title: USS Abraham Lincoln (CVN-72)

text: On 2 August 2018, it was announced that "Abraham Lincoln" would return to San Diego as part of a home port shift for three carriers, thus returning her to the Pacific Fleet. At the end of August 2018, VFA-125 began operating from "Abraham Lincoln" as an integrated part of CVW-7, the first time that the F-35C had operated integrated cyclic operations, simulating the full spectrum of planned operations.


title: USS Abraham Lincoln (CVN-72)

text: Also in August, a movie crew was aboard filming flight deck operations and flying sequences for the sequel "" off the coast of Virginia.


title: USS Abraham Lincoln (CVN-72)

text: On 1 April 2019, "Abraham Lincoln" and Carrier Strike Group 12 departed Norfolk for a six-month deployment that will end with a shifting of homeport to San Diego. On 9 April she arrived in the United States Sixth Fleet area of operations, where she would operate in the Mediterranean Sea before proceeding to the Persian Gulf, then the Indian Ocean and the South China Sea, before heading across the Pacific Ocean to her new homeport in San Diego. On 5 May 2019 this deployment was diverted to the Middle East due to tensions with Iran and headed to the Persian Gulf. Her transit was expedited by omitting a port visit to Split, Croatia.


title: USS Abraham Lincoln (CVN-72)

text: On 23 April 2019, "Abraham Lincoln" was reported to have operated simultaneously along with "John C. Stennis" in the Mediterranean Sea, the two carrier strike groups' operations including more than 130 aircraft, 10 ships, and 9,000 sailors and marines, according to the press release published by the U.S. Naval Forces Europe-Africa/US 6th Fleet. The operations were observed from the aircraft carrier by U.S. Ambassador to Russia, Jon Huntsman and Admiral James Foggo, commander, U.S. Naval Forces Europe-Africa and Allied Joint Force Command Naples. While aboard, Huntsman said: "Diplomatic communication and dialogue coupled with the strong defense these ships provide demonstrate to Russia that if it truly seeks better relations with the United States, it must cease its destabilizing activities around the world."


title: USS Abraham Lincoln (CVN-72)

text: In October 2019, it was revealed that "Abraham Lincoln"s Middle East deployment would be extended due to an electrical malfunction on .


title: USS Abraham Lincoln (CVN-72)

text: "Abraham Lincoln" arrived in her new homeport in San Diego on 20 January following a record-breaking 295 days at sea, the longest post-Cold War era deployment for a US carrier, breaking her own record in the process.


title: USS Abraham Lincoln (CVN-72)

text: On 18 December, the Navy announced Captain Amy Bauernschmidt would take command of "Abraham Lincoln" in following summer of 2021, the first time a woman will command an aircraft carrier.


title: USS Abraham Lincoln (CVN-72)

text: Captain Amy Bauernschmidt, who previously served as the carrier’s executive officer from 2016 to 2019, relieved Captain Walt Slaughter at a change of command ceremony in San Diego on 19 August.


title: USS Abraham Lincoln (CVN-72)

text: On 31 August, an MH-60S Knighthawk helicopter, embarked aboard "Abraham Lincoln", crashed into the Pacific


title: USS Abraham Lincoln (CVN-72)

text: Ocean at approximately 4:30pm (PST) while conducting routine flight operations, approximately off the coast of San Diego. Five crew members were killed while one was rescued during subsequent search and rescue operations.


title: USS Abraham Lincoln (CVN-72)

text: On 4 January, Marine Fighter Attack Squadron 314 (VMFA-314) became the first Marine Corps F-35C squadron to be deployed on an aircraft carrier.


title: USS Abraham Lincoln (CVN-72)

text: On 11 November, "Abraham Lincoln" hosted a college basketball game on her deck between Gonzaga University and Michigan State University, won 64–63 by Gonzaga.


title: USS Abraham Lincoln (CVN-72)

text: The carrier suffered a minor fire that injured 9 sailors on 29 November. The cause is unknown and an investigation was launched.


title: Battle of Grunwald

text: The Battle of Grunwald, Battle of Žalgiris or First Battle of Tannenberg was fought on 15 July 1410 during the Polish–Lithuanian–Teutonic War. The alliance of the Crown of the Kingdom of Poland and the Grand Duchy of Lithuania, led respectively by King Władysław II Jagiełło (Jogaila), who did not participate in the battle himself, and Grand Duke Vytautas, decisively defeated the German Teutonic Order, led by Grand Master Ulrich von Jungingen. Most of the Teutonic Order's leadership were killed or taken prisoner.


title: Battle of Grunwald

text: Although defeated, the Teutonic Order withstood the subsequent siege of the Malbork Castle and suffered minimal territorial losses at the Peace of Thorn (1411), with other territorial disputes continuing until the Treaty of Melno in 1422. The order, however, never recovered their former power, and the financial burden of war reparations caused internal conflicts and an economic downturn in the lands controlled by them. The battle shifted the balance of power in Central and Eastern Europe and marked the rise of the Polish–Lithuanian union as the dominant regional political and military force.


title: Battle of Grunwald

text: The battle was one of the largest in medieval Europe. The battle is viewed as one of the most important victories in the histories of Poland and Lithuania. It is also commemorated in Ukraine and Belarus. It has been used as a source of romantic legends and national pride, becoming a larger symbol of struggle against foreign invaders. During the 20th century, the battle was used in Nazi German and Soviet propaganda campaigns. Only in recent decades have historians moved towards a dispassionate, scholarly assessment of the battle, reconciling the previous narratives, which differed widely by nation.


title: Battle of Grunwald

text: Traditionally, the battle's location was thought to be in the territory of the monastic state of the Teutonic Order, on the plains between three villages: Grünfelde (Grunwald) to the west, Tannenberg (Stębark) to the northeast and Ludwigsdorf (Łodwigowo, Ludwikowice) to the south. However, research by Swedish historian and archaeological excavations in 2014–2017 proved that the actual site was south of Grünfelde (Grunwald). Władysław II Jagiełło referred to the site in Latin as "in loco conflictus nostri, quem cum Cruciferis de Prusia habuimus, dicto Grunenvelt". Later, Polish chroniclers interpreted the word "Grunenvelt" ("green field" in Low German) as "Grünwald", meaning "green forest" in German. The Lithuanians followed suit and translated the name as "Žalgiris". The Germans named the battle after Tannenberg ("fir hill" or "pine hill" in German). Thus, there are three commonly used names for the battle: , , . Its names in the languages of other involved peoples include , , , , .


title: Battle of Grunwald

text: There are few contemporary, reliable sources about the battle, and most were produced by the Polish side. The most important and trustworthy source is "Cronica conflictus Wladislai regis Poloniae cum Cruciferis anno Christi 1410", which was written within a year of the battle by an eyewitness. Its authorship is uncertain, but several candidates have been proposed: Polish deputy chancellor Mikołaj Trąba and Władysław II Jagiełło's secretary Zbigniew Oleśnicki. While the original "Cronica conflictus" did not survive, a short summary from the 16th century has been preserved. Another important source is "Historiae Polonicae" by Polish historian Jan Długosz (1415–1480). It is a comprehensive and detailed account written several decades after the battle. The reliability of this source suffers not only from the long gap between the events and the chronicle, but also Długosz's alleged biases against the Lithuanians. "Banderia Prutenorum" is a mid-15th-century manuscript with images and Latin descriptions of the Teutonic battle flags captured during the battle and displayed in Wawel Cathedral and Vilnius Cathedral. Other Polish sources include two letters written by Władysław II Jagiełło to his wife Anne of Cilli and Bishop of Poznań Wojciech Jastrzębiec and letters sent by Jastrzębiec to Poles in the Holy See. German sources include a concise account in the chronicle of Johann von Posilge. An anonymous letter, discovered in 1963 and written between 1411 and 1413, provided important details on Lithuanian maneuvers.


title: Battle of Grunwald

text: In 1230, the Teutonic Order, a crusading military order, moved to Chełmno Land (Kulmerland) and launched the Prussian Crusade against the pagan Prussian clans. With support from the pope and Holy Roman Emperor, the Teutons conquered and converted the Prussians by the 1280s and shifted their attention to the pagan Grand Duchy of Lithuania. For about 100 years, the order raided Lithuanian lands, particularly Samogitia, as it separated the order in Prussia from their branch in Livonia. While the border regions became an uninhabited wilderness, the order gained very little territory. The Lithuanians first gave up Samogitia during the Lithuanian Civil War (1381–84) in the Treaty of Dubysa.


title: Battle of Grunwald

text: In 1385, Grand Duke Jogaila of Lithuania agreed to marry Queen Jadwiga of Poland in the Union of Kreva. Jogaila converted to Christianity and was crowned King of Poland and became known as Władysław II Jagiełło, thus creating a personal union between the Kingdom of Poland and the Grand Duchy of Lithuania. The official Lithuanian conversion to Christianity removed the religious rationale for the order's activities in the area. Its grand master, Conrad Zöllner von Rothenstein, supported by Hungarian King Sigismund of Luxemburg, responded by publicly contesting the sincerity of Jogaila's conversion, bringing the charge to a papal court. The territorial disputes continued over Samogitia, which had been in Teutonic hands since the Peace of Raciąż in 1404. Poland also had territorial claims against the order in Dobrzyń Land and Gdańsk (Danzig), but the two states had been largely at peace since the Treaty of Kalisz (1343). The conflict was also motivated by trade considerations: the order controlled the lower reaches of the three largest rivers (the Neman, Vistula and Daugava) in Poland and Lithuania.


title: Battle of Grunwald

text: In May 1409, an uprising in Teutonic-held Samogitia started. Lithuania supported it and the order threatened to invade. Poland announced its support for the Lithuanian cause and threatened to invade Prussia in return. As Prussian troops evacuated Samogitia, Teutonic Grand Master Ulrich von Jungingen declared war on the Kingdom of Poland and the Grand Duchy of Lithuania on 6 August 1409. The order hoped to defeat Poland and Lithuania separately, and began by invading Greater Poland and Kuyavia, catching the Poles by surprise. The order burned the castle at Dobrin (Dobrzyń nad Wisłą), captured Bobrowniki after a 14-day siege, conquered Bydgoszcz (Bromberg) and sacked several towns. The Poles organized counterattacks and recaptured Bydgoszcz. The Samogitians attacked Memel (Klaipėda). However, neither side was ready for a full-scale war.


title: Battle of Grunwald

text: Wenceslaus, King of the Romans, agreed to mediate the dispute. A truce was signed on 8 October 1409 and was set to expire on 24 June 1410. Both sides used this time to prepare for war, gathering troops and engaging in diplomatic maneuvering. Both sides sent letters and envoys accusing each other of various wrongdoings and threats to the Christendom. Wenceslaus, who received a gift of 60,000 florins from the order, declared that Samogitia rightfully belonged to the order and only Dobrzyń Land should be returned to Poland. The order also paid 300,000 ducats to Sigismund of Hungary, who had ambitions regarding the Principality of Moldavia, for mutual military assistance. Sigismund attempted to break the Polish–Lithuanian alliance by offering Vytautas a king's crown; Vytautas' acceptance would have violated the terms of the Ostrów Agreement and created Polish-Lithuanian discord. At the same time, Vytautas managed to obtain a truce from the Livonian Order.


