Considerations for the value of three-dimensional printed (3DP) versus cadaveric specimens for anatomy education.

We enjoyed reading the Brumpt et al. paper, which showed that a three-dimensional printed model (3DPM) of the ear was more effective than conventional cadaveric models for teaching anatomy. We would like to comment on the findings of this exciting study. In this case, the 3DPM of the ear was compared with dried bone models but not with a cadaveric specimen (with all adjacent soft tissues). The better results after the first test of students who used the 3DPMs were probably attributed to the optimized 3D representation of the ear anatomy. Also, the educational outcomes will likely be better if a more complex 3DPM is used, as it permits better visualization of the structures compared to the dried bone specimens. We certainly agree that 3DPMs have a remarkable ability to represent anatomy. Still, their effectiveness has not been proven superior to cadaveric specimens teaching complex anatomy. In conclusion, although we agree that 3DPMs have a high educational potential and can contribute to complex anatomy teaching, those models were not proven significantly more effective than cadaveric specimens in the Brumpt et al. study. The better effectiveness of 3DPMs compared to dried bone specimens (at the first test) does not mean those models are superior to specimens with retained soft tissues. Such cadaveric specimens permit visualization of complex structures and have proven valuable for teaching complex anatomy. Currently, the literature does not support the educational superiority of 3DPMs to those cadaveric specimens.

Use of photogrammetry-based digital models in anatomy education: An overview.

PURPOSE: Photogrammetry is a technique which includes taking multiple digital photographs from various angles and using those photographs to create three-dimensional virtual models. We aimed to review the outcomes of the implementation of photogrammetry in anatomy education. METHODS: We searched PubMed, Scopus and Cochrane library for studies with purpose to explore the outcomes of the use of photogrammetry-based digital models in anatomy teaching. From each included paper we extracted: authors, number of participants, anatomical region of interest, educational outcomes, and their level according to Kirkpatrick hierarchy. RESULTS: Seven studies were included. Four of them concerned neuroanatomy and three of them concerned other systems. All studies comprised participants' perceptions about the educational intervention, while two of them also evaluated anatomical knowledge acquisition. Overall, the participants rated photogrammetry-based models very highly and preferred them to other teaching tools. These models were also shown able to significantly enhance the anatomical knowledge. CONCLUSIONS: Photogrammetry-based digital objects seem to have a promising anatomy teaching potential. The value of these objects seems to be especially pertinent in teaching the relatively complex field of neuroanatomy. Further research may investigate the effectiveness of photogrammetry-based models in comparison with other anatomy education tools, and with other methods of creation of three-dimensional virtual objects.

An unusual combination of a bilateral aberrant suprascapular artery with neurovascular structures variants.

PURPOSE: The report describes a bilateral suprascapular artery (SPSA) of atypical origin in coexistence with neurovascular aberrant structures. METHODS: The variants were identified in a 91-year-old formalin-embalmed male cadaver, derived from a body donation program after a signed informed consent. RESULTS: The left-sided SPSA emanated from the 1st part of the axillary artery, coursed between the brachial plexus lateral and medial cords, accompanied by the suprascapular nerve, and passed below the superior transverse scapular ligament. Ipsilateral coexisted variants were the lateral thoracic artery multiplication, the subscapular trunk formation, and the musculocutaneous nerve duplication. In the right supraclavicular area, a SPSA duplication was identified. The main artery emanated from the thyrocervical trunk in common with the transverse cervical artery and the accessory SPSA emanated from the dorsal scapular artery. Both SPSAs coursed over the superior transverse scapular ligament, while the suprascapular nerve ran below the ligament. CONCLUSIONS: The current study reported a bilateral aberrant SPSA, originating from the AA 1st part (left side) and from the dorsal scapular artery (right side), which coexisted with adjacent neurovascular structures' variants. The left SPSA atypically coursed below the superior transverse scapular ligament. Such an unusual combination of variations, present bilaterally in the current study, may be challenging for radiologists and surgeons.

Coracobrachialis muscle morphology and coexisted neural variants: a cadaveric case series.

