Risk factors for the development of degenerative changes among patients undergoing rotator cuff repair: A systematic review.

Background: Osteoarthritis (OA) of the glenohumeral joint results in significant pain and functional limitations. It is unclear which risk factors increase the risk of developing glenohumeral OA amongst Rotator Cuff Repair (RCR) patients. The purpose of this systematic review was to examine the risk factors which may contribute to the development of osteoarthritic changes post-operatively. Methods: MEDLINE, Embase, and PubMed databases were searched to identify studies reporting on demographics of patients who develop OA following RCR. Results: Seventeen articles were identified investigating a total of 1292 patients. The overall quality of evidence was low. Pooled assessment of OA incidence following RCR at minimum 5 years follow-up found 26% of patients developed OA. Patients requiring revision surgery following retears developed OA at a rate of 29%. Surgical technique and patient demographics may also contribute to degenerative changes. Discussion: This review found correlations between the aforementioned risk factors and glenohumeral joint degeneration at long-term follow-up after RCR. These findings suggest that future long-term studies should aim to identify prognostic factors that may place a patient at increased risk of developing OA. Such data can be used to counsel patients with respect to long-term outcomes following surgical intervention.

Gouty tophus presenting as an anterior cruciate ligament mass in the knee: Case report and brief review of relevant literature.

INTRODUCTION AND IMPORTANCE: Tophacious gout presenting at the anterior cruciate ligament (ACL) is extremely rare and difficult to differentiate from other intraarticular pathology. This is mainly due to conventional diagnostic tools, such as MRI, producing ambiguous results versus pigmented villonodular synovitis (PVNS) and ganglion cysts. CASE PRESENTATION: Here we report an individual in their late-20s with a gouty tophus located at the origin of the ACL in the knee. Urate crystals on the articular cartilage in all three compartments was noted as well as on the synovium. On advanced imaging with an MRI, a large mass was seen anteriorly in the notch surrounding the ACL and posterior cruciate ligament (PCL). The tophus was biopsied and excised arthroscopically with excellent results. CLINICAL DISCUSSION: An ACL mass in the knee has a very broad differential diagnosis. MRI imaging alone makes it very difficult to differentiate between PVNS and gout tophi yielding a pre-operative diagnostic challenge. Additionally, we review diagnostic challenges faced by other groups with similar cases, as well as their chosen treatment. CONCLUSION: Gouty tophi arising from the origin of the ACL are extremely rare and remain difficult to diagnose due to their ambiguous nature in conventional imaging. In this report, we clearly convey the disparity in the diagnostic protocol for this type of intraarticular pathology. Future research should look to develop a superior protocol for identifying these pathologies to improve diagnostic accuracy.

The utility of head CT scans in geriatric patients with hip fractures following a low energy injury mechanism: A retrospective review.

OBJECTIVES: Hip fractures are common low-energy orthopaedic injuries in the geriatric population. The purpose of this study is to determine the frequency of CT head exams and the incidence of clinically significant intracranial bleed in patients with low energy hip fractures. DESIGN: A retrospective cross-sectional review was completed to identify hip fractures presenting to an academic health centre between 2006 and 2015. Our inclusion criteria were those patients with low energy hip fractures and medical records were reviewed to determine whether a CT head scan was utilized as part of their workup. RESULTS: A total of 2114 patients were reviewed with an average age of 83.2 years. Hip fractures were treated with a hemiarthroplasty in 59.1% of the patients and with a dynamic hip screw in 40.9% of the patients. 26.9% (n = 502) of the patients received a CT head scan as part of their workup. Sixty-two patients (12.3% of patients who received a CT scan or 2.9% of the study population) were found to have had an acute intracranial bleed. None of these patients required neurosurgical intervention and only 9 (14.5% of patients with a positive CT head) had a modification to their thromboprophylaxis post-op. Of the 15 (26.4%) patient on home anticoagulation for a pre-existing medical condition, 10 (67%) had a delay in reinitiating their anticoagulation greater than 24 h post-operatively. CONCLUSION: During the study period, 26.7% of patients received a CT scan, with only 2.9% of patients suffering from a concurrent intracranial bleed. None of the patients with a positive scan required neurosurgical intervention, and scan results did not routinely alter DVT prophylaxis. Resuming home anticoagulation was delayed greater than 24 h post-operatively in ten (67%) of cases. With the challenges of resource allocation, potential delays to surgery and costs associated with CT scans, these investigations should be reserved for patients who have a history or physical exam findings of head trauma or are on anticoagulation pre-injury in the low energy hip fracture population. LEVEL OF EVIDENCE: Level III.