title: Battle of Grunwald

text: By December 1409, Władysław II Jagiełło and Vytautas had agreed on a common strategy: their armies would unite into a single massive force and march together towards Marienburg (Malbork), capital of the Teutonic Order. The order, who took a defensive position, did not expect a joint attack and were preparing for a dual invasion—by the Poles along the Vistula River towards Danzig (Gdańsk) and the Lithuanians along the Neman River towards Ragnit (Neman). To counter this perceived threat, Ulrich von Jungingen concentrated his forces in Schwetz (Świecie), a central location from where troops could respond to an invasion from any direction rather quickly. Sizable garrisons were left in the eastern castles of Ragnit, Rhein (Ryn) near Lötzen (Giżycko) and Memel (Klaipėda). To keep their plans secret and mislead the order, Władysław II Jagiełło and Vytautas organized several raids into border territories, thus forcing the order to keep their troops in place.


title: Battle of Grunwald

text: The precise number of soldiers involved has proven difficult to establish. None of the contemporary sources provided reliable troop counts. Jan Długosz provided the number of banners, the principal unit of each cavalry: 51 for the Teutons, 50 for the Poles and 40 for the Lithuanians. However, it is unclear how many men were under each banner. The structure and number of infantry units (pikemen, archers, crossbowmen) and artillery units is unknown. Estimates, often biased by political and nationalistic considerations, were produced by various historians. German historians tend to present lower numbers, while Polish historians tend to use higher estimates. The high-end estimates by Polish historian Stefan Kuczyński of 39,000 Polish–Lithuanian and 27,000 Teutonic men have been cited in Western literature as "commonly accepted".


title: Battle of Grunwald

text: While outnumbered, the Teutonic army had advantages in discipline, military training and equipment. They were particularly noted for their heavy cavalry, although only a small percentage of the Order's army at Grunwald were heavily armoured knights. The Teutonic army was also equipped with bombards that could shoot lead and stone projectiles.


title: Battle of Grunwald

text: Both armies were composed of troops from several states and lands, including numerous mercenaries, primarily from Silesia and Bohemia. Bohemian mercenaries fought on both sides. The Silesian mercenaries were led in battle by Duke Konrad VII the White, of Oels, who was supported by knights from the Silesian nobility including Dietrich von Kottulin and Hans von Motschelnitz.


title: Battle of Grunwald

text: Soldiers from twenty-two different states and regions, mostly Germanic, joined the Order's army. Teutonic recruits known as guest crusaders included soldiers from Westphalia, Frisia, Austria, Swabia, Bavaria, and Stettin (Szczecin). Two Hungarian nobles, Nicholas II Garai and Stibor of Stiboricz, brought 200 men for the Order, but support from Sigismund of Hungary was disappointing.


title: Battle of Grunwald

text: Poland brought mercenaries from Moravia and Bohemia. The Czechs produced two full banners, under the command of John Sokol of Lamberg. Serving among the Czechs was possibly Jan Žižka, future commander of the Hussites. Alexander I of Moldavia commanded an expeditionary corps and the Moldavian king was so brave that the Polish troops and their king honoured him with a royal sword, the Szczerbiec. Vytautas gathered troops from Lithuanian and Ruthenian lands (present-day Belarus and Ukraine). Among them were three banners from Smolensk led by Władysław II Jagiełło's brother Lengvenis and the Tatar contingent of the Golden Horde under the command of the future Khan Jalal ad-Din. The overall commander of the joint Polish–Lithuanian force was King Władysław II Jagiełło; however, he did not directly participate in the battle. The Lithuanian units were commanded directly by Grand Duke Vytautas, who was second in command, and helped design the grand strategy of the campaign. Vytautas actively participated in the battle, managing both Lithuanian and Polish units. Jan Długosz stated that the low-ranking swordbearer of the Crown, Zyndram of Maszkowice, commanded the Polish army, but that is highly doubtful. More likely, marshal of the Crown Zbigniew of Brzezia commanded the Polish troops in the field.


title: Battle of Grunwald

text: The first stage of the Grunwald campaign was the gathering of all Polish–Lithuanian troops at Czerwińsk, a designated meeting point about from the Prussian border, where the joint army crossed the Vistula over a pontoon bridge. This maneuver, which required precision and intense coordination among multi-ethnic forces, was accomplished in about a week, from 24 to 30 June. Polish soldiers from Greater Poland gathered in Poznań, and those from Lesser Poland, in Wolbórz. On 24 June, Władysław II Jagiełło and Czech mercenaries arrived in Wolbórz. Three days later the Polish army was already at the meeting place. The Lithuanian army marched out from Vilnius on 3 June and joined the Ruthenian regiments in Hrodna. They arrived in Czerwińsk on the same day the Poles crossed the river. After the crossing, Masovian troops under Siemowit IV and Janusz I joined the Polish–Lithuanian army. The massive force began its march north towards Marienburg (Malbork), capital of Prussia, on 3 July. The Prussian border was crossed on 9 July.


title: Battle of Grunwald

text: The river crossing remained secret until Hungarian envoys, who were attempting to negotiate a peace, informed the Grand Master. As soon as Ulrich von Jungingen grasped the Polish–Lithuanian intentions, he left 3,000 men at Schwetz (Świecie) under Heinrich von Plauen and marched the main force to organize a line of defense on the Drewenz River (Drwęca) near Kauernik (Kurzętnik). The river crossing was fortified with stockades. On 11 July, after meeting with his eight-member war council, Władysław II Jagiełło decided against crossing the river at such a strong, defensible position. The army would instead bypass the river crossing by turning east, towards its sources, where no other major rivers separated his army from Marienburg. The march continued east towards Soldau (Działdowo), although no attempt was made to capture the town. The Teutonic army followed the Drewenz River north, crossed it near Löbau (Lubawa) and then moved east in parallel with the Polish–Lithuanian army. According to the Order's propaganda, the latter ravaged the village of Gilgenburg (Dąbrówno). Later, in the self-serving testimonies of the survivors before the Pope, the order claimed that Von Jungingen was so enraged by the alleged atrocities that he swore to defeat the invaders in battle.


title: Battle of Grunwald

text: In the early morning of 15 July, both armies met in an area covering approximately between the villages of Grunwald, Tannenberg (Stębark) and Ludwigsdorf (Łodwigowo). The armies formed opposing lines along a northeast–southwest axis. The Polish–Lithuanian army was positioned in front and east of Ludwigsdorf and Tannenberg. Polish heavy cavalry formed the left flank, Lithuanian light cavalry the right flank and various mercenary troops made up the center. Their men were organized in three lines of wedge-shaped formations about 20 men deep. The Teutonic forces concentrated their elite heavy cavalry, commanded by Grand Marshal Frederic von Wallenrode, against the Lithuanians. The order, which was the first to organize their army for the battle, hoped to provoke the Poles or Lithuanians into attacking first. Their troops, wearing heavy armor, had to stand in the scorching sun for several hours waiting for an attack. One chronicle suggested that they had dug pits that an attacking army would fall into. They also attempted to use field artillery, but a light rain dampened their powder and only two cannon shots were fired. As Władysław II Jagiełło delayed, the Grand Master sent messengers with two swords to "assist Władysław II Jagiełło and Vytautas in battle". The swords were meant as an insult and a provocation. Known as the "Grunwald Swords", they became one of the national symbols of Poland.


title: Battle of Grunwald

text: Vytautas, supported by the Polish banners, started an assault on the left flank of the Teutonic forces. After more than an hour of heavy fighting, the Lithuanian light cavalry began a full retreat. Jan Długosz described this development as a complete annihilation of the entire Lithuanian army. According to Długosz, the order assumed that victory was theirs, broke their formation for a disorganized pursuit of the retreating Lithuanians, and gathered much loot before returning to the battlefield to face the Polish troops. He made no mention of the Lithuanians, who later returned to the battlefield. Thus, Długosz portrayed the battle as a single-handed Polish victory. This view contradicted "Cronica conflictus" and has been challenged by modern historians.


title: Battle of Grunwald

text: Starting with an article by Vaclaw Lastowski in 1909, they proposed that the retreat had been a planned maneuver borrowed from the Golden Horde. A feigned retreat had been used in the Battle of the Vorskla River (1399), when the Lithuanian army had been dealt a crushing defeat and Vytautas himself had barely escaped alive. This theory gained wider acceptance after the discovery and publication, in 1963 by Swedish historian , of a German letter. Written a few years after the battle, it cautioned the new Grand Master to look out for feigned retreats of the kind that had been used in the Great Battle. Stephen Turnbull asserts that the Lithuanian tactical retreat did not quite fit the formula of a feigned retreat; such a retreat was usually staged by one or two units (as opposed to almost an entire army) and was swiftly followed by a counterattack (whereas the Lithuanians had returned late in the battle).


title: Battle of Grunwald

text: While the Lithuanians were retreating, heavy fighting broke out between Polish and Teutonic forces. Commanded by Grand Komtur Kuno von Lichtenstein, the Teutonic forces concentrated on the Polish right flank. Six of von Walenrode's banners did not pursue the retreating Lithuanians, instead joining the attack on the right flank. A particularly valuable target was the royal banner of Kraków. It seemed that the order were gaining the upper hand, and at one point the royal standard-bearer, Marcin of Wrocimowice, lost the Kraków banner. However, it was soon recaptured and fighting continued. Władysław II Jagiełło deployed his reserves—the second line of his army. Grand Master Ulrich von Jungingen then personally led 16 banners, almost a third of the original Teutonic strength, to the right Polish flank, and Władysław II Jagiełło deployed his last reserves, the third line of his army. The melee reached the Polish command and one knight, identified as Lupold or Diepold of Kökeritz, charged directly against King Władysław II Jagiełło. Władysław's secretary, Zbigniew Oleśnicki, saved the king's life, gaining royal favor and becoming one of the most influential people in Poland.


title: Battle of Grunwald

text: At that time the reorganized Lithuanians returned to the battle, attacking von Jungingen from the rear. The Teutonic forces were by then becoming outnumbered by the mass of Polish knights and advancing Lithuanian cavalry. As von Jungingen attempted to break through the Lithuanian lines, he was killed. According to "Cronica conflictus", Dobiesław of Oleśnica thrust a lance through the Grand Master's neck, while Długosz presented Mszczuj of Skrzynno as the killer. Surrounded and leaderless, the Teutonic Order began to retreat. Part of the routed units retreated towards their camp. This move backfired when the camp followers turned against their masters and joined the manhunt. The knights attempted to build a wagon fort: the camp was surrounded by wagons serving as an improvised fortification. However, the defense was soon broken and the camp was ravaged. According to "Cronica conflictus", more knights died there than on the battlefield. The battle lasted for about ten hours.