PURPOSE: The current cadaveric case series evaluates the coracobrachialis muscle morphology, the related musculocutaneous nerve origin, course, and branching pattern, as well as associated adjacent neuromuscular variants. MATERIALS AND METHODS: Twenty-seven (24 paired and 3 unpaired) cadaveric arms were dissected to identify the coracobrachialis possible variants with emphasis on the musculocutaneous nerve course and coexisted neural variants. RESULTS: Four morphological types of the coracobrachialis were identified: a two-headed muscle in 62.96% (17/27 arms), a three-headed in 22.2% (6/27), a one-headed in 11.1% (3/27), and a four-headed in 3.7% (1 arm). A coracobrachialis variant morphology was identified in 37.04% (10/27). A three-headed biceps brachii muscle coexisted in 23.53% (4/17). Two different courses of the musculocutaneous nerve were recorded: 1. a course between coracobrachialis superficial and deep heads (in cases of two or more heads) (100%, 24/24), and 2. a medial course in case of one-headed coracobrachialis (100%, 3/3). Three neural interconnections were found: 1. the lateral cord of the brachial plexus with the medial root of the median nerve in 18.52%, 2. the musculocutaneous with the median nerve in 7.41% and 3. the radial with the ulnar nerve in 3.71%. Duplication of the lateral root of the median nerve was identified in 11.1%. CONCLUSIONS: The knowledge of the morphology of the muscles of the anterior arm compartment, especially the coracobrachialis variant morphology and the related musculocutaneous nerve variable course, is of paramount importance for surgeons. Careful dissection and knowledge of relatively common variants play a significant role in reducing iatrogenic injury.

A rare bilateral variant of the coracobrachialis muscle with supernumerary heads and coexisted variant branching patterns of the brachial plexus and the axillary artery.

PURPOSE: The study report describes a rare bilateral variant of a six- and five-headed coracobrachialis muscle (CB). The musculocutaneous nerve (MCN) (bilaterally) and the median nerve (MN) lateral root (unilaterally) pierced CB heads, separating superficial from deep heads. METHODS: The variant bilateral CB was identified in a 78-year-old formalin-embalmed male cadaver, derived from a body donation program after a signed informed consent. RESULTS: At the right side: The 6-headed CB was pierced by the MCN, while the MN lateral root pierced the one superficial and deep head. CB was supplied by the lateral cord and the MCN. At the left side: A 5-headed CB was identified with three superficial distinct origins that fused into a common superficial head coursing anterior to MCN. The variant CB bilaterally (with 11 heads in total) coexisted with a MN variant formation, an atypical course of the MN lateral root through CB (right side), a connection of the MN lateral root with the MCN (left side) and a variant axillary artery branching pattern (bilaterally). CONCLUSIONS: Course and direction of the accessory CB heads may occasionally entrap the MCN and/or adjacent structures (brachial artery and MN). The MCN compression results in problems in the glenohumeral joint flexion and adduction, and tingling or numbness of the elbow joint, the forearm lateral parts and the hand.

Are extended reality technologies (ERTs) more effective than traditional anatomy education methods?

PURPOSE: Reviews and meta-analyses concerning the effectiveness of extended reality technologies (ERTs) (namely virtual, augmented, and mixed reality-VR, AR, and MR) in anatomy education (AE) have resulted in conflicting outcomes. The current review explores the existing evidence provided by reviews of AE literature regarding the effectiveness of ERTs after their comparison with traditional (either cadaveric or two-dimensional) anatomy teaching modalities and sheds light on the factors associated with the conflicting outcomes. METHODS: PubMed, SCOPUS, ERIC, and Cochrane databases were searched for review articles with the purpose to investigate the effectiveness of ERTs in AE. RESULTS: Nine (four systematic with or without meta-analysis and five non-systematic) reviews were included. A lack of robust evidence provided by those reviews was noted, mainly due to a remarkable confusion in the definition of each ERT, along with confusion when authors referred to traditional AE (TAE) methods. CONCLUSIONS: To clarify to what extent VR, AR, or MR can replace or supplement TAE methods, there is a primary need for addressing issues regarding the definition of each technology and determining which specific TAE methods are used as comparators.

"Dissection Educational Videos" (DEVs) and their contribution in anatomy education: a students' perspective.

