Removal Of Osteophytes Research Articles

Morphological features and anatomical variations of the Foramen Transversarium in Cervical vertebrae: A study in Eastern Indian population

Introduction: The foramina transversaria (FT) is a cardinal feature of the Cervical Vertebra. It transmits the vertebral vascular bundle (vertebral artery, and veins) and the sympathetic plexus which accompanies the vessels. Variations in number, size, shape & other morphological details of foramen transversarium give rise to neurological as well as hearing impairment. We in the index study, deliberated over the variations of FT as well as accessory FT. This in turn will help neurology surgeons as well as orthopedic surgeons while performing surgeries on the cervical spine. Objectives: Study of variations in number, size, shape & other morphological details of foramen transversarium in order to facilitate spinal surgery of cervical vertebra. Materials and Methods: A cross sectional, single center, observational study was conducted in a tertiary care hospital with 160 sets, exactly 1099 human cervical vertebrae. All cervical vertebrae were observed macroscopically, on both the sides for presence of: Variations in number, size, shape & other morphological details of foramen transversarium. Variations in number, size, shape & other morphological details of accessory foramen transversarium. Results: According to our observation type 4 is the most prevalent category in the right side (39.67%); whereas type 5 (30.12%) is the commonest category in the left side, being closely seconded by type 1(28.57%). The incidence of AFT (Accessory Foramina Transversarium) varied from 2.5% to 17.61 %. There is progressive increase in incidence from C1 to C7 except C2 where the incidence was zero. Conclusion: The data provided by the present study on the morphology of foramen transversarium can be helpful in the interpretation of radiographic pictures and in computerized tomography for the diagnostic purposes. They may also be of assistance in determining a more accurate surgical approach to the removal of osteophytes or spurs compressing the vertebral arteries, or for other interventions in that area.

Are soft tissue releases sufficient to correct moderate to severe flexion contractures during total knee replacement? Role of hamstring tenotomy and horizontal capsular release

BackgroundPerforming total knee arthroplasty (TKA) in arthritic knees with persistent flexion deformities is a challenging task because secondary tightening of surrounding soft tissues makes it difficult to achieve appropriate ligament balancing. In this study, we shared our algorithm for correction of flexion contractures of moderate to severe grade while performing TKA as well as their outcomes with 1 year of follow up. MethodsForty-three patients (61 knees) having knee arthritis with moderate to severe flexion contractures (Lombardi classification) were included in the study. We followed a stepwise algorithm of soft tissue releases for correction of flexion contracture, which included: removal of posterior osteophytes, release of posterior capsule, gastrocnemius release, horizontal capsular release, and hamstring tenotomy. Patients were followed up at 15 days, 6 weeks, 3 months and 1 year, and assessed clinically for residual flexion deformity (FFD), range of motion (ROM), New Knee Society (New KSS) score and Hospital for Special Surgery (HSS) score. ResultsPre-operative mean FFD 29.07 ± 18.04 standard deviation (SD) was corrected to 0.77 ± 2.93 SD at 1 year follow up. Pre-operative mean ROM 71.37 ± 22.18 increased to 107.7 ± 10.38 at 1 year follow up. There was statistically significant improvement in mean New KSS score and reduction in number of cases with poor HSS score at 1 year follow up. ConclusionsModerate flexion contractures can be corrected with soft tissue releases without distal femoral over-resection. In severe deformities, horizontal release of posterior capsule and hamstring tenotomy are crucial, and residual contractures of up to 20° can be well corrected by postoperative physiotherapy and extension bracing.

