A role for total alloplastic temporomandibular joint replacement in Gardner syndrome

Gardner syndrome (GS) is a rare autosomal dominant disorder that can present with craniomaxillofacial abnormalities. The identification of osteomas or craniomaxillofacial abnormalities can therefore serve as a marker of this condition, facilitating early referral and diagnosis. A 17-year-old female with GS was referred for the management of severe limited mouth opening, causing a major problem for routine endoscopy to monitor the gastrointestinal alterations of GS. Clinical and radiological evaluations showed multiple osteomas in the mandibular angle, condylar and coronoid regions bilaterally and maximum mouth opening of 8 mm. The patient underwent surgery for osteoma removal and bilateral customized alloplastic total temporomandibular joint replacement (TMJ-TJR). At the 2-year follow-up, the patient showed improvements in quality of life, with a maximum mouth opening of 34 mm, allowing routine upper endoscopy to be performed. This is the first report of GS, a rare and challenging craniomaxillofacial abnormality, treated with TMJ-TJR. A comprehensive overview of the patient's clinical presentation, diagnostic assessment, treatment planning, and outcomes is provided.

The potential distribution of Bacillus anthracis suitability across Uganda using INLA

To reduce the veterinary, public health, environmental, and economic burden associated with anthrax outbreaks, it is vital to identify the spatial distribution of areas suitable for Bacillus anthracis, the causative agent of the disease. Bayesian approaches have previously been applied to estimate uncertainty around detected areas of B. anthracis suitability. However, conventional simulation-based techniques are often computationally demanding. To solve this computational problem, we use Integrated Nested Laplace Approximation (INLA) which can adjust for spatially structured random effects, to predict the suitability of B. anthracis across Uganda. We apply a Generalized Additive Model (GAM) within the INLA Bayesian framework to quantify the relationships between B. anthracis occurrence and the environment. We consolidate a national database of wildlife, livestock, and human anthrax case records across Uganda built across multiple sectors bridging human and animal partners using a One Health approach. The INLA framework successfully identified known areas of species suitability in Uganda, as well as suggested unknown hotspots across Northern, Eastern, and Central Uganda, which have not been previously identified by other niche models. The major risk factors for B. anthracis suitability were proximity to water bodies (0-0.3 km), increasing soil calcium (between 10 and 25 cmolc/kg), and elevation of 140-190 m. The sensitivity of the final model against the withheld evaluation dataset was 90% (181 out of 202 = 89.6%; rounded up to 90%). The prediction maps generated using this model can guide future anthrax prevention and surveillance plans by the relevant stakeholders in Uganda.

Defining a Standard Set of Health Outcomes for Patients With Squamous Cell Carcinoma of the Head and Neck in Spain

Purpose

A systematic, standardized collection of health outcomes during patient treatment and follow-up, relevant from the perspective of all stakeholders, is a crucial step toward effective and efficient disease management. This project aimed to define a standard set of health outcomes for patients with squamous cell carcinoma of the head and neck (SCCHN).

Methods

The project was led and coordinated by a scientific committee (SC). It comprised: (1) a literature review (to identify variables used during SCCHN management); (2) 1^st-SC meeting (to select the variables for presentation during nominal groups-NG); (3) five NG (n=42 experts) and four interviews with patients (to reach consensus on the variables for inclusion); and (4) final-SC meeting (to review the results of NG ensuring consensus on the variables where consensus was not reached).

Results

Experts agreed to include the following variables in the standard set: treatment-related (treatment intent and type, response to treatment, treatment toxicity/complication, treatment completion), degree of health (performance status, patient-reported health status, pain, dysphonia, feeding and speech limitations, body image alteration, tracheotomy), survival (overall and progression-free survival, cause of death), nutritional (weight, nutritional intervention), other variables (smoking status, alcohol consumption, patient satisfaction with aftermath care, employment status), and case-mix variables (demographic, tumor-related, clinical and nutritional factors).

Conclusions

This project may pave the way to standardizing the collection of health outcomes in SCCHN and promote the incorporation of patients’ perspective in its management. The information provided through the systematic compilation of this standard set may define strategies to achieve high-quality, patient-centered care.