Neuromuscular partitioning of the gastrocnemius based on intramuscular nerve distribution patterns: implications for injections

Spasticity of the gastrocnemius is commonly treated with botulinum toxin injections; however, the optimal injection sites within each head have not been evaluated in relation to neuromuscular partitions. The purpose of the present study was to (1) document the intramuscular innervation patterns of the medial and lateral heads of gastrocnemius using 3 dimensional modeling; (2) determine if the medial and lateral heads of gastrocnemius are neuromuscularly partitioned; and (3) propose botulinum toxin injection strategies based on these findings. In this cadaveric study (n=24) the extramuscular and intramuscular innervation was serially dissected followed by digitization and 3D reconstruction and/or photography of the innervation pattern throughout the muscle volume. Intramuscular innervation patterns were defined to determine if the heads of gastrocnemius were neuromuscularly partitioned and based on these findings approaches for botulinum toxin injections were proposed. In all specimens except one, both heads of the gastrocnemius received independent innervation from three discrete nerve branches. Therefore, each head had three neuromuscular partitions defined by location as superior, inferomedial and inferolateral. In one specimen, the lateral head also received nerve branches via the soleus that innervated the inferolateral partition distally. Functionally, independent activation of the neuromuscular partitions of the gastrocnemius may result in differential contribution of the partitions to knee flexion and ankle plantarflexion. To capture all partitions, four injection sites into each belly were proposed. Future clinical studies are needed to determine if there is improved spasticity reduction by targeting neuromuscular partitions

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Cadaveric study of sacroiliac joint innervation: implications for diagnostic blocks and radiofrequency ablation.

BACKGROUND AND OBJECTIVES: Optimization of clinical outcomes of lateral branch radiofrequency ablation or blocks for sacroiliac joint (SIJ) pain requires precise nerve localization; however, there is a lack of comprehensive morphological studies. The objectives of this cadaveric study were to document SIJ innervation relative to bony landmarks in 3 dimensions and to identify reference points visible under ultrasound and fluoroscopy for optimal needle placement. METHODS: In 25 cadaveric hemipelves, L5-S4 lateral branches were exposed, digitized, and modeled in 3 dimensions. The models were used to compare innervation patterns between specimens and to quantify the distances of the nerves innervating the SIJ relative to the transverse sacral tubercles (TSTs) and posterior sacral foramina. Quadrants of origin of the nerves were recorded. RESULTS: The SIJ was innervated by the posterior sacral network: S1-S2 contributed in all specimens, S3 in 88%, L5 in 8%, and S4 in 4%. Most frequently, the lateral branch(es) emerged from the inferolateral S1, superolateral and inferolateral S2, and superolateral S3 quadrants. All TSTs were easily identifiable elevations that were used to landmark the nerves innervating the SIJ. The majority of branches of the posterior sacral network crossed the lateral sacral crest between TST1-3, with the greatest concentration between TST2-3. Only 3 specimens had a branch superior or inferior to these landmarks. CONCLUSIONS: Based on the innervation pattern and using bony landmarks identifiable under ultrasound and fluoroscopy, 2 radiofrequency ablation techniques were proposed. Further research is required to determine the accuracy and reliability of needle placement and to evaluate clinical outcomes.

Musculotendinous architecture of pathological supraspinatus: a pilot in vivo ultrasonography study.

Architectural changes associated with tendon tears of the supraspinatus muscle (SP) have not been thoroughly investigated in vivo with the muscle in relaxed and contracted states. The purpose of this study was to quantify the geometric properties within the distinct regions of SP in subjects with full-thickness tendon tears using an ultrasound protocol previously developed in our laboratory, and to compare findings with age/gender matched normal controls. Twelve SP from eight participants (6 male/2 female), mean age 57 ± 6.0 years, were investigated. Muscle geometric properties of the anterior region (middle and deep parts) and posterior region (deep part) were measured using image analysis software. Along with whole muscle thickness, fiber bundle length (FBL) and pennation angle (PA) were computed for architecturally distinct regions and/or parts. Pathologic SP was categorized according to the extent of the tear in the tendon (with or without retraction). In the anterior region, mean FBL of the pathologic SP was similar with normal controls; however, mean PA was significantly smaller in pathologic SP with retraction compared with normal controls, in the contracted state (P < 0.05). Mean FBL in the posterior region in both relaxed and contracted states was significantly shorter in the pathologic SP with retraction compared with normal controls (P < 0.05). Findings suggest FBL changes associated with tendon pathology vary between the distinct regions, and PA changes are related to whether there is retraction of the tendon. The ultrasound protocol may provide important information on architectural changes that may assist in decision making and surgical planning.

Robust estimation of physiological cross-sectional area and geometric reconstruction for human skeletal muscle.

