) system before and after midurethral sling operation.

OBJECTIVE: The aim of the present study was to verify the usefulness of Point Aa as a substitute marker of the Q-tip angle and urethral mobility before and after midurethral sling operation for the treatment of stress urinary incontinence (SUI) in women. METHODS: In this study, 118 women presenting with SUI who underwent the tension-free vaginal tape obturator (TVTO) procedure were prospectively examined and followed-up for ≥6 months after operation. Spearman's correlation coefficient was used to assess the degree of correlation between Point Aa of the Pelvic Organ Prolapse Quantification system and Q-tip angles before and after midurethral sling surgery. RESULTS: There were significant postoperative changes in Point Aa (from -0.4 ± 1.9 to -2.7 ± 0.6; P = .001) and Q-tip angle (from 58.7 ± 19.4 to 15.4 ± 17.5 degrees; P =.001) compared with preoperative values. A fair correlation between Point Aa position and straining Q-tip angle was found before (r = 0.45, P = .05) and after (r = 0.49, P = .04) the procedure, with no significant difference in values before and after the procedure (P = .62). CONCLUSIONS: The results of the present study show fair correlation between the Point Aa position and straining Q-tip angle before and after midurethral sling surgery. Point Aa could be used as an indicator of urethral mobility after the TVTO procedure in women with SUI.

Pectoral Block Failure May Be Due to Incomplete Coverage of Anatomical Targets: A Dissection Study.

BACKGROUND AND OBJECTIVES: The popularization of ultrasound-guided nerve blocks in cosmetic and reconstructive breast surgery calls for better anatomical understanding of chest wall innervation. When inserting subpectoral implants, pain from pocket dissection, stretching of muscle, and release of costal attachments may be relieved by blocking the pectoral nerves in the interpectoral (IP) space.We describe the variable anatomy of the pectoral nerves in the IP space in order to define the area to be covered for sufficient blockade, based on cadaver dissections. METHODS: Twenty-six fresh cadavers were dissected bilaterally. The number, location, and course of the pectoral nerves were recorded. Distances to surface landmarks (sternum, clavicle, and costae) and ultrasound landmarks (thoracoacromial artery [TAA] and pectoralis minor muscle [Pm]) were recorded. RESULTS: The lateral pectoral nerve and the TAA entered together into the IP space 8.9 cm (range, 8.0-12.0 cm) lateral to the midsternal line. The medial pectoral nerve (MPN) had between 1 and 4 branches that pierced the Pm, and 69% had additional branches lateral to the Pm. The muscle-piercing MPN branches were located 3.8 cm (range, 0.4-8.1 cm) and the lateral MPN branches 5.4 cm (range, 3.0-8.4 cm) from the lateral pectoral nerve. The IP course was 2.6 cm (range, 0.7-6.5 cm). All specimens were asymmetrical in location or number of MPN branches. CONCLUSIONS: The MPN branches that innervate the lower part of the pectoralis major muscle are asymmetrical and variable in location and length; all located in a triangular area easily defined by sonographic landmarks, lateral to the TAA.

Therapeutic Failure in Trigeminal Neuralgia: from a Clarification of Trigeminal Nerve Somatotopy to a Targeted Partial Sensory Rhizotomy.