title: Battle of Grunwald

text: The Teutonic Order attributed the defeat to treason on the part of Nicholas von Renys (Mikołaj of Ryńsk), commander of the Culm (Chełmno) banner, and he was beheaded without a trial. He was the founder and leader of the Lizard Union, a group of knights sympathetic to Poland. According to the order, von Renys lowered his banner, which was taken as a signal of surrender and led to the panicked retreat. The legend that the order was "stabbed in the back" was echoed in the post-World War I stab-in-the-back myth and preoccupied German historiography of the battle until 1945.


title: Battle of Grunwald

text: A note sent in August by envoys of King Sigismund of Hungary, Nicholas II Garai and Stibor of Stiboricz, put total casualties at 8,000 dead "on both sides". However, the wording is vague and it is unclear whether it meant a total of 8,000 or 16,000 dead. A papal bull from 1412 mentioned 18,000 dead Christians. In two letters written immediately after the battle, Władysław II Jagiełło mentioned that Polish casualties were small ("paucis valde" and "modico") and Jan Długosz listed only 12 Polish knights who had been killed. A letter by a Teutonic official from Tapiau (Gvardeysk) mentioned that only half of the Lithuanians returned, but it is unclear how many of those casualties are attributable to the battle and how many to the later siege of Marienburg.


title: Battle of Grunwald

text: The defeat of the Teutonic Order was resounding. According to Teutonic payroll records, only 1,427 men reported back to Marienburg to claim their pay. Of 1,200 men sent from Danzig, only 300 returned. Between 203 and 211 brothers of the Order were killed, out of 270 that participated in battle, including much of the Teutonic leadership—Grand Master Ulrich von Jungingen, Grand Marshal Friedrich von Wallenrode, Grand Komtur Kuno von Lichtenstein, Grand Treasurer Thomas von Merheim, Marshal of Supply Forces Albrecht von Schwartzburg, and ten of the komturs. Marquard von Salzbach, Komtur of Brandenburg (Ushakovo) and Heinrich Schaumburg, voigt of Sambia, were executed by order of Vytautas after the battle. The bodies of von Jungingen and other high-ranking officials were transported to Marienburg Castle for burial on 19 July. The bodies of lower-ranking Teutonic officials and 12 Polish knights were buried at the church in Tannenberg. The rest of the dead were buried in several mass graves. The highest-ranking Teutonic official to escape the battle was Werner von Tettinger, Komtur of Elbing (Elbląg).


title: Battle of Grunwald

text: Polish and Lithuanian forces took several thousand captives. Among these were Dukes Konrad VII of Oels (Oleśnica) and Casimir V of Pomerania. Most of the commoners and mercenaries were released shortly after the battle on condition that they report to Kraków on 11 November 1410. Only those who were expected to pay ransom were kept. Considerable ransoms were recorded; for example, the mercenary Holbracht von Loym had to pay "150 kopas of Prague groschen", amounting to more than of silver.


title: Battle of Grunwald

text: After the battle, the Polish and Lithuanian forces delayed their attack on the Teutonic capital in Marienburg (Malbork), remaining on the battlefield for three days and then marching an average of only about per day. The main forces did not reach heavily fortified Marienburg until 26 July. This delay gave Heinrich von Plauen enough time to organize a defense. Władysław II Jagiełło also sent his troops to other Teutonic fortresses, which often surrendered without resistance, including the major cities of Danzig (Gdańsk), Thorn (Toruń), and Elbing (Elbląg). Only eight castles remained in Teutonic hands. The besiegers of Marienburg expected a speedy capitulation and were not prepared for a long siege, suffering from lack of ammunition, low morale, and an epidemic of dysentery. The order appealed to their allies for help, and Sigismund of Hungary, Wenceslaus, King of the Romans, and the Livonian Order promised financial aid and reinforcements.


title: Battle of Grunwald

text: The siege of Marienburg was lifted on 19 September. The Polish–Lithuanian forces left garrisons in the fortresses they had taken and returned home. However, the order quickly recaptured most of the castles. By the end of October only four Teutonic castles along the border remained in Polish hands. Władysław II Jagiełło raised a fresh army and dealt another defeat to the order in the Battle of Koronowo on 10 October 1410. Following other brief engagements, both sides agreed to negotiate.


title: Battle of Grunwald

text: The Peace of Thorn was signed in February 1411. Under its terms, the order ceded the Dobrin Land (Dobrzyń Land) to Poland and agreed to resign their claims to Samogitia during the lifetimes of Władysław II Jagiełło and Vytautas, although another two wars—the Hunger War of 1414 and the Gollub War of 1422—would be waged before the Treaty of Melno permanently resolved the territorial disputes. The Poles and Lithuanians were unable to translate the military victory into territorial or diplomatic gains. However, the Peace of Thorn imposed a heavy financial burden on the order from which they never recovered. They had to pay an indemnity in silver in four annual installments. To meet these payments, the order borrowed heavily, confiscated gold and silver from churches, and increased taxes. Two major Prussian cities, Danzig (Gdańsk) and Thorn (Toruń), revolted against the tax increases. The defeat at Grunwald left the Teutonic Order with few forces to defend their remaining territories. Since Samogitia became officially christened, as both Poland and Lithuania were for a long time, the order had difficulties recruiting new volunteer crusaders. The Grand Masters then needed to rely on mercenary troops, which proved an expensive drain on their already depleted budget. The internal conflicts, economic decline, and tax increases led to unrest and the foundation of the Prussian Confederation, or "Alliance against Lordship", in 1441. This in turn led to a series of conflicts that culminated in the Thirteen Years' War (1454).


title: Battle of Grunwald

text: Ideas about commemorating the battle rose right after the event. Władysław II Jagiełło wanted to build a monastery dedicated to Saint Bridget of Sweden, who had prophesied the downfall of the Teutonic Order, at the location of the battle. When the order regained the territory of the battlefield, the new grand master Heinrich von Plauen built a chapel dedicated to Saint Mary and it was consecrated in March 1413. It was destroyed by the Poles when they invaded during the Hunger War of 1414, but it was quickly rebuilt. The chapel fell to ruins during the Protestant Reformation and was demolished in 1720. Over time, the location of the chapel became associated with the location where Grand Master Ulrich von Jungingen was killed. In 1901, a large memorial stone was erected for the fallen Grand Master in the midst of the chapel ruins for the 200th anniversary of the coronation of King Frederick I of Prussia. The inscription was chiseled in 1960 and the stone was removed from the chapel ruins and placed inscription facing down in 1984.


title: Battle of Grunwald

text: In 1960, for the 550th anniversary, a museum and monuments were constructed a little northeast of the chapel ruins in 1960. The grounds were designed by sculptor Jerzy Bandura and architect . The monuments included an obelisk of Silesian granite depicting two faces of knights, a bundle of eleven -high flagpoles with emblems of the Polish–Lithuanian army, and a sculptural map depicting the supposed positions of the armies before the battle. Presumed locations where Władysław II Jagiełło and Vytautas had their main camps were marked with artificial mounds and flagpoles. The battle site is one of Poland's national Historical Monuments, as designated on 4 October 2010, and tracked by the National Institute of Cultural Heritage. The museum, which is open during summers, has an exhibition space of in which it displays archaeological finds from the battlefield, original and reproduced medieval weapons, reconstructed flags from the battle, as well as various maps, drawings, and documents related to the battle. In 2018, the museum was visited by about 140,000 people. Construction of a larger year-round museum at an estimated cost of 30 million Polish złoty (6.5 million euros) started in April 2019.


title: Battle of Grunwald

text: In July 2020, a large stone with engraved Vytis was erected by the Lithuanians near the monument site to commemorate the 610th anniversary of the battle. The monument was unveiled by Lithuanian and Polish presidents Gitanas Nausėda and Andrzej Duda.


title: Battle of Grunwald

text: Several artifacts from the battlefield are known from historical record, for example stone balls in the church of Stębark (Tannenberg) and a metal helmet with holes in the church of Mielno which was gifted to Frederick William IV of Prussia when he visited the battlefield in 1842, but they have not survived to the present day. The first amateur archeological research was carried out in 1911 in hopes of finding the mass graves mentioned by Jan Długosz at the church of Stębark. The church was surveyed with ground-penetrating radar in 2013 but little evidence of the mass graves was found.


title: Battle of Grunwald

text: The first more thorough archaeological excavations of the battlefield were carried out in 1958–1960 in connection with the construction of the memorial site and museum. The government showed great interest in the excavations and sent helicopters and 160 soldiers to help. Research continued in later decades, but yielded very little results with the exception of the area around the ruined chapel. Several mass graves were found at the chapel: remains of six people in the vestibule, 30 people next to the southern wall, more than 130 people in three pits adjacent to the chapel, and about 90 people in the sacristy. Many remains showed signs of traumatic injuries. Some skeletons showed signs of being burned and moved. Mass burials, including of women and children, were also found in the villages of Gilgenburg (Dąbrówno) and Faulen (Ulnowo). The massacre in Gilgenburg was known from written sources, but the burial in Faulen was unexpected. In the fields, very few items of militaria were found. In 1958–1990, only 28 artifacts were found connected to the battle: ten crossbow bolts, five arrowheads, a javelin head, two sword pieces, two gun bullets, six pieces of gauntlets, and two small arms bullets.


title: Battle of Grunwald

text: Swedish historian formulated hypothesis that the traditionally identified location of the battlefield is not correct in 1960s but published it only in 2000s. According to him, the main battlefield was located northeast of the road between Grunwald and Łodwigowo, i.e. about southwest of the memorial site. Archaeologists from Scandinavia and Poland investigated an area of approximately with metal detectors in 2014–2017 and located the main battle site according to Ekdahl's predictions. In 2017, the team found approximately 65 crossbow bolts and 20 arrowheads, as well as parts of spurs, stirrups, gauntlets, etc. The research is ongoing. As of 2020, archaeologists discovered about 1,500 artifacts of which about 150 are linked to the battle. Among them are a Teutonic clasp to fasten coat with the Gothic inscription ‘Ave Maria’, a seal with the image of a pelican feeding its young with blood, two well preserved axes, and Teutonic coins.


title: Battle of Grunwald

text: In William Urban's summary, almost all accounts of the battle made before the 1960s were more influenced by romantic legends and nationalistic propaganda than by fact. Historians have since made progress towards dispassionate scholarship and reconciliation of the various national accounts of the battle.


