Thickness Asymmetry of the Vertebral Artery Groove: A Dried Vertebrae Study.

BACKGROUND: The vertebral artery groove (VAG), located on the posterior arch of the first cervical (atlas) vertebra plays a pivotal role in guiding the vertebral artery's (VA) third part (V3). Deviations in VAG morphology and morphometry (dimensions) can influence vascular dynamics and pose clinical implications. AIM: The current study delves into the morphometric variants and explores the less-explored morphometric variable of the VAG thickness, highlighting possible laterality (asymmetry). METHODS: A morphometric investigation was conducted on 141 dried atlas (73 male and 68 female) vertebrae from a Greek adult population. The VAG's minimum thickness was investigated by considering the laterality (sides' differences), gender, and age impact on it. Measurements were performed by two independent researchers, ensuring the data reliability. RESULTS: A significant asymmetry was identified in the VAG thickness between the left (3.9 ± 0.9 mm) and right (4.1 ± 1.1 mm) (p=0.005) sides, with the left side having the mean minimum thickness. Gender had a significant impact on VAG thickness only on the left side, with females presenting a significantly thinner left-sided VAG (3.6 ± 0.9 mm) than males (4.10 ± 0.7 mm) (p=0.001). Age had no significant impact on the VAG thickness.  Conclusion: The present study underscores the significance of asymmetry in the VAG thickness in craniocervical interventions. This less-explored morphometric variable warrants careful consideration by surgeons during preoperative planning to minimize potential complications. The current findings highlight the importance of understanding the VAG thickness asymmetry and its clinical implications, as this osseous variable may be an index of a different diameter of the VA by side. It is recommended that surgeons incorporate this variable into their preoperative assessments to improve the safety and efficacy of craniocervical interventions.

A bilateral gastrocnemius tertius coexisting with a unilateral two-headed plantaris muscle.

The current cadaveric report aims to present a coexistence of two uncommon variants of the posterior leg compartment. The variations were detected, during classical dissection in an 84-year-old donated male cadaver. On the left lower limb, the gastrocnemius muscle was identified as having a third head that was attached to the lateral head. This variant is known as gastrocnemius tertius muscle and was bilaterally identified. The left-sided plantaris muscle had two distinct heads that fused into a common tendon that was inserted into the calcaneal tuberosity. Knowledge of these variants is important, due to their close relationship with the popliteal neurovascular bundle. Clinicians should be aware, to avoid pitfalls and take them into account in their differential diagnosis.

Restoring Hip Joint Anatomy With the Robotic Arm-Assisted System in Hip Fractures: Expanding the Applications for Hip Surgery.

Total hip arthroplasty (THA) has improved the life quality of osteoarthritic patients, yet challenges persist. The robotic arm-assisted system, integrated into THA, aims to refine implant positioning, enhance precision, reduce errors, and restore the hip joint's anatomy, including hip center, femoral offset, and limb length. We present the first use of the system for the treatment of a subcapital femoral neck hip fracture. A 62-year-old female suffering a left subcapital hip fracture underwent THA using the robotic arm-assisted system. After acetabular registration, accurate component placement was achieved, and a 9-mm limb length discrepancy was addressed. The patient had an unremarkable recovery with a reported Harris hip score of 96.5 at 18 months postsurgery. Robotic-guided navigation in THA, as showcased in this case, ensures accurate implant positioning by restoring the anatomical features of the hip joint. Its potential extends beyond conventional applications, hinting at future use in trauma, revision, and oncology cases. While promising, future adaptations should consider soft tissue dynamics to ensure joint stability and overall success.

A Bilateral Symmetrical Variant Formation of the Sural Nerve.

