Bone Removal Research Articles

Endoscopic Posterior Cervical Craniolateral Inclinatory Foraminotomy

Study Design: Case series. Objective: Endoscopic posterior cervical foraminotomy gains attention for cervical radiculopathy due to its feasibility, better outcomes, and lower complications than traditional approaches, enabling efficient multilevel decompression in a single operation while avoiding anterior cervical diskectomy and fusion–related issues. However, with multilevel decompression, the remnant lamina becomes thin and fragile. We propose craniolateral inclinatory foraminotomy to minimize bone removal during laminotomy, reducing the risk of iatrogenic or postoperative lamina fractures in tandem decompression. Materials and Methods: From 2021 to 2022, 8 consecutive patients underwent the procedure and were followed up for at least 6 months. The VAS, NDI, and MacNab scores were recorded for clinical recovery and patient satisfaction evaluations. Preoperative and postoperative CT scans were utilized to measure the lamina preservation percentage at each level. Results: The clinical outcomes improved significantly in every patient. No postoperative neck pain, segmental instability, or lamina fracture were observed. The mean lamina preservation percentages of C5, C6, C7, and all vertebrae were 68.8%, 73.22%, 71.86%, and 72.18%, respectively. Conclusions: Ongoing technical adjustments will accompany endoscopic technique development to decrease complications and enhance benefits. Our reported technique avoids extensive laminotomy in multilevel tandem decompression, aiming to prevent lamina fractures and anticipate a reduction in postoperative neck pain. Level of Evidence: Level IV.

Single Stage Cranioplasty with Customized Polyetheretherketone Implant After Removal of Eosinophilic Granuloma skull bone: Case Report

Eosinophilic granuloma is a localized form of Langerhans cell histiocytosis, most commonly involving the skeletal system. Their origin from the dura is rare with only a handful of cases on record. We present one such rare case of an eosinophilic granuloma originating from the Extradural with secondary osseous invasion in a 20 year old male who presented with a swelling in the right fronto orbital region. A complete resection was scheduled with single stage reconstruction of the frontoorbital bone by a polyetheretherketone (PEEK) specific implant. This implant was computer-assisted designed and manufactured and verified by the surgeon before the intervention. Bang. J Neurosurgery 2024; 13(2): 152-156

Palatal root endodontic microsurgery in maxillary molars using the palatal approach: a case study

BackgroundIn clinical practice, the buccal approach is typically the primary choice for endodontic microsurgery. Owing to the thickness of the buccal bone plate, the distance between the buccal bone plate and palatal lesion location, and soft tissue traction, the palatal approach may be more suitable for microsurgery for apical periodontitis of the palatal roots of the maxillary molars. However, the length of the palatal root, location of the greater palatine artery (GPA) and foramen (GPF), and surgical field of observation make palatal surgery challenging.Case presentationWith the aid of Cone-beam computed tomography imaging, the palatal approach was successfully applied in nine cases of endodontic microsurgery of the palatal root of a maxillary molar with a periapical lesion in Hangzhou Stomatology Hospital from January to December 2022.ConclusionsComplete healing was assessed based on clinical symptoms and radiographic images at the 3- and 24-month follow-up visits in all nine cases. Several tips have been proposed including surgical positioning, incision design, palate flap modification, bone removal, and root-end resection.

Regional differences in reimbursement rates from Medicare, Medicaid, and FAIR Health across common procedures for neurological surgeons.