Risk factors of instability following reverse total shoulder arthroplasty in patients with no history of shoulder surgery

IntroductionAs its indications expand, reverse total shoulder arthroplasty (rTSA) utilization continues to increase. Though relatively uncommon, instability following rTSA can be associated with significant morbidity and need for subsequent revision and treatment. This case control study aims to characterize factors leading to instability after rTSA, especially in those with no previous shoulder surgery. Methods194 rTSAs performed within the study period with appropriate operative indications and follow-up were included. Risk factors used in analysis included age, gender, BMI, ASA class, Charlson comorbidity index (CCI), glenosphere, tray, and liner size. Data was analyzed using a hierarchical binary logistical regression to create a predictive model for instability. ResultsSeven patients sustained a post-operative dislocation. Mean time to dislocation was 60.4 weeks. Five required open reduction with placement of either a larger humeral tray or polyethylene spacer. One required open reduction with osteophyte removal, and one was converted to a resection arthroplasty. Dislocators were more likely to have a larger BMI (p = 0.002), higher ASA classification (p = 0.09), and larger liner size (p = 0.01). ConclusionThis study demonstrates a large series of patients successfully treated with rTSA. Dislocations were an uncommon complication, but were clearly associated with higher patient BMI, ASA classification, and increased liner size.

Intraoperative changes in medial joint gap after posterior femoral condylar resection, posterior osteophyte removal, and femoral component placement during primary total knee arthroplasty

Background“Mid-flexion stability” is important for superior patient satisfaction following total knee arthroplasty (TKA). Thus, it is important to control medial joint gap intraoperatively as a countermeasure. However, reports on the precise intraoperative changes in medial joint gap during TKA are scarce. This study evaluated the intraoperative changes in medial joint gap during TKA. MethodsWe studied 167 knees with varus osteoarthritis that underwent 80 cruciate-retaining (CR) and 87 posterior-stabilized (PS) TKAs between January 2018 and December 2020. We measured the intraoperative changes in medial joint gap with a tensor device at 137.5 N. ResultsThe medial joint gap after posterior femoral condylar resection was significantly increased not only at 90° of flexion but also at 0° of extension in CR and PS TKAs (p < 0.01). The medial joint gap after posterior osteophyte removal was significantly increased not only at 0° of extension but also at 90° of flexion in CR and PS TKAs (p < 0.01). The medial joint gap at 0° of extension was reduced by 0.60 mm after femoral component placement in PS TKA. ConclusionSurgeons need to pay close attention to these intraoperative changes in medial joint gap by measuring the medial joint gap before and after each procedure or assuming the changes in those values before bone cutting to achieve superior patient satisfaction following TKA.

Diagnosis and Treatment of Posteromedial Elbow Impingement in the Throwing Athlete.

Posteromedial elbow impingement is a common pathological entity in the throwing athlete. The posteromedial articulation of the elbow is a significant stabilizer to medial elbow forces and valgus stress noted during repetitive throwing. This current review investigates recent literature regarding the relevant anatomy, diagnosis, and treatment of posteromedial impingement in the thrower. Improvements in advanced imaging have provided accurate and detailed diagnostic capability for the assessment of the throwers' elbow. After failure of conservative measures, arthroscopic treatment of posteromedial elbow impingement with posteromedial osteophyte removal has demonstrated excellent outcomes with a reliable return to play in the competitive thrower. In addition to a thorough history and physical examination, MRI, MR arthrogram, CT, and dynamic ultrasound imaging modalities are useful in the assessment of a presumed diagnosis of posteromedial impingement. Arthroscopic decompression with posteromedial osteophyte removal provides effective clinical results and return to play. The surgeon should be careful to avoid creating medial ulnar collateral instability by means of over-resection of the posteromedial olecranon.

Effect of Posterior Osteophytes on Total Knee Arthroplasty Coronal Soft Tissue Balance: Do They Matter?

Achieving coronal plane balance in total knee arthroplasty (TKA) is of paramount importance. There is concern that obtaining balancing before removal of posterior osteophytes may lead to asymmetrical extension balance once removed. We hypothesized that there is a particular posterior osteophyte size and location that does not result in significant change in coronal gap balancing. In this study of 245 robotic arm-assisted TKAs, the size and location of posterior osteophytes were obtained from preoperative computer tomography scans. Gap measurements at 10°-25° and 90° flexion after removal of medial and lateral osteophytes, before and after posterior osteophyte removal and bone resection were compared with respect to the size and location of posterior osteophytes. The largest size posterior osteophytes measured >10mm in 8.2% of cases, 5-10mm in 34.7%, <5mm in 23.7%, and 23.7% had no osteophytes. The mean osteophyte size was 5.7mm. The cohorts with and without posterior osteophytes were both found to have significant but similar changes in all gaps after osteophyte removal and bone resection (mean 0.8-1.4mm, P < .0001 and mean 0.7-1.7mm, P < .0001, respectively). Osteophyte size and location had no significant effect on the change in postresection gaps. This included osteophytes greater than 10mm, but their incidence was small. There is a small significant change in gaps between initial assessment and subsequent TKA bone resections, with or without posterior osteophytes. Our study found that where the surgeon thoroughly removes the medial and lateral osteophytes on initial exposure, posterior osteophytes <10mm can be ignored during initial knee coronal balancing.

