Aditya Aggarwal

Anatomic consideration of caudal epidural space: A cadaver study

The knowledge of sacral hiatus anatomy is imperative in clinical situations requiring caudal epidural block for various diagnostic and therapeutic procedures of the lumbosacral spine to avoid failure and dural injury. In this study, a detailed anatomic study of the sacral region was carried out on 49 male adult Indian cadavers. Dorsal surface of sacral region was dissected to study sacral cornua, sacral hiatus, and the dimensions of triangle formed by the right and left posterosuperior iliac spines with apex of the hiatus. Midsagittal sections were subjected for various anatomical measurements. The angle of needle insertion and the depth of caudal space were noted. Cornu was not palpable bilaterally in 7 (14.3%) and palpable unilaterally in 12 (24.5%) specimens. Mean (standard deviation) distance between apex of hiatus and coccyx tip was 57.5 (8.7) mm and length of sacrococcygeal ligament was 34.2 (7.4) mm. The dimensions of the triangle were found to be interchangeable in 25 cadavers. Once the needle is introduced into the canal after penetrating the sacrococcygeal ligament, it should not be advanced >5 mm to prevent dural puncture. The level of maximum curvature of sacrum was S3 in 34 (69.4%) of cases. The dural sac was found to terminate at S2 in 41 (83.6%). The mean (SD) angle of depression of the needle was 65.7 (5.5) (range 58–78). The measurements described for the identification of the sacral hiatus, optimal angle of depression, and depth of the needle may improve the safety and reliability of a caudal epidural block. Clin. Anat. 22:730–737, 2009.

Electric discharge machining – A potential choice for surface modification of metallic implants for orthopedic applications: A review

Among the various metallic implant materials, titanium (Ti) alloy is the best choice for the long-term hard body tissue replacements such as hip and knee joints. It has excellent mechanical, superior biological and strong anticorrosion properties. Besides the appropriate implant material, its surface topology also plays a very important role in the success of any surgery. The surface topology is supposed to be the key factor for the promotion of osseointegration. This research article focuses its attention mainly on surface modification of Ti-based alloys by electric discharge machining process. Electric discharge machining is one of the most popular nonconventional manufacturing methods. Besides machining and surface modification of implants, it finds applications in almost all areas of manufacturing industries. This article reviews the various research work done on surface modification of Ti alloy by electric discharge machining and attempts to bring out the current scenario along with future directions. The area under focus for this research review is orthopedics applications. Furthermore, a new promising advancement in the area of enhancement of electric discharge machining performance for surface modification, particularly with regard to biocompatibility and surface quality of biomaterials, has also been introduced.

Anatomical variation in formation of brachial plexus and its branching

Variant brachial plexus formation with two trunks and two cords is uncommon and has clinical implications as it may result in failure of regional brachial or axillary block. During routine anatomical dissection, unilateral variation in the formation of brachial plexus accompanied by unusual positional relationship with axillary artery was discovered in the left upper extremity of a 52-year-old Indian male cadaver. Brachial plexus showed two trunks formed by ventral rami of C5, C6 and C7, C8, T1 spinal nerves, respectively, which first split and then reunited in an unusual manner to form two cords: posterior and lateral instead of three. Medial cord was absent. The branching pattern of the brachial plexus also showed important variations. Second part of axillary artery was found lying inferomedial to brachial plexus instead of passing between medial and lateral cords. Transverse cervical artery was found to be coursing between two trunks instead of passing superficial to brachial plexus. Median nerve was observed to be formed from a single root, instead of usual two roots. Embryologically, this rare variation may be due to the development of axillary artery from ninth segmental artery instead of usual seventh cervical intersegmental artery. Such rare variation is clinically important as this knowledge may help the anesthesiologists and the surgeons to avoid any inadvertent damage to nerves and axillary artery during blocks and surgical interventions.

