Anatomic Evaluation of the Sacroiliac Joint: A Radiographic Study with Implications for Procedures.

BACKGROUND: Sacroiliac joint (SI) pain is increasingly being recognized as a source of low back pain. Injections and percutaneous type procedures are performed to treat symptomatic joints. However, there are limited studies available assessing the anatomy of the SI joint in vivo among patients with pain. OBJECTIVES: The purpose of this study was to provide more precise information on the dimensions and orientation of the SI joint using a new technique for the radiographic evaluation of this joint. STUDY DESIGN: Observational study. SETTING: Emergency department METHODS: Three dimensional computed tomographic (CT) reconstructions of the pelvis were formatted from 100 SI joints in 50 patients who had clinically indicated abdominal/pelvic scans. These images were manipulated to evaluate the SI joint in multiple planes and measure its dimensions, area, and relationship to anatomic landmarks such as the anterior superior iliac spine (ASIS) and posterior superior iliac spine (PSIS). RESULTS: Of the 50 patients, 23 were men and 27 women. Their mean age was 47.6 years (± 18.1). The SI joint consists of a superior limb which measures 39.7 mm (± 4.8) in length, and an inferior limb which measures 54.3 mm (± 5.1), oriented at an angle of 100.1° (± 8.1) to one another. The mean area of the joint was 1276.8 mm2 (± 189.8). The horizontal distance from the ASIS to the front of the superior SI joint is 75.4 mm (± 8.4). The horizontal distance from the PSIS to the back of the superior SI joint is 43.9 mm (± 5.6). The joint stretches 7.5 mm (± 5.9) cephalad and 38.1 mm (± 6.4) caudal to the PSIS, and 35.4 mm (± 8.8) cephalad and 10.2 mm (± 11.4) caudal to the ASIS. LIMITATIONS: CT scans were performed with patients lying supine, while most SI joint procedures are performed with a patient prone. However it is doubtful that the bony anatomic landmarks would change appreciable in this largely immobile joint. These patients were seen in the emergency department for a variety of conditions related to abdominal and pelvic pain, and not exclusively for SI joint pain. CONCLUSIONS: Treatment of the SI joint by surgeons and interventionalists is hampered by the limited number of anatomic studies in the literature. Our study presents the SI joint as a 2-limbed structure, sitting from slightly above the level of the PSIS rostrally to slightly below the level of the ASIS caudally. Palpation of these landmarks may assist in directing physicians to the joint. To begin an interventional pain procedure, with a patient lying prone, this data supports tilting the x-ray image intensifier 10 degrees caudal past the vertical anteroposterior (AP) view for optimal approach of the SI joint's inferior limb. The needle entry should be about 44.1 mm (1.75 inches) caudal to the PSIS. The image intensifier should have a 12 degree left lateral oblique view for injection of the right SI joint, and a 12 degree right lateral oblique view for the left SI joint.

An analysis of the Orthopaedic In-Training Examination rehabilitation section.

OBJECTIVE: One subject tested by the Orthopaedic In-Training Examination (OITE) is rehabilitation. Our purpose was to analyze the OITE's rehabilitation section to (1) identify the rehabilitation subjects that are tested, (2) evaluate trainee performance on this section, and (3) evaluate the literature cited for this section as an aide to the trainee preparation for future OITE examinations. DESIGN: This study included OITE examinations from 2004 through 2009. The rehabilitation sections of these examinations were analyzed for content, type of questions asked (taxonomy 1: direct recall; taxonomy 2: diagnosis; taxonomy 3: evaluation/decision making and development of a treatment plan), and literature cited. The mean score in the rehabilitation section of the OITE from 2004 to 2009 was also evaluated, and literature citations were tabulated. SETTING: Orthopaedic surgery residency. RESULTS: In the 2004-2009 OITE examinations, a total of 1619 questions were administered, of which 53 (3.3%) related to rehabilitation. The most common rehabilitation questions assessed knowledge of prosthetic/orthotics (20.8%) and neuro-orthopedics (20.8%). Other questions addressed amputation (18.9%), physical therapy treatment and outcomes (18.9%), rehabilitation terminology (9.4%), and spinal cord injury (7.7%). Most frequently, the questions evaluated the trainee's direct recall of the subject (51%), evaluation/decision making and development of a treatment plan (30.1%), and diagnosis (18.9%). The mean score in the rehabilitation section of the OITE from 2004 through 2009 was 54.1% (range, 40% to 77.8%). A total of 53 references was used. The 3 most common references were the Journal of Bone and Joint Surgery-American Volume (10), Orthopaedic Knowledge Update (volumes 7 through 9) (8), and Clinical Orthopaedics and Related Research (7). CONCLUSION: To our knowledge, our study is the first to analyze the rehabilitation section of the OITE. Our results will help the trainee prepare for the examination by focusing on the appropriate content and literature.