PURPOSE: The suspension imposed on Universities due to COVID-19 pandemic impeded students' educational opportunities. Alternative teaching modalities have been used. Substitution of dissection courses on cadavers was a great challenge. Present study investigates students' view on the efficacy of the "online" pre-recorded "dissection educational videos" (DEVs) in assisting anatomy teaching, aiming to modernize the lectures and reinforce comprehension. METHODS: The adequacy of the "online" anatomy courses and a possible new teaching modality were evaluated by the 2nd year pre-graduate students, employing an online questionnaire. RESULTS: One hundred and ninety-six volunteer students participated. Before the pandemic, 78.1% of the students constantly attended the "auditorium-based" lectures and 73% used self-teaching tools (STTs) for a better understanding of anatomy. During pandemic, a slight lower frequency (76%) attended the "online" lectures and a higher frequency (84.2%) used at least one STT. Up to 59.2% of the students disagreed with the permanent replacement of the "auditorium-based" by the "online" lectures, while 62.8% supported the idea of parallel conduction of the lectures. Combined teaching tools were the most preferred resources. 83.2% of the students stated that the dissection labs' cancellation negatively affected their education, and 75.5% supported the permanent addition of the pre-recorded DEV series in the lectures. CONCLUSIONS: COVID-19 pandemic created the temporary need for pure remote education. During lockdown, the use of STTs has significantly increased. A novel teaching modality (DEV series), presented in the study, can be used both as educational material and as a STT.

A systematic review of splenic artery variants based on cadaveric studies.

PURPOSE: The splenic artery (SA) is the largest and most tortuous branch of the celiac trunk with a wide spectrum of variants, particularly in its terminal branches. METHODS: The current study presents a systematic review of the English literature on the SA variations, with emphasis on its terminal branching patterns. RESULTS: Thirty cadaveric studies (3132 specimens) were included in the analysis. The SA originated from the celiac trunk in 97.2%, from the abdominal aorta in 2.1% and from the superior mesenteric or the common hepatic artery in 0.7% of cases. A suprapancreatic course was observed in 77.4%, retropancreatic course in 17.8%, anteropancreatic course in 3.4% and intrapancreatic course in 1.3%. In the majority of cases, the SA bifurcated into superior and inferior lobar arteries (83.4%), with trifurcation and quadrifurcation in 11.3% and 2.7%, respectively. Five or more lobar branches (1.4%) and a single lobar artery (1.2%) were rarely identified. The distributed branching pattern was found in 72.7%, whereas the magistral pattern in 26.9%. The inferior and superior polar arteries (IPA and SPA) were found in 47.7% and 41.7% of cases, respectively, while polar artery agenesis was recorded in 28.2%. The SPA usually originated from the SA main trunk (53.6%) or from the superior lobar artery (33.1%). The IPA emanated mainly from the left gastroepiploic artery (53%), from the SA (23.5%) or the inferior lobar artery (21.9%). Intersegmental anastomoses between adjacent arterial segments were identified in 14.2%. CONCLUSION: Knowledge of the SA aberrations is important for surgeons and radiologists involved in angiographic interventions.

Three-dimensional printing in anatomy teaching: current evidence.

PURPOSE: The critical literature review investigates the extent to which the current evidence supports that three-dimensional printing (3DP) could play an important role in human anatomy education. METHODS: PubMed, ERIC, and Cochrane databases were searched for papers dealing with the outcomes of 3DP implementation in human undergraduate anatomy education. The following data were extracted from each paper: authors, year of publication, type of study (comparative or not), number of participants, level of outcome according to Kirkpatrick hierarchy, influence of 3DP on acquisition of anatomical knowledge and skills, as well as perceptions about the 3DP use in anatomy teaching. RESULTS: Eight papers were eligible for analysis. All of them comprised comparison of 3DP with other anatomy teaching tools. Two papers evaluated only students' perceptions about 3DP, while six papers explored its impact on students' knowledge. The 3DP was statistically significantly superior to two-dimensional images in terms of the investigated parameters. However, comparison between 3DP and cadavers' dissection by students did not take place in any study. CONCLUSION: The 3DP implementation in anatomy education showed promising outcomes. However, the lack of studies which compared the educational effectiveness of 3DP with that of cadavers' dissection is highlighted. It seems that 3DP could certainly be used as an adjunct to cadavers' dissection. Further research could clarify if 3DP could obtain a more prominent role in anatomy pedagogy compared to other anatomy teaching modalities.