A randomized controlled preclinical trial on 3 interposal temporomandibular joint disc implants: TEMPOJIMS-Phase 2

The effort to develop an effective and safe temporomandibular joint (TMJ) disc substitute has been one of the mainstreams of tissue engineering. Biodegradable customized scaffolds could approach safety and effectiveness to regenerate a new autologous disc, rather than using non-biodegradable materials. However, it is still technically challenging to mimic the biomechanical properties of the native disc with biodegradable polymers. In this study, new 3D tailored TMJ disc implants were developed: (1) Poly(glycerol sebacate) (PGS) scaffold reinforced with electrospun Poly(εcaprolactone) (PCL) fibers on the outer surface (PGS+PCL); (2) PCL and polyethylene glycol diacrylate (PEGDA) (PCL+PEGDA); and (3) PCL. The TMJ implants were tested in a randomized preclinical trial, conducted in 24 black Merino sheep TMJ, perfoming bilateral interventions. Histologic, imaging, and kinematics analysis was performed. No statistical changes were observed between the PGS+PCL disc and the control group. The PCL+PEGDA and PCL groups were associated with statistical changes in histology (p = 0.004 for articular cartilage mid-layer; p = 0.019 for structure changes and p = 0.017 for cell shape changes), imaging (p = 0.027 for global appreciation) and dangerous material fragmentation was observed. No biomaterial particles were observed in the multi-organ analysis in the different groups. The sheep confirmed to be a relevant animal model for TMJ disc surgery and regenerative approaches. The PCL and PCL+PEGDA discs presented a higher risk to increase degenerative changes, due to material fragmentation. None of the tested discs regenerate a new autologous disc, however, PGS+PCL was safe, demonstrated rapid resorption, and was capable to prevent condyle degenerative changes.

Is the "Habsburg jaw" related to inbreeding?

Background: The "Habsburg jaw" has long been associated with inbreeding due to the high prevalence of consanguineous marriages in the Habsburg dynasty. However, it is thought that mandibular prognathism (MP) is under the influence of a dominant major gene.Aim: To investigate the relationship between the "Habsburg jaw" and the pedigree-based inbreeding coefficient (F) as a relative measure of genome homozygosity.Subjects and methods: The degree of MP and maxillary deficiency (MD) of 15 members of the Habsburg dynasty was quantified through the clinical analysis of 18 dysmorphic features diagnosed from 66 portraits.Results: A statistically significant correlation (r = 0.711, p = 0.003) between MP and MD was observed among individuals. Only MP showed a statistically significant positive regression on F as evidenced from univariate analysis (b = 6.36 ± 3.34, p = 0.040) and multivariate analysis (PCA) performed from single dysmorphic features (b = 14.10 ± 6.62, p = 0.027, for the first PC).Conclusion: Both MP and MD are generally involved in the "Habsburg jaw." The results showed a greater sensitivity to inbreeding for the lower third of the face and suggest a positive association between the "Habsburg jaw" and homozygosity and therefore a basically recessive inheritance pattern.

The importance of a One Health approach for prioritising zoonotic diseases to focus on capacity-building efforts in Uganda

Zoonotic diseases constitute a significant threat to the health of humans, livestock and wildlife, as well as to livestock production, and can also have a negative impact on our shared environment and on livelihoods. Uganda is a hotspot for emerging and re-emerging zoonotic disease threats, with the main drivers of this phenomenon being identified as agricultural intensification, proximity to wildlife reservoirs and climate change. The threat of zoonotic disease outbreaks affects not only human healthcare systems but also livestock production, food security, human capital development, wildlife health, environmental health and privatesector growth. Firstly, to prevent, control and mitigate the threat from zoonotic diseases, in March 2017, Uganda prioritised zoonotic diseases using a One Health approach that focuses the limited resources available on those diseases that have the greatest impact at the national level. The prioritised zoonotic diseases in question are anthrax, zoonotic influenza viruses, viral haemorrhagic fevers, brucellosis, trypanosomiosis (African sleeping sickness), plague and rabies. Secondly, in January 2018, Uganda published a National One Health Strategic Plan, which was developed after these zoonotic diseases had been prioritised. In addition, the Ugandan Government and its partners are currently collaboratively addressing several of these previously neglected, endemic zoonotic diseases, such as anthrax, brucellosis and rabies. As a result of these One Health efforts, capacity has increased for early detection of, reporting on and response to zoonotic diseases at all levels. To consolidate the achievements of the One Health approach, the Ugandan Government and its partners should continue to support capacity building for the prevention and control of zoonotic diseases.