FAIR Health-a nonprofit, state-funded database-was created as an independent repository of healthcare claims paid data to address allegations of price fixing. Many insurers have forced physicians to negotiate payments based on Medicare rates, rather than utilizing FAIR Health. The authors' objective was to provide an overview of regional differences in reimbursement rates per several sample neurosurgical Current Procedural Terminology (CPT) codes and to compare Medicare, Medicaid, and usual, customary, and reasonable rates via FAIR Health rate estimates. The authors compared FAIR Health rates for three common neurosurgical CPT codes: 61510 (removal of bone from skull for removal of upper brain tumor), 22630 (fusion of lower spine bones with removal of disc, posterior approach, single interspace), and 62223 (creation of a brain fluid drainage shunt, ventriculoperitoneal, ventriculopleural, or other terminus), with Medicare and Medicaid reimbursement to evaluate differences in five different regions in the US. Medicare and Medicaid reimbursement rates were consistently and significantly lower than FAIR Health in-network rates across all three CPT codes evaluated (p < 0.001 for all). Significant regional differences exist per census data in median age, median income, employment rates, and degree of health coverage (p < 0.001, p = 0.002, p = 0.002, and p = 0.001, respectively). Reimbursement estimates were found to have regional variation: Medicare/Medicaid rates were significantly lower than FAIR Health in-network rates for all codes across regions with a region-based interaction for reimbursement for code 62223 (p = 0.020). Medicare and Medicaid rates did not significantly vary across regions. Inherent differences exist between cities and states, including median income, employment rates, and health coverage. Despite geographic cost practice indices for Medicare and state-specific production of Medicaid, Medicaid/Medicare reimbursement rates did not vary across regions but were consistently and significantly lower than FAIR Health estimates throughout the US. Locale-specific variation in FAIR Health may further indicate a better accounting of regional differences in cost of practice.

328 - Evaluation of the usefulness of the MV3D RECON technique with Bone Removal in CT Brain Angiography

328 - Evaluation of the usefulness of the MV3D RECON technique with Bone Removal in CT Brain Angiography

Transcanal Endoscopic Management of Squamosal Type of Chronic Otitis Media.

Endoscopic middle ear surgery can be utilized to visualize and excise retraction pockets without the need for extensive bone work and removal of lateral bone. To evaluate the role of endoscope in the management of squamosal type of chronic otitis media. A total of 25 adults subjects (male = 12, female = 13) in the age group of 18-55years suffering with chronic otitis media were operated by transcanal endoscopic approach. High resolution computed tomography of temporal bone was done to help identify the anatomy and underlying extent of disease. All patients were operated by transcanal endoscopic technique. The study concluded that the endoscope gives a better visualization of the middle ear and its hidden areas. The extensive bone work and associated cavity related problems can be avoided and normal anatomy can be preserved with the help of endoscopic ear surgery.

Pleomorphic Adenoma of Hard Palate: A Case Report

Salivary gland tumors are rare and account for only 2-3% of head and neck tumors, most of which are benign. Pleomorphic adenoma is the most common salivary gland tumor. This tumor mostly involves the parotid gland. However, if it occurs in the minor salivary glands, the palate is the most common site, followed by the lips, buccal mucosa, floor of the mouth, tongue, tonsils, pharynx, retromolar trigone, and gingiva. It usually presents as a slow-growing, painless submucosal mass on the hard palate. For a definitive diagnosis, it is necessary to perform a preoperative core biopsy for histopathological examination and Computed Tomography to evaluate the erosion of the hard palate and the severity of the erosion. We aim to describe the clinical, and radiological features, as well as the management of this rare localization of pleomorphic adenoma. In this case, a 30-year-old Iranian male patient with pleomorphic adenoma of the small salivary glands of the hard palate with the chief complaint of painless swelling on the left side of the palate for the past 5 years was reported. Although pleomorphic adenoma is a common entity, it is still a challenging tumor for pathologists, radiologists and surgeons. Various histological and topographic features make this tumor unique. Computed tomography and correct histopathological diagnosis are necessary to establish an appropriate surgical treatment, to achieve complete removal of the lesion through extensive local excision with periosteum or bone removal if involved to prevent recurrence.

Influence of Mechanical Factors on the Cutting Performance of an Ultrasonic Bone Scalpel

Abstract The ultrasonic bone scalpel is a cutting-edge surgical instrument that leverages ultrasonic mechanical effects to remove bone tissue with precision, safety, and efficacy. While the adoption of the instrument has surged, the intricate relationship between its mechanical effects and the efficiency of bone removal remains ambiguous. This study aimed to elucidate the quantitative interplay between the mechanical parameters of the instrument and its bone removal performance. To achieve this, we engineered a testing apparatus capable of consistently regulating the scalpel’s cutting force, traversal speed, and depth of cut. The bone removal proficiency of the instrument was then assessed under varying conditions: cutting forces, ultrasonic power outputs, tip traversal speeds, and bone densities. Comprehensive data analysis unveiled a distinct quantitative correlation between the aforementioned parameters and bone removal rates. Furthermore, we identified optimal parameter combinations that maximize cutting efficiency. These insights are pivotal for the design, fabrication, evaluation, and clinical application of ultrasonic bone scalpels, offering a robust reference for future advancements in the field.