Typically, the sural nerve is formatted by the connection of the lateral sural cutaneous nerve (branch of the common fibular nerve) and the medial sural cutaneous nerve (branch of the tibial nerve). The current cadaveric report aims to describe a quite unusual symmetrical variant of the sural nerve. Classical dissection was performed on an 84-year-old donated male cadaver. On both sides, the sural nerve was formatted directly by the sciatic nerve. After its emanation, it continued its typical course between the gastrocnemius muscle heads. Sural nerve formation has been extensively studied due to its great clinical significance. The identified variant corresponds to one of the rarest types of sural nerve formation. Knowledge of sural nerve variants may play a crucial role in lower limb surgery and nerve harvest for reconstruction.

Morphological variability of the pectoralis minor muscle. Study in human fetuses.

BACKGROUND: The pectoralis minor muscle is located in the anterior thoracic wall. Typically, is constituted by a single belly originating from the 3rd to the 5th rib and inserted into the coracoid process near the origins of the biceps brachii shorth head and of the coracobrachialis muscle. The current study, on human fetuses, aims to detect all morphological muscle variants and to create a new classification system. MATERIAL AND METHODS: Classical dissection of the thoracic wall and the upper limb was bilaterally performed on 25 (13 male and 12 female) human formalin-fixed fetuses aged 18-38 weeks of gestation. The spontaneously aborted fetuses were donated after parental consent to the Medical University anatomy program. The pectoralis minor muscle's morphology, the number of the muscle's bellies, their origins, and insertions, as well as the morphometric details of each belly of the pectoralis minor, were assessed. RESULTS: The pectoralis minor was bilaterally found in all fetuses (50 cases). Three types of muscle were identified based on the number of muscle bellies. In type, I (typical anatomy), were classified the cases with a single belly (in 66%). This type was divided into two subtypes (Ia and Ib). In the subtype Ia, the single belly had a typical course, and in Ib, a proximal attachment was characterized by two small bellies connecting together and creating one muscular mass. In type II, two bellies (24%), and in type III, three bellies (10%) were identified. CONCLUSIONS: Pectoralis minor is morphologically variable in the number of its bellies, its course, its origins, its insertions, and the location of its proximal attachments. The most common type (typical anatomy) was the type I represented by one belly. Other identified variants in the number of bellies by the present study may be hypothetically a result of prematurely terminated embryogenesis.

Entrapment of the Subscapular Artery between the Radial Nerve and the Posterior Wall of the Axilla: An Anatomical Variation with Clinical Significance.

OBJECTIVE: The subscapular artery vascularizes a substantial region of the thoracic wall, and the significance of its distribution is well depicted in the diversity of reconstructive procedures that rely on its blood supply. The aim of this study is to present an uncommon anatomical variation of the artery and discuss the clinical implications of its presence. CASE REPORT: This case report depicts a rare variant of compression and the kinking of the subscapular artery by the radial nerve on the posterior wall of the axilla that was encountered during dissection of a male cadaver of Greek origin. CONCLUSION: The use of autologous tissues in the reconstruction of defects and treatment of lymphedema is expanding, so the need to establish safer surgical dissections is also becoming more apparent. The case of entrapment of the subscapular artery by the radial nerve is extremely rare, however, utilizing tissues perfused by this artery for reconstructive purposes could potentially be futile and unsuccessful due to the inadequate blood supply or vessel thrombosis. Hence, the surgeon should adapt the treatment plan according to preoperative findings, as the presence of anatomical variants should always be suspected.

Systematic Review and Meta-analysis of Suprascapular Notch Morphological Variability: Do We Know Everything?

The suprascapular notch represents a depression on the lateral part of the superior border of the scapula, medially to the coracoid process. The current paper presents a systematic review with a meta-analysis of the suprascapular notch morphological variability. Related clinical implications were further discussed as well to emphasize the value of the topic. A total of 31 articles were included in the meta-analysis, which depicted great heterogeneity. Thus, due to the different classification systems, difficulties were faced in creating a complete and united classification. All the problems and pitfalls that arise from each classification system were discussed, and we concluded with the most complete one. The knowledge of the suprascapular notch morphological anatomy is of great importance, especially for orthopedic surgeons, due to its relationship with the suprascapular nerve. Thus, further research in this area is adequate.