Rare primary leiomyosarcoma of the internal jugular vein with cervical extravascular extension

Leiomysarcoma of intravascular origin is a rare malignant tumour of the soft tissue. We present what is, to our knowledge, the first example of one that has arisen from the wall of the internal jugular vein.

Choosing sheep (Ovis aries) as animal model for temporomandibular joint research: Morphological, histological and biomechanical characterization of the joint disc

Preclinical trials are essential to the development of scientific technologies. Remarkable molecular and cellular research has been done using small animal models. However, significant differences exist regarding the articular behavior between these models and humans. Thus, large animal models may be more appropriate to perform trials involving the temporomandibular joint (TMJ). The aim of this work was to make a morphological (anatomic dissection and white light 3D scanning system), histological (TMJ in bloc was removed for histologic analysis) and biomechanical characterization (tension and compression tests) of sheep TMJ comparing the obtained results with human data. Results showed that sheep processus condylaris and fossa mandibularis are anatomically similar to the same human structures. TMJ disc has an elliptical perimeter, thinner in the center than in periphery. Peripheral area acts as a ring structure supporting the central zone. The disc cells display both fibroblast and chondrocyte-like morphology. Marginal area is formed by loose connective tissue, with some chondrocyte-like cells and collagen fibers in diverse orientations. Discs obtained a tensile modulus of 3.97±0.73MPa and 9.39±1.67MPa, for anteroposterior and mediolateral assessment. The TMJ discs presented a compressive modulus (E) of 446.41±5.16MPa and their maximum stress value (σmax) was 18.87±1.33MPa. Obtained results suggest that these animals should be considered as a prime model for TMJ research and procedural training. Further investigations in the field of oromaxillofacial surgery involving TMJ should consider sheep as a good animal model due to its resemblance of the same joint in humans.

Endoscopically-Assisted Zygomatic Implant Placement: A Novel Approach

BACKGROUND

Zygomatic implants (ZIs) have been proposed as a valid alternative to advance bone-grafting procedures in the rehabilitation of the severe atrophied upper maxilla, with a reported overall success rate of more than 95 %. Otherwise, the use of the endoscope has been described for the treatment of maxillofacial trauma, orthognatic surgical procedures, sinonasal pathology, salivary gland disease, and TMJ internal derangement. A careful identification of anatomical landmarks is of utmost importance while trying to avoid potential complications during the insertion of ZIs. Several approaches for ZI insertion have been reported, such as the classical approach; the sinus slot technique; and the exteriorized approach.

MATERIALS AND METHODS

The authors first introduce in the literature the endoscopically-assisted approach for the insertion of ZIs in the extremely severe atrophic maxilla.

RESULTS

Optimal results in terms of ZIs positioning with no damage to surrounding structures were obtained.

CONCLUSIONS

By means of this new technique the surgeon may minimize the risk of complications related to the damage of neighbouring anatomic structures, such as orbital disruption or infraorbitary nerve damage, while ensuring an adequate drill positioning and angulation for the placement of one or two implants into the zygomatic bone.

Comparison of microstructures between block grafts from the mandibular ramus and calvarium for horizontal bone augmentation of the maxilla: a case series study

The primary purpose of this clinical study was to compare architectural metric parameters using microcomputed tomography (micro-CT) between sites grafted with blocks harvested from the mandibular ramus and calvarium for horizontal bone augmentation in the maxilla. The second aim was to compare the primary stability of implants placed in both types of block grafts. Ten consecutive healthy partially edentulous patients requiring extensive horizontal bone reconstruction in the maxilla were included. A total of 14 block grafts (7 each from the mandibular ramus and calvarium) were studied. After 4 to 6 months of healing, 41 implants were placed: 24 implants (58.5%) in calvarial (group 1) and 17 (41.5%) in ramus grafts (group 2). A resonance frequency analysis (RFA) was performed to test implant stability. Furthermore, two biopsy specimens were randomly selected for histomorphometric analysis. Micro-CT analyses showed no significant difference in the morphometric parametric values analyzed between groups. Furthermore, RFA also showed no difference between groups. However, slightly higher RFA values were noted for implants placed in ramus grafts. Bone quality, as assessed by micro-CT and histomorphometric analyses, was similar in both ramus and calvarial block grafts. In addition, there was no difference in primary implant stability between groups.