Artificial Neural Network Approach to Competency-Based Training Using a Virtual Reality Neurosurgical Simulation.

The methodology of assessment and training of surgical skills is evolving to deal with the emergence of competency-based training. Artificial neural networks (ANNs), a branch of artificial intelligence, can use newly generated metrics not only for assessment performance but also to quantitate individual metric importance and provide new insights into surgical expertise. To outline the educational utility of using an ANN in the assessment and quantitation of surgical expertise. A virtual reality vertebral osteophyte removal during a simulated surgical spine procedure is used as a model to outline this methodology. Twenty-one participants performed a simulated anterior cervical diskectomy and fusion on the Sim-Ortho virtual reality simulator. Participants were divided into 3 groups, including 9 postresidents, 5 senior residents, and 7 junior residents. Data were retrieved from the osteophyte removal component of the scenario, which involved using a simulated burr. The data were manipulated to initially generate 83 performance metrics spanning 3 categories (safety, efficiency, and motion) of which only the most relevant metrics were used to train and test the ANN. The ANN model was trained on 6 safety metrics to a testing accuracy of 83.3%. The contributions of these performance metrics to expertise were revealed through connection weight products and outlined 2 identifiable learning patterns of technical skills. This study outlines the potential utility of ANNs which allows a deeper understanding of the composites of surgical expertise and may contribute to the paradigm shift toward competency-based surgical training.

Treatment of condylar osteophyte in temporomandibular joint osteoarthritis with muscle balance occlusal splint and long-term follow-up: A case report

BACKGROUNDCondylar osteophytes, a remodeling form of temporomandibular joint osteoarthritis (TMJ OA), mainly manifest as marginal angular outgrowths of the condyle. Previous researchers have advocated surgical removal of condylar osteophytes. Reports on the effect of occlusal splint on TMJ OA patients’ joints have mostly focused on treatment with this splint, which can reduce the absorption of the affected condyle and promote repair and regeneration. However, the effect of the splint on the dissolution of condylar osteophytes has not yet been reported.CASE SUMMARYA 68-year-old female patient suffered from occlusal discomfort with left facial pain for 2 years. Cone beam computed tomography showed a rare osteophyte on top of her left condyle. She was finally diagnosed with TMJ OA. The patient refused surgical treatment and received conservative treatment with a muscle balance occlusal splint. The pain experienced by the patient on the left side of her face was relieved, and her chewing ability recovered after treatment. The osteophyte dissolved, and the condylar cortex remained stable during long-term follow-up observations.CONCLUSIONThe muscle balance occlusal splint could be a noninvasive means of treating condylar osteophytes in TMJ OA patients.

Effectiveness analysis of computer-aided technology in the treatment of primary elbow osteoarthritis combined with stiffness under arthroscopy

