Dysgeusia induced and resolved by focused ultrasound thalamotomy: case report

Dysgeusia, or distorted taste, has recently been acknowledged as a complication of thalamic ablation or thalamic deep brain stimulation as a treatment of tremor. In a unique patient, left-sided MR-guided focused ultrasound thalamotomy improved right-sided essential tremor but also induced severe dysgeusia. Although dysgeusia persisted and caused substantial weight loss, tremor slowly relapsed. Therefore, 19 months after the first procedure, the patient underwent a second focused ultrasound thalamotomy procedure, which again improved tremor but also completely resolved the dysgeusia. On the basis of normative and patient-specific whole-brain tractography, the authors determined the relationship between the thalamotomy lesions and the medial border of the medial lemniscus—a surrogate for the solitariothalamic gustatory fibers—after the first and second focused ultrasound thalamotomy procedures. Both tractography methods suggested partial and complete disruption of the solitariothalamic gustatory fibers after the first and second thalamotomy procedures, respectively. The tractography findings in this unique patient demonstrate that incomplete and complete disruption of a neural pathway can induce and resolve symptoms, respectively, and serve as the rationale for ablative procedures for neurological and psychiatric disorders.

The Plantar Fascia Talar Head Correlation: A Radiographic Parameter With a Distinct Threshold to Validate Flatfoot Deformity and Its Corrective Surgery on Conventional Weightbearing Radiographs

Background: Corrective surgery for flexible flatfoot deformity (FD) remains controversial, and one of the main reasons for this is the lack of standardized radiographic measurements to define an FD. Previously published radiographic parameters to differentiate between a foot with and without an FD do not have a commonly accepted and distinct threshold. Methods: The plantar fascia–talar head correlation (PTC) with its defined threshold was assessed by measuring the distance between the medial border of the plantar fascia and the center of the talar head (DPT) on conventional dorsoplantar and lateral weightbearing radiographs; the authors were blinded to the clinical diagnosis of the 189 patients’ first visits. Feet were sorted into groups with and without an FD based on their clinical examination. The effect of operative corrections of FD on the PTC was retrospectively evaluated on an additional 38 patients. Results: The sensitivity of the PTC was 0.98 (95% CI: 0.9-1) and specificity 0.96 (95% CI: 0.92-0.98), respectively, to identify an FD, consistent with the clinical examination. Thirty-five of 38 surgeries sufficiently corrected the FD and the PTC comparable to that in subjects without an FD. Three corrections with a residual FD did not adequately correct the PTC. Conclusion: The PTC is a reliable radiographic parameter with a distinct threshold that is sensitive and specific for the differentiation of feet with and without an FD including feet with and without residual FD after corrective surgery. The PTC is applicable to monitor the needed intraoperative amount of correction using simulated weightbearing fluoroscopy. Level of Evidence: Level III, diagnostic.

A Solitary Ventral Scapular Osteochondroma causing Pseudo-winging of Scapula: A Case Report

Introduction: Winging of scapula is defined as a failure of dynamic stabilizing structures that anchor the scapula to the chest wall, leading to prominence of the medial border of scapula. It could be primary, secondary, or voluntary. Primary winging could be true winging due to neuromuscular causes or pseudo-winging due to osseous or soft-tissue masses. A scapular osteochondroma is a very rare presentation site and causes pseudo-winging leading to pushing away of the scapula away from the chest wall presenting as medial border prominence. Here, we are reporting a rare case of a scapular osteochondroma causing a pseudo-winging of the scapula. Case Report: A 2-year-old male child presented with painless, immobile, and non-fluctuant swelling over the left scapular region, insidious in onset and progressive in nature. On examination, a non-tender, immobile swelling was palpable with a painless and unrestricted range of motion at the shoulder joint. After evaluating radiographs and CT scan, the patient was diagnosed to have a ventral scapular osteochondroma leading to pseudo-winging of the scapula. Conclusion: Despite the rarity, a differential diagnosis of a scapular osteochondroma should be kept in mind while examining a young child presenting with a winged scapula. Keywords: Scapula, osteochondroma, pseudo-winging.

Defining a Safe Corridor of Cervical Branch Preservation in Lateral Platysmaplasty Surgery During Facial Rejuvenation Surgery

Background During rhytidectomies, the cervical branch of the facial nerve (CBFN) can easily be encountered, and potentially injured, when releasing the cervical retaining ligaments in the lateral neck. This nerve has been shown to occasionally co-innervate the depressor anguli oris muscle, and damage to it can thus potentially compromise outcomes with a post-operative palsy. Objectives To examine the lateral cervical anatomy specific to the CBFN, to ascertain if the position of the nerve can be predicted, enhancing safety of the platysmal flap separation and dissection from this lateral zone of adhesion. Methods Eleven cadaveric hemifaces were dissected and the distance between the medial border of sternocleidomastoid (SCM), and the CBFN was measured at three key points: (1) ‘Superior’: the distance between SCM and the nerve at the level of the angle of the mandible in neutral. (2) ‘Narrowest’: the narrowest distance measurable between the ‘superior’ and ‘inferior’ points as the CBFN descends into the neck medial to the SCM. (3) ‘Inferior’: the distance at the most distal part of the cervical nerve identified before its final intramuscular course. Results The average distances (in mms) were: Superior = 12.1 (range: 10.1-15.4), Narrowest = 8.8 (range: 5.6-12.2) and Inferior = 10.9 (range: 7.9-16.7). Conclusions There is a narrow range between the nerve and the anterior border of SCM. We thus propose a safe corridor where lateral deep plane dissection can be performed to offer cervical retaining ligament release, with reduced risk of endangering the CBFN.