Effect of location on primary stability and healing of dental implants

PURPOSE

To study implant primary stability and bone healing using resonance frequency analysis in different anatomical locations 4 months after placement.

MATERIAL AND METHODS

Fifty-six partially edentulous patients restored by dental implants were included. Overall, 214 implants were placed without bone or soft tissue augmentation. All implants were placed with the same drilling protocol and implant insertion torque (35-40 N · cm).

RESULTS

The mean implant stability quotient (ISQ) value at baseline for all the locations was 75.4 mm (95% confidence interval, 74.20-76.59 mm). Higher ISQ values were found in the mandible. A significant difference between ISQ values of each location (P < 0.001) was identified. The mean values obtained showed an increase (3.4%) in all the locations, being greater in the posterior lower and upper maxillae (3.8%), whereas for the anterior maxilla, it was the least (1.5%) 4 months after healing. This increase was statistically significant in the posterior upper and lower maxillae (P < 0.001).

CONCLUSION

Higher implant stability was found in mandible compared with maxilla in both periods, immediately after insertion and 4 months later. Therefore, according to ISQ values, restoring implants immediately after insertion or after a healing period of 4 months represents safe time points.

Surface Topographical Changes of a Failing Acid-Etched Long-Term in Function Retrieved Dental Implant

The aim of the present study was to report the main topographical and chemical changes of a failing 18-year in function retrieved acid-etching implant in the micro- and nanoscales. A partially edentulous 45 year old rehabilitated with a dental implant at 18 years of age exhibited mobility. After careful examination, a 3.25 × 13-mm press-fit dental implant was retrieved. Scanning electron microscope (SEM) analysis was carried out to study topographical changes of the retrieved implant compared with an unused implant with similar topographical characteristics. Moreover, X-ray photoelectron spectroscopy (XPS) analysis was used to study the surface composition of the retrieved failing implant. Clear changes related to the dual dioxide layer are present as visible in ≥×500 magnification. In addition, it was found that, for the retrieved implant, the surface composition consisted mainly of Ti2p, O1s, C1s, and Al2p. Also, a meaningful decrease of N and C was noticed, whereas the peaks of Ti2p, Al2p, and O1s increased when analyzing deeper (up to ×2000s) in the sample. It was shown that the superficial surface of a retrieved press-fit dual acid-etched implant 18 years after placement is impaired. However, the causes and consequences for these changes cannot be determined.

Unusual case of cervical syphilis with Piringer-Kuchinka-like lymphadenitis

Syphilis rarely presents with cervical lymphadenopathy. We describe a patient with a cervical mass associated with weight loss, asthenia, and night sweats. The mass was excised and histological examination suggested Piringer-Kuchinka lymphadenitis, which is usually present in cervical toxoplasmosis. To the best of our knowledge, Piringer-Kuchinka lymphadenitis has not previously been reported in cervical syphilis.

Microarchitectural pattern of pristine maxillary bone

PURPOSE

There is limited evidence available on the influence of location on bone density in the maxilla. Therefore, this study was aimed at comparing the microarchitecture of bone harvested from different nonatrophic maxillary locations.

MATERIALS AND METHODS

A total of 37 partially edentulous subjects (aged 48.15 ± 15.85 years) were included in the study. A bone core biopsy specimen was obtained from one site per patient at the planned implant surgery location. Thirty-four specimens were used for microcomputed tomography (micro-CT) analysis. Mann-Whitney U tests (independent samples) were performed to determine whether the distributions of the six bone-related parameters showed significant differences between sexes and site locations. Study sites were categorized as either anterior (incisors and canines) or posterior (premolars and molars). The possible associations among variables (bone volume fraction [BV/TV], age, and five bone-related parameters) were examined using the Spearman rank correlation test.

RESULTS

The mean BV/TV values showed no significant difference between the maxillary anterior (46.93 ± 26.2) and posterior (51.90 ± 28.42) locations. Statistically significant positive correlations were identified between BV/TV and trabecular thickness (Tb.Th) (r = 0.6, P < .001) and between BV/TV and trabecular number (Tb.N) (r = 0.49, P = .006). Statistically significant negative correlations were found between BV/TV and trabecular spacing (Tb.Sp) (r = -0.65, P < .001), between BV/TV and trabecular pattern factor (Tb.Pf) (r = -0.7, P <.001), and between BV/TV and the structural model index (SMI) (r = -0.68, P <.001). However, no correlations between BV/TV and age or sex were found.