title: Battle of Grunwald

text: The Battle of Grunwald is regarded as one of the most important in the histories of Poland and Lithuania. In Lithuania, the victory is synonymous with the Grand Duchy's political and military peak. It was a source of national pride during the age of Romantic nationalism and inspired resistance to the Germanization and Russification policies of the German and Russian Empires. The Teutonic Order was portrayed as bloodthirsty invaders and Grunwald as a just victory achieved by a small, oppressed nation.


title: Battle of Grunwald

text: In 1910, to mark the 500th anniversary of the battle, a monument by Antoni Wiwulski was unveiled in Kraków during a three-day celebration attended by some 150,000 people. About 60 other towns and villages in Galicia also erected Grunwald monuments for the anniversary. About the same time, Nobel Prize-winner Henryk Sienkiewicz wrote the novel "The Knights of the Cross" (Polish: "Krzyżacy"), prominently featuring the battle in one of the chapters. In 1960, Polish filmmaker Aleksander Ford used the book as the basis for his film, "Knights of the Teutonic Order". At the 1939 New York World's Fair, Poland exhibited the King Jagiello Monument which commemorated the battle and was later installed in the Central Park, New York City. The battle has lent its name to military decorations (Order of the Cross of Grunwald), sports teams (BC Žalgiris, FK Žalgiris), and various organizations. 72 streets in Lithuania are named after the battle.


title: Battle of Grunwald

text: An annual battle re-enactment takes place on 15 July. In 2010, a pageant reenacting the event and commemorating the battle's 600th anniversary was held. It attracted 200,000 spectators who watched 2,200 participants playing the role of knights in a re-enactment of the battle. An additional 3,800 participants played peasants and camp followers. The pageant's organisers believe that the event has become the largest re-enactment of medieval combat in Europe. The reenactment attracts about 60,000 to 80,000 visitors annually.


title: Battle of Grunwald

text: The battle is also commemorated in Ukraine and Belarus. In 2010, the National Bank of Ukraine released a jubilee coin of 20 hryvnia commemorated to the 600 anniversary of the battle. At least three cities in Ukraine (Lviv, Drohobych, and Ivano-Frankivsk) have a street named after the battle. In Belarus, interest in the battle began to grow in the late 1980s and early 1990s. In 2010, Belarus issued postage stamps for the 600th anniversary. Since 2008, Our Grunwald Festival is hosted by a private museum of medieval culture near Minsk and includes battle reenactment.


title: Battle of Grunwald

text: Germans generally saw the Teutonic knights as heroic and noble men who brought Christianity and civilization to the east, although many came to the region with more material motives. In August 1914, during World War I, Germany won a battle against Russia near the site. When the Germans realized its propaganda potential, they named the battle the Battle of Tannenberg, despite it having actually taken place much closer to Allenstein (Olsztyn), and framed it as revenge for the Polish–Lithuanian victory 504 years earlier. To cement this symbolism, Germany built the Tannenberg Memorial, which became the tomb of the national hero Paul von Hindenburg.


title: Battle of Grunwald

text: Nazi Germany later exploited the sentiment by portraying their "Lebensraum" policies as a continuation of the order's historical mission. For example, SS Chief Heinrich Himmler told Nazi Germany's leader Adolf Hitler on the first day of the Warsaw Uprising in August 1944: "After five, six weeks we shall leave. But by then Warsaw, the capital, the head, the intelligence of this former 16–17 million Polish people will be extinguished, this Volk that has blocked our way to the east for 700 years and has stood in our way ever since the First Battle of Tannenberg."


title: Battle of Grunwald

text: Due to the participation of the three Smolensk banners, Russians saw the battle as a victory of a Polish–Lithuanian–Russian coalition against invading Germans. However, ethnic composition of men under these banners cannot be determined as Smolensk had rebelled against Vytautas in 1404 and 1408. Chronicler Jan Długosz praised the Smolensk banners, who fought bravely and, according to him, were the only banners from the Grand Duchy of Lithuania not to retreat. In Soviet historiography, the Battle of Grunwald was styled as an ethnic struggle between Slavs and Germanics. The Teutonic Order was portrayed as the medieval forerunners of Hitler's armies, while the battle itself was seen as the medieval counterpart to the Battle of Stalingrad.


title: Battle of Grunwald

text: In 2014, the Russian Military Historical Society stated that Russian troops and their allies defeated the German knights in the Battle of Grunwald, though evidence that the Grand Duchy of Moscow was involved with this battle is lacking. In July 2017, billboards appeared on the streets of Russian cities with statements that seemed to attribute the victory in the battle of Grunwald to Russia.


title: Tracheotomy

text: Tracheotomy (, ), or tracheostomy, is a surgical airway management procedure which consists of making an incision (cut) on the anterior aspect (front) of the neck and opening a direct airway through an incision in the trachea (windpipe). The resulting stoma (hole) can serve independently as an airway or as a site for a tracheal tube or tracheostomy tube to be inserted; this tube allows a person to breathe without the use of the nose or mouth.


title: Tracheotomy

text: The etymology of the word "tracheotomy" comes from two Greek words: the root "tom-" (from Greek τομή "tomḗ") meaning "to cut", and the word "trachea" (from Greek τραχεία "tracheía"). The word "tracheostomy", including the root "stom-" (from Greek στόμα "stóma") meaning "mouth," refers to the making of a semi-permanent or permanent opening, and to the opening itself. Some sources offer different definitions of the above terms. Part of the ambiguity is due to the uncertainty of the intended permanence of the stoma (hole) at the time it is created.


title: Tracheotomy

text: In the acute (short term) setting, indications for tracheotomy include such conditions as severe facial trauma, tumors of the head and neck (e.g., cancers, branchial cleft cysts), and acute angioedema and inflammation of the head and neck. In the context of failed tracheal intubation, either tracheotomy or cricothyrotomy may be performed.


title: Tracheotomy

text: In the chronic (long-term) setting, indications for tracheotomy include the need for long-term mechanical ventilation and tracheal toilet (e.g., comatose patients, extensive surgery involving the head and neck). Tracheotomy may result in a significant reduction in the administration of sedatives and vasopressors, as well as the duration of stay in the intensive care unit (ICU).


title: Tracheotomy

text: In extreme cases, the procedure may be indicated as a treatment for severe obstructive sleep apnea (OSA) seen in patients intolerant of continuous positive airway pressure (CPAP) therapy. The reason tracheostomy works well for OSA is because it is the "only" surgical procedure that completely bypasses the upper airway. This procedure was commonly performed for obstructive sleep apnea until the 1980s, when other procedures such as the uvulopalatopharyngoplasty, genioglossus advancement, and maxillomandibular advancement surgeries were described as alternative surgical modalities for OSA.


title: Tracheotomy

text: If prolonged ventilation is required, tracheostomy is usually considered. The timing of this procedure is dependent on the clinical situation and an individual's preference. An international multicenter study in 2000 determined that the median time between starting mechanical ventilation and receiving a tracheostomy was 11 days. Although the definition varies depending on hospital and provider, early tracheostomy can be considered to be less than 10 days (2 to 14 days) and late tracheostomy to be 10 days or more.


title: Tracheotomy

text: Biphasic cuirass ventilation is a form of non-invasive mechanical ventilation that can — in a small subset of cases — allow people to avoid a tracheostomy.


title: Tracheotomy

text: A tracheostomy tube may be single or dual lumen, and also cuffed or uncuffed. A dual lumen tracheostomy tube consists of an outer cannula or main shaft, an inner cannula, and an obturator. The obturator is used when inserting the tracheostomy tube to guide the placement of the outer cannula and is removed once the outer cannula is in place. The outer cannula remains in place but, because of the buildup of secretions, there is an inner cannula that may be removed for cleaning after use or it may be replaced. Single-lumen tracheostomy tubes do not have a removable inner cannula, suitable for narrower airways. Cuffed tracheostomy tubes have inflatable balloons at the end of the tube to secure them in place. A tracheostomy tube may be fenestrated with one or several holes to let air through the larynx, allowing speech.


title: Tracheotomy

text: Special tracheostomy tube valves (such as the Passy-Muir valve) have been created to assist people in their speech. The patient can inhale through the unidirectional tube. Upon expiration, pressure causes the valve to close, redirecting air around the tube, past the vocal folds, producing sound.


title: Tracheotomy

text: The typical procedure done is the open surgical tracheotomy (OST) and is usually done in a sterile operating room. The optimal patient position involves a cushion under the shoulders to extend the neck. Commonly a transverse (horizontal) incision is made two fingerbreadths above the suprasternal notch. Alternatively, a vertical incision can be made in the midline of the neck from the thyroid cartilage to just above the suprasternal notch. Skin, subcutaneous tissue, and strap muscles (a specific group of neck muscles) are retracted aside to expose the thyroid isthmus, which can be cut or retracted upwards. After proper identification of the cricoid cartilage and placement of a tracheal hook to steady the trachea and pull it forward, the trachea is cut open, either through the space between cartilage rings or vertically across multiple rings (cruciate incision). Occasionally a section of a tracheal cartilage ring may be removed to make insertion of the tube easier. Once the incision is made, a properly sized tube is inserted. The tube is connected to a ventilator and adequate ventilation and oxygenation is confirmed. The tracheotomy apparatus is then attached to the neck with tracheotomy ties, skin sutures, or both.


title: Tracheotomy

text: The first widely accepted percutaneous tracheotomy technique was described by Pat Ciaglia, a New York surgeon, in 1985. The next widely used technique was developed in 1989 by Bill Griggs, an Australian intensive care specialist. In 1995, Fantoni developed a translaryngeal approach of percutaneous tracheostomy. The Griggs and Ciaglia Blue Rhino techniques are the two main techniques in current use. A number of comparison studies have been undertaken between these two techniques with no clear differences emerging An advantage of PDT over OST is the ability to perform the procedure at the patient's bedside. This significantly decreases costs and time/people-power needed for an operating room (OR) procedure. Contraindications for percutaneous tracheostomy include infection at the site of tracheostomy, uncontrolled bleeding disorder, unstable cardiopulmonary status, patient unable to stay still, abnormal anatomy of the tracheolaryngeal structures.


title: Tracheotomy

text: As with most other surgical procedures, some cases are more difficult than others. Surgery on children is more difficult because of their smaller size. Difficulties such as a short neck and bigger thyroid glands make the trachea hard to open. There are other difficulties with patients with irregular necks, the obese, and those with a large goitre.


title: Tracheotomy

text: The many possible complications include hemorrhage, loss of airway, subcutaneous emphysema, wound infections, stomal cellulites, fracture of tracheal rings, poor placement of the tracheostomy tube, and bronchospasm.


title: Tracheotomy

text: Early complications include infection, hemorrhage, pneumomediastinum, pneumothorax, tracheoesophageal fistula, recurrent laryngeal nerve injury, and tube displacement. Delayed complications include tracheal-innominate artery fistula, tracheal stenosis, delayed tracheoesophageal fistula, and tracheocutaneous fistula.