To explore the effectiveness of computer-aided technology in the treatment of primary elbow osteoarthritis combined with stiffness under arthroscopy. The clinical data of 32 patients with primary elbow osteoarthritis combined with stiffness between June 2018 and December 2020 were retrospectively analyzed. There were 22 males and 10 females with an average age of 53.4 years (range, 31-71 years). X-ray film and three-dimensional CT examinations showed osteophytes of varying degrees in the elbow joint. Loose bodies existed in 16 cases, and there were 7 cases combined with ulnar nerve entrapment syndrome. The median symptom duration was 2.5 years (range, 3 months to 22.5 years). The location of bone impingement from 0° extension to 140° flexion of the elbow joint was simulated by computer-aided technology before operation and a three-dimensional printed model was used to visualize the amount and scope of impinging osteophytes removal from the anterior and posterior elbow joint to accurately guide the operation. Meanwhile, the effect of elbow joint release and impinging osteophytes removal was examined visually under arthroscopy. The visual analogue scale (VAS) score, Mayo elbow performance score (MEPS), and elbow range of motion (extension, flexion, extension and flexion) were compared between before and after operation to evaluate elbow function. The mean operation time was 108 minutes (range, 50-160 minutes). All 32 patients were followed up 9-18 months with an average of 12.5 months. There was no other complication such as infection, nervous system injury, joint cavity effusion, and heterotopic ossification, except 2 cases with postoperative joint contracture at 3 weeks after operation due to the failure to persist in regular functional exercises. Loose bodies of elbow and impinging osteophytes were removed completely for all patients, and functional recovery was satisfactory. At last follow-up, VAS score, MEPS score, extension, flexion, flexion and extension range of motion significantly improved when compared with preoperative ones ( P<0.05). Arthroscopic treatment of primary elbow osteoarthritis combined with stiffness using computer-aided technology can significantly reduce pain, achieve satisfactory functional recovery and reliable effectiveness.

Arthroscopic Partial Excision of the Radial Head for Advanced Rheumatoid Elbow.

We treated humeroradial joint disorder in rheumatoid elbows with arthroscopic partial excision of the radial head, in which the radial head is minimally resected under arthroscopy to ensure adequate joint space and articular congruity. To examine the effect of this method, we investigated outcomes using a retrospective case series. The hypothesis of this study was that this method decreases symptoms related to the humeroradial joint and ensures articular congruity. Since 2008, we have performed arthroscopic partial excision of the radial head for 14 patients (15 rheumatoid elbows) with more than 2 years of follow-up. Surgical indications for this method were motion pain with crepitus around the humeroradial joint and joint narrowing and sclerosis on plain radiography. After synovectomy, the surface of the radial head was resected 4 to 5 mm under arthroscopy, ensuring adequate joint space and articular congruity. Osteophyte removal and anterior capsular release were performed if necessary. At the final follow-up of 54 months, pain around the humeroradial joint had resolved in all cases. Range of motion improved from 115° flexion, -39° extension, 55° pronation, and 54° supination preoperatively to 127° flexion, -27° extension, 60° pronation, and 65° supination postoperatively. The articular congruity of the humeroradial joint was well maintained at final follow-up, with the exception of 2 cases in which the space decreased after 4 years. Arthroscopic partial excision of the radial head is a promising procedure for improvement of humeroradial symptoms. This method is effective, even for advanced cases, and should be considered before total arthroplasty. [Orthopedics. 2022;45(4):209-214.].

Relationship between Severity of Varus Osteoarthritis of the Knee and Contracture of Medial Structures.

Knees with severe varus osteoarthritis can develop medial structure contracture. However, there is no report on the relationship between severity of varus deformity and contracture of the medial structure. We aimed to determine the threshold angle that could be corrected in proportion to the width of medial osteophyte removal and to examine correction differences between angles larger and smaller than the threshold angle in total knee arthroplasty. This study included 27 varus osteoarthritic knees scheduled for total knee arthroplasty (TKA). A navigation system was used to measure hip-knee-ankle angle (HKA) in all knees at maximum extension and 30˚ and 60˚ flexion, before and after osteophyte removal and with and without external 10 N-m valgus torque loads. Subsequently, resected osteophyte widths were measured. Mean correction angle per 1 mm of osteophyte removal was calculated, and the threshold angle was calculated with the receiver operating characteristic curve. HKA differences were compared against deformities larger and smaller than the threshold angle. Mean osteophyte width was 7.1±2.20 mm. Osteophyte removal produced a mean 3.1° correction, which equaled a 0.4° correction per 1 mm of osteophyte width removal. The varus deformity threshold angle was 9.5°. However, when comparing groups with angles larger and smaller than the threshold angle, there was no significant difference in HKA difference between each step and flexion angle. The threshold angle for expected correction with medial osteophyte removal was 9.5˚. However, because there were no differences in correction between those with angles larger or smaller than this, medial structure contracture seemed to be unrelated to the severity of deformity.