CONCLUSION

Bone density was independent of the anatomical location, assessed by micro-CT in the pristine nonatrophic maxillary bone. Studies with a larger sample size and different population should be conducted to validate the findings of the current project.

Sensitivity of resonance frequency analysis for detecting early implant failure: a case-control study

PURPOSE

The aim of this study was to test the sensitivity of the resonance frequency analysis for detecting early implant failure.

MATERIALS AND METHODS

In all, 3,786 implants placed from June 2007 to January 2013 were retrospectively evaluated. A total of 20 implants (in 20 patients) placed in pristine bone were found to have failed before loading. The implant stability quotient (ISQ) values were extracted from these 20 implants at baseline (immediate) and 4 months after placement (delayed). Simple linear regression, logistic regression, and two-way contingency tables were used to test for the relationships between ISQ values and early implant failure.

RESULTS

Immediate ISQ values were significantly related to failure (odds ratio [OR] = 4.27). Furthermore, the results of the second regression showed a significant relationship between ISQ at delayed measurement and implant failure (OR = 9.20). For immediate ISQ, it seems that the 73.7% correct classifications were obtained at the cost of an incorrect classification of 55% of the implant failures. However, for the delayed ISQ, 86.2% correct classifications were obtained at the cost of assuming that all implants will survive.

CONCLUSION

The present study showed that ISQ values are not reliable in predicting early implant failure. In addition, the real cutoff ISQ value to differentiate between success and early implant failure remains to be determined.

Horizontal Bone Augmentation Using Autogenous Block Grafts and Particulate Xenograft in the Severe Atrophic Maxillary Anterior Ridges: A Cone-Beam Computerized Tomography Case Series

The aim of the present study was to use cone-beam computerized tomography (CBCT) to assess horizontal bone augmentation using block grafts, harvested from either the iliac crest (IC) or mandibular ramus (MR) combined with particulate xenograft and a collagen membrane for in the severe maxillary anterior ridge defects (cases Class III-IV according to Cadwood and Howell's classification). Fourteen healthy partially edentulous patients requiring extensive horizontal bone reconstruction in the anterior maxilla were selected for the study. Nineteen onlay block grafts (from IC or MR) were placed. The amount of horizontal bone gain was recorded by CBCT at 3 levels (5, 7, and 11 mm from the residual ridge) and at the time of bone grafting as well as the time of implant placement (≈5 months). Both block donor sites provided enough ridge width for proper implant placement. Nonetheless, IC had significantly greater ridge width gain than MR (Student t test) (4.93 mm vs 3.23 mm). This was further confirmed by nonparametric Mann-Whitney test (P = .007). Moreover, mean pristine ridge and grafted ridge values showed a direct association (Spearman coefficient of correlation = .336). A combination of block graft, obtained from the IC or MR, combined with particulate xenograft then covered with an absorbable collagen membrane is a predictable technique for augmenting anterior maxillary horizontal ridge deficiency.

Maxillary sinus lateral wall thickness and morphologic patterns in the atrophic posterior maxilla

BACKGROUND

The aim of the present study is to examine the sinus lateral wall thickness (LWT) of atrophic posterior maxilla (<10 mm) of patients with complete and partial edentulism and determine the influence of residual ridge height (RH), sex, and age on maxillary LWT.

METHODS

Four hundred fourteen measures were taken from 140 consecutive patients that met the inclusion criteria. On the selected sagittal section, a built-in digital caliper recorded in millimeters the RH and LWT (a perpendicular line at 3, 5, 7, 10, 13, and 15 mm from the lowest point of the sinus floor). Edentulous spans were further classified as complete edentulous atrophic maxilla (CEM) and partial edentulous atrophic maxilla (PEM). The mixed linear model was used to test the effects of sex, type of edentulism, edentulous span, and RH on the measurement of the LWT of the sinus.