Bone Preservation in Femoral Intercondylar Box Cut - A Comparative Study between Older and Newer Generation Implants.

This study was conducted to compare the quantity of intercondylar bone removed during femoral box osteotomy for implantation of three contemporary newer generation posterior stabilized (PS) total knee arthroplasty designs Attune PS (DePuy), Anthem (Smith and Nephews), and NexGen Legacy (Zimmer) with the older version from the same manufacturers. We compared the maximum volumetric bone resection required for the housing of the PS mechanism of these six designs. Bone removal by each PS box cutting jig was three-dimensionally measured. The differences between the three designs were analyzed by the Kruskal-Wallis test. The Mann-Whitney U-test was used for pairwise comparisons. The level of significance was set at P < 0.05. The newer generation implants save approximately 33% of bone that was resected from the box cut as compared to the older versions. DePuys Attune PS saved 27.1% bone as compared to Sigma PS resecting 6.96 cm3 of bone, and Zimmers Persona saved 40.57% bone as compared to NexGen from the intercondylar box cut resecting 6.18 cm3. Smith and Nephew s Anthem and Genesis have no difference in their box volume with both resecting 7.8 cm3 of bone. Irrespective of implant size, the Attune PS (DePuy) and Nexgen Legacy (Zimmer) cutting jigs always resected significantly less bone than did the jigs of older generations. There was no significant difference in the bone removed during femoral box osteotomy in the newer and older generations of Smith and Nephew.

Evaluation of Two Clinical Stem-Fit Philosophies Within the Femoral Canal Using a Preoperative Planning Tool: Could a Hybrid Approach Be Best?

BackgroundTotal hip arthroplasty (THA) has transformed patient lives, yet evolving expectations and the number of postoperative foot angle changes have underscored the need for precise component positioning. The objective of this study was to use 3-dimensional (3D) preoperative planning to evaluate stem alignment and orientation for three THA systems using two different stem-fit algorithms. It was hypothesized that the different stem alignments would yield similar changes in stem orientation and placement within the canal for all 3 systems. MethodsThis study introduced a novel 3D preoperative planning tool, comparing two different surgical stem-fit philosophies within the canal: “canal fit” (CF) and “anatomical fit” (AF). We virtually implanted 10 subjects with three different THA implant systems using both philosophies, evaluating 60 total fits within the canals. The CF philosophy aimed to minimize cortical bone removal. In contrast, the AF philosophy prioritized aligning the implanted head with the anatomical head center. ResultsDetailed analyses revealed that AF led to fixation occurring mainly on the medial aspect of the stem, while CF exhibited a more even distribution between medial and lateral sides. The AF philosophy achieved significantly closer placement of the implanted head to the anatomical center (2.0 to 2.1 mm) compared to the CF philosophy (3.0 to 6.0 mm) (P < 0.01). The AF resulted in neutral stem orientation (0°) across all stems, whereas the CF exhibited greater malrotation (2.0 to 7.0°) (P < 0.02). The AF required more bone removal (0.13 to 0.46 cm³) than the CF (0.02 to 0.06 cm³) (P < 0.01). ConclusionsThe findings underscore the importance of 3D planning, emphasizing its potential to improve stem version alignment in THA. The results from this study may advocate 3D preoperative planning with robotic surgery to plan stem placement within the canal while maintaining anatomical femoral head restoration.

6-Degree Vision based Tracking of a Mandible Phantom with Deep Learning

Abstract During maxillofacial surgery, the precise placement of surgical tools is crucial for accurate implant placement. Particularly if multiple implants are needed, e.g., after cancerous bone removal, visual landmarks might not be obtainable. To this end, we propose a vision-based tracking approach with deep learning. Our markerless tracking approach is based on video streams from two cameras for tracking a mandible phantom. We study, to what extent vision-based localization using deep learning is feasible. For real-time 6D pose estimation we propose a Siamese network with a ResNet-18 subnetwork. We acquire a large training dataset with a robot and evaluate the tracking accuracy on partially occluded images. Thereby, we mimic visual information that is accessible during clinical interventions. We report a mean position error of 1.33 ± 1.14mm and a rotation error of 0.86 ± 0.71 deg for partially occluded images. Overall we present a promising tracking approach that is marker-free and robust toward image artifacts.