title: Tracheotomy

text: A 2013 systematic review (published cases from 1985 to April 2013) studied the complications and risk factors of percutaneous dilatational tracheostomy (PDT), identifying major causes of fatality to be hemorrhage (38.0%), airway complications (29.6%), tracheal perforation (15.5%), and pneumothorax (5.6%) A similar systematic review in 2017 (cases from 1990 to 2015) studying fatality in both open surgical tracheotomy (OST) and PDT identified similar rates of mortality and causes of death between the two techniques.


title: Tracheotomy

text: Hemorrhage is rare, but the most likely cause of fatality after a tracheostomy. It usually occurs due to a tracheoarterial fistula, an abnormal connection between the trachea and nearby blood vessels, and most commonly manifests between 3 days to 6 weeks after the procedure is done. Fistulas can result from incorrectly positioned equipment, high cuff pressures causing pressure sores or mucosal damage, a low surgical trachea site, repetitive neck movement, radiotherapy, or prolonged intubation.


title: Tracheotomy

text: A potential risk factor identified in a 2013 systematic review of the percutaneous technique was the lack of bronchoscopic guidance. Use of the bronchoscope, an instrument inserted through a patient's mouth for internal visualization of the airway, can help with proper placement of instruments and better visualization of anatomical structures. However, this can also be dependent on the skills and familiarity of the surgeon with both the procedure and the patient's anatomy.


title: Tracheotomy

text: There are a multitude of potential complications related to the airway. The main causes of mortality during PDT include dislodgment of the tube, loss of airway during procedure and misplacement of the tube. One of the more urgent complications include displacement or dislodgment of the tracheotomy tube, either spontaneously or during a tube change. Although uncommon (< 1/1000 tracheostomy tube days), the associated fatality is high due to the loss of airway. Due to the seriousness of such a situation, individuals with a tracheotomy tube should consult with their healthcare providers to have a specific, written, emergency intubation and tracheostomy recannulation (reinsertion) plan prepared in advance.


title: Tracheotomy

text: Tracheal stenosis, otherwise known as an abnormal narrowing of the airway, is a possible long term complication. The most common symptom of stenosis is gradually-worsening difficulty with breathing (dyspnea). However incidence is low, ranging from 0.6 to 2.8% with increased rates if major bleeding or wound infections are present. A 2016 systematic review identified a higher rate of tracheal stenosis in individuals who underwent a surgical tracheostomy, as compared to PDT, however the difference was not statistically significant.


title: Tracheotomy

text: A 2000 Spanish study of bedside percutaneous tracheostomy reported overall complication rates of 10–15% and a procedural mortality of 0%, which is comparable to those of other series reported in the literature from the Netherlands and the United States. A 2013 systematic review calculated procedural mortality to be 0.17% or 1 in 600 cases. Multiple systematic reviews identified no significant difference in rates of mortality, major bleeding, or wound infection between the percutaneous or open surgical methods.


title: Tracheotomy

text: Specifically a 2017 systematic review calculated the most common causes of death and their frequencies, out of all tracheotomies, to be hemorrhage (OST: 0.26%, PDT: 0.19%), loss of airway (OST: 0.21%, PDT: 0.20%), and misplacement of tube (OST: 0.11%, PDT: 0.20%).


title: Tracheotomy

text: A 2003 American cadaveric study identified multiple tracheal ring fractures with the Ciaglia Blue Rhino technique as a complication occurring in 100% of their small series of cases. The comparative study above also identified ring fractures in 9 of 30 live patients while another small series identified ring fractures in 5 of their 20 patients. The long term significance of tracheal ring fractures is unknown.


title: Tracheotomy

text: Tracheotomy was first potentially depicted on Egyptian artifacts in 3600 BC. Hippocrates condemned the practice of tracheotomy as incurring an unacceptable risk of damage to the carotid artery. Warning against the possibility of death from inadvertent laceration of the carotid artery during tracheotomy, he instead advocated the practice of tracheal intubation.


title: Tracheotomy

text: Despite the concerns of Hippocrates, it is believed that an early tracheotomy was performed by Asclepiades of Bithynia, who lived in Rome around 100 BC. Galen and Aretaeus, both of whom lived in Rome in the 2nd century AD, credit Asclepiades as being the first physician to perform a non-emergency tracheotomy. Antyllus, another Roman-era Greek physician of the 2nd century AD, supported tracheotomy when treating oral diseases. He refined the technique to be more similar to that used in modern times, recommending that a transverse incision be made between the third and fourth tracheal rings for the treatment of life-threatening airway obstruction.


title: Tracheotomy

text: In 1000, Abu al-Qasim al-Zahrawi (936–1013), an Arab who lived in Arabic Spain, published the 30-volume "Kitab al-Tasrif", the first illustrated work on surgery. He never performed a tracheotomy, but he did treat a slave girl who had cut her own throat in a suicide attempt. Al-Zahrawi (known to Europeans as "Albucasis") sewed up the wound and the girl recovered, thereby proving that an incision in the larynx could heal. Circa AD 1020, Avicenna (980–1037) described tracheal intubation in "The Canon of Medicine" in order to facilitate breathing. The first correct description of the tracheotomy operation for treatment of asphyxiation was described by Ibn Zuhr (1091–1161) in the 12th century. According to Mostafa Shehata, Ibn Zuhr (also known as Avenzoar) successfully practiced the tracheotomy procedure on a goat, justifying Galen's approval of the operation.


title: Tracheotomy

text: The European Renaissance brought with it significant advances in all scientific fields, particularly surgery. Increased knowledge of anatomy was a major factor in these developments. Surgeons became increasingly open to experimental surgery on the trachea. During this period, many surgeons attempted to perform tracheotomies, for various reasons and with various methods. Many suggestions were put forward, but little actual progress was made toward making the procedure more successful. The tracheotomy remained a dangerous operation with a very low success rate, and many surgeons still considered the tracheotomy to be a useless and dangerous procedure. The high mortality rate for this operation, which had not improved, supported their position. From the period 1500 to 1832 there are only 28 known reports of tracheotomy.


title: Tracheotomy

text: In 1543, Andreas Vesalius (1514–1564) wrote that tracheal intubation and subsequent artificial respiration could be life-saving. Antonio Musa Brassavola (1490–1554) of Ferrara treated a patient with peritonsillar abscess by tracheotomy after the patient had been refused by barber surgeons. The patient apparently made a complete recovery, and Brassavola published his account in 1546. This operation has been identified as the first recorded successful tracheostomy, despite many ancient references to the trachea and possibly to its opening. Ambroise Paré (1510–1590) described suture of tracheal lacerations in the mid-16th century. One patient survived despite a concomitant injury to the internal jugular vein. Another sustained wounds to the trachea and esophagus and died.


title: Tracheotomy

text: Towards the end of the 16th century, anatomist and surgeon Hieronymus Fabricius (1533–1619) described a useful technique for tracheotomy in his writings, although he had never actually performed the operation himself. He advised using a vertical incision and was the first to introduce the idea of a tracheostomy tube. This was a straight, short cannula that incorporated wings to prevent the tube from advancing too far into the trachea. He recommended the operation only as a last resort, to be used in cases of airway obstruction by foreign bodies or secretions. Fabricius' description of the tracheotomy procedure is similar to that used today. Julius Casserius (1561–1616) succeeded Fabricius as professor of anatomy at the University of Padua and published his own writings regarding technique and equipment for tracheotomy. Casserius recommended using a curved silver tube with several holes in it. Marco Aurelio Severino (1580–1656), a skillful surgeon and anatomist, performed multiple successful tracheotomies during a diphtheria epidemic in Naples in 1610, using the vertical incision technique recommended by Fabricius. He also developed his own version of a trocar.


title: Tracheotomy

text: In 1620 the French surgeon Nicholas Habicot (1550–1624), surgeon of the Duke of Nemours and anatomist, published a report of four successful "bronchotomies" which he had performed. One of these is the first recorded case of a tracheotomy for the removal of a foreign body, in this instance a blood clot in the larynx of a stabbing victim. He also described the first tracheotomy to be performed on a pediatric patient. A 14-year-old boy swallowed a bag containing 9 gold coins in an attempt to prevent its theft by a highwayman. The object became lodged in his esophagus, obstructing his trachea. Habicot suggested that the operation might also be effective for patients with inflammation of the larynx. He developed equipment for this surgical procedure which displayed similarities to modern designs (except for his use of a single-tube cannula).


title: Tracheotomy

text: Sanctorius (1561–1636) is believed to be the first to use a trocar in the operation, and he recommended leaving the cannula in place for a few days following the operation. Early tracheostomy devices are illustrated in Habicot's "Question Chirurgicale" and Julius Casserius' posthumous "Tabulae anatomicae" in 1627. Thomas Fienus (1567–1631), Professor of Medicine at the University of Louvain, was the first to use the word "tracheotomy" in 1649, but this term was not commonly used until a century later. Georg Detharding (1671–1747), professor of anatomy at the University of Rostock, treated a drowning victim with tracheostomy in 1714.


title: Tracheotomy

text: In the 1820s, the tracheotomy began to be recognized as a legitimate means of treating severe airway obstruction. In 1832, French physician Pierre Bretonneau employed it as a last resort to treat a case of diphtheria. In 1852, Bretonneau's student Armand Trousseau reported a series of 169 tracheotomies (158 of which were for croup, and 11 for "chronic maladies of the larynx") In 1858, John Snow was the first to report tracheotomy and cannulation of the trachea for the administration of chloroform anesthesia in an animal model. In 1871, the German surgeon Friedrich Trendelenburg (1844–1924) published a paper describing the first successful elective human tracheotomy to be performed for the purpose of administration of general anesthesia. In 1880, the Scottish surgeon William Macewen (1848–1924) reported on his use of orotracheal intubation as an alternative to tracheotomy to allow a patient with glottic edema to breathe, as well as in the setting of general anesthesia with chloroform. At last, in 1880 Morell Mackenzie's book discussed the symptoms indicating a tracheotomy and when the operation is absolutely necessary.


title: Tracheotomy

text: In the early 20th century, physicians began to use the tracheotomy in the treatment of patients affected by paralytic poliomyelitis who required mechanical ventilation. However, surgeons continued to debate various aspects of the tracheotomy well into the 20th century. Many techniques were described and employed, along with many different surgical instruments and tracheal tubes. Surgeons could not seem to reach a consensus on where or how the tracheal incision should be made, arguing whether the "high tracheotomy" or the "low tracheotomy" was more beneficial. The currently used surgical tracheotomy technique was described in 1909 by Chevalier Jackson of Pittsburgh, Pennsylvania. Jackson emphasised the importance of postoperative care, which dramatically reduced the death rate. By 1965, the surgical anatomy was thoroughly and widely understood, antibiotics were widely available and useful for treating postoperative infections, and other major complications had also become more manageable.