Ultrasonographic Analysis of Optimal Needle Placement for Extensor Indicis

Objective To determine the most optimal needle insertion point of extensor indicis (EI) using ultrasound.Methods A total 80 forearms of 40 healthy volunteers were recruited. We identified midpoint (MP) of EI using ultrasound and set MP as optimal needle insertion point. The location of MP was suggested using distances from landmarks. Distance from MP to medial border of ulna (MP-X) and to lower margin of ulnar head (MP-Y) were measured. Ratios of MP-X to Forearm circumference (X ratio) and MP-Y to forearm length (Y ratio) were calculated. In cross-sectional view, depth of MP (Dmp), defined as middle value of superficial depth (Ds) and deep depth (Dd) was measured and suggested as proper depth of needle insertion.Results Mean MP-X was 1.37±0.14 cm and mean MP-Y was 5.50±0.46 cm. Mean X ratio was 8.10±0.53 and mean Y ratio was 22.15±0.47. Mean Dmp was 7.63±0.96 mm.Conclusion We suggested that novel optimal needle insertion point of the EI. It is about 7.6 mm in depth at about 22% of the forearm length proximal from the lower margin of the ulnar head and about 8.1% of the forearm circumference radial from medial border of ulna.

Kirschner Wire as a Reference Marker for the Positioning of a Syndesmotic Screw: A Radiological Study

Background: Without a reliable and static reference, the rate of eccentrically positioned distal syndesmotic screw trajectories is very high. Meanwhile, a malpositioned screw may result in poor outcomes and early osteoarthritis. As such, this article describes an additional method to improve surgeons’ ability to ideally place a screw trajectory. The purposes of our study were (1) to determine if an ideal space at 2.5 cm proximal to the plafond existed between the tibia and fibula for the placement of a Kirschner (K) wire and (2) to detect if it could act as a reliable and static fibular incisura plane reference.Methods: Computed tomography scans of 42 uninjured adult ankles with foot fractures were analysed to measure the tibiofibular vertical distance (TFVD) at 2.5 cm proximal to the tibial plafond on cross-sectional images. The TFVD was defined as the distance between two lines: Line 1 was tangent to the fibular incisura, and Line 2 was parallel to Line 1 along the medial border of the fibula. Patients were divided into 4 groups according to our TFVD data: 0–1, 1–2, 2–3, and 3–4 mm, and the number of patients in each group was counted.Results: The TFVD measured 2.23±1.01 mm (mean ± standard deviation) at 2.5 cm proximal to the plafond. According to our grouping, TFVD occurred at 25% of the distance from 2 to 3 mm in 47.6% of patients. Conclusions: Placing a 1.6-mm K-wire in the syndesmosis at 2.5 cm proximal to the tibial plafond is easy because of emerging TFVDs. The K-wire’s path is restricted to the anterior and posterior borders of the fibular incisura pass because of the limitation of the medial border of the fibula and syndesmosis tendon. Therefore, K-wire could be used as a reliable and static intraoperative reference of the fibular incisura plane through which surgeons can accurately place a screw trajectory.

Ostmann’s Fat Pad—Does it Really Matter?

Objective: To compare the size of Ostmann’s fat pad (OFP) between healthy ears and ears with chronic otitis media with cholestatoma (COMwC) using magnetic resonance imaging (MRI). Methods: Twenty-six patients with unilateral COMwC underwent mastoidectomy. Pre-operative MRI records were reviewed retrospectively. The healthy ears served as the control group. OFP is represented by the maximum diameter of the high intensity area medial to the tensor veli palatini muscle (TVP); M1. A reference diameter was defined from the medial border of OFP reaching the medial border of the medial pterygoid muscle; M2. Values of M1, M2 and the ratio of M1:M2 was compared between the healthy and pathological ear in each patient. Results: All 26 patients (16 females,10 males) had unilateral cholestatoma. Mean age was 37.6 years (range 19-83). In the healthy (H) ears group, mean M1H was 2.04 ± 0.53 mm, mean M2H was 9.57 ± 2.57 mm. In the pathological (P) ears group; mean M1P was 2.03 ± 0.55 mm, mean M2P was 9.86 ± 2.37 mm. A comparison of M1 and M2 values between the healthy and pathological ear groups was not statistically significant ( P = .853 and P = .509, respectively). Mean M1H:M2H ratio in the healthy ears group was 0.22 ± 0.05, mean M1P:M2P ratio in the pathological ear group was 0.21 ± 0.06. A comparison between these ratios found no significant statistical correlation ( P = .607). Conclusion: The size of Ostmann’s fat pad does not affect the development of chronic otitis media with cholestatoma in adults.

A RARE CASE OF TENDINOUS INSERTION OF CORACOBRACHIALIS ASSOCIATED WITH VARIANT MUSCULOCUTANEOUS NERVE

We report a rare case of the tendinous insertion of coracobrachialis muscle which has not been reported in the literature. The insertion of the novel coraco-brachialis muscle is usually into the medial border of the humerus in a 3-5cm impression at the mid-shaft level. Contrary to this, in the present case, it was seen getting inserted as a sharp slender tendon in the middle of the medial border of the humerus. Variable insertion of coracobrachialis muscle may be responsible for the causation of compression of surrounding structures like median nerve, musculocutaneous nerve, and brachial artery. This article aims to point out a rare case of the unusual tendinous insertion of coracobrachialis and its association with musculocutaneous nerve, providing necessary information to surgeons performing surgical reconstruction using coracobrachialis.