The Current Role of Ankle Arthrodesis in Hemophilic Patients.

There are several manners to take care of the hemophilic ankle in the initial phases of degeneration of the articular cartilage, in the event that hematologic prophylaxis is unsuccessful in accomplishing no bleeds. Some of these are nonoperative, with which management must start. These are Physical and Rehabilitation Medicine protocols and the utilization of orthoses (patellar tendon bearing). When these are unsuccessful, more aggressive types of treatment can be utilized, such as radiosynovectomy and some surgical operations (open or arthroscopic removal of anterior osteophyte of the distal part of the tibia, arthroscopic ankle debridement). Nonetheless, in the late phases of degeneration of the articular cartilage (advanced arthropathy), the solely options are surgical: ankle fusion or total ankle arthroplasty. The review of the literature has shown that the percentage of consolidation is between 90% and 100%, and that the percentage of postoperative infection is between 0% and 10%%. When the Ilizarov external fixator is utilized for ankle fusion, the percentage of pin tract infection is around 14%. Ankle fusion is a secure surgical technique that meliorates articular pain and improves the quality of life of hemophilic patients.

“In-Situ” Joint Preparation Technique for First Metatarsophalangeal Joint Arthrodesis: A Retrospective Comparative Study with “Flat-Cuts” Technique

Category:Midfoot/Forefoot; BunionIntroduction/Purpose:The most common joint preparation techniques mentioned in literature for 1st metatarsophalangeal (MTP) joint arthrodesis are 'cup and cone' and 'flat-cuts'. A third option of an 'in-situ' technique, has rarely been studied. This study compares the clinical, radiographic, and patients-reported outcomes of 'in-situ' joint preparation with a traditional 1st MTP joint preparation technique.Methods:The 'in-situ' technique utilizes the same dorsal surgical incision as traditional techniques. Cartilage and osteophyte removal are carried out using standard techniques without the use of specific reamers or a sagittal saw. The arthrodesis is performed in-situ with the similar freedom of joint positioning as the cup and cone technique, and traditional fixation constructs are applied. In this study, A retrospective chart review was performed for patients who underwent 1st MTP joint arthrodesis between January 2015 and December 2019. The complication, revision and non-union rates were examined in a multivariable logistic regression model. Patient reported outcome were analyzed in a repeated measures general linear model. Analysis of variance and Receiver Operating Characteristic were used to assess radiographic measurements.Results:Total of 388 1st MTP joint arthrodesis cases were included. Overall, 262 'Flat-Cuts' and 126 'In-Situ' cases were analyzed. Mean follow-up time was 292 days (median 174, SD 305). Joint-preparation technique did not have statistically significant impact on union rates (p=0.311) or revision rates (p=0.898). Diabetes-Mellitus was the most powerful predictor of non-union (p<0.001, OR 6.558, 95% CI: 2.534-16.969) and revision (p=0.02, OR 3.662, 95% CI: 1.230-10.905). The rate of transfer- metatarsalgia was significantly higher in 'flat-cuts' (p=0.015, OR 6.808, 95% CI: 1.460-31.744). Visual-Analogue-Scale and PROMIS- CAT-Physical significantly improved at 6-weeks, 3-months, and at last follow-up in both techniques (p<0.001, p=0.001), and the improvement was comparable between the techniques (p=0.078, p=0.100).'In-situ' technique resulted in significantly less mean 1st- ray shortening (3.05mm vs 7.64mm, p<0.001). In a Receiver-Operating-Characteristic analysis of transfer metatarsalgia and 1st ray shortening, the optimal diagnostic cut-off was 6.87 mm (LR 1.67, AUC 0.652, p=0.005, 95% CI: 0.56-0.74).Conclusion:'In-situ' joint preparation technique is a simple, safe, and cost-effective technique for 1st MTP joint arthrodesis. In our series, 'in-situ' technique had a similar or better complication profile than the 'flat-cuts', while providing similar patient- reported outcomes. 'In-situ' technique resulted in significantly less 1st ray shortening, which was a predictor of transfer metatarsalgia.