Hump Rasping Using Powered Instruments: A Retrospective Review.

Nasal hump reduction, a common procedure in rhinoplasty, aims to create a harmonious nasal appearance with smooth dorsal lines. An alternative to traditional osteotomes is the carbide-tip nasal rasp, effective in eliminating modest contour deformities. However, the broad movements and physical forces of manual rasping can significantly weaken the osseocartilaginous vault. Power-assisted instruments have been used to reduce soft tissue trauma. Although long-term clinical outcomes of power-assisted instrumentation are pending, initial reports have been positive. This retrospective chart review encompassed 220 consecutive rhinoplasty cases conducted by the senior author, all involving women aged 19-37 years. Excluding 80 cases that did not involve bone reduction, the analysis concentrated on 140 patients who underwent bone reduction procedures. The success of nasal hump reduction was evaluated based on the joint satisfaction of both the patient and the surgeon with the surgical improvement. The open rhinoplasty approach was predominantly used for surgical exposure to minimize inadvertent rasping of the nasal cartilage. Among the 140 patients undergoing power-assisted bone removal, all but five achieved an initially satisfactory refinement of the bony nasal contour. Notably, no serious complications were observed throughout the study. Unfortunately, one patient did not comply with the monthly steroid injections, leading to the necessity of revision surgery for the removal of regenerated bone. The integration of power-assisted instrumentation in rhinoplasty procedures represents a promising advancement, addressing challenges associated with traditional methods.

Minimally Destabilizing Corridor for Resection of Dumbbell Nerve Sheath Tumors: A Novel Surgical Technique.

Current surgical strategies for dumbbell nerve sheath tumors (DNSTs) with cord compression have primarily involved wide spinal exposures with total laminectomy and unilateral facetectomy, often leading to spinal destabilization and requiring fusion, or staged procedures separately addressing the intraspinal and extraforaminal tumor components. This study highlights technical nuances of a novel approach for DNST resection to minimize spinal destabilization and avoid fusion while facilitating safe, single-stage complete resection. A retrospective chart review was conducted on patients undergoing DNST resection. Using unilateral subperiosteal dissection, hemilaminotomy and medial facetectomy procedures are performed. The extradural tumor component is resected, followed by internal decompression of the intradural tumor. A small horizontal incision at the origin of the nerve root sleeve releases the underlying dural stricture, facilitating delivery of the remaining intradural tumor and allowing section of the nerve root of origin. Ultrasonography confirms complete tumor resection and return of cord pulsation, and excludes intradural hemorrhagic complications. The dura is reconstructed using a dural substitute bolstered with fat graft and sealant. Twelve consecutive patients undergoing this approach from 2014 to 2021 were included. Mean patient age was 53.5 years, and 58.3% were male. Nine tumors were cervical and 3 were lumbar. Five patients presented with myelopathy, 4 with radiculopathy, and 4 with axial pain. Two cases had transient intraoperative neuromonitoring signal changes. Eleven tumors were diagnosed as schwannomas and 1 as neurofibroma. All patients had complete resection of the intraspinal component; 2 had far distal extraforaminal residual. No patient has had recurrence, progression of residual, or signs of spinal instability during follow-up (median 28.5 months, range 6-66 months). This study highlights technical considerations for DNST resection, focusing the approach at the center of the tumor, with minimal bone removal and ligamentous disruption. Intraoperative ultrasound is instrumental in the safety of this approach.

Correlation Between Planned and Executed Bone Cuts Using Robotics in Total Knee Arthroplasty: A Prospective Study of 500 Patients.

This study evaluated the precision of robotic-arm-assisted total knee arthroplasty (RATKA) in performing bone resection, predicting component size, managing soft tissue tension, and determining postoperative range of motion (ROM). A total of 500 participants were enrolled in this prospective cohort research. The procedures were conducted at a single facility, with a uniform method and implant design. The Cuvis system, a fully automated robot, was utilized for the study. The precise removal of bone at both the tibial and femur sites, the positioning of the implant, and the release of soft tissue were documented and then compared to the preoperative plan. The distal (medial and lateral) femoral cuts had a mean absolute deviation from the plan of 0.23mm, while the posterior (medial and lateral) femoral cuts had a mean absolute difference of 1mm and 1.4mm, respectively. The absolute discrepancies in the medial and lateral tibial cuts are 0.93mm and -0.06mm, respectively. Out of 1000 bone resections, 980 (98%) were within < 1mm from the preoperative plan. The predictions for the sizes of the tibial and femoral components had accuracies of 100% and 98.9%, respectively. These findings collectively underscore the effectiveness of the fully automated Cuvis robotic system in achieving consistent and accurate results in bone resections and implant sizing, highlighting its potential as a valuable tool in orthopedic surgery.

