Rapid implementation of Veterans Health Administration telehealth creative arts therapies: survey evaluation of adoption and adaptation.

BACKGROUND: Creative arts therapies (CAT) are employed throughout the Veterans Health Administration (VHA) and are predominantly delivered in-person. Though telehealth delivery of CAT was used at several VHA facilities to increase services to rural Veterans, due to guidance from the Center for Disease Control and VHA that temporarily suspended or reduced in-person services, there was a large increase of CAT therapists enterprise-wide who adopted telehealth delivery. The aims of this study were to evaluate adoption and adaptation of CAT telehealth delivery and identify related barriers and facilitators. METHODS: We deployed a survey guided by the Consolidated Framework for Implementation Research and administered it via email to all VHA CAT therapists (N = 120). Descriptive statistics were used to summarize data and responses were compared based on therapists' age, years of experience and CAT discipline. Open survey field responses were summarized, qualitatively coded, and analyzed thematically. RESULTS: Most therapists (76%) reported adopting telehealth with 74% each delivering > 50 CAT sessions in the prior year. Therapists adapted interventions or created new ones to be delivered through telehealth. Barriers included: technical challenges, control of the virtual space, and building rapport. Facilitators included added equipment, software, and infrastructure. CAT therapists adapted their session preparation, session content, outcome expectations, and equipment. CAT therapists reported being able to reach more patients and improved access to care with telehealth compared to in person visits. Additional benefits were patient therapeutic effects from attending sessions from home, therapist convenience, and clinician growth. CONCLUSIONS: VHA CAT therapists used their inherent creativity to problem solve difficulties and make adaptations for CAT telehealth adoption. Future studies may explore CAT telehealth sustainment and its effectiveness on clinical processes and outcomes.

Veterans Hospital Administration Telehealth Utilization for Recreation and Creative Arts Therapies: A Brief Report.

Background: A brief query was fielded to Veterans Health Administration (VHA) facilities across the United States to provide an initial assessment of recreation therapy (RT) and creative arts therapy (CAT) telehealth utilization. Methods: To develop an understanding of barriers and identify potential solutions for better delivery of services, a cross-sectional survey was deployed to points of contact at 136 VHA facilities. The survey included questions across five areas: staff, infrastructure, barriers to use, training, and interventions being deployed. Descriptive statistics were calculated, and a thematic analysis of qualitative responses was conducted. Results: The most frequent themes from aggregated responses indicated a need for hands-on training, reliable telehealth equipment, and accessible training and tools for Veteran patients who want to use telehealth services. Conclusion: Telehealth delivery of RT/CAT has increased services to Veteran patient populations; however, equipment and training are needed to expand consistent delivery to enhance patient reach across a national health care system.

Towards improving the identification of anterior cruciate ligament tears in primary point-of-care settings.

BACKGROUND: Only a small proportion of anterior cruciate ligament (ACL) tears are diagnosed on initial healthcare consultation. Current clinical guidelines do not acknowledge that primary point-of-care practitioners rely more heavily on a clinical history than special clinical tests for diagnosis of an ACL tear. This research will assess the accuracy of combinations of patient-reported variables alone, and in combination with clinician-generated variables to identify an ACL tear as a preliminary step to designing a primary point-of-care clinical decision support tool. METHODS: Electronic medical records (EMRs) of individuals aged 15-45 years, with ICD-9 codes corresponding to a knee condition, and confirmed (ACL+) or denied (ACL-) first-time ACL tear seen at a University-based Clinic between 2014 and 2016 were eligible for inclusion. Demographics, relevant diagnostic indicators and ACL status based on orthopaedic surgeon assessment and/or MRI reports were manually extracted. Descriptive statistics calculated for all variables by ACL status. Univariate between group comparisons, clinician surveys (n = 17), availability of data and univariable logistic regression (95%CI) were used to select variables for inclusion into multivariable logistic regression models that assessed the odds (95%CI) of an ACL-tear based on patient-reported variables alone (consistent with primary point-of-care practice), or in combination with clinician-generated variables. Model performance was assessed by accuracy, sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios (95%CI). RESULTS: Of 1512 potentially relevant EMRs, 725 were included. Participant median age was 26 years (range 15-45), 48% were female and 60% had an ACL tear. A combination of patient-reported (age, sport-related injury, immediate swelling, family history of ACL tear) and clinician-generated (Lachman test result) variables were superior for ACL tear diagnosis [accuracy; 0.95 (90,98), sensitivity; 0.97 (0.88,0.98), specificity; 0.95 (0.82,0.99)] compared to the patient-reported variables alone [accuracy; 84% (77,89), sensitivity; 0.60 (0.44,0.74), specificity; 0.95 (0.89,0.98)]. CONCLUSIONS: A high proportion of individuals without an ACL tear can be accurately identified by considering patient-reported age, injury setting, immediate swelling and family history of ACL tear. These findings directly inform the development of a clinical decision support tool to facilitate timely and accurate ACL tear diagnosis in primary care settings.

Relationship Between Time to ACL Reconstruction and Presence of Adverse Changes in the Knee at the Time of Reconstruction.

BACKGROUND: Treatment of patients with anterior cruciate ligament (ACL) injuries is often complicated by secondary damage to the meniscus and cartilage. PURPOSE: To assess the association between time from ACL tear to ACL reconstruction (ACLR) and the presence of intra-articular injuries at the time of ACLR, including meniscal tears, irreparable meniscal tears, chondral damage, and knee compartment degenerative changes. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Consecutive patients undergoing primary ACLR performed by a single surgeon in a Canadian health system over a 5.5-year period were included. Age at ACLR, activity level prior to injury, time from injury to ACLR (TFI), presence and degree of radiographic osteoarthritic features (International Knee Documentation Committee [IKDC] score by tibiofemoral and/or patellofemoral compartment), and surgeon-recorded meniscal lesions (presence and treatment [repair or excision]) and chondral lesions (International Cartilage Repair Society [ICRS] scale grade >2) at time of ACLR were extracted from medical records. The association between TFI (in quartiles: first quartile [0-36 wk] through fourth quartile [110-1000 wk]) and each outcome was assessed with multivariable logistic regression adjusted for age at ACLR and activity level. RESULTS: A total of 860 individual patient records were included. The median patient age was 