A novel efficient and precise technique for removing acetabular osteophytes in patients undergoing total hip arthroplasty: the SH-9Hospital acetabular edge file.

BackgroundTotal hip arthroplasty (THA) is frequently performed in patients with end-stage hip disease. Periacetabular osteophytes are common during THA; however, these osteophytes should be removed intraoperatively to avoid potential impingement between osteophytes and femoral prostheses and decrease dislocation risk. There are no current standard procedures or surgical technique criteria to remove these osteophytes. Osteophytes around the acetabulum are usually removed with an osteotome, yet this presents certain disadvantages. Hence, this study aimed to introduce a novel and more efficient technique than the aforementioned one, the SH-9Hospital acetabular edge file.MethodsFifty-four patients (54 hips) who underwent primary THA using osteotome and the SH-9Hospital acetabular edge file to remove periacetabular osteophytes intraoperatively were retrospectively studied. Clinical and radiographic data were obtained for all patients intra- and postoperatively.ResultsThe mean osteophyte removal time was 274.6±102.7 s and 51.3±21.1 s in the osteotome and SH-9Hospital acetabular edge file groups, respectively. Intraoperative images and postoperative radiographs showed that acetabular osteophytes were removed thoroughly and precisely by the acetabular edge file and that there was no iatrogenic injury and prostheses malposition in both groups.ConclusionsThe SH-9Hospital acetabular edge file was a novel, efficient, highly precise, and repeatable method for removing periacetabular osteophytes in patients undergoing total hip arthroplasty.

Correction of Varus Alignment with Peripheral Osteophyte Removal during Total Knee Arthroplasty: An Assessment with Computer Navigation.

Techniques for symmetrical balancing in flexion and extension have been described; however, the ideal technique is unclear. This study aimed to clarify whether resection of peripheral osteophytes could restore neutral hip-knee-ankle (HKA) angle of varus deformity of arthritic knees. Data from 90 varus arthritic knees that had undergone total knee arthroplasty (TKA) using a nonimage-based navigation system were analyzed. The change in the coronal mechanical axis, while applying manual valgus stress at extension and 90 degrees of knee flexion, was recorded after the following sequential procedures: (1) anterior cruciate ligament (ACL) sectioning, (2) subperiosteal stripping of the deep medial collateral ligament (MCL) from the underlying osteophytes on the medial tibia, and (3) complete removal of peripheral osteophytes from the proximal medial tibia and distal medial femoral condyle. Repeated measures of analysis of variance (ANOVA) were performed to compare the varus angle among each step, and a post hoc analysis by paired t-test was utilized to compare the parameters between baseline and each step. The varus alignment with valgus stress at extension and 90 degrees of flexion (mean: 6.0 ± 3.6 and 5.2 ± 3.9 degrees of varus, respectively) was significantly corrected to a near-neutral mechanical axis (mean: 0.9 ± 2.4 and 1.4 ± 4.2 degrees of varus, respectively) after peripheral osteophyte resection (p < 0.01, both). In many cases, varus deformity of arthritic knees could be corrected to near-neutral HKA angle by applying manual valgus stress after complete peripheral osteophyte resection. These procedures could facilitate soft tissue balancing in TKA, minimizing the risk of overrelease of the medial soft tissues.