The Anatomical Variation of the Distal Anterior Cerebral Artery: An Angiographic Study in a Greek Population Sample.

Objective The current retrospective angiographic study establishes the rates of variants in the distal anterior cerebral artery (DACA) in a sample of the Greek population. Methods Data were collected from 456 patients who underwent two-dimensional (2D) or three-dimensional (3D) digital subtraction angiography (DSA) of the carotid and vertebral arteries bilaterally. The study focused on patients with good visualization of the anterior and posterior circulations and employed magnetic resonance (MR) or computed tomography (CT) angiography for 3D reconstruction. The anterior cerebral artery (ACA) was classified into one of its two basic configurations, that is, with or without the callosomarginal artery (CMA). The bihemispheric, median, and azygos ACA patterns were also identified. Results The majority (373/456, 81.8%) exhibited a typical DACA pattern. The bihemispheric, median, and azygos patterns were identified in 66/456 (14.5%), 10/456 (2.2%), and 7/456 (1.5%), respectively. The CMA was present in 824/912 (90.4%) of the hemispheres, with a trend toward male predominance for bilateral presence (males: 167/192, 86.98%; females: 210/264, 79.55%; p = 0.05). In particular, the CMA was present significantly more frequently (p = 0.002) in the left hemispheres of male patients. Gender differences in CMA presence persisted in the analysis of the patients with a typical DACA pattern. Conclusion This study provides insights into the variations of the DACA in the Greek population. The observed gender differences in CMA rates suggest potential morphological variations in cerebral vasculature between males and females and contribute to a better understanding of vascular anatomy for clinical and surgical applications.

Are There Any Differences in the Healing Capacity between the Medial Collateral Ligament's (MCL) Proximal and Distal Parts in the Human Knee? Quantitative and Immunohistochemical Analysis of CD34, α-Smooth Muscle Actin (α-SMA), and Vascular Endothelial Growth Factor (VEGF) Expression Regarding the Epiligament (EL) Theory.

The human knee is a complex joint that comprises several ligaments, including the medial collateral ligament (MCL). The MCL provides stability to the knee and helps prevent its excessive inward movement. The MCL also has a thin layer of connective tissue known as the epiligament (EL), which adheres to the ligament. This unique feature has drawn attention in the field of ligament healing research, as it may have implications for the recovery process of MCL injuries. According to the EL theory, ligament regeneration relies heavily on the provision of cells, blood vessels, and molecules. The present study sought to compare the expression of vascular endothelial growth factor (VEGF), CD34, and α-smooth muscle actin (α-SMA) in healthy knees' proximal and distal MCL segments to better understand how these proteins affect ligament healing. By improving the EL theory, the current results could lead to more effective treatments for ligament injury. To conduct the present analysis, monoclonal antibodies were used against CD34, α-SMA, and VEGF to examine samples from 12 fresh knee joints' midsubstance MCLs. We identified a higher cell density in the EL than in the ligament connective tissue, with higher cell counts in the distal than in the proximal EL part. CD34 immunostaining was weak or absent in blood vessels and the EL, while α-SMA immunostaining was strongest in smooth muscle cells and the EL superficial layer. VEGF expression was mainly in the blood vessels' tunica media. The distal part showed more SMA-positive microscopy fields and higher cell density than the proximal part (4735 vs. 2680 cells/mm2). Our study identified CD34, α-SMA, and VEGF expression in the MCL EL, highlighting their critical role in ligament healing. Differences in α-SMA expression and cell numbers between the ligament's proximal and distal parts may explain different healing capacities, supporting the validity of the EL theory in ligament recovery.

A bilateral four-headed brachialis muscle with a variant innervation: a cadaveric report with possible clinical implications.