Understanding muscle architecture is crucial to determining the mechanical function of muscle during body movements, because architectural parameters directly correspond to muscle performance. Accurate parameters are thus essential for reliable simulation. Human cadaveric muscle specimen data provides the anatomical detail needed for in-depth understanding of muscle and accurate parameter estimation. However, as muscle generally has non-uniform architecture, parameter estimation, specifically, physiological cross-sectional area (PCSA), is rarely straightforward. To deal effectively with this non-uniformity, we propose a geometric approach in which a polygon is sought to best approximate the cross-sectional area of each fascicle by accounting for its three-dimensional trajectory and arrangement in the muscle. Those polygons are then aggregated to determine PCSA and volume of muscle. Experiments are run using both synthetic data and muscle specimen data. From comparison of PCSA using synthetic data, we conclude that the proposed method enhances the robustness of PCSA estimation against variation in muscle architecture. Furthermore, we suggest reconstruction methods to extract 3D muscle geometry directly from fascicle data and estimated parameters using the level set method.

Neuromuscular partitioning in the extensor carpi radialis longus and brevis based on intramuscular nerve distribution patterns: A three-dimensional modeling study.

Differential activation of specific regions within a skeletal muscle has been linked to the presence of neuromuscular compartments. However, few studies have investigated the extra- or intramuscular innervation throughout the muscle volume of extensor carpi radialis longus (ECRL) and brevis (ECRB). The aim of this study was to determine the presence of neuromuscular partitions in ECRL and ECRB based on the extra- and intramuscular innervation using three-dimensional modeling. The extra- and intramuscular nerve distribution was digitized and reconstructed in 3D in all the muscle volumes using Autodesk Maya in seven formalin embalmed cadaveric specimens (mean age, 75.7 ± 15.2 years). The intramuscular nerve distribution was modeled in all the muscle volumes. ECRL was found to have two neuromuscular compartments, superficial and deep. One branch from the radial nerve proper was found to innervate ECRL. This branch was divided into anterior and posterior branches to the superficial and deep compartments, respectively. Five innervation patterns were identified in ECRB with partitioning of the muscle belly into two, three, or four compartments, in a proximal to distal direction depending on the number of nerve branches entering the muscle belly. The ECRL and ECRB both demonstrated neuromuscular compartmentalization based on intramuscular innervation. According to the partitioning hypothesis, a muscle may be differentially activated depending on the required function of the muscle, thus allowing multifunctional muscles to contribute to a variety of movements. Therefore, the increased number of neuromuscular partitions in ECRB when compared with ECRL could be due to the need for more differential recruitment in the ECRB depending on force requirements.

Fibre bundle element method of determining physiological cross-sectional area from three-dimensional computer muscle models created from digitised fibre bundle data.

Physiological cross-sectional area (PCSA) is used to compare force-producing capabilities of muscles. A limitation of PCSA is that it cannot be measured directly from a specimen, as there is usually no area within the muscle traversed by all fibres. Traditionally, a formula requiring averaged architectural parameters has been used. The purpose of this paper is to describe the development of a fibre bundle element (FBE) method to calculate PCSA from digitised fibre bundle data of five architecturally distinct muscles and compare the FBE and PCSA formula. An FBE method was developed that used a serially arranged set of cylinders as the volumetric representation of each fibre bundle, and PCSA was computed as the summation of the cross-sectional area of each FBE. Four of five muscles had significantly different PCSA between FBE and formula methods. The FBE method provides an approach that considers architectural variances while minimising the need for averaged architectural parameters.

Subacromial morphometric assessment of the clavicle hook plate.

BACKGROUND: Clavicle hook plates are an effective plate fixation alternative for distal clavicle fractures and severe acromioclavicular joint dislocations. However, post-operative complications associated with the subacromial portion of the hook include acromial osteolysis and subacromial impingement. We examine and quantify the three-dimensional position of the subacromial portion of the hook plate relative to surrounding acromial and subacromial structures in a series of cadaveric shoulders to determine if hook positioning predisposes the shoulder to these noted post-operative complications. MATERIALS AND METHODS: Fifteen cadaveric shoulders (seven males, eight females) were implanted with 15- or 18-mm hook plates. Dimensions of the acromion and hook plate were digitised and reconstructed into a three-dimensional model to measure acromion dimensions and distances of the subacromial hook relative to surrounding acromial and subacromial structures. RESULTS: Inter-specimen dimensions of the acromion were highly variable. Mean acromion width and thickness were greater in males than in females (p=0.01). The posterior orientation of the subacromial hook varied widely (mean posterior implantation angle=32.5+/-20 degrees, range 0-67 degrees). The hook pierced the subacromial bursa in 13/15 specimens, made contact with the belly of the supraspinatus muscle in 9/15 specimens, and had focal contact at the hook tip with the undersurface of the acromion in 9/15 specimens. CONCLUSIONS: The wide range of acromial dimensions leads to a high degree of variability in the positioning of the subacromial hook. The observed frequency of hook contact with surrounding subacromial structures in a static shoulder confirms that the position of the hook portion of the implant can predispose anatomic structures to the post-operative complications of subacromial impingement and bony erosion.