RESULTS

Mean LWT for PEM was 1.71 ± 0.12 mm, and for CEM, 1.57 ± 0.07 mm (P = 0.01). The mixed model yielded significant effect of edentulous span (P = 0.048) and interactions among type of edentulism and edentulous span (P <0.001) and edentulous span by RH (P <0.01). Age and RH were positively associated with LWT; however, they did not interact with RH, sex, or type of edentulism. RH has been shown to correlate with edentulous span (P <0.001) and type of edentulism (P = 0.01). The longer the edentulous span, the thinner the LWT. Similarly, RH was larger for PEM (6.85 ± 0.34 mm) than CEM (5.69 ± 0.26 mm).

CONCLUSIONS

The maxillary sinus lateral wall tends to increase in thickness from the second premolar to the second molar and from 5 mm up to 15 mm. In addition, RH, presence of teeth adjacent to the edentulous atrophic ridge, and age were shown to influence maxillary sinus LWT.

Comparison of implant primary stability between maxillary edentulous ridges receiving intramembranous origin block grafts

Purpose: The purposes of the present study were: to compare the resonance frequency analysis (RFA) values of implant placed in either ramus or calvaria block grafts; and to determine if implant diameter influences RFA implant stability quotient (ISQ) value. Material and Methods: This was a retrospective study that included 16 consecutives healthy patients treated with autogenous onlay block grafts for horizontal bone reconstruction in maxilla. Ten ramus and ten calvaria block graft treated patients were selected and compared. Results: Totally, 59 implants were placed, 35 (59.3%) were placed on the calvaria bone grafts and the remaining 24 (40.7%) were on the ramus bone graft. Of all the implants studied, 13 (22%), 35 (59.3%), and 11 (18.6%) were 10 mm, 11.5 mm and 13 mm in length respectively. Regarding the diameter, 4 (7%) were 3.3 mm, 3 (5%) were 3.5 mm, 20 (34%) were 3.7 mm and 32 (54%) were 4 mm. Mean ISQ value obtained by RFA was 73.06 ± 6.08, being 72.19 ± 6 and 74.47 ± 6.06 for the calvaria and ramus treated group respectively. No significant differences were noted between the two groups (p= 0.154). Implants were pooled and divided by their diameter. Mean ISQ value obtained for 3.3 mm was 80 ± 5.09, while for 4.0 mm was 72.5 ± 7.19. Again, no significant differences were found among the groups (p= 0.138). Conclusion: For RFA ISQ value, the bone graft origins (calvaria or ramus) or implant diameters did not influence the outcome.

Key words:Bone augmentation, dental implant, resonance frequency analysis, implant stability.

C-modified osteotomy for bilateral advancement of the orbital rim in Graves orbitopathy: a technical note

The authors present a modification of the classical three-wall orbital decompression for the treatment of Graves' orbitopathy. It consists of two 'C' osteotomies for the bilateral projection of the superolateral, lateral and inferolateral orbital rims, associated with the removal of the lateral orbital walls. This technique is performed following a coronal approach. Ultrasound cutting instruments were used for the osteotomies. They avoided lesion of surrounding soft tissues, such as the duramater and the periorbital tissues. Stabilization of the advanced structure was achieved by interposition of autologous bone graft obtained from the outer cortex of the calvaria. An extreme advancement of the orbital rim with resolution of diplopia, ocular pain and eyelid incompetence was obtained. Using this procedure, a good functional and aesthetic outcome was achieved.

Vascularization of the peroneal muscles. Critical evaluation in fibular free flap harvesting

This anatomical study was carried out in order to discover the etiology of partial necrosis of the peroneus longus and brevis muscles after fibular osteocutaneous flap harvest. The vascular supply to the lateral compartment peroneal muscles was investigated in 10 fresh cadaveric lower limbs. The peroneal muscles are supplied by two principal sources arteries, the anterior tibial artery (ATA) and the peroneal artery (PA). The ATA is the dominant artery and supplies the proximal and middle thirds of these muscles. The PA is considered to be a supplementary vascular source and supplies the distal thirds of these muscles. After harvesting the PA in a fibular flap, regions of the peroneal muscles preoperatively vascularized by its branches become supplied through the anastomotic "choke" vessels between the ATA and the PA. Primary closure of the cutaneous defect increases the possibility of developing a pseudo-compartment syndrome with necrosis of the more precariously vascularized portions of the peroneal muscles. This complication is difficult to diagnosis early and the reason why we advocate that direct skin closure following composite harvest must be avoided. Moreover, conservation of the inferior and superior lateral branches of the ATA is imperative in order to preserve the peroneal muscles vascularization.