Even though there are many options for mandibular reconstruction, a free fibula osteocutaneous flap is regarded as the most frequently used flap. Despite having some previous anatomical studies pertaining to syndesmotic ligaments, there is no study pointing out that surgical landmarks can be used while free fibula osteocutaneous flaps are performed and used for surgical landmarks in order to avoid syndesmotic ligament injuries. Therefore, this study investigates the characteristics and relationship between inferior syndesmotic ligaments and fibula in cadavers. A total of 140 legs were obtained from 83 embalmed cadavers as well as other soft ones, which were donated for the inferior tibiofibular syndesmotic system's study. Detailed dissection and measurement of each ligament's distance to the end of the fibula and lateral malleolus were performed. Distances from the distal end of the fibula to anterior inferior tibiofibular ligament, posterior inferior tibiofibular, and inferior transverse ligament, and the lower border of the interosseous membrane are 3.5 AE 0.4 cm, 3.4 AE 0.5 cm, 1.9 AE 0.4 cm, and 5 AE 1 cm (mean AE SD), respectively. Distance from the most distal part of the fibula to lateral malleolus is 1.6 AE 0.4 cm (mean AE SD). Thus, the remaining distance of the fibular should be left at least 4 cm without disrupting the syndesmotic ligament complex. It is argued that the lateral malleolus can be applied as a surgical landmark while harvesting fibula.

Background: Augmented reality (AR) is an imaging technology encompassing an interactive experience of a real-world environment enhanced by computer-generated perceptual information. It has been introduced to current medical practice to help the preoperative planning in many surgical fields. Methods: The authors applied AR to the computed tomography angiography of 8 patient's legs. Computed tomography angiography images were processed into Digital Imaging and communications in Medicine files to make a prefabricated cutting guide and customized titanium plate. Also, three-dimensional reconstruction of the arterial supply of the leg was performed to identify the perforators. Results: Followed by preoperative marking of operative details on patient's skins in antero-posterior view, lateral view, and combination of both views. Inaccuracy of measurement was confirmed by duplex ultrasound which average error of the combination of antero-posterior and lateral viewed of both legs was lowest (0.7 AE 0.2 cm). Followed by lateral view (1.0 AE 0.3 cm) and antero-posterior view (1.2 AE 0.4 cm), respectively. Conclusions: Augmented reality can improve patient's safety by directly locate the perforator and easily to design the skin paddle. Followed by satisfaction and confidence in patients and their relatives. Augmented reality also promoted understanding of operative steps for related assistants, residents, or fellows. Augmented reality can perform with existing equipment, mobile phone application, and can save the cost for preoperative planning. Distortion in the depth view can be more accurate by combining of AR in antero-posterior and lateral view.

BackgroundComputer-assisted surgery (CAS) has been introduced to mandible reconstruction with bular free ap in cutting guide placement. When CAS is cooperated with different plate xations, the results show various degrees of errors by which this study aimed to evaluate. MethodsMock surgeries were conducted in 3D-printed mandibles with either 2 types of defects; limited or extensive, reconstructed from 2 ameloblastoma patients. Three types of xations; miniplate, manually bending reconstruction plate and patient-speci c plates are tested, each of which was performed 3 times in each type of defects, adding up to 18 surgeries. One with the least errors was selected and applied with patients whose 3D-printed mandibles derived. Finally, in vivo errors were compared with the mock. ResultsIn limited defect, average errors show no statistical signi cance among all types. In extensive defect, patient-speci c plate had a signi cantly lower average condylar error than manually bending reconstruction plate and miniplate (8.09±2.52 mm vs. 25.49±2.72 and 23.13±13.54 mm, respectively).When patient-speci c plate was applied in vivo, the errors were not signi cantly different from the mock. ConclusionPatient-speci c plates cooperated with CAS shows the least errors. Nevertheless, manually bent reconstruction plates and miniplates could be applied in limited defects with caution.

Background: Lymphedema occurrence in patients that underwent breast cancer-related lymphedema (BCRL) treatment can become a major problem. Over the past decade, lymphaticovenular anastomosis (LVA) has become widely utilized. This surgery replicates the body’s system by creating a connection between the lymphatic tracts and the venous system and replaces a damaged lymphatic system caused by the consequences from BCRL. Objective: To analyze the results of LVA surgery targeting particularly the upper extremity areas from BCRL patients at Siriraj Hospital, Thailand. Materials and Methods: This retrospective study was based on the medical records of patients that underwent LVA surgery between January 2010 and August 2018. Lymphoscintigraphy examination (⁹⁹ᵐTc-dextran lymphoscintigraphy) or ICG lymphography was performed to confirm the physician’s diagnosis. The present study aimed to compare the arm circumference size and the rate of infection of patients between the pre-surgery and post-surgery of LVA. Results: One hundred eighteen patients underwent the LVA operation and were included in the study. They had an average of 3.2±1.3 anastomoses. The average duration for the follow-up after surgery was 32 weeks. The different sizes in both arms were 5.8±1.6 cm and 5.5±1.4 cm, which were measured from 10 centimeters above and below the elbows, respectively. Comparing the sizes of the arms based on pre-surgery and post-surgery measurements, the arm circumference decreased by 0.9±0.6 centimeters (15.5%) and 0.9±0.4 centimeters (16.4%) post-surgery for the position above and below the elbow, respectively. The number of infections decreased from 1.9±0.8 times per year to 0.8±0.1 times per year. However, it was found that the rate of applying skin-care treatments in patients was relatively low at 3.4%. Conclusion: The authors’ revealed that LVA surgery of the upper extremity is one of the most effective treatments for lymphedema patients. According to the authors experience in Siriraj Hospital, this treatment is not only decreasing the size of the limb, but it can also minimize the infection rate. However, most patients note that other additional treatments, such as elastic bandage, elastic stocking, or skin-care treatment, are still necessary. Keywords: Lymphedema, Lymphatic obstruction, Breast Cancer Related Lymphedema (BCRL), Lymphaticovenular anastomosis (LVA)

No abstract