Revision surgery after resection arthroplasty of the CMC-1 joint using the extensor carpi radialis longus muscle tendon

Resuspension of the first metacarpal bone using the extensor carpi radialis longus muscle tendon. Prevention of contact between the first metacarpal bone and adjacent bones (scaphoid, trapezoideum, second metacarpal bone). Preservation of motion. Pain after preceeding resectional arthroplasty due to proximalisation of the first ray. Radiologically demonstrated contact between the base of the first metacarpal bone and adjacent bones (scaphoid, trapezoideum, second metacarpal bone). Instability of the first ray at the site of the suspension. Proven specific reasons: neuropathical complaints and dysaesthesia in the region supplied by the superficial branch of the radial nerve, tendinitis of the flexor carpi radialis tendon etc. SURGICAL TECHNIQUE: Distalisation of the first ray after mobilisation and debridement at the base of the first metacarpal bone with resection of scar tissue, Resection of the pre-existing tendon plasty and contouring the base of the first metacarpal bone with removal of osteophytes. Interposition of tendon material between the base of the first and second metacarpal bones. Immobilisation in aforearm cast including the thumb metacarpophalangeal joint for 6weeks. Of 21patients treated using this procedure, 15(13women, 2men, average age 59(51-70)years) were evaluated retrospectively on average 4(2-10)years postoperatively. Opposition of the thumb was nearly normal. Grip strength and strength of pinch grip did not differ significantly from the contralateral side. Pain at rest and exercise (evaluated by avisual analogue scale from 0-10) was postoperatively significantly reduced. On plain X‑rays the distance between the base of the first metacarpal bone and the distal scaphoid pole was significantly increased as asign of asuccessful distalisation. Ultimately, 12patients postoperatively returned to work, 10to their original occupation. No patient required additional procedures.

The subscapularis-sparing windowed anterior technique for total shoulder arthroplasty.

Traditionally, total shoulder arthroplasty (TSA) involves detaching the subscapularis tendon through either tenotomy or lesser tuberosity osteotomy. A subscapularis-sparing approach avoids detachment but may make re-creation of the anatomy more difficult because of limited exposure. The primary aim of this study was to evaluate the ability to re-create the proximal humeral geometry and assess for osteophyte removal with this technique. The secondary aim was to assess for complications or an inability to complete the procedure with this technique. We performed a retrospective review of a consecutive series of 47 patients (100% with osteoarthritis; 59% Walch type A and 41% Walch type B; 50% male and 50% female patients; and average body mass index, 28.21 ± 4.6) who underwent the subscapularis-sparing windowed anterior technique for TSA. The ability to reconstruct the proximal humeral geometry and remove the inferior osteophytes was assessed by 2 independent observers using the center-of-rotation difference (ΔCOR) between the native and prosthetic humeral heads. The ability to complete the procedure was recorded, and a chart review was performed to assess for complications. The procedure was successfully completed in 44 of the 47 patients. Radiographic review demonstrated an average ΔCOR of 2.28 mm (range, 0.2-6.05 mm; intraclass correlation coefficient, 0.971), below the previously reported acceptable ΔCOR of 3 mm. The ΔCOR was >3 mm in 31.8% of patients (14 of 44; 8 Walch type A and 6 Walch type B; 9 male and 5 female patients). There was no difference in ΔCOR based on Walch type (P = .824). Male patients on average showed a higher ΔCOR (2.62 mm) than female patients (1.94 mm) (P = .099) and more commonly had a ΔCOR > 3 mm (P = .195). Body mass index was not significantly correlated with ΔCOR (r = 0.077, P = .619). For all cases in which the ΔCOR was >3 mm, the prosthetic humeral head was undersized. Osteophytes were successfully removed in 75% of cases (33 of 44) and had no effect on average ΔCOR (P = .468). No revisions or mechanical failures in the early postoperative period were identified in the treatment group of 44 patients (range, 3-15 months). In the group with unsuccessful treatment, there was 1 case of infection treated with 1-stage revision reverse TSA. The subscapularis-sparing windowed anterior technique is an effective approach to TSA that allows for early unrestricted motion. Over 90% of cases can be completed using this technique. Radiographic analysis demonstrated that this approach can be used successfully without compromising anatomic reconstruction of the proximal humerus. Further study is necessary to identify patient factors that would favor a traditional deltopectoral approach and to assess the functional outcomes of this technique.