title: Tracheotomy

text: Notable individuals who have or have had a tracheotomy include Mika Häkkinen, Stephen Hawking, Christopher Reeve, Roy Horn, William Rehnquist, Gabby Giffords, Val Kilmer, and many others.


title: Tracheotomy

text: Across movies and TV shows, there are many situations where an emergency procedure is done on an individual's neck to re-establish an airway. An example is in the 2008 horror, "Saw V", in which a character being drowned from the neck up performs a manual tracheotomy, stabbing his neck with a pen to create an airway to breathe through. The most common procedure is a cricothyrotomy (or "crike"), which is an incision through the skin and cricothyroid membrane. This is often confused or misnamed as a tracheotomy (or "trach") and vice versa. However, they are quite different based on location of the opening and length of time the alternate airway is needed.


title: Tobe Hooper

text: Willard Tobe Hooper (; January 25, 1943 – August 26, 2017) was an American director, screenwriter, and producer best known for his work in the horror genre. The British Film Institute cited Hooper as one of the most influential horror filmmakers of all time.


title: Tobe Hooper

text: Born in Austin, Texas, Hooper's feature film debut was the independent "Eggshells" (1969), which he co-wrote with Kim Henkel. The two reunited to co-write "The Texas Chain Saw Massacre" (1974), which Hooper also directed. The film went on to become a classic of the genre, and was described in 2010 by "The Guardian" as "one of the most influential films ever made." Hooper subsequently directed the horror film "Eaten Alive" (1977), followed by the 1979 miniseries "Salem's Lot", an adaptation of the novel by Stephen King. Following this, Hooper signed on to direct "The Funhouse" (1981), a major studio slasher film distributed by Universal Pictures. The following year, he directed the supernatural thriller "Poltergeist", written and produced by Steven Spielberg.


title: Tobe Hooper

text: In the mid-1980s, Hooper directed two science fiction horror films: "Lifeforce" (1985) and "Invaders from Mars" (1986), followed by "The Texas Chainsaw Massacre 2" (1986), a big-budget sequel to his original film. The 1990s saw Hooper directing various horror and sci-fi projects, including "Spontaneous Combustion" (1990), which he also co-wrote; the television anthology film "Body Bags" (1993); and "The Mangler" (1995), another adaptation of a Stephen King story.


title: Tobe Hooper

text: Hooper directed several projects throughout the 2000s, including the monster film "Crocodile" (2000), an episode of the sci-fi miniseries "Taken" (2002), and two episodes of "Masters of Horror" (2005–2006). He died in 2017 at the age of 74 of natural causes.


title: Tobe Hooper

text: Hooper was born January 25, 1943 in Austin, Texas, to Lois Belle ("née" Crosby) and Norman William Ray Hooper, who owned a theater in San Angelo. The film "The Texas Chain Saw Massacre" explores hicksploitation themes related to his childhood. He first became interested in filmmaking when he used his father's 8 mm camera at the age of nine. He went to college at the University of Texas, Austin. He was present at the college on August 1, 1966, when Charles Whitman opened fire on random people from the University's clock tower, nonfatally shooting a police officer that was close by Hooper.


title: Tobe Hooper

text: Hooper spent the 1960s as a college professor and documentary cameraman. His 1965 short film "The Heisters" was invited to be entered in the short subject category for an Academy Award, but was not finished in time for the competition that year. His first feature film, "Eggshells" (1969), was made for $40,000.


title: Tobe Hooper

text: Soon after, Hooper leapt to fame with "The Texas Chain Saw Massacre" (1974). He combined elements from a story he wrote about isolation and darkness with the inspiration of graphic news coverage of violence, with his belief that people were the true monsters being a key element for the film. Along with Kim Henkel, they co-wrote a screenplay that had elements based on the murders of Ed Gein and Elmer Wayne Henley while forming a company named Vortex, Inc. They produced the film alongside Jay Parsley and Richard Saenz. The low budget (roughly less than $140,000) meant that the film was shot seven days a week, having shooting times up to 16 hours a day, dealing with brutally hot temperatures, high humidity and limited special effects. Hooper had to deal with the Motion Picture Association of America (MPAA) with the rating; he had hoped the limited amount of gore seen in the film would give it a PG, but the original print was given an X rating. After some cuts, it was given an R rating. The film was cited as one of the scariest films of all time, with film critic Roger Ebert, despite awarding it only two out of four stars, describing it as a "weird, off-the-wall achievement." It was also a huge commercial success, making $30 million in the United States and Canada, while being one of the highest grossing independent films of the 1970s.


title: Tobe Hooper

text: Hooper's next film was "Eaten Alive" (1976), co-written by Henkel and producers Alvin L. Fast and Mardi Rustam. As with "Massacre", the film was inspired by serial killings, this time the murderer Joe Ball, who killed at least two people in the 1930s and whose crimes led to his nicknames of 'The Alligator Man' and 'The Butcher of Elmendorf'. The movie was filmed on sound-stages in California. Hooper provided the music alongside Wayne Bell - but walked off the production before shooting completed.


title: Tobe Hooper

text: Hooper had his biggest budget yet with the television mini-series of "Salem's Lot" (1979), filmed on a budget of $4 million for CBS while being released theatrically in some countries. It was a screening of "Massacre" that led producer Richard Kobritz to hire Hooper as director. He shot the film from July to August 1979, although the film differed from the source material (particularly with the violence and graphic scenes) in order to meet broadcast standards. He described it as 'very spooky - it suggests things and always has the overtone of the grave. It affects you differently than my other horror films. It's more soft-shelled...it has atmosphere which creates something you cannot escape - the reminder that our time is limited and all the accoutrements that go with it, such as the visuals.' Hooper then went on to make "The Funhouse" (1981) about teenagers who are stalked by a killer in a carnival fun-house.


title: Tobe Hooper

text: In 1982, Hooper made "Poltergeist", based on a story by Steven Spielberg. Hooper was selected to direct based on his prior work by Spielberg, who co-wrote the screenplay and co-produced the film. It was Hooper who collaborated with Spielberg to make it more of a ghost story than the original science-fiction-based treatment had been, as it had originally been conceived as a sequel to "Close Encounters of the Third Kind".


title: Tobe Hooper

text: Cannon Films approached Hooper with the offer of a three-picture deal. He made "Lifeforce" (1985), "Invaders from Mars" (1986) and "The Texas Chainsaw Massacre 2" (1987). Hooper also began working steadily in television.


title: Tobe Hooper

text: Hooper's later works included "Spontaneous Combustion" (1990); the television movie "I'm Dangerous Tonight" (1990); and "Night Terrors" (1993). He directed an installment of the made-for-television feature "Body Bags" (1993). His works also include "The Mangler" (1995), "The Apartment Complex" (1999), "Crocodile" (2000), "Toolbox Murders" (2004), and "Mortuary" (2005).


title: Tobe Hooper

text: Hooper was asked to contribute to the series "Masters of Horror"; he responded by directing "Dance of the Dead" (2005) with Robert Englund in the first season, and "The Damned Thing" in the second season.


title: Tobe Hooper

text: In 2010, writer and actor Mark Gatiss interviewed Hooper for the third episode of his BBC documentary series "A History of Horror".


title: Tobe Hooper

text: Hooper was married three times. He married his first wife, Maev Margaret Noonan, in 1961. They divorced in the early 1970s, producing one son, William Tony Hooper, who was born approximately 1966. In the Fall of 1979 issue of "Cinefantastique" magazine, Hooper declared "I'm divorced. I was married very young and been divorced about eight years." At the time of the interview, his son was 13 and lived with him in Los Angeles.


title: Tobe Hooper

text: Hooper married again in 1983 to Carin Berger (daughter of actor William Berger), but they divorced in 1990. He later married Rita Marie Bartlett in 2008, but they divorced in 2010.


title: Tobe Hooper

text: Hooper died of natural causes in Sherman Oaks neighborhood of Los Angeles, California, on August 26, 2017, at the age of 74.


title: Tobe Hooper

text: Filmmakers who have been influenced by Hooper include Hideo Nakata, Wes Craven, Rob Zombie, Alexandre Aja, Jack Thomas Smith, and Nicolas Winding Refn. Director Ridley Scott has stated that his work on "Alien" was influenced more by Hooper's "The Texas Chain Saw Massacre" than any other genre film.


title: MT-LB

text: The MT-LB (, literally "multi-purpose towing vehicle light armored") is a Soviet multi-purpose, fully amphibious, tracked armored fighting vehicle in use since the 1950s. It was also produced in Poland, where (starting in the mid-1990s) its YaMZ engine was replaced by a Polish 6-cylinder SW 680 diesel engine.


title: MT-LB

text: In the 1950s, the Soviet Central Auto and Tractor Directorate began a development program to replace the AT-P series of artillery tractors (which were based on the ASU-57 airborne self-propelled gun) with a new generation of vehicles. The MT-L was developed to meet this requirement based on the PT-76 amphibious light tank chassis. The MT-LB is the armored variant of the MT-L. Entering production in the early 1970s, it was cheap to build, being based on many existing components, e.g. the engine, which was originally developed for trucks. It is built at the Kharkiv Tractor Plant and Bulgaria. Formerly it was also manufactured under license in Poland by Huta Stalowa Wola


title: MT-LB

text: The crew, a driver and a commander/gunner, sit in a compartment at the front of the vehicle, with the engine behind them. A compartment at the rear enables up to 11 infantry to be carried or a cargo of up to 2,000 kg. A load of 6,500 kg can be towed. The vehicle is fully amphibious, being propelled by its tracks in the water.


title: MT-LB

text: A small turret at the front of the vehicle fits a 7.62 mm PKT machine gun with 360-degree manual traverse and an elevation of −5 to +30 degrees. The vehicle is lightly armored against small arms and shell splinters with a thickness of 3 to 10 mm of steel with a maximum of 14 mm for the turret front.


title: MT-LB

text: Polish HSW S.A. (Huta Stalowa Wola S.A.) license produced MT-LB since 1976, and it also developed a modified chassis SPG-2, with better floating capabilities.


title: Polydactyly

text: Polydactyly or polydactylism (), also known as hyperdactyly, is an anomaly in humans and animals resulting in supernumerary fingers and/or toes. Polydactyly is the opposite of oligodactyly (fewer fingers or toes).


title: Polydactyly

text: In humans/animals this condition can present itself on one or both hands or feet. The extra digit is usually a small piece of soft tissue that can be removed. Occasionally it contains bone without joints; rarely it may be a complete functioning digit. The extra digit is most common on the ulnar (little finger) side of the hand, less common on the radial (thumb) side, and very rarely within the middle three digits. These are respectively known as postaxial (little finger), preaxial (thumb), and central (ring, middle, index fingers) polydactyly. The extra digit is most commonly an abnormal fork in an existing digit, or it may rarely originate at the wrist as a normal digit does.