Review of the current literature as a preparatory tool for the trauma content of the Orthopaedic in-Training Examination.

Currently, the only standardized evaluation of trauma knowledge throughout orthopedic training is found in the Orthopaedic In-Training Examination, which is administered annually to all residents by the American Academy of Orthopaedic Surgeons. Our goals were to assess the Orthopaedic In-Training Examination to (1) determine the content of the trauma questions, (2) identify the content of the 3 most frequently referenced journals on the answer keys, and (3) evaluate the correlation between those contents.We reviewed the trauma-related Orthopaedic In-Training Examination questions and answer keys for 2002 through 2007. Content for test questions and cited literature was assessed with the same criteria: (1) category type, (2) anatomic location, (3) orthopedic focus, and (4) treatment type. For each of the 3 most frequently referenced journals, we weighted content by dividing the number of times it was referenced by the number of its trauma-related articles. We then compared the journal data individually and collectively to the data from the Orthopaedic In-Training Examination trauma questions. A chi-square analysis with Yates correction was used to determine differences. Questions and literature were similar in the most frequently addressed items in each of the 4 areas: category type (taxonomy 3, treatment), 52.4% and 60.7%, respectively; anatomic location (femur), 23.3% and 27.7%, respectively; orthopedic focus (fracture), 51.0% and 56.5%, respectively; and treatment type (multiple/nonspecific), 39.0% and 35.4%, respectively.The content correlation found between the questions and literature supports the idea that reviewing current literature may help prepare for the trauma content on the Orthopaedic In-Training Examination.

Septic elbow in the setting of neuropathic joint as the initial presentation of a cervical syrinx.

Neuropathic arthropathy, or Charcot's joint, is a degenerative disorder resulting from abnormal sensory innervation that is associated with diabetes mellitus, tabes dorsalis, and syringomyelia. Patients may present with a painless instability of the affected joint, although a range of symptoms are seen. This article presents a case of a patient who presented with a swollen elbow, consistent with septic arthritis, and bilateral lower extremity weakness. Joint fluid cultures were positive for methicillin-resistant Staphylococcus aureus. Extensive joint destruction on radiographic imaging and a thorough neurologic examination revealing generalized weakness and upper motor neuron signs prompted magnetic resonance imaging (MRI) of the spine which revealed a cervical syrinx. Our patient was diagnosed with syringomyelia-associated neuropathic arthropathy that initially presented as a septic joint. In the setting of septic arthritis, substantial joint destruction (particularly in a patient with neurologic deficits) should prompt additional investigation, including MRI of the spine, for neurologic causes. Although surgery is generally not recommended for neuropathic arthropathy because of poor healing and high rates of complication, neuropathic arthropathy in the setting of a septic joint requires operative irrigation and debridement.

The effects of hospital and surgeon volume on postoperative complications after LumbarSpine surgery.

