Patellar Articular Overlap on MRI Is a Simple Alternative to Conventional Measurements of Patellar Height.

BACKGROUND: Patella alta describes an abnormally high-riding patella in relationship to the femur and has been shown to correlate with patellofemoral pain, instability, chondromalacia, and arthrosis. Conventional measurements of patella alta involve multiple measurements and are often not defined on cross-sectional imaging as related to radiographs. HYPOTHESIS: Patellar articular overlap on sagittal magnetic resonance imaging (MRI) will correlate well with conventional measurements of patella alta as measured by a standardized technique defined by our group. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: MRIs of 239 knees were reviewed by 3 attending surgeons with practices focusing on patellofemoral disease, as well as 2 sports medicine fellows and 1 musculoskeletal radiologist. Measurements included articular overlap, percentage of articular coverage, Caton-Deschamps index, Blackburne-Peel index, and modified Insall-Salvati index. RESULTS: Interrater reliability was high for Caton-Deschamps, Blackburne-Peel, and modified Insall-Salvati indices (intraclass correlation coefficient [ICC], 0.877, 0.828, and 0.787, respectively). Articular overlap and percentage articular coverage correlated well with each other (ICC, 0.961; P < .001) and with the Caton-Deschamps (overlap r = -0.271, P < .001; coverage r = -0.131, P = .037) and Blackburne-Peel (overlap r = 0.343, P < .001; coverage r = -0.238, P < .001) indices. Articular overlap and percentage coverage failed to correlate with the modified Insall-Salvati index (overlap r = -0.117, P = .091; coverage r = 0.007, P = .918). CONCLUSION: Patellar articular overlap and percentage of patellar articular coverage show promise as a simpler alternative to conventional, ratio-based measurements of patellar height. Future studies are needed to evaluate the range of normal and the relationship to our traditionally used measurements.

A scoring system to predict postoperative medical complications in high-risk patients undergoing elective thoracic and lumbar arthrodesis.

BACKGROUND CONTEXT: Various surgical factors affect the incidence of postoperative medical complications following elective spinal arthrodesis. Because of the inter-relatedness of these factors, it is difficult for clinicians to accurately risk-stratify individual patients. PURPOSE: Our goal was to develop a scoring system that predicts the rate of major medical complications in patients with significant preoperative medical comorbidities, as a function of the four perioperative parameters that are most closely associated with the invasiveness of the surgical intervention. STUDY DESIGN/SETTING: This study used level 2, Prognostic Retrospective Study. PATIENT SAMPLE: The patient sample consisted of 281 patients with American Society of Anesthesiologists (ASA) scores of 3-4 who underwent elective thoracic, lumbar, or thoracolumbar fusion surgeries from 2007 to 2011. OUTCOME MEASURES: Physiologic risk factors, number of levels fused, complications, operative time, intraoperative fluids, and estimate blood loss were the outcome measures of this study. METHODS: Risk factors were recorded, and patients who suffered major medical complications within the 30-day postoperative period were identified. We used chi-square tests to identify factors that affect the medical complication rate. These factors were ranked and scored by quartiles. The quartile scores were combined to form a single composite score. We determined the major medical complication rate for each composite score, and divided the cohort into quartiles again based on score. A Pearson linear regression analysis was used to compare the incidence of complications to the score. RESULTS: The number of fused levels, operative time, volume of intraoperative fluids, and estimated blood loss influenced the complication rate of patients with ASA scores of 3-4. The quartile ranking of each of the four predictive factors was added, and the sum became the composite score. This score predicted the complication rate in a linear fashion ranging from 7.6% for the lowest risk group to 34.7% for the highest group (r=0.998, p<.001). CONCLUSIONS: Taken together, the four factors, though not independent of one another, proved to be strongly predictive of the major medical complication rate. This score can be used to guide medical management of thoracic and lumbar spinal arthrodesis patients with preexisting medical comorbidities.

Preoperative epidural spinal injections increase the risk of surgical wound complications but do not affect overall complication risk or patient-perceived outcomes.

OBJECT A lack of information exists on the relationship between preoperative epidural spinal injections and outcomes after spine surgery. There is concern that injections might cause local changes, increasing the infection risk and surgical difficulty. Therefore, the authors explored the relationship between preoperative spinal injections and postoperative outcome. METHODS The cohort was comprised of patients who underwent thoracic and/or lumbar arthrodesis during the years 2007-2010 and had complete (preoperatively and 3 months postoperatively) outcome scores. Patients' clinical courses were reviewed to determine the occurrence of major complications within a 30-day postoperative period. Patient-perceived outcomes were evaluated using the Oswestry Disability Index (ODI) and the SF-12 (12-Item Short Form Health Survey): mental component summary (MCS) and physical component summary (PCS) scores. Analyses were based on exposure to injections and were performed using chi-square exact tests and paired and unpaired t-tests. RESULTS Two hundred eighty patients met the inclusion criteria: 117 patients (41.8%) received and 163 patients (58.2%) did not receive preoperative epidural spinal injections. Overall, the likelihood of complication did not differ with respect to exposure (13.7% injection vs 11.7% noninjection); however, injected patients observed a 7.4-fold risk of developing surgical wound complications over noninjected patients (5.1% vs 0.6%, p = 0.02). Patient-perceived outcomes measures demonstrated no differences between groups. Three months postoperatively, the MCS and ODI scores were similar (MCS: 49.6 ± 11.6 injection vs 47.4 ± 12.8 noninjection; ODI: 35.8 ± 18.0 vs 34.4 ± 19.1). MCS or ODI score improvement (preoperatively compared with 3 months postoperatively) did not vary between groups. Injected patients maintained a 2-point lower PCS score at entry and 3 months postoperatively as compared with noninjected peers (entry: 27.6 ± 8.2 injection vs 29.5 ± 9.3 noninjection, p = 0.09; 3 months: 33.3 ± 8.6 vs 35.7 ± 9.0, p = 0.03); the PCS score improvements between injected and noninjected groups were similar (5.7 ± 9.9 vs 6.2 ± 9.7). CONCLUSIONS Patients exposed to preoperative epidural injections had similar complication rates to those who never received a spinal injection. However, they had a greater risk of developing wound complications. These complications had no effect on short-term improvements in outcome measures.