Bilateral multiple complex variations in the formation and branching pattern of brachial plexus

Bilateral variations in the formation and branching of brachial plexus are extremely rare. Multiple bilateral variations in brachial plexus right from divisions to branching pattern were observed during the dissection in an adult male cadaver. Lateral and medial cord formation showed deviation from the usual pattern. Anterior division of upper trunk continued as lateral cord. Medial cord was formed by the union of anterior division of lower trunk and anterior division of middle trunk, thus receiving fibers from both the trunks. Anterior division of middle trunk bifurcated into upper and lower branches. We encountered two lateral roots bilaterally and two medial roots of median nerve on the left side with anomalous origin. There were three upper subscapular nerves on the left and two on the right side with variations in their origin. Anomalous origin of many other branches on both sides was encountered. It is extremely uncommon to find so many variations in one body and bilateral variations are still too rare. Understanding of such variations is clinically important for diagnosing unexplained clinical signs and symptoms as well as during nerve blocks and certain surgical procedures around the neck and proximal arm.

Surgical anatomy of round window and its implications for cochlear implantation

The objective of this work was to study the morphometry and morphology of the round window (RW) and its relationships with the internal carotid artery, jugular bulb (JB), facial nerve and oval window (OW). Fifty cadaveric temporal bones were microdissected to expose the medial wall of the middle ear. The areas around the RW were cleared and its shape, height and width were noted. Its distances from the carotid canal (CC), jugular fossa (JF), facial canal (FC), and OW were measured. Oval, round, triangular, comma, quadrangular, and pear shapes of RW were observed. The average height and width of the RW were 1.62 ± 0.77 mm and 1.15 ± 0.39 mm, respectively. There was a statistically significant correlation (r = 0.4, P < 0.01) between the height and width. The distances between the RW and the CC, JF, FC, and OW were in the ranges 4.39–11.05 mm, 0.38–8.65 mm, 2.99–6.3 mm, and 1.39–3.57 mm, respectively. In 8% of cases, the distance between the RW and the JF was <1 mm. There were no statistically significant differences with regard to age group, gender, or side. Electrode insertion can be challenging in cases where the height and width of the RW are <1 mm. The thin bone separating the roof of the JF from the RW (<1 mm in 8%) highlights a potential risk of injury to the JB during cochleostomy placement. This information could be useful for selecting cochlear implant electrodes in order to avoid potential risks to vital neurovascular structures during implant surgery. Clin. Anat. 27:331–336, 2014.

Mobile vs Fixed-Bearing Total Knee Arthroplasty Performed by a Single Surgeon A 4- to 6.5-Year Randomized, Prospective, Controlled, Double-Blinded Study

The superiority between posterior-stabilized mobile-bearing and fixed-bearing designs still remains controversial. Fifty-six consecutive patients undergoing primary, unilateral knee arthroplasty for osteoarthritis were randomly assigned to receive either a mobile-bearing (29 patients) or fixed-bearing (27 patients) prosthesis. We report the results at 4 to 6.5 years (mean, 5.5) follow-up. The Knee Society knee scores, pain scores, functional scores and Oxford knee scores were not statistically different (P > 0.05) between the two groups. Mean postoperative range-of-motion of mobile-bearing knees was significantly greater than that of fixed-bearing knees (127º versus 111º, P = 0.011). 72% of patients could sit cross legged, 48% could sit on the floor, and 17% could squat. Kaplan-Meier survival rate was 100%. No spin-out of mobile bearing was observed. The radiological analysis showed no osteolysis or implant loosening.