Thoracic osteophyte as a cause of symptomatic greater splanchnic nerve compression. Case report

Thoracic osteophytes are a common feature of degenerative spine disease. However, it is rare that osteophytes overgrowth on the anterior surface of thoracic spine results in the compression of vital structures and causes symptoms. A 39-year old man with a two-year history of thoracic and upper abdominal pain was admitted to the neurosurgery ward after having been seen by several specialists. Thoracic spine MRI and CT scans were analyzed. Osteophytes were identified on the anterolateral right side at level T8–T9 and were indicated as a possible cause of the symptoms. After obtaining patient consent, surgery was performed with transthoracic access to the anterolateral surface of the spine. Intraoperatively, the greater splanchnic nerve was released by osteophyte removal. The patient reported improvement of the preoperative symptoms at the six-month and two-year follow-up visit. Postoperative MRI indicated complete osteophyte excision. To the best of our knowledge, this is the first report of symptomatic sympathetic trunk branch compression by thoracic osteophytes.

Is Standing Coronal Long-Leg Alignment View Effective in Predicting the Extent of Medial Soft Tissue Release in Varus Deformity during Total Knee Arthroplasty?

The aim of this study was to assess the predictive value of the femoral intermechanical-anatomical angle (IMA), mechanical lateral distal femoral angle (mLDFA), medial proximal tibia angle (MPTA), femorotibial or varus angle (VA), and joint line convergence angle (CA) in predicting the stage of the medial collateral ligament (MCL) during total knee arthroplasty (TKA) of varus knee. We evaluated 229 patients with osteoarthritic varus knee who underwent primary TKA, prospectively. They were categorized in three groups based on the extent of medial soft tissue release that performed during TKA Group 1, osteophytes removal and release of the deep MCL and posteromedial capsule (stage 1); Group 2, the release of the semimembranosus (stage 2); and Group 3, release of the superficial MCL (stage 3) and/or the pes anserinus (stage 4). We evaluated the preoperative standing coronal hip-knee-ankle alignment view to assessing the possible correlations between the knee angles and extent of soft tissue release. A significant difference was observed between the three groups in terms of preoperative VA, CA, and MPTA by using the Kruskal-Wallis test. The extent of medial release increased with increasing VA and CA as well as decreasing MPTA in preoperative long-leg standing radiographs. Finally, a patient with a preoperative VA larger than 19, CA larger than 6, or MPTA smaller than 81 would need a stage 3 or 4 of MCL release. The overall results showed that the VA and MPTA could be useful in predicting the extent of medial soft tissue release during TKA of varus knee.

Assessing the Role of Minimal Medial Tissue Release during Navigation-Assisted Varus Total Knee Arthroplasty Based on the Degree of Preoperative Varus Deformity.

We assessed the impact of a minimal medial soft-tissue release with complete peripheral osteophyte removal on the ability to attain manual preresection deformity correction during navigation-assisted total knee arthroplasty (TKA) for varus osteoarthritis. We included 131 TKAs for 109 patients with medial compartment predominant osteoarthritis. The steps for achieving minimal medial soft-tissue release were performed as follows: (1) elevation of a periosteal sleeve to 5-mm distal to the joint line and (2) complete removal of peripheral osteophytes. The evaluation criteria of this study were as follows: (1) age, (2) height, (3) weight, (4) body mass index (BMI), (5) sex, (6) the preoperative femorotibial mechanical angle in the neutral position before medial release and (7) the mechanical angle in maximum manual valgus stress after the two-step medial-release procedure (measured on the navigation screens). Multiple regression analysis of the criteria was performed to determine the degree of varus deformity that allowed neutral alignment but required extensive medial release. The femorotibial mechanical angle in the neutral position before medial release and sex correlated with the mechanical angle in maximum manual valgus stress on the navigation screen after medial release (r = 0.72, p < 0.001). Based on the regression formula, the maximum degree of preoperative varus deformity that allowed neutral alignment by the minimum medial-release procedure was 5.3 degrees for males and 9.1 degrees for females. The magnitude of deformity which has an impact on the ability to correct varus deformity (by minimal soft-tissue release and complete osteophyte removal) was clarified. If the preoperative degree of varus deformity was within 5.3 degrees for males and 9.1 degrees for females, an extensive medial release was not required to obtain neutral alignment.