title: Polydactyly

text: The incidence of congenital deformities in newborns is approximately 2%, and 10% of these deformities involve the upper extremity. Congenital anomalies of the limb can be classified in seven categories, proposed by Frantz and O’Rahilly and modified by Swanson, based on the embryonic failure causing the clinical presentation. These categories are failure of formation of parts, failure of differentiation, duplication, overgrowth, undergrowth, congenital constriction band syndrome, and generalized skeletal abnormalities. Polydactyly belongs to the category of duplication.


title: Polydactyly

text: Because there is an association between polydactyly and several syndromes, children with a congenital upper extremity deformity should be examined by a geneticist for other congenital anomalies. This should also be done if a syndrome is suspected, or if more than two or three generations of the family are affected.


title: Polydactyly

text: Research has shown that the majority of congenital anomalies occur during the 4-week embryologic period of rapid limb development. Polydactyly has been associated with 39 genetic mutations. More specific loci and genetic mechanisms responsible for disorders of duplications will be defined with time, as molecular research continues.


title: Polydactyly

text: Polydactyly can be divided into three major types, which are discussed below, which depend on the location of the additional digit.


title: Polydactyly

text: Research conducted by the University of Freiburg, Imperial College London, Lausanne University Hospital and EPFL as a case study in "Nature Communications" in 2019 found that in cases of polydactyly that result in a fully functional additional digit, muscles to control the extra digit may be duplicated, resulting in increased motor control that allows the patient to carry out certain tasks with one hand that would normally require two.


title: Polydactyly

text: This is the most common situation, in which the extra digit is on the ulnar side of the hand, thus the side of the little finger. This can also be called postaxial polydactyly. It can manifest itself very subtly, for instance only as a nubbin on the ulnar side of the little finger, or very distinctly, as a fully developed finger. Most commonly, the extra finger is rudimentary, consisting of an end phalanx with a nail, and connected to the hand with a small skin pedicle. Mostly one neurovascular bundle can be identified, with no tendons present in the extra digit. In case of a fully developed extra finger, the duplication usually presents itself at the level of the metacarpophalangeal joint. A triplication of the little finger is very rare. Ulnar polydactyly occurs ten times more often in African populations. The incidence in Caucasians is reported as 1 in 1,339 live births, compared with 1 in 143 live births in Africans and African Americans. Ulnar polydactyly is also often part of a syndrome. In patients with African ancestry ulnar polydactyly mostly occurs isolated, whereas the presentation in Caucasians is often associated with a syndrome, though in a retrospective review, only 4 of 37 cases of ulnar polydactyly in Caucasians were syndromic.


title: Polydactyly

text: This is a less common situation, in which the affectation is on the side of the hand towards the thumb. Radial polydactyly refers to the presence of an extra digit (or extra digits) on the radial side of the hand. It is most frequent in Indian populations and it is the second most common congenital hand disorder. The incidence of radial polydactyly is reported as 1 in every 3,000 live births. The clinical features of radial polydactyly will depend upon the extent of duplication.


title: Polydactyly

text: Radial polydactyly varies from a barely visible radial skin tag to complete duplication. Thumb polydactyly varies from barely visible broadening of the distal phalanx to full duplication of the thumb including the first metacarpal.


title: Polydactyly

text: This is a very rare situation, in which the extra digit is on the ring, middle or index finger. Of these fingers, the index finger is most often affected, whereas the ring finger is rarely affected.


title: Polydactyly

text: Polydactyly is associated with different mutations, either mutations in a gene itself or in a cis-regulatory element responsible for the expression of a specific gene. Mutations in Hoxa- or Hoxd clusters are reported leading to polydactyly. Interactions of Hoxd13 and GLI3 induce synpolydactyly, a combination of extra and consolidated digits. Other signal transduction pathways in this context are the Wnt signaling pathway or Notch.


title: Polydactyly

text: In the specific case of preaxial polydactyly (Hemingway mutant), a cis-acting mutation approximately 1Mb upstream of SHH gene has been implicated. Normally SHH is expressed in an organiser region, called the zone of polarizing activity (ZPA) on the posterior limb side. From there it diffuses anteriorly, laterally to the growth direction of the limb. In the mutant, smaller ectopic expression in a new organiser region is seen on the anterior side of the limb. This ectopic expression causes cell proliferation delivering the raw material for one or more new digits.


title: Polydactyly

text: In addition to the study of genetic causes of polydactyly, limb patterning models are used to simulate the congenital disorder at the limb, being able to explain the development paths of polydactyly.


title: Polydactyly

text: Polydactyly can occur by itself, or more commonly, as one feature of a syndrome of congenital anomalies. When it occurs by itself, it is associated with autosomal dominant mutations in single genes, i.e. it is not a multifactorial trait. But mutation in a variety of genes can give rise to polydactyly. Typically the mutated gene is involved in developmental patterning, and a syndrome of congenital anomalies results, of which polydactyly is one feature or two.


title: Polydactyly

text: Polydactyly has been linked to the prenatal environment, however, with a recent study showing a relationship to maternal pollution exposure in China.


title: Polydactyly

text: Ulnar polydactyly is often bilateral and associated with syndactyly and polydactyly of the feet. This can be a simple or complex polydactyly. Ulnar polydactyly occurs as an isolated congenital condition, but can also be part of a syndrome. The syndromes which occur with ulnar polydactyly are: Trisomy 13, Greig cephalopolysyndactyly syndrome, Meckel syndrome, Ellis–van Creveld syndrome, McKusick–Kaufman syndrome, Down syndrome, Bardet–Biedl syndrome, Smith–Lemli–Opitz syndrome.


title: Polydactyly

text: Holt–Oram syndrome, Fanconi anemia (aplastic anemia by the age of 6), Townes–Brocks syndrome, and Greig cephalopolysyndactyly (also known to occur with ulnar polydactyly).


title: Polydactyly

text: Bardet–Biedl syndrome, Meckel syndrome, Pallister–Hall syndrome, Legius syndrome, Holt–Oram syndrome. Also, central polydactyly can be associated with syndactyly and cleft hand. Other syndromes including polydactyly include acrocallosal syndrome, basal cell nevus syndrome, Biemond syndrome, ectrodactyly-ectodermal dysplasias-cleft lip/palate syndrome, mirror hand deformity, Mohr syndrome, oral-facial-digital syndrome, Rubinstein-Taybi syndrome, short rib polydactyly, and VATER association.


title: Polydactyly

text: The classification of ulnar polydactyly exists of either two or three types. The two-stage classification, according to Temtamy and McKusick, involves type A and B. In type A there is an extra little finger at the metacarpophalangeal joint, or more proximal including the carpometacarpal joint. The little finger can be hypoplastic or fully developed. Type B varies from a nubbin to an extra, non-functional little finger part on a pedicle. According to the three-type classification, type I includes nubbins or floating little fingers, type II includes duplications at the MCPJ, and type III includes duplications of the entire ray.


title: Polydactyly

text: The Wassel classification is the most widely used classification of radial polydactyly, based upon the most proximal level of skeletal duplication. The most common type is Wassel 4 (about 50% of such duplications) followed by Wassel 2 (20%) and Wassel 6 (12%).


title: Polydactyly

text: The classification of central polydactyly is based on the extent of duplication and involves the following three types:


title: Polydactyly

text: Type I is a central duplication, not attached to the adjacent finger by osseous or ligamentous attachments; it frequently does not include bones, joints, cartilage, or tendons.


title: Polydactyly

text: Type IIA is a nonsyndactylous duplication of a digit or part of a digit with normal components, and articulates with a broad or bifid metacarpal or phalanx.


title: Polydactyly

text: Type IIB is a syndactylous duplication of a digit or part of a digit with normal components, and articulates with a broad or bifid metacarpal or phalanx.


title: Polydactyly

text: Ulnar polydactyly usually does not interfere with hand function, but for social reasons it can be treated operatively.


title: Polydactyly

text: The treatment of Type A ulnar polydactyly is complex as its goal is to remove the accessory digit while maintaining a stable, functional small finger. When the duplicated proximal phalanx articulates with a common, broad metacarpal head, the ulnar collateral ligament must be considered. In those cases with a common articulation or with a sixth metacarpal the muscle executing the abduction of the little finger ("abductor digiti minimi") must be preserved.


title: Polydactyly

text: In patients with a common metacarpal articulation an elliptical incision at the base of the post-axial digit is made. This incision may be extended proximally in order to adequately expose the "abductor digiti minimi". The ulnar collateral ligament and the insertions of the "abductor digiti minimi" are then elevated with a periosteal sleeve. The duplicated extensor and flexor tendons to the ulnar digit are transected and after that the digit is amputated at its articulation with the metacarpal. If the articular surface is wide the metacarpal may be shaved. At last the collateral ligament and "abductor digiti minimi" are reinserted at the base of the preserved proximal phalanx and a wire is then placed across the reconstructed joint.


title: Polydactyly

text: In patients with a duplicated metacarpal, the accessory digit is amputated in a standard ray fashion with transfer of the "abductor digiti minimi" to the retained small finger.


title: Polydactyly

text: In this situation there is an absence of osseous and ligamentous structures. The surgical technique is analogous to radial polydactyly, in which the level of duplication and anatomical components should guide operative treatment.


title: Polydactyly

text: The pedicled ulnar extra digit can be removed by suture ligation to devise the skin bridge of the newborn child. This might be easier than an excision of the extra digit when the child is 6 to 12 months old. Ligation occludes the vascular supply to the duplicated digit, resulting in dry gangrene and subsequent autoamputation. This must be done with consideration of the presence of a neurovascular bundle, even in very small skin bridges. When the ligation is done inappropriately it can give a residual nubbin. Also, a neuroma can develop in the area of the scar. An excision can prevent the development of a residual nubbin and the sensitivity due to a neuroma.


title: Polydactyly

text: For infants with ulnar type B polydactyly the recommended treatment is ligation in the neonatal nursery. Studies have shown that excision of the extra digit in the neonatal nursery is a safe and simple procedure with a good clinical and cosmetic outcome.


title: Polydactyly

text: Because neither of the two thumb components is normal, a decision should be taken on combining which elements to create the best possible composite digit. Instead of amputating the most hypoplastic thumb, preservation of skin, nail, collateral ligaments and tendons is needed to augment the residual thumb. Surgery is recommended in the first year of life, generally between 9 and 15 months of age.


title: Polydactyly

text: This type of procedure is recommended for Wassel types 1 and 2 (in which both thumbs are severely hypoplastic) by some congenital hand surgeons. The technique contains a composite wedge resection of the central bone and soft-tissue. This will be achieved with approach of the lateral tissue of each thumb. The goal is to achieve a normal thumb, what concerns the size, which is possible. If the width of the nail bed is greater than 70% of the contralateral thumb, it may be split.