BACKGROUND: Trigeminal neuralgia (TN) is a severe unilateral facial pain involving 1 or more branches of the trigeminal nerve (CNV). Microvascular decompression is a standard curative treatment of pharmacoresistant classic TN. Alternative procedures used for secondary or idiopathic TN usually lead to a high rate of pain recurrence and sensitive deficits. Partial sensory rhizotomy (PSR) is one of these ablative procedures. However, the lack of anatomic knowledge about the somatotopy of CNV lead to variable results in pain relief and hypoesthesia. OBJECTIVE: To refine the somatotopy of CNV and bring new anatomic landmarks for PSR, studying a cohort of patients treated by a targeted PSR (TPSR). METHODS: Retrospective and consecutive cases of adult patients treated in our institution between March 2000 and June 2015 for pharmacoresistant TN without vascular compression were collected. Our surgical procedure was performed using a precision map of the somatotopy of CNV. We compared our results with other surgical and nonsurgical therapies. RESULTS: Twenty-two patients had undergone TPSR. Fourteen had an idiopathic TN without compression of the nerve root, 6 had a secondary TN caused by multiple sclerosis, and 2 had a trigeminal conflict by inoperable tumor. Complete pain relief was achieved in 86.4% of the patients. Postoperative hypoesthesia was partial and focalized (22.7%). TN recurrence rate at 5 years was 31.5% (standard deviation, 10.9%). CONCLUSIONS: We clarified the functional somatotopy of CNV in its juxtapontine portion. TPSR is an interesting alternative to other ablative procedures to treat pharmacoresistant TN without vascular compression.

Flexion-valgus unicondylar tibial plateau depression fracture pattern: Classification and treatment.

PURPOSE: The authors have identified a subset of unicondylar tibial plateau depression fracture patterns caused by a flexion-valgus force. The purpose of this study was to describe this fracture pattern and suggest a modified lateral approach that may allow for improved reduction and stabilization. METHODS: The preoperative radiographs and CT scans of 102 patients who sustained unicondylar tibial plateau fractures (OTA 41B) were reviewed. Twenty-six fracture patients had posterolateral (PL) tibial plateau depression fractures. By medical record review and telephone follow-up, the injury mechanism of the 22 unicondylar tibial plateau fractures was confirmed as a flexion-valgus force. The radiographic features of those cases were analyzed and measured. To address this specific fracture pattern, a modified approach combined with a novel intra-articular osteotomy was applied. RESULTS: According to the morphological characteristics, this tibial plateau fracture pattern could be divided into two subtypes: type A was a confined, basin-like articular surface depression fracture located in the PL quadrant, and type B was a cancellous fracture involving the PL tibial plateau resulting in a decrease in the posterior slope. One radiographic hallmark of this fracture pattern is an anatomically or a mechanically intact posterior column wall. The novel approach was applied to both types. The postoperative radiographic measurements revealed excellent reduction quality. On axial scans, the distance between the most posterior rafting screw and the tangent line of the tibial plateau rim was 3.0 ±â€¯2.07 mm (from -1.9 to 4.3), and the angulation between them was 8.9 ±â€¯3.02° (from -7.3 to 15.6). These results indicated excellent PL quadrant coverage from the rafting screws. CONCLUSION: Flexion-valgus force-induced unicondylar tibial plateau depression fracture is a unique injury pattern. We suggest a novel surgical approach to address this injury's key features, which may facilitate exposure and enhance fixation strength.

The Nuchal Lines as Anatomic Landmarks to Dissect the Muscles in the Far Lateral Approach.

BACKGROUND: A critical step in the far lateral approach (FLA) is exposure of the V3 segment of the vertebral artery, located deep in the suboccipital triangle (SOT). Safe exposure of the SOT is achieved by means of a plane-by-plane dissection, which carries the risk of devascularization. A suitable alternative is to lift a cutaneous muscle flap including the 3 first muscle planes and leave the deepest plane (SOT) attached to the skull base. To achieve this, it is necessary to have superficial anatomic landmarks to help identify the cleavage site. We describe the use of the nuchal lines as a safe, effective, and reproducible method to dissect the muscles to expose the SOT and vertebral artery. METHODS: Eight adult cadaveric heads, fixed with formaldehyde and injected, were studied. On both sides, FLA was simulated by using the nuchal lines as anatomic landmarks to expose the SOT. This technique was later applied on 10 patients requiring FLA. RESULTS: Anatomic dissections confirmed identification, by means of the nuchal lines, of a cleavage site, which made it possible to separate the deepest muscle plane from the rest of the flap. This technique was successfully applied in 10 patients undergoing FLA. CONCLUSIONS: The nuchal lines allow dissection of muscles in 2 groups, one superficial and the other deep (SOT), which remains attached to the skull base. The V3 segment of the vertebral artery is easily exposed.