Mesial Inclination of Bur for the Sectioning of Impacted Distoangular Mandibular Third Molar: A Novel Technique.

Distoangular impacted teeth account for about 4.8% of all impacted tooth angulations. Various indices in the literature used to assess the difficulty of surgically extracting impacted third molars indicate that distoangular impactions are the most complex. This complexity necessitates the development of specific skills by the operator. The difficulty arises primarily due to the challenging position of these teeth, which complicates access and instrumentation. The proposed method aims to simplify the sectioning process for distoangular third molars by avoiding unnecessary buccal bone removal, improving the accuracy of root sectioning, and preserving buccal bone. Consequently, this technique reduces postoperative pain and swelling, resulting in better patient outcomes.

Blended learning compared to traditional learning for the acquisition of competencies in oral surgery by dental students: A randomized controlled trial.

To determine whether blended learning results in better educational outcomes compared to traditional learning in the acquisition of oral surgery technical skills for 4th-year undergraduate dental students. Seventy-three students participated in this two-arm parallel randomized controlled trial. Only students in the blended learning group had access to the online preparation platform for oral surgery practical work (PW) on a pig's jaw and to the debriefing. Kirkpatrick's four-level model was used to assess the educational outcomes directly after (levels 1 and 2) and 6 months later, after the start of the students' clinical activity (levels 3 and 4). For level 1, higher global satisfaction scores were found for students in the blended learning compared to the traditional learning group (p = .002). For level 2, blended learning resulted in an increase in knowledge score (p < .01), comparable to that observed in the traditional learning group. For level 3, students in the blended group made more progress in 6 months than those in the traditional group in terms of feeling able to assess and perform anaesthesia (p = .040) and surgical tooth extraction (p = .043). No difference in level 4 was found for the 6-month clinical surgical activity between groups, but students in the blended group felt more able to assess and perform the surgical management of a failed extraction requiring bone removal (p = .044). Blended learning for oral surgery PW had a positive impact on three of the four Kirkpatrick levels (level 1, 3 and 4). Efforts should focus on the procedures that are perceived as the most difficult.

Image Quality Assessment of a Deep Learning-Based Automatic Bone Removal Algorithm for Cervical CTA.

The present study aims to evaluate the postprocessing image quality of a deep-learning (DL)-based automatic bone removal algorithm in the real clinical practice for cervical computed tomography angiography (CTA). A total of 100 patients (31 females, 61.4 ± 12.4 years old) who had performed cervical CTA from January 2022 to July 2022 were included retrospectively. Three different types of scanners were used. Ipsilateral cervical artery was divided into 10 segments. The performance of the DL algorithm and conventional algorithm in terms of bone removal and vascular integrity was independently evaluated by two radiologists for each segment. The difference in the performance between the two algorithms was compared. Inter- and intrarater consistency were assessed, and the correlation between the degree of carotid artery stenosis and the rank of bone removal and vascular integrity was analyzed. Significant differences were observed in the rankings of bone removal and vascular integrity between the two algorithms on most segments on both sides. Compared to DL algorithm, the conventional algorithm showed a higher correlation between the degree of carotid artery stenosis and vascular integrity (r = -0.264 vs r = -0.180). The inter- and intrarater consistency of DL algorithm were found to be higher than or equal to those of conventional algorithm. The DL algorithm for bone removal in cervical CTA demonstrated significantly better performance than conventional postprocessing method, particularly in the segments with complex anatomical structures and adjacent to bone.

Alveolar Bone Actinomycosis Affecting a Pediatric Patient: Diagnosis and Conservative Management.

