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OBJECTIVES We have hypothesized that an endoscopically assisted transaxillary approach in the zero-position would be able to improve visualization and allow safe surgery for thoracic outlet syndrome (TOS). METHODS We performed surgery only for patients with certain objective findings, including blood flow disruption, low blood flow, and accelerated blood flow in the subclavian artery demonstrated using Doppler sonography, narrowing of the scalene interval width between the anterior and middle interscalene muscles (interscalene base) or costoclavicular space demonstrated using Duplex ultrasonography or CT angiography. The present study included 45 consecutive patients (50 limbs) who underwent endoscopic transaxillary first rib resection with scalenotomy and brachial plexus neurolysis. We assessed the intraoperative parameters, including the interscalene base, blood loss, operation time, patient satisfaction, preoperative and postoperative QuickDASH, and complications. RESULTS The mean intraoperatively measured interscalene base width was 6.4 mm. All patients showed improvement after surgery. The outcome was excellent in 40% of cases, good in 48%, fair in 12%, and poor in none. Pneumothorax was present in 6%. There were no other complications and no recurrences. Among patients who had been followed up for at least 2 years, the QuickDASH score was significantly improved (42 before surgery vs 12 at final follow-up), especially in athletes relative to non-athletes (0.2 vs 16). The present approach achieved complete relief in 43% of cases overall (91% in athletes and 16% in non-athletes). CONCLUSIONS Endoscopically assisted transaxillary first rib resection and brachial plexus neurolysis in the zero-position is useful and safe for TOS, especially in athletes. Clinical registration number This research has been approved by the IRB of the authors’ affiliated institutions: identification number 2020-358

Case: We performed computed tomography (CT)-assisted dorsal approach osteosynthesis for stress fractures of the hook of the hamate using the dorsal approach in 3 high school baseball players in the hybrid operating room. Bony union was observed in all patients on CT. All patients were able to play baseball without pain for at least 6 months after surgery. However, refractures were observed in all patients at a mean 9.7 months after surgery. Conclusion: The indications of osteosynthesis for stress fractures of the hook of the hamate in baseball players should be carefully considered.

The present study included 27 consecutive patients (30 limbs) undergoing arthroscopy-assisted transaxillary first rib resection and brachial plexus neurolysis for thoracic outlet syndrome (TOS). To improve visualization, we changed the intraoperative limb position in three stages. We assessed the intraoperative parameters, including the scalene interval width between the anterior and middle interscalene muscles (interscalene base), blood loss, operation time, preoperative and postoperative QuickDASH, patient satisfaction, and complications. The mean intraoperatively measured interscalene base width was 6.2 mm. Appropriate visualization could be obtained at zero-position in the late phase. Intraoperative blood loss and operation time were significantly less in the late phase (p < 0.001). The QuickDASH score was significantly improved (42 before surgery vs. 9 at final follow-up, p < 0.001), especially in athletes relative to non-athletes (0.2 vs 14, p < 0.001). The outcome was excellent in 43.3% of cases, good in 43.3%, fair in 13.3%, and poor in none. The present approach achieved complete relief in 43% of cases overall (91% in athletes and 16% in non-athletes). Pneumothorax was present at the early phase in 3.3%. There were no other complications and no recurrences. Arthroscopic surgery is useful for TOS, especially in athletes.