Andreas Vesalius of Brussels (1514-1564): his contribution to the field of functional neuroanatomy and the criticism to his predecessors.

Until the fifteenth century, the knowledge about anatomy and function of the nervous system had been significantly influenced by theological notions. Andreas Vesalius of Brussels (1514-1564), based on human cadavers' dissections, criticized his predecessors and contributed to the construction of the current knowledge about functional neuroanatomy. Although he did not avoid mistakes, he successfully demonstrated the high value of human cadavers' dissection in anatomical teaching.

Is Oxidized Zirconium Femoral Head Superior to Other Bearing Types in Total Hip Arthroplasty? A Systematic Review and Meta-Analysis.

BACKGROUND: Oxidized zirconium (OxZi) is a relatively new type of material that combines the strength of a metal with the surface/wears properties of a ceramic. Our aim was to investigate whether OxZi femoral heads lead to lower polyethylene wear, higher survival rate, and better clinical outcomes than the other bearing types in patients treated with total hip arthroplasty (THA). METHODS: Two reviewers independently conducted a systematic search according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses using the MEDLINE/PubMed database and the Cochrane Database of Systematic Reviews. These databases were queried with the terms: a. "oxidized" AND "zirconium" AND "total" AND "hip" AND "arthroplasty"; b. "oxinium" AND "total" AND "hip" AND "arthroplasty". The primary outcome measures were the survival rate of the bearing surfaces as well as the polyethylene wear. RESULTS: The vast majority (85.7%) of the studies, which reported the mean polyethylene wear rate, showed that there was not any significant difference between OxZi and cobalt-chrome (CoCr) femoral heads (rate ratio: 0.836; 95% confidence interval: 0.362-1.928; P = .674). All studies comparing the survival rate of OxZi and CoCr femoral heads illustrated almost excellent survivorship with both implants. CONCLUSION: OxZi femoral heads did not lead to lower polyethylene wear rate or higher survival rate, when compared with CoCr femoral heads in patients treated with THA. On the basis of these results and taking into account the higher cost of these implants, we would not recommend the routine use of OxZi femoral heads in primary THAs. LEVEL OF EVIDENCE: Systematic review and meta-analysis of therapeutic studies I-III.

Outcomes of the use of plastination in anatomy education: current evidence.

PURPOSE: We aimed to evaluate the quantity and quality of current evidence concerning the outcomes of use of plastinated specimens in anatomy education. METHODS: We performed a narrative literature review, searching for papers dealing with the use of plastination in anatomy education. PubMed, Scopus, ERIC, Cochrane, Web of Science and CINAHL complete electronic databases were searched. The following data were extracted: author(s), year of publication, type of study (comparative or not), number of participants, evaluation of statistical significance, educational outcomes and their level according to Kirkpatrick hierarchy. RESULTS: Six studies were eligible for analysis. Five of them evaluated only students' reactions about plastination and one study also assessed their examinations results. There were four non-comparative and two comparative studies. Only a study evaluated statistical significance (p < 0.05) with higher score of perception in 2nd year undergraduate medical students, who were more familiar with plastination in comparison to 1st year students. Although the use of plastination was accompanied by positive outcomes in the majority of studies (five out of six), this method was not proved superior to traditional cadavers dissection. CONCLUSIONS: The existing evidence about the outcomes of the use of plastination in anatomy education is relatively limited and lacks comparative studies with statistical significant results. Positive students' reactions were generally noted, but further research is needed to clarify if plastination could be of benefit to students' attitude and anatomy knowledge.

Accuracy and Interobserver and Intraobserver Reliability of Ultrasound in the Early Diagnosis of Occult Scaphoid Fractures: Diagnostic Criteria and a Way of Interpretation.