Incidence of Deep Venous Thrombosis After Tibial Tubercle Osteotomy: A Single Case Series Study.

BACKGROUND: Tibial tubercle osteotomy (TTO) is performed in a predominantly young and often female population due to the prevalence of patellofemoral disorders in this group. While considered a procedure that falls within the realm of sports surgeries, the procedure can carry significant morbidity, including infection, fracture, and deep vein thrombosis (DVT). The incidence of postoperative DVT in this population has not been described in the literature, although it has been mentioned anecdotally, and current guidelines do not address the issue of DVT prophylaxis in postoperative TTO patients. PURPOSE: To describe the incidence of DVT after TTO and identify any predisposing factors. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Subjects who had undergone TTO by the senior author from 2002 to 2013 were identified, and a retrospective chart review was performed. Those who presented with symptomatic DVT confirmed with ultrasonography were reported. Demographic data, as well as potential risk factors such as body mass index, family history of bleeding/clotting disorders, duration of the nonweightbearing period, total tourniquet time, use of contraceptive medication, smoking status, and use of anticoagulants, were collected from the chart and analyzed for correlation with development of DVT. RESULTS: A total of 156 patients were included in this study. Six patients were found to have developed symptomatic DVT during the first 6 weeks after surgery. The mean age at the time of surgery in the DVT group was 34.94 ± 6.57 years, compared with 26.26 ± 10.20 years in the non-DVT group (P = .04). Due to the small number of patients with positive findings, there was no statistically significant correlation between the development of DVT and factors such as nonweightbearing duration, tourniquet time, or the use of contraceptives. CONCLUSION: The incidence of postoperative DVT in arthroscopic and sports procedures has been thought to be low. This case series reported a rate of 3.8% with symptomatic DVT after TTO, and patients diagnosed with DVT were significantly older than unaffected patients. It is anticipated that the actual rate including asymptomatic DVT would be higher, as only 60% of patients with DVT are symptomatic. More studies are needed to define the actual incidence in this population. Given the number of common risk factors in this population, including nonweightbearing duration and the use of oral contraceptive pills, future studies may show the advantage of chemical prophylaxis for DVT in this group.

Reconstruction of a bony bankart lesion: best fit based on radius of curvature.

BACKGROUND: The inferior coracoid process has traditionally been considered to be the gold standard for glenoid augmentation after anteroinferior bone loss. Other autograft sites, and more recently, osteochondral allograft sites, have been described as potential donor sources. PURPOSE: Potential autograft and osteochondral allograft sites were compared to identify the graft source that would provide the best fit for glenoid augmentation. STUDY DESIGN: Controlled laboratory study. METHODS: Mose circles, a geometric tool found on a standard goniometer, were used to make radius of curvature measurements of 10 anatomic locations in 17 cadaveric specimens. The bony surface of the glenoid, measured from superior to inferior (G-SI) and from anterior to posterior (G-AP), was used as the standard for comparison. Autograft sites were the inferior coracoid, lateral coracoid, and inner table of the iliac crest. Potential osteochondral allograft sites were the radial head, scaphoid fossa of the distal radius (S-DR), lunate fossa of the distal radius (L-DR), medial tibial plateau, and lateral distal tibia. An acceptable match for autograft sites was based on a paired analysis and defined as a radius of curvature within 5 mm of the G-SI or the G-AP of the same cadaveric specimen. Allograft sites were evaluated using an unpaired analysis in which an ideal fit was defined as a radius of curvature of 25 to 30 mm, based on the interquartile range of the G-SI and G-AP. RESULTS: The median (interquartile range) radii of curvature for the G-SI and G-AP were 30 mm (range, 25-30 mm) and 25 mm (range, 25-25 mm), respectively. The inferior coracoid was within 5 mm of the G-SI 59% of the time and the G-AP 94% of the time; no measurements from the lateral coracoid or iliac crest were within the range of the glenoid radius of curvature. Analysis of the allograft sites demonstrated an acceptable fit for 94% of the distal tibia, 68% of the medial tibial plateau, 12% of the S-DR, and 0% of the L-DR and the radial head specimens. CONCLUSION: An autograft of the inferior coracoid or an osteochondral allograft of the lateral distal tibia provided the best match to re-establish the native radius of curvature of the glenoid. CLINICAL RELEVANCE: To best re-create the native glenohumeral anatomy, surgeons should consider the use of an autograft of the inferior coracoid or an osteochondral allograft of the lateral distal tibia for the reconstruction of osseous glenoid defects.