Actinomycosis is a rare infection that involves soft and bone tissues caused by gram-positive, anaerobic filamentous bacteria, usually Actinomyces israelii. About 3% of all cases affect children. Not uncommonly, actinomycosis is initially diagnosed as neoplasm or other granulomatous diseases. Paediatric actinomycosis affecting the jaws is rare. To date, 20 and 1 case affecting the mandible and maxilla, respectively, have been reported. A 4-year-old girl was referred presenting an extensive symptomatic ulcerative lesion with bone exposure in the posterior region of the right maxilla two months ago. One month before, she has been diagnosed with scarlet fever. The lesion progressed, damaging the supporting periodontal tissue. After surgical removal of necrotic bone and deciduous molar, the microscopy revealed actinomycosis, which showed excellent healing after local treatment with hydrogen peroxide solution and adequate oral hygiene. Although actinomycosis of the jaws affecting pediatric patients is rare, paediatric dentists must be aware of their clinicopathological characteristics, with therapeutic and prognostic impact.

Diabetic Foot Osteomyelitis in Patients with and without Peripheral Arterial Disease: Two Different Diseases?

The aim of the current study was to evaluate the outcomes of patients with diabetic foot osteomyelitis (DFO), comparing subjects with and without peripheral arterial disease (PAD). The study is a prospective study including a population of patients affected by a DFO located in the forefoot. All patients were managed by a surgical conservative approach defined by the removal of the infected bone, in association with the antibiotic therapy. Patients were divided into two groups: those with PAD (neuro-ischaemic DFO) and those without (neuropathic DFO). After 1 year of follow-up, the following outcome were evaluated and compared between groups: healing, healing time, minor amputation, major amputation, hospitalization, need for surgical re-intervention. Overall, 166 patients were included, 87(52.4%) of them had neuro-ischaemic DFO and 79 (47.6%) neuropathic DFO. Patients with neuro-ischaemic DFO in comparison to neuropathic DFO were older (72.5 ± 9 vs 64.1 ± 15.5 years, P < .0001), had longer diabetes duration (21.8 ± 5.6 vs 16.4 ± 7.6 years, P < .0001), higher rate of dialysis (13.8 vs 1.3%, P = .001) and ischaemic heart disease (79.3 vs 12.7%, P < .0001). Outcomes for neuro-ischaemic DFO and neuropathic DFO were: healing (96.5 vs 97.5%, P = .7), healing time (7.8 ± 6.2 vs 5.7 ± 3.7 weeks, P = .01), minor amputation (16.1 vs 3.8%, P = .006), major amputation (0 vs 0%, ns), hospitalization (90.8 vs 51.9%, P < .0001), surgical re-intervention (14.9 vs 8.8%, P = .004) respectively. In addition, PAD resulted in an independent predictor of minor amputation, hospitalization, and surgical re-intervention. DFO in patients with PAD was characterized by longer healing time, more cases of minor amputation, hospitalization, and surgical re-intervention. PAD independently predicted the risk of minor amputation, hospitalization, and surgical re-intervention, while it was not associated with the healing rate.

Surgical treatment of tardy ulnar nerve palsy due to non-neurogenic heterotopic ossification in the elbow.

Heterotopic ossification (HO) is characterized by the formation of pathological bone within the soft tissues. HO predominantly affects elbow joints and may be accompanied by tardy ulnar nerve palsy. This study aimed to explore the clinical and functional outcomes of patients with tardy ulnar nerve palsy caused by HO following surgical treatment, with a review of the relevant literature. A retrospective study was conducted on 4 patients with tardy ulnar nerve palsy caused by HO, who underwent anterior subcutaneous ulnar nerve transposition between 2015 and 2020. The patients were followed up for more than 1 year and the cause of HO was also identified. Clinical and functional outcomes were evaluating using the grip strength and pinch strength, visual analog scale (VAS) pain score and Quick disabilities of the arm, shoulder and hand (DASH) score. The causes of HO were repetitive micro-trauma in 1 case and excessive physical or rehabilitation therapy in 3 cases. The average follow-up period was 15.6 months (range; 12-21 months). The grip strength increased from an average of 14kg to 26.5kg. The pinch strength increased from an average of 1.5 kg to 3.63 kg. The Quick DASH score decreased from an average of 55.6 to 6.15. The VAS score for pain decreased from an average of 7 to 0.25. Rapid surgical treatment, including removal of the heterotopic bone and ulnar nerve anterior transposition, might improve outcomes in patients with tardy ulnar nerve palsy caused by HO.