title: Polydactyly

text: This type of procedure is used for all Wassel types of polydactyly and is the most commonly used technique. It is recommended in all cases of thumb duplication with a hypoplastic, less-functional thumb. Otherwise, one could consider the Bilhaut-Cloquet. The ulnar thumb is preferably preserved as it is the more developed one in most cases.


title: Polydactyly

text: By detaching the radial collateral ligament from distal to proximal, a periosteal sleeve can be preserved.


title: Polydactyly

text: In this way, the radial collateral band of the radial digit, will function as the absent radial collateral ligament of the preserved ulnar thumb.


title: Polydactyly

text: Elevation of the APB and FPB is performed in Wassel type 4 duplication; this can be accomplished via the periosteum or separately. As the tendons insert proximally, the elevation is performed proximally too to potentially rebalance the ulnar thumb. After the radial thumb is amputated, the ulnar elements are centralized and fixed with a Kirschner wire. In most cases, a longitudinal and sagittal osteotomy is needed to centralize the bony parts of the ulnar thumb. While the soft-tissue of the radial thumb was preserved, it is now attached to the radial side of the ulnar thumb together with the periosteal sleeve. The APB and FPB of the ablated radial thumb are attached to the distal phalanx for more stability. If necessary, the extensor pollicis longus and the flexor pollicis longus are reattached to centralize their course.


title: Polydactyly

text: In Wassel type 5 and 6 the opponens pollicis muscle must be transferred to the ulnar metacarpal. Soft tissue with collateral ligament reconstruction is used to avoid any angular deformity in the preserved thumb. Tendon centralization is also often used for correction. Still, cases with osseous deformities may happen. To provide alignment, osteotomies are necessary to be done. This operation may need bone grafting, which is obtained from the amputated thumb.


title: Polydactyly

text: This type is indicated when one thumb is larger proximally and the other thumb has a larger distal component. (The procedure is initially described as a way to lengthen amputated digits.) The goal is to create a functional thumb by combining less-hypoplastic components. On top plasty procedure is rarely employed in the treatment of congenital thumb duplication. It might be necessary for Wassel types 4, 5, 6.


title: Polydactyly

text: At the level of the mid-proximal phalanx or mid-metacarpal, the distal component is transferred to the proximal component. The tendons of the distal component are preserved as the rest of the distal component is amputated. The neurovascular bundle which supplies the distal component is reserved and transferred proximally.


title: Polydactyly

text: Early osteotomy and ligament reconstructions should be done to prevent deformities, such as angular growth deformities.


title: Polydactyly

text: The surgical treatment of central polydactyly is highly variable. After the surgery the hand must be functional and stable, but also aesthetically pleasing. This requires intraoperative creativity and flexibility. The surgeon must also consider whether retention of a fully functional supranumerary digit is preferable to surgical intervention. In contrast, a functional, four-fingered hand achieved via ray amputation may be preferable to a five-fingered hand with a deformed or stiff reconstructed finger.


title: Polydactyly

text: Cases of polysyndactyly are approached through a standard opposing zig-zag incision. The incision is favored toward the accessory digit, preserving extra skin for subsequent closure. Depending on the level and extent of duplication, the flexor and extensor tendons may require centralization or rebalancing. Also, the collateral ligaments must be preserved or reconstructed. Wide articular surfaces should be narrowed and phalangeal wedge osteotomies may be required to provide an axial alignment. Attention must also be given to reconstruct the intermetacarpal ligament. Furthermore, one should take in mind the provision for adequate web-space soft tissue.


title: Polydactyly

text: There are no substantive outcome studies regarding the function of these hands following surgical intervention. This is mainly caused by the fact that there is a generally normal function of these patients’ hands following ablation with collateral ligament reconstruction. In a study on 27 patients undergoing surgical excision for Type A ulnar polydactyly, only one complication was noted in the form of an infection


title: Polydactyly

text: However, no investigators have objectively reviewed functional range of motion or articular stability.


title: Polydactyly

text: In a study on 21 patients with Type B ulnar polydactyly treated with suture ligation it was found that the duplicated digit was typically amputated at an average of 10 days and no complications of infection or bleeding were reported.


title: Polydactyly

text: In a large study on 105 patients treated with suture ligation an overall complication rate of 23.5% was reported, citing a residual tender or unacceptable bump in 16%, infection in 6%, and bleeding in 1% of patients.


title: Polydactyly

text: In general, suture ligation is safe and effective when applied to appropriate cases of Type B polydactyly in which no substantial ligamentous or osseous structures are present within the pedicle. Parents should be educated as to the progression of necrosis, and that revision of residual tissue or scar may be necessary when the child is six months of age or older.


title: Polydactyly

text: By combining two hypoplastic thumbs a sufficient thumb size is acquired. Furthermore, the IP and MCP joints are very stable as the collateral ligaments are not violated during reconstruction.


title: Polydactyly

text: Violation during reconstruction can lead to growth arrest or asymmetric growth. Nail deformity could also occur after reconstruction. Although the joints are stable, restriction of flexion may be possible.


title: Polydactyly

text: The average IP flexion in a reconstructed thumb is 55 degrees less than the contralateral thumb. MCP flexion averaged 55 degrees in reconstructed thumbs, compared to 75 degrees in the contralateral thumb.


title: Polydactyly

text: The reconstructed joints tend to remain flexible. Also, it preserves the nail bed and physis, this increases the prevention of nail deformities over time.


title: Polydactyly

text: Although surgeons try to obtain a stable thumb of appropriate size, instability of the IP and MCP joint may occur, as well as a size mismatch. Thumbs are defined as unacceptable if IP joint deviation exceeds 15 degrees, MCP joint deviation exceeds 30 degrees, and thumb size is inappropriate based on the examiner's assessment. Also, thumb size one-third greater or less than the contralateral thumb is defined as unacceptable.


title: Polydactyly

text: No surgical outcomes studies exist for evaluating the function of the thumbs after an on-top plasty reconstruction.


title: Polydactyly

text: Few clinical outcome studies exist regarding the treatment of central polydactyly. Tada and colleagues note that satisfactory surgical correction of central polydactyly is difficult to achieve and that outcomes are generally poor. In Tada's study, 12 patients were reviewed. All patients required secondary surgical procedures to address flexion contractures and angular deviation at the IP joint level.


title: Polydactyly

text: However, several primary factors contribute to the complexity of central polydactyly reconstruction. Hypoplastic joints and soft tissues that predispose the reconstructed finger to joint contracture, and angular deformities as well as complex tendon anomalies, are often difficult to address. Therefore, treatment is wholly dependent on the anatomic components present, the degree of syndactyly, and the function of the duplicated finger.


title: Polydactyly

text: The condition has an estimated occurrence of 0.3–3.6 per 1000 live births. Postaxial hand polydactyly is most frequent in the United States in Black males. Preaxial polydactyly occurs in 0.08 to 1.4 in 1,000 live births. In the United States, it is more common in White people and also relatively frequent in Native American and Asian people. A 1994 study by Finley et al. combined data from Jefferson County, Alabama, United States, and Uppsala County, Sweden. This study found incidence of all types of polydactyly at rates of 2.3 per 1000 live births of White males, 0.6 per 1000 live births of White females, 13.5 per 1000 live births of Black males, and 11.1 per 1000 live births of Black females.


title: Polydactyly

text: Polydactyly occurs in numerous types of animals. The condition is sporadically seen in livestock, where it affects cattle, sheep, pigs, and occasionally horses. Conversely, it is a common trait in several heritage chicken breeds. Chickens normally have 4 toes on each foot. The chicken breeds known for being polydactyl are the Dorking, Faverolle, Houdan, Lincolnshire Buff, Meusienne, Sultan, and non-bearded Silkie Bantams. The breed standard of these varieties of chickens calls for five toes on each foot, although sometimes more than five toes will occur. The extra digit in these breeds presents as an extra "thumb" that does not touch the ground. Mixed-breed chickens may also have extra digits if the aforementioned breeds are part of their genetic makeup.


title: Polydactyly

text: Polydactyly also occurs in dogs, cats, and small mammals such as guinea pigs and mice. Cats normally have five digits on the front paws and four on the rear. Polydactyl cats have more, and this is a moderately common condition, especially in certain cat populations. Dogs, like other canids, normally have four claws on their rear paws; a fifth is often called a dewclaw and is especially found in certain dog breeds, including the Norwegian Lundehund and Great Pyrenees.


title: Polydactyly

text: A number of mutations of the LMBR1 gene, in dogs, humans, and mice, can cause polydactyly. A 2014 report indicated that mice could also exhibit polydactyly arising from mutation in the VPS25 gene. In cattle, it appears to be polygenic with a dominant gene at one locus and a homozygous recessive at another.


title: Polydactyly

text: Polydactyly was believed to be common in early tetrapods, the extinct amphibians that represented the earliest landliving vertebrates. Their number of toes fluctuated until the early Carboniferous period when they finally began developing a uniform number of toes. Amniotes settled on five toes per limb, while amphibians developed four toes on each front limb and five toes on each back limb. (For more information, see Polydactyly in early tetrapods). Polydactyly also occurs in modern extant reptiles


title: Polydactyly

text: and amphibians. Polydactyly was a non-pathological, reacquired condition in extinct marine reptiles such as ichthyosaurs and hupehsuchians, some of which containing upwards of ten digits within their flippers.


title: Hygiene

text: According to the World Health Organization (WHO), "Hygiene refers to conditions and practices that help to maintain health and prevent the spread of diseases." Personal hygiene refers to maintaining the body's cleanliness. Hygiene activities can be grouped into the following: home and everyday hygiene, personal hygiene, medical hygiene, sleep hygiene and food hygiene. Home and every day hygiene includes hand washing, respiratory hygiene, food hygiene at home, hygiene in the kitchen, hygiene in the bathroom, laundry hygiene and medical hygiene at home.


title: Hygiene

text: Many people equate hygiene with 'cleanliness,' but hygiene is a broad term. It includes such personal habit choices as how frequently to take a shower or bath, wash hands, trim fingernails, and wash clothes. It also includes attention to keeping surfaces in the home and workplace clean, including bathroom facilities. Some regular hygiene practices may be considered good habits by the society, while the neglect of hygiene can be considered disgusting, disrespectful, or threatening.


title: Hygiene

text: Hygiene is a practice related to lifestyle, cleanliness, health and medicine. In medicine and everyday life, hygiene practices are employed as preventive measures to reduce the incidence and spreading of germs leading to disease.


title: Hygiene

text: In the manufacturing of food, pharmaceutical, cosmetic and other products, good hygiene is a critical component of quality assurance.


title: Hygiene

text: The terms cleanliness and hygiene are often used interchangeably, which can cause confusion. In general, hygiene refers to practices that prevent spread of disease-causing organisms. Cleaning processes (e.g., handwashing) remove infectious microbes as well as dirt and soil, and are thus often the means to achieve hygiene.