PURPOSE: Anterior compartment muscles of the arm present high morphological variability, with possible clinical significance. The current cadaveric report aims to describe a bilateral four-headed brachialis muscle (BM) with aberrant innervation. Emphasis on the embryological background and possible clinical significance are also provided. METHODS: Classical upper limb dissection was performed on an 84-year-old donated male cadaver. The cadaver was donated to the Anatomy Department of the National and Kapodistrian University of Athens. RESULTS: On the left upper limb, the four-headed BM was supplied by the musculocutaneous and the median nerves after their interconnection. On the right upper limb, the four-headed BM received its innervation from the median nerve due to the musculocutaneous nerve absence. A bilateral muscular tunnel for the radial nerve passage was identified, between the BM accessory heads and the brachioradialis muscle. CONCLUSION: BM has clinical significance, due to its proximity to important neurovascular structures and frequent surgeries at the humerus. Hence, knowledge of these variants should keep orthopedic surgeons alert when intervening in this area. Further dissection studies with a standardized protocol are needed to elucidate the prevalence of BM aberrations and concomitant variants.

The anterior communicating artery variants: a meta-analysis with a proposed classification system.

Morphological and morphometric variants of the anterior communicating artery (AComA) have been described by multiple studies; however, a complete classification system of all possible morphological variants with their prevalence is lacking. The current systematic review with meta-analysis combines data from different databases, concerning the AComA morphological and morphometric variants (length and diameter). Emphasis was given to the related clinical implications to highlight the clinical value of their knowledge. The typical AComA morphology occurs with a pooled prevalence (PP) of 67.3%, while the PP of atypical AComA is 32.7%. The identified AComA morphological variants (artery's hypoplasia, absence, duplication, triplication, differed shape, fenestration, and the persistence of a median artery of the corpus callosum- MACC) were classified in order of frequency. The commonest presented variants were the AComA hypoplasia (8%) and the anterior cerebral artery (ACA) fusion (5.9%), and the rarest ones were the MACC persistence (2.3%), and the AComA triplication (0.7%). The knowledge of those variants is essential, especially for neurosurgeons operating in the area. Given the high prevalence of AComA aneurysms, an adequate and complete classification of those variants is of utmost importance.

The enigmatic os supratrochleare anterius: from rarity to recognition in elbow pathology-case report and review of literature.

Accessory bones around the elbow are scarce, with a reported mean incidence rate of 0.77%. The rarest one is the os supratrochleare anterius, with only a handful of documented cases in the literature. Despite their scarcity, various types of ossicles have been documented, posing diagnostic challenges and potential misinterpretation on X-rays. Herein, we report a case of an accidentally found os supratrochleare anterius in a 43-year-old pig farmer presenting with symptoms of tennis elbow. After conservative treatment with nonsteroidal anti-inflammatory drugs and physiotherapy, he made a full recovery within 2 weeks. This report emphasizes the rarity of the ossupra trochleare anterius, the importance of accurate diagnosis, and the need for continued research and awareness of this anatomical variation.

Recurrence Patterns of Odontogenic Keratocysts in Syndromic and Non-Syndromic Patients.

Purpose: Odontogenic keratocysts (OKCs) have high recurrence rates. We aimed to identify recurrence patterns in OKCs and the onset of second primary OKCs in non-syndromic and syndromic patients. Material and Methods: Patients with OKCs reporting to our department from 1998 to 2021 (23 years) were retrospectively evaluated using demographic, clinical (age, sex, location, and size), histopathological, radiographic, and treatment data. All patients were followed-up for > 3 years and evaluated for OKC recurrence. Patients with naevoid basal cell carcinoma syndrome (NBCCS) were evaluated separately. Results: We included 38 and 13 patients in the non-syndromic and syndromic OKC groups, respectively. The recurrence rates were 15.8 and 21.4% in the non-syndromic and syndromic groups, respectively; 8.9% of patients exhibited a second recurrence and 1.8% a third recurrence. No second primary OKCs were observed in the non-syndromic group; 76.9% of patients in the syndromic group developed at least one. Conclusion: We found a higher recurrence rate in patients with NBCCS compared with patients with non-syndromic OKCs (21.4 versus 15.8%). The probability of developing a second primary OKC in patients with NBCCS was higher compared with that in patients with non-syndromic OKCs (76.9 versus 0%). No statistically significant risk factors for OKC recurrence were identified.