Soft tissue changes: a comparison between changes caused by the construction bite and by successful treatment with a modified Twin-block appliance.

Background/objectives: Functional appliances are commonly used to correct Class II malocclusion. This study aimed to compare the facial soft tissue changes in Caucasians between pre-treatment and with the construction bite versus pre-treatment and completion of treatment with a modified Twin-block appliance (MTBA). Materials and methods: Fifty-eight Caucasian subjects with Class II division 1 malocclusion had 3D stereophotogrammetric images captured pre-treatment (T1), with the construction bite (T2), and on completion of MTBA treatment (T3). Twenty-six landmarks were located on each image and 10% were re-landmarked 1 month later. Soft-tissue linear and volumetric changes (T1-T2 and T1-T3) were analyzed using linear mixed effect models (SAS® Version 9.4, www.sas.com). Results: Forty-seven subjects [mean age 13.2 (SD 1.7) years] completed treatment [mean duration 9.8 (SD 3.8) months]. Differences between the changes from T1 to T2 versus T1 to T3 for upper facial and upper lip landmarks were insignificant (all P > 0.05) except for nasion, orbitale right, pronasale, and subnasale. For the same comparisons, lower lip and chin landmarks changed significantly (all P < 0.05) as did facial soft tissue volume (P< 0.0001). Limitations: There was no control group. Conclusion: The facial soft tissue changes from pre-treatment to with the construction bite were considerably more than those from pre-treatment to completion of treatment with a MTBA. Implication: With MTBA treatment, the soft tissue changes from pre-treatment to with the construction bite in situ, overestimate those from pre- to post-treatment.

Three-dimensional analysis of cranial base morphology in patients with hemifacial microsomia.

BACKGROUND: Many researchers have studied the relationship between facial asymmetry and cranial base morphology, but they have failed to reach a consensus. In this study, we aimed to verify whether the cranial base is involved in hemifacial microsomia (HFM). METHODS: We included 66 patients with HFM who were treated at the Plastic and Reconstructive Surgery Department of Shanghai Ninth People's Hospital from January 2013 to October 2016. The patients were divided into three groups according to Pruzansky and OMENS classifications, separately. The controls were 20 patients diagnosed with mandibular angle hypertrophy but with no facial asymmetry. Angular and linear measurements of the cranial base were obtained for all patients. RESULTS: The two classification methods yielded similar results. The intersection angle between two planes showed differences in the severe group. In the moderate and severe groups, the middle and posterior cranial angles were significantly different and the CIP and SP lengths were shorter in the affected side. Landmarks such as the carotid canal and internal acoustic canal could be considered as references. CONCLUSIONS: The cranial base is involved in hemifacial microsomia. This relationship supports the hypothesis of HFM pathogenesis and opens new avenues to classification methods.

Arrested Foveal Development in Preterm Eyes: Thickening of the Outer Nuclear Layer and Structural Redistribution Within the Fovea.

Purpose: The aim of this study was to define landmarks to better characterize foveal microstructure in normal subjects and in preterms with or without signs of immaturity, and to report on thickness changes of outer foveal layers following analysis of optical coherence tomography (OCT) B-scan images. Methods: Selected eyes from eight young adults with a history of prematurity (24-33 weeks of gestation) and five controls were imaged using conventional and directional OCT. Retinal layer thickness analysis was performed at selected temporal eccentricities defined by the individual distance between two landmarks for each case, the foveal center and the foveal rim. Results: The use of a foveal center and foveal rim landmark transformation enabled comparisons of interindividual B-scans at corresponding landmark positions in both controls and preterms. We found a 20% shorter foveal center to foveal rim distance in preterms with an immature fovea than in controls. Reflectometric and manual segmentation measurements showed increased thickness of inner retinal layers and photoreceptor cell body and outer plexiform layers centrally, but no observable change of photoreceptor inner and outer segment thickness. Conclusions: Our landmark-based analysis of OCT images using reflectometry and manual segmentation provides complementary findings in comparisons of normal and immature foveal structures. We show a central thickness increase in the outer nuclear layer, outer plexiform layer, and postreceptor layers in preterms with signs of arrested foveal development. We found no indication of abnormal photoreceptor inner or outer segment development in preterms.