STUDY DESIGN: Retrospective review. OBJECTIVE: To determine the correlation of surgeon/hospital volume with complication/mortality rates and with in-hospital health care utilization in lumbar spine surgery. SUMMARY OF BACKGROUND DATA: Studies have shown improved outcomes in patients treated by high-volume surgeons and hospitals. To our knowledge, no studies evaluate this relationship for lumbar spine surgery. METHODS: To evaluate the 1992-2005 data in the National Inpatient Sample, we used the International Classification of Diseases, ninth Revision, Clinical Modification (ICD-9-CM) codes for lumbar spine surgery to identify relevant hospitalizations. We assessed 232,668 hospitalization records listed as posterolateral lumbar decompression with fusion and/or exploration/decompression of the spinal canal. Annual surgeon and hospital volumes were stratified into quartiles via identifier codes. Patient demographics and comorbidity status were recorded for each group. Mortality and morbidity were primary endpoints. We used the Shapiro-Wilk test for normality for the distribution of variables; one-way analysis of variance to assess continuous measures; χ statistics for categorical measures; and logistic regression for the effect of procedure on the probability of morbidity and mortality, adjusting for confounding variables, including patient demographics. Logistic regression data were tabulated as odd ratios (ORs) and 95% confidence intervals (CIs) (statistical significance, P < 0.05). RESULTS: When controlled for other variables, mortality was significantly lower in the highest volume hospitals (OR, 0.78; 95% CI 0.66 to 0.89) and among the highest volume surgeons (OR, 0.66; 95% CI 0.59 to 0.89) than in their lowest volume counterparts. The complication rate was slightly lower in the highest volume hospitals (OR, 0.94; 95% CI 0.81 to 0.99) and significantly lower among the highest volume surgeons (OR, 0.73; 95% CI 0.68 to 0.91) than in their lowest volume counterparts. CONCLUSION: The mortality and complication rates associated with lumbar spine surgery are lower when patients are treated by high-volume surgeons and hospitals.

Evaluation of the Orthopaedic In-Training Examination: spine questions.

BACKGROUND: The annual Orthopaedic In-Training Examination (OITE) is an objective evaluation administered annually to all residents by the American Academy of Orthopaedic Surgeons. To our knowledge, there are no guidelines for the type of material included on the examination; therefore, it is difficult for many academic centers to develop education programs directed toward improving resident performance on the OITE. Our goals were to determine the most commonly tested subjects in the spine portion of the OITE and to help direct development of an associated teaching program. METHODS: We analyzed the number, type, anatomic focus, subject matter, and visual diagnostic modalities of spine questions on the OITEs from 2002 through 2007 and identified the most commonly referenced journals. RESULTS: The average annual number of spine questions was 23.1 (8.4% of the examination). The most common types of spine questions related to knowledge (44.5%), evaluation and decision making (29.1%), and diagnosis (26.3%); the most common subject matters were trauma (15.1%) and anatomy (13.7%). The most frequently examined anatomic locations were the cervical (30.9% of questions) and lumbar (17.4%) spines. General spine information (no anatomic focus) accounted for 31.6% of questions. The most commonly referenced journals were Spine and The Journal of Bone and Joint Surgery, American Volume. CONCLUSIONS: Developing a study plan focusing on these journals and the most commonly tested topics and question types will better prepare orthopedic residents for the spine questions on the OITE.

A study of the cutaneous nerves encountered during thoracoplasty.

STUDY DESIGN: Ten cadavers were dissected to describe the cutaneous branches of the dorsal rami nerves that should be identified and protected throughout the thoracoplasty procedure. OBJECTIVE: To identify the anatomic distribution of the cutaneous branches of the dorsal rami in the thoracic spine. SUMMARY OF BACKGROUND DATA: The last anatomic description of cutaneous branches of the dorsal rami nerves dates back to the early 1900s. METHODS: Ten cadavers were dissected. Each of the branches was followed deeper into the musculature of the back. The Steel 2-incision approach, the Geissele subcutaneous approach, and the subfascial/subtrapezial approach were then carried out on each cadaver. RESULTS: We determined the course traveled by each of these cutaneous branches of the dorsal rami. Medial branches traverse the paraspinal muscles running dorsally within a few millimeters of the midline before exiting beneath the trapezius. Lateral branches cross the top border of the inferior rib at an average of 6.8 mm from the tip of the transverse process and the lower border of the rib 27 mm from the tip of the transverse process. CONCLUSIONS: Both branches of the dorsal rami nerves are encountered during the posterior approaches used. Medial branches have the best chance for identification and preservation with the subtrapezial approach. Lateral branches can be identified and protected in each of the 3 posterior exposures.