A biceps-bicaudatus sartorius muscle: dissection of a variant with possible clinical implications.

The current cadaveric report describes an unusual morphology of the sartorius muscle (SM), the biceps-bicaudatus variant. The SM had two (lateral and medial) heads, with distinct tendinous origins from the anterior superior iliac spine. The lateral head was further split into a lateral and a medial bundle. The anterior cutaneous branch of the femoral nerve emerged between the origins of the lateral and medial heads. SM morphological variants are exceedingly uncommon, with only a few documented cases in the literature, and several terms used for their description. Although their rare occurrence, they may play an important role in the differential diagnosis of entrapment syndromes, in cases of neural compressions, such as meralgia paresthetica, while careful dissection during the superficial inter-nervous plane of the direct anterior hip approach is of utmost importance, to avoid adverse effects due to the altered SM morphology.

The axillary artery high bifurcation: coexisting variants and clinical significance.

Several branching patterns of the axillary artery (AA) have been described. Unusually, the brachial artery (BA) follows a course in front of the median nerve (MN), the so-called superficial brachial artery (SBA). The SBA may result in MN entrapment. The current cadaveric report highlights a high AA bifurcation, its continuation as SBA and the coexistence of muscular, neural, and vascular asymmetric aberrations. At the right side, the coracobrachialis muscle (CB) had a single head, and the ipsilateral musculocutaneous nerve (MCN) followed a medial course. The AA was highly divided into superficial and deep stems (SAS and DAS), at the 2nd rib lower border. Between two stems, the brachial plexus (BP) lateral and medial cords were identified. The MN originated from the BP lateral cord. The SAS, continued as SBA with a tortuous course. The DAS coursed posterior to the BP medial and lateral cords and gave off the subscapular artery. A bilateral 3rd head of the biceps brachii was identified. The MN atypically originated from the BP lateral cord. At the left side, the two-headed CB was typically penetrated by the MCN. A common trunk of the circumflex humeral arteries was identified in coexistence with an interconnection of the BP lateral cord with the MN medial root. The rare coexistence of muscular, neural, and arterial variants in axillary and brachial region is emphasized, taking into consideration the AA high division and related branching pattern. Documentation of such rare vascular variants is important in aneurysm and trauma surgery, and angiography, where all therapeutic manipulations must be accurately performed due to the possibility of complications.

The coracobrachialis muscle: typical morphology, accessory forms, and the issues with terminology.

The coracobrachialis muscle (CB) represents one of the anterior arm compartment muscles. It has been defined by classic anatomy textbooks and old papers, as a muscle of one belly arising from the coracoid process tip and partially from the tendon of the biceps brachii short head, and inserted into the humeral shaft, above the bone's midpoint. However, recent cadaveric studies have confirmed that in the majority of cases, the CB is a two-headed muscle consisting of a superficial and a deep head. This finding has caused confusion regarding the terminology of CB's morphology. Typical CB morphology, according to recent data should not be considered the muscle of one belly, but the two-headed muscle. In particular, the musculocutaneous nerve's (MCN) course plays an important role in defining the CB morphological characteristics. If the MCN courses medially to the CB, with no signs of penetration after dissection, it can be concluded, that the CB is composed of one head; otherwise, if the muscle is composed of two or more heads, the MCN will courses between the CB bellies. In conclusion, it is of paramount importance to adopt common-universal terminology. Hence, considering recent findings, if the CB origin and/or the insertion differs from the typical anatomy, an "atypical CB" is the proper definition of the muscle, while if this "atypical CB" coexists with a typical CB, the terminology "accessory CB" may be used.