Predictors of posterior cruciate ligament degeneration in osteoarthritic knees

Purpose. To evaluate the tibial articular cartilage and histology of the posterior cruciate ligament (PCL) in osteoarthritic knees so as to determine predictors of PCL degeneration. Methods. 23 advanced osteoarthritic knees (mean patient age, 61 years) treated with total knee arthroplasty (TKA) were prospectively studied. The Knee Society Score was assessed. Osteoarthritic changes on radiographs were graded as mild, moderate, or severe. Tibial articular cartilage erosion was assessed. The appearance of both cruciate ligaments was classified as normal, abnormal (thinner and sclerotic), or ruptured. Both ligaments were examined histologically for degenerative changes. Each degenerative change of the PCL was graded by 2 histopathologists twice separately. Higher scores indicated more severe degeneration. Results. Of the 23 knees, the gross appearance of the anterior cruciate ligaments (ACLs) was normal in 6, abnormal in 11, and ruptured in 6. Histologically, the PCLs were normal in 4, minimally degenerated in 2, mildly in 8, moderately in 5, and severely in 4. The predominant degenerative change was the presence of loose fibrous tissue. ACL appearance correlated positively with PCL degeneration (r=0.883, p=0.001). The mean Knee Society Score was 24 (range, 0–43), and the mean function score was 30 (range, 5–55). PCL degeneration correlated positively with the Knee Society Score (r=0.565, p=0.02) but not with the function score (r=0.061, p=0.447). Anteroposterior instability correlated positively with PCL degeneration (r=0.691, p=0.01). Erosion in the lateral tibiofemoral compartment and ACL insufficiency were indicators of PCL degeneration (despite a normal appearance). Inter-observer reliability and intra-observer reproducibility were 0.82 and 0.87, respectively. Conclusion. The Knee Society Score, anteroposterior instability, ACL appearance, and erosion in the lateral tibiofemoral compartment are predictors of PCL degeneration and can help decide on the optimal type of TKA implant (PCL-retaining vs. PCL-sacrificing design).

Case report of a patient with tuberculosis of the femur after osteosynthesis with review of literature

phate and has been described in the literature. Regenbaum et al. reported the first case of IHPS in a premature infant with TNMG. The occurrence of TNMG with IHPS was explained on the use of anticholinesterase therapy, which may potentiate a vagal response, leading secondarily to smooth muscle pyloric hypertrophy. This association warrants further investigation, but remains intriguing in view of the possibility of medical treatment of IHPS.

Histological and immunohistochemical study of estrogen and progesterone receptors in normal human breast tissue in adult age groups vulnerable to malignancy

Analysis of receptor status has become standard procedure for assessing breast cancer patients. Estrogen causes epithelial proliferation in breast tissue via the estrogen receptor (ER). The progesterone receptor (PR) is also regulated by the estrogen gene. Analyzing ER and PR together gives information regarding the likely response of carcinoma patients to hormonal therapy. The aim of the present study was to record the expression patterns of ER and PR in normal mammary tissue in different age groups to provide reference data to facilitate histological diagnosis. Breast tissues from the upper outer quadrant of each side of 27 adult female cadavers were examined after H & E staining. ER and PR were identified and examined by immunohistochemistry. The percentage area occupied by parenchyma relative to stromal tissue was calculated in different age groups and was about 4:6, 3.5:6.5, 3:7, 2:8, and 1.5:8.5 in the 3rd, 4th and 5th, 6th, 7th, 8th and 9th, and 10th decades of life, respectively. Both ER and PR were present in all age groups and the numbers of both receptors were maximal during the 4th decade. The distribution and staining patterns for both ER and PR were recorded in different age groups. The contiguous pattern of ER, which is considered pathognomonic of breast carcinoma, was not seen except in one case in the 6th decade. Moderately stained ER and PR receptor sites predominated throughout. The study of normal breast tissue of similar age might provide comparisons that will help histopathologists to make clinical diagnoses from breast biopsies. Clin. Anat. 29:729–737, 2016.

Emergence of Orthobiologics as a Novel Therapeutic Modality for Osteoarthritis of Knee

Osteoarthritis [OA] of knee is a common cause of disability worldwide. The number of non-operative treatment options is on the rise. Orthobiologic therapy has emerged as a novel yet effective modality for early OA. It aims at achieving biologic repair, by repairing the damaged joint surface with autologous articular cartilage. Exploiting the healing and rejuvenating properties of bodys own cells for the repair and renewal of damaged tissues is the basic crux behind orthobiologic therapy. Creation of an ambient structural, biological and biomechanical environment is an essential prerequisite for successful orthobiologic therapy. There are a number of orthobiologic options - platelet rich plasma (PRP), bone marrow concentrate (BMC), adipose tissue derived mesenchymal stem cells (ADMSC), autologous chondrocyte implantation (ACI) and autologous conditioned serum. This review article discusses the clinical indications, rationale, preparation, pros and cons of each one of them in detail along with a comprehensive review of published literature.