Influence of different setups of the Frankfort horizontal plane on 3-dimensional cephalometric measurements.

INTRODUCTION: The Frankfort horizontal (FH) is a plane that intersects both porions and the left orbitale. However, other combinations of points have also been used to define this plane in 3-dimensional cephalometry. These variations are based on the hypothesis that they do not affect the cephalometric analysis. We investigated the validity of this hypothesis. METHODS: The material included cone-beam computed tomography data sets of 82 adult subjects with Class I molar relationship. A third-party method of cone-beam computed tomography-based 3-dimensional cephalometry was performed using 7 setups of the FH plane. Six lateral cephalometric hard tissue measurements relative to the FH plane were carried out for each setup. Measurement differences were calculated for each pair of setups of the FH plane. The number of occurrences of differences greater than the limits of agreement was counted for each of the 6 measurements. RESULTS: Only 3 of 21 pairs of setups had no occurrences for the 6 measurements. No measurement had no occurrences for the 21 pairs of setups. Setups based on left or right porion and both orbitales had the greatest number of occurrences for the 6 measurements. CONCLUSIONS: This investigation showed that significant and undesirable measurement differences can be produced by varying the definition of the FH plane.

Use of Paine's Technique: Projecting Puncture Point to the Skull and Skin.

OBJECTIVE: Ventriculostomy from Paine's point is an effective technique to ensure that the brain is relaxed for aneurysm surgery. This study aimed to use Paine's point for other neurosurgical procedures (except for those that require a pterional approach) by delineation of surface landmarks for identification of Paine's point on the cranium and scalp. METHODS: Based on the anatomical knowledge and examination of 3-dimensional computed tomography images of skull, we determined novel surface landmarks to identify Paine's point on the cranium and scalp. The new method was used in patients with intraventricular hemorrhage and aneurysmal subarachnoid hemorrhage caused by ruptured aneurysm of the anterior communicating artery. RESULTS: The puncture point was determined at a point located 2.5 cm superior to the supraorbital margin on linea temporalis on the skull and 2.5 cm superior to the eyebrow along the anterior edge of temporal muscle on the skin. Ventriculostomy was performed from Paine's point in patients with intraventricular hemorrhage or aneurysmal subarachnoid hemorrhage who underwent aneurysm surgery via an interhemispheric approach. No adverse events were observed in any of the patients. CONCLUSIONS: By accurate surface marking on skull and skin, the use of Paine's point for ventriculostomy performed via an interhemispheric approach or for simple burr-hole surgery was found to be safe and reliable.

Ultrasound-Guided Percutaneous Biopsy of the Native Kidney: An Axial Approach Along Brödel Avascular Plane of the Lower Pole.

PURPOSE: This study demonstrates the feasibility and safety of the axial approach for real-time ultrasound-guided percutaneous renal biopsy along Brödel avascular plane. METHODS: In this retrospective analysis of 41 percutaneous biopsies performed from June 2014 to June 2015, patients' medical records, pathology results, complication rate, and pain score before and during the procedure were reviewed. RESULTS: The average number of sampled glomeruli was 16.1 ± 7.2 (mean ± SD). There were no major complications. The 2 minor complications, transient macrohematuria and small perirenal hematoma, occurred at a rate of 4.89% but regressed spontaneously in both cases. CONCLUSIONS: The axial approach along Brödel avascular plane is a feasible alternative approach for percutaneous biopsy of the native kidney.

Ultrasound Versus Landmarks for Great Toe Arthrocentesis.

BACKGROUND: Several studies have demonstrated ultrasound (US) is superior to traditional landmark (LM)-based techniques for large and medium joint aspiration; however, no studies of sufficient size have evaluated these interventions in the smaller toe joints. The purpose of this study was to determine if US provides an advantage over LM for successful first-pass aspiration of first metatarsophalangeal joint (1st MTPJ) effusions. METHODS: A cross-over, cadaveric trial evaluating the interventions of US and LM. Eighteen emergency medicine residents performed four US and four LM aspirations each of 1st MTPJ effusions simulated in fresh-frozen cadavers. The initial intervention utilized was randomized. The primary outcome measured was aspiration success or failure. A secondary outcome measured was time in seconds taken to complete a successful aspiration. RESULTS: A total of 144 1st MTPJ aspirations were attempted-72 by US and 72 by LM. US was the initial intervention used in 9 of 18 (50%) participants. Fifty-seven of 72 (79.2%) US attempts were successful, while 53 of 72 (73.6%) LM attempts were successful (95% confidence interval 69.5%, 83.3%; p = 0.56). Successful US aspirations took 43.7 seconds (±31.0), whereas successful LM aspirations averaged 34.0 seconds (±24.3). The mean difference in time to successful aspiration was 9.7 seconds (95% confidence interval 20.3, -0.9; p = 0.07). There was no statistically significant difference in success and time between US and LM. CONCLUSION: In this study, US did not prove superior to LM for first-pass aspiration of 1st MTPJ effusions.

Posterior Decentering of the Humeral Head on Shoulder MR Arthrography: Significant Association With Posterior Synovial Proliferation.

OBJECTIVE: The purpose of this study is to analyze MRI findings associated with posterior decentering of the humeral head on shoulder MR arthrogram. MATERIALS AND METHODS: A total of 255 MR arthrograms were obtained during a 10-month period. MR arthrograms in patients with posterior decentering of the humeral head (n = 33) were reviewed and compared with those of randomly selected control group without posterior decentering (n = 66). MR arthrograms were retrospectively evaluated by two observers for posterior factors (posterior synovial proliferation, posterior capsular thickening, and posterior labral abnormality), rotator cuff factors related to fatty degeneration, glenoid version, and anterior factors (subcoracoid bursa effusion and rotator interval tear). The chi-square test, Fisher exact test, and linear-by-linear association were used for comparison of categoric data; the t test was used for comparison of the glenoid version; and multivariate stepwise logistic regression analysis was performed. RESULTS: At univariate analysis, posterior synovial proliferation (27.3% [9/33] in the posterior decentering group vs 6.1% [4/66] in the control group; p = 0.003); posterior capsule thickening (21.2% [7/33] vs 0.0% [0/66]; p < 0.001); fatty infiltration of the supraspinatus, infraspinatus, and teres minor (linear-by-linear association values, 7.944, 10.496, and 5.985, respectively; p = 0.005, 0.001, and 0.014, respectively); and rotator interval tear (51.5% [17/33] vs 30.3% [20/66]; p < 0.04) were more frequently found in the posterior decentering group, with a statistically significant difference. At multivariate analysis, only the posterior synovial proliferation was significantly associated with posterior decentering of the humeral head (odds ratio, 7.675; 95% CI, 2.159-27.288). CONCLUSION: Posterior decentering of the humeral head is most significantly associated with posterior synovial proliferation. In addition, rotator cuff interval abnormalities and rotator cuff atrophy are associated with posterior decentering of the humeral head to a lesser extent. Awareness of the association of the posterior decentering of the humeral head with the factors described here will facilitate the effective interpretation of routine MR arthrograms in daily practice.