Determining physiological cross-sectional area of extensor carpi radialis longus and brevis as a whole and by regions using 3D computer muscle models created from digitized fiber bundle data.

Architectural parameters and physiological cross-sectional area (PCSA) are important determinants of muscle function. Extensor carpi radialis longus (ECRL) and brevis (ECRB) are used in muscle transfers; however, their regional architectural differences have not been investigated. The aim of this study is to develop computational algorithms to quantify and compare architectural parameters (fiber bundle length, pennation angle, and volume) and PCSA of ECRL and ECRB. Fiber bundles distributed throughout the volume of ECRL (75+/-20) and ECRB (110+/-30) were digitized in eight formalin embalmed cadaveric specimens. The digitized data was reconstructed in Autodesk Maya with computational algorithms implemented in Python. The mean PCSA and fiber bundle length were significantly different between ECRL and ECRB (p < or = 0.05). Superficial ECRL had significantly longer fiber bundle length than the deep region, whereas the PCSA of superficial ECRB was significantly larger than the deep region. The regional quantification of architectural parameters and PCSA provides a framework for the exploration of partial tendon transfers of ECRL and ECRB.

Three-dimensional study of pectoralis major muscle and tendon architecture.

A thorough understanding of the normal structural anatomy of the pectoralis major (PM) is of paramount importance in the planning of PM tendon transfers or repairs following traumatic PM tears. However, there is little consensus regarding the complex musculotendinous architecture of the PM in the anatomic or surgical literature. The purpose of this study is to model and quantify the three-dimensional architecture of the pectoralis muscle and tendon. Eleven formalin embalmed cadaveric specimens were examined: five (2M/3F) were serially dissected, digitized, and modeled in 3D using Autodesk Maya; six (4M/2F) were dissected and photographed. The PM tendon consisted of longer anterior and shorter posterior layers that were continuous inferiorly. The muscle belly consisted of an architecturally uniform clavicular head (CH) and a segmented sternal head (SH) with 6-7 segments. The most inferior SH segment in all specimens was found to fold anteriorly forming a trough that cradled the inferior aspect of the adjacent superior segment. No twisting of either the PM muscle or tendon was noted. Within the CH, the fiber bundle lengths (FBL) were found to increase from superior to inferior, whereas the mean FBLs of SH were greatest in segments 3-5 found centrally. The mean lateral pennation angle was greater in the CH (29.4 +/- 6.9 degrees ) than in the SH (20.6 +/- 2.7 degrees ). The application of these findings could form the basis of future studies to optimize surgical planning and functional recovery of repair/reconstruction procedures.

Three-dimensional study of the musculotendinous architecture of lumbar multifidus and its functional implications.

Lumbar multifidus (LMT) is a key muscle, which provides stability to the lumbar spine, and has been shown to have altered neuromuscular recruitment following acute episodes of low back pain. Architectural parameters are important determinants of function, but have not been well documented for LMT. Therefore, the purpose of this study is to model and quantify the architecture of LMT throughout its volume. Nine male and one female formalin-embalmed cadaveric specimens (average age 80 +/- 11 years) without any evidence of spinal deformity/pathology were used. The musculotendinous components of LMT were serially dissected and digitized. Next, the data were imported into MAYA to create a three-dimensional model of each segment of LMT from which architectural parameters including fiber bundle length (FBL), fiber bundle angle (FBA), and tendon length were quantified. Water displacement was used to determine volume. The data were analyzed using paired t-tests and ANOVA followed by Tukey's post-hoc test (P

Three-dimensional study of the musculotendinous architecture of supraspinatus and its functional correlations.

The supraspinatus is most frequently involved in shoulder pathology. However, the musculotendinous architecture of the supraspinatus has not been well documented. Therefore, the purpose of this study is to investigate the detailed three-dimensional architecture of the supraspinatus throughout its volume. Ten male formalin embalmed cadaveric specimens (mean age 61.9 +/- 16 years) without any evidence of rotator cuff pathology were used. Three-dimensional coordinates (x, y, and z) of the tendon and muscle fiber bundles were collected in situ, using serial dissection and digitization. The data was reconstructed into a three-dimensional model using Maya. Fiber bundle lengths, pennation angles (PA), muscle volumes, and tendon dimensions for each architecturally distinct area were computed and then analyzed using paired t-tests and ANOVA (P < 0.05). The supraspinatus was found to consist of anterior and posterior regions, which were each further subdivided into superficial, middle, and deep parts. Mean PA were found to be significantly different between the distinct parts of the anterior region of the muscle. Medial PA was also found be significantly different between the superficial and middle, and superficial and deep parts of the posterior region. These results provide insight into the normal function of the muscle and its possible contribution to the initiation and progression of supraspinatus tendon tears.