The Anterolateral Ligament of the Knee Is a Nonisometric Thin Ligament With High Prevalence and Almost Constant Attachment to the Lateral Meniscus: A Systematic Review With Meta-analysis.

PURPOSE: To provide comprehensive information about the anterolateral ligament (ALL) prevalence, morphometry, isometry, insertions, histology, and its relationship with the lateral meniscus (LM). METHODS: The study was performed, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Eligible cadaveric studies investigating the frequency of the ALL presence, and anatomical features were identified through an online search of the PubMed, Scopus, and Cochrane Central databases from inception to June 2022. Statistical analysis was conducted with the open-source R programming language using the "meta" package. The Higgins I2 statistic was used for quantifying heterogeneity. RESULTS: Thirty-three studies (1,478 cadaveric knees) were included. The ALL had a 79% prevalence. It was attached to the LM periphery in 97% of studies. Most studies reported a femoral insertion of the ALL, just proximal and posterior to the lateral epicondyle. Tibial attachment is constant at the midpoint between Gerdy's tubercle and fibular head. The mean ALL thickness at the joint line was 1.6 [1.2; 2.0] mm. The ALL length was found to significantly change across the knee flexion (P < .01). It was increased from 0° to 60° and decreased after 60° flexion. Seven histological studies demonstrated a typical ligamentous microstructure. CONCLUSION: The ALL is a thin ligament, distinct to the knee capsule, which may be found in 79% of the knees having an almost constant attachment to the LM. The ALL is not isometric. It becomes tense during internal rotation and between 30° and 60° knee flexion. Pooled results should be interpreted with caution due to the high heterogeneity among the included studies. CLINICAL RELEVANCE: This study sheds light on controversial issues and provides comprehensive and accurate information about the essential anatomical knowledge on ALL, which may contribute to optimizing ALL reconstruction surgical techniques and biomechanical settings.

The legal and ethical framework governing body donation in Europe - 2nd update on current practice.

BACKGROUND: In 2008, members of the TEPARG provided first insights into the legal and ethical framework governing body donation in Europe. In 2012, a first update followed. This paper is now the second update on this topic and tries to extend the available information to many more European countries. METHODS: For this second update, we have asked authors from all European countries to contribute their national perspectives. By this enquiry, we got many contributions compiled in this paper. When we did not get a personal contribution, one of us (EB) searched the internet for relevant information. RESULTS: Perspectives on the legal and ethical framework governing body donation in Europe. CONCLUSIONS: We still see that a clear and rigorous legal framework is still unavailable in several countries. We found national regulations in 18 out of 39 countries; two others have at least federal laws. Several countries accept not only donated bodies but also utilise unclaimed bodies. These findings can guide policymakers in reviewing and updating existing laws and regulations related to body donation and anatomical studies.

Hippocrates: A Pioneer in Orthopaedics and Traumatology.

PURPOSE: Hippocrates, the ancient Greek physician, is considered the father of Medicine; however, his contributions to Orthopaedics and Traumatology have not been highlighted enough. The present historical review represents an effort to present and categorize his work, in this field, per clinical disorder and anatomical region. METHODS: The "Hippocratic Corpus" original text was thoroughly studied to identify all Hippocrates' contributions in Orthopaedics and Traumatology. Volume III of his works, especially "On Fractures", "On Joints", and "Mochlicon" includes a plethora of information regarding the management of traumas, as well as other disorders and clinical entities of the musculoskeletal system. RESULTS: In particular, Hippocrates describes reduction techniques for fractures, as well as joint dislocations, elaborates on the biology of the fractures' healing process and the basic principles of fracture management and fixation, presents the signs and symptoms of gangrene, teaches the treatment of osseous infections and offers valuable insight on the biomechanics and treatment of spinal diseases. CONCLUSIONS: Hippocrates' contributions in Orthopaedics and Traumatology are unprecedented, making him a true pioneer in this field, while the basic principles that he presented were further studied and confirmed in the 19th and 20th centuries.