Clinical measurement of patellar tendon: accuracy and relationship to surgical tendon dimensions.

Patellar tendon width and length are commonly used for preoperative planning for anterior cruciate ligament reconstruction (ACLR). In the study reported here, we assessed the accuracy of preoperative measurements made by palpation through the skin, and correlated these measurements with the actual dimensions of the tendons at surgery. Before making incisions in 53 patients undergoing ACLR with patellar tendon autograft, we measured patellar tendon length with the knee in full extension and in 90° of flexion, and tendon width with the knee in 90° of flexion. The tendon was then exposed, and its width was measured with the knee in 90° of flexion. The length of the central third of the tendon was measured after the graft was prepared. Mean patellar tendon length and width with the knee in 90° of flexion were 39 mm and 32 mm, respectively. No clinical difference was found between the estimated pre-incision and surgical widths. However, the estimated pre-incision length with the knee in full extension and in 90° of flexion was significantly shorter than the surgical length. Skin measurements can be used to accurately determine patellar tendon width before surgery, but measurements of length are not as reliable

Inter- and intra-observer reliability of the Baumann angle of the humerus in children with supracondylar humeral fractures

The Baumann angle of the humerus has been commonly used as an outcome measure for supracondylar fractures in children. However, there is limited or no information about the reliability of this measurement. The purpose of this study was to determine the inter-observer reliability (IEOR) and intra-observer reliability (IAOR) of the Baumann angle of the humerus. The Baumann angle of the humerus was measured by five observers on the anteroposterior radiographs of 35 children’s elbows, all of which had sustained a nondisplaced supracondylar humeral fracture. The values of IEOR and IAOR were calculated using a Pearson coefficient of correlation. Ranges of differences in the measurement of the Baumann angle of the humerus were established, and the percentage of agreement between observers was then calculated using those ranges. The Baumann angle of the humerus is a simple, repeatable and reliable measurement that can be used for the determination of the outcome of supracondylar humeral fractures in the paediatric population. An excellent IEOR was found for the measurement of the Baumann angle (r = 0.78, p = 0.0001). When the difference between observers in the reported measurement of the Baumann’s angle was calculated to be within seven degrees of each other, at least four of the five observers agreed 100% of the time. Similarly, excellent values of IAOR were found for the measurement of the Baumann’s angle (r = 0.80, p = 0.0001). Level of evidence for this study was III

Vaccine Associated Subacromial Bursitis

Intramuscular injection into the deltoid muscle of the upper arm is a common method of delivery for a variety of vaccines. Potential for injury exists if the vaccine is given in an incorrect location due to the proximity of nearby anatomical structures such as the subacromial bursa, long head of the biceps tendon, and axillary nerve among others. Within the past decade, there have been multiple reports of shoulder injury associated with vaccine administration. This report details a case of a 34 year old woman who presented with acute left shoulder pain and limited range of motion following the administration of a Tdap vaccination into her left upper arm. The patient indicated that she thought that the vaccine injection had been given abnormally high in the shoulder. Subsequent MRI imaging showed an increased T2 signal in the subacromial/subdeltoid space suggesting an inflammatory process in the subacromial/subdeltoid bursa consistent with subacromial bursitis. A guidance document provided by the Immunization Action Coalition indicates that intramuscular deltoid vaccines should be given “in the central and thickest portion of the deltoid muscle – above the level of the armpit and approximately 2–3 fingerbreadths (~2 ) below the acromion process.” The CDC’s Vaccine Administration Pink Book recommended a 1” to 1 ½” needle based on our patient’s female gender and weight. A 2006 study by Bodor and Montalvo found that the subdeltoid bursa extends distally from the acromion with a range of 3.0 to 6.0 cm (1.2 to 2.4 inches) and that its depth from the skin ranged from 0.8 to 1.6 cm (0.3 to 0.6 inches). Thus, the potential exists to inject vaccine into the subdeltoid bursa even with the recommended vaccine administration protocol detailed previously. Therefore, when evaluating a patient with complaints of shoulder pain and/or dysfunction, vaccine associated shoulder injury should be added to the differential diagnosis if the history reveals a recent upper arm intramuscular vaccination