The purpose of this study was to illustrate the usefulness of ultrasound in the early diagnosis of occult scaphoid fractures. Forty-eight patients with clinical symptoms of scaphoid fracture and negative initial X-rays were examined. All patients underwent ultrasonography in the emergency room (ER). After 14 days, a computed tomography (CT) scan was performed, which confirmed or not the initial suspicion of fracture. Twenty-two patients were found with subperiosteal hematoma, while six also had cortical discontinuity. The sensitivity of ultrasound in the diagnosis of occult scaphoid fractures was 90% and the specificity was 85.7%. The positive prognostic value was 81.8%. The authors support the use of the scaphoid ultrasound only under strict circumstances. If subperiosteal hematoma or cortical discontinuity is present, there is a high likelihood of scaphoid fracture. On the contrary, if the ultrasound is negative and symptoms persist, the patient will require a CT scan or magnetic resonance imaging for definitive diagnosis. (Journal of Surgical Orthopaedic Advances 28(1):1-9, 2019).

Vesalius criticism on Galen's musculoskeletal anatomy.

Galen of Pergamum (129-216/217 AD), an important Greek physician, influenced the history of medicine for more than 1400 years. However, Andreas Vesalius (1514-1564), after performing dissections of human cadavers, remarked that Galen made several mistakes due to the fact that his dissections were on animals, particularly on apes. The current study summarizes the main points in which Vesalius criticized Galen in terms of the musculoskeletal anatomy.

Arthroscopic versus open Latarjet: a step-by-step comprehensive and systematic review.

PURPOSE: To investigate whether arthroscopic Latarjet procedure significantly differs from the open procedure as for the clinical, functional and radiographic outcomes. METHODS: Two reviewers independently conducted a systematic search according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses using the MEDLINE/PubMed database and the Cochrane Database of Systematic Reviews. These databases were queried with the terms "shoulder" AND "anterior" AND "instability" AND "Latarjet". RESULTS: From the 259 initial papers, we finally assessed five clinical studies which were eligible to our inclusion-exclusion criteria. The mean modified Coleman score for methodological deficiencies of the studies was 65.4/100, whereas it ranged from 53/100 to 77/100. The arthroscopic technique illustrated comparable results to the open technique regarding the postoperative recurrence rate. No significant difference was found amongst groups in relation to the postoperative osteoarthritis, infection rates, soft tissue healing, postoperative mean American Shoulder and Elbow Surgeons score, mean Walch-Duplay score, fatty infiltration of the subscapularis muscle and posterior protrusion of the screw. The arthroscopic technique yielded significantly superior results as for the non-union rate of the graft, the total graft osteolysis and graft resorption, the mean Western Ontario Shoulder Instability Index score and the early postoperative pain. CONCLUSIONS: Both the open and the arthroscopic Latarjet procedures led to satisfactory radiographic and clinical outcomes for the treatment of patients with recurrent anterior shoulder instability and significant glenoid bone loss. However, the overall quality of the studies ranged from low to moderate. LEVEL OF EVIDENCE: Comprehensive and systematic review of level II-III therapeutic studies.

Platelet-rich plasma injections for carpal tunnel syndrome: a systematic and comprehensive review.

A series of clinical trials focused on the use of ultrasound-guided platelet-rich plasma (PRP) infusions for the treatment of patients with carpal tunnel syndrome (CTS) were published over the last few years. However, the role of PRP for CTS remains unclear. We performed a systematic review according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Two reviewers independently conducted the search using multiple databases: MEDLINE/PubMed, SCOPUS, Cochrane Database, and Web of Science. These databases were searched using terms "platelet" AND "rich" AND "plasma" AND "carpal" AND "tunnel". To maximize the search, backward chaining of references from retrieved papers was also undertaken. From the initial 19 studies, only five met our eligibility criteria. These articles included one randomized controlled double-blind study, one randomized controlled single-blind study, one randomized controlled non-blind study, one case-control study, and one case report. The vast majority of the included studies supported that PRP infusion improved the clinical condition of the patients and that PRP infusion was beneficial for patients with mild-to-moderate CTS. Therefore, PRP seems to be an interesting alternative for the treatment of mild-to-moderate CTS which, still, has not been thoroughly investigated. However, despite the promising results of the present studies, PRP has to be further tested before we reach to a definite conclusion regarding its therapeutic value.