Impact of Smoking on Outcomes Following Knee and Shoulder Arthroscopy

Arthroscopy of the knee and shoulder are two of the most commonly performed orthopaedic surgeries. Optimization of modifiable risk factors such as smoking status is crucial for good outcomes. Approximately 15.5% of Americans smoke, and the prevalence of smoking is highest in males ages 25-64, a group which also encompasses the majority of patients undergoing arthroscopic procedures. The purpose of this study was to determine whether there is any association between preoperative smoking and perioperative and early postoperative complications in a large population following shoulder and knee arthroscopic surgery. The National Surgical Quality Improvement Program (NSQIP) database was queried retrospectively for patients who underwent knee or shoulder arthroscopic sports medicine procedures between 2010-2016. These patients were identified using the current procedural terminology (CPT) codes. Deaths and complications recorded in the first 30 days postoperatively were included. Complications were categorized as cardiac, renal, wound (including all surgical site infections), sepsis, thromboembolic, or pulmonary. A composite outcome was defined as a patient experiencing any of the above complications. Univariate and multivariate analyses were performed examining associations between preoperative smoking and any of the complications individually or for the composite outcome. 134,822 cases were included in the study. In univariate analysis, smoking was associated with increased rates of complication in knee arthroscopy with the following: ACL reconstruction or medial and lateral meniscectomy, and shoulder arthroscopy with the following: debridement, decompression, or rotator cuff repair. Multivariate analysis, demonstrated that smoking was an independent risk factor for any complication/mortality event in shoulder arthroscopy with decompression (OR=1.46; 95% CI: 1.030-2.075), or debridement (OR=1.933; 95% CI: 1.211-3.084) and knee arthroscopy with medial and lateral meniscectomy (OR=1.97, 95% CI:1.407-2.757). Preoperative smoking is an independent risk factor for complications after several arthroscopic procedures, though with variability between types of procedure. In our study, patients who smoked were significantly younger, and presumably healthier, which may account for some of this variability. Advantages of the NSQIP database are high reliability, national validation, and a large sample size. Limitations include the retrospective nature of the study, lack of data on surgical technique and simultaneous procedures, and self-reporting of smoking status. Our data highlights that even in generally low-risk arthroscopic procedures, smoking may increase the risk of serious perioperative and early-postoperative complications, and adds to the evidence base regarding the dangers of smoking in orthopaedic surgery patients

Pitfalls of using performance measures to evaluate the quality of hip fracture care

The objective of this study was to determine feasibility of using RAND quality indicators to evaluate hip fracture care. Retrospective chart review was used to determine the adherence to quality indicators and the location of documentation of compliance. A chart abstraction tool was created for systematic extraction of data from multiple chart components. A total of 111 patients underwent operative treatment of a hip fracture and met inclusion criteria in either 1998 or 2003. The main outcome measure was the rate of compliance with quality measures. Overall, compliance was 88% for the 7 performance measures. Physician notes were the most accurate chart component but, if examined alone, would have only resulted in a reported rate of 81% adherence to indicators. Review of the nursing notes, ancillary service notes, results, and orders was required to fully document quality of care. Ceiling effects were noted for 4 of the 7 quality indicators as noncompliance was rare for these measures. The results of this study highlight the need for a thorough method of abstracting multiple chart components to accurately report quality of care. This is an important consideration for any pay-for-performance program. Specifically, the failure to review all chart components may lead to incorrect conclusions about the quality of care delivered by individual providers. In addition, the selection of quality measures subject to ceiling effects may limit the usefulness of quality reporting initiatives. Copyright ® 2009 SLACK Incorporated. All rights reserved

Anterior Tibial Subluxation following Anterior Cruciate Ligament (ACL) Tears Increases with Time

Introduction: A complete ACL tear results in the loss of the primary restraint to anterior tibial subluxation. The extent to which tibiofemoral subluxation develops over time in the ACL-deficient knee is not well understood. Methods: In this retrospective cohort study, we assessed the anterior subluxation of the tibia relative to the femur using MRI studies of 74 patients diagnosed with complete ACL tears in both the medial and lateral compartments. The definition of chronicity was set at four months from injury. Standard t-tests with assumed equal variances were used to compare the means of the acute (≤4 months) and chronic (\u3e4 months) populations. Results: The average medial compartment tibial subluxations among the acute and chronic groups were 0.06 cm and 0.37 cm, respectively (p=0.002). The average lateral compartment tibial subluxations among the acute and chronic groups were 0.25 cm and 0.50 cm, respectively (p=0.016). The average overall tibial subluxations among the acute and chronic groups were 0.16 cm and 0.44 cm, respectively (p=0.001). Conclusion: Anterior tibial subluxation is greater among patients with chronic ACL injuries than among those with acute ACL injuries, the implications of which may favor earlier surgical intervention

Knee Stability Following Anterior Cruciate Ligament Rupture and Surgery: The Contribution of Irreducible Tibial Subluxation

Background: Knee stability after anterior cruciate ligament reconstruction is generally determined by measuring total anteroposterior tibial motion. In spite of a decrease in excessive anteroposterior tibial motion after anterior cruciate ligament reconstruction, problems can still develop. In the present study, we sought to define the tibiofemoral relationship more accurately with use of stress radiographs of human knees after anterior cruciate ligament rupture and after anterior cruciate ligament reconstruction. Methods: A previously described radiographic technique was used to evaluate the position of the tibia relative to the femur with the application of an anteriorly directed tibial force and subsequently with the application of a posteriorly directed tibial force. Tibial position and total tibial translation were calculated from these radiographs. In addition, KT-1000 measurements were obtained. Three groups of patients were studied: Group 1 included twenty-eight patients with an untreated anterior cruciate ligament rupture, Group 2 included nineteen patients who had undergone a clinically successful anterior cruciate ligament reconstruction, and Group 3 included twenty-five control subjects with normal knees. Results: KT-1000 testing showed that the average side-to-side differences in Group 1 (5.8 mm) and Group 2 (2.7 mm) were significantly different from that in Group 3 (0.8 mm) (p \u3c 0.01 and p \u3c 0.05, respectively). Stress radiographs showed that the average total tibial translation in Group 1 (9.8 mm) was significantly different from those in Group 2 (5.6 mm) and Group 3 (4.3 mm) (p \u3c 0.05 and p \u3c 0.001, respectively). Within Group 1, knees with radiographic signs of osteoarthritis were more stable, with an average total tibial excursion of 6.8 mm. The improved stability of the reconstructed knees in Group 2 and the osteoarthritic knees in Group 1 was not entirely the result of decreased anterior tibial translation; it was, in part, due to an irreducible anterior subluxation of the tibia. A posteriorly directed stress in these knees did not reduce the tibia to the anatomic position relative to the femur; the osteoarthritic knees in Group 1 were 9.9 mm short of full reduction and the knees in Group 2 were 3.1 mm short of full reduction (p \u3c 0.01) Conclusions: Irreducible tibial subluxation can be present in the knee following surgical reconstruction of the anterior cruciate ligament. Osteoarthritic changes following an untreated anterior cruciate ligament rupture are also associated with uncorrectable tibial subluxation along with a decrease in instability. The irreducible tibial subluxation could explain why osteoarthritic changes still may develop in stable, reconstructed knees in spite of the improved stability. Currently used arthrometric measurements, such as KT-1000 scores, do not measure this phenomenon. Level of Evidence: Therapeutic study, Level III-2 (retrospective cohort study)

Arthroscopic management of patellar instability

Several arthroscopic techniques have been described to address patellar instability. Most arthroscopic procedures focus on soft-tissue plication or tightening of the medial retinacular structures to correct lateral patellar instability. Good results have been reported using these techniques; however, we have found these techniques to be ineffective when the medial stabilizers have been avulsed from the patella. As a result, we have developed an arthroscopic technique to repair medial patellofemoral ligament avulsions to the patella using suture anchors. The purpose of this article is to review our indications for arthroscopic management of patellar instability and describe our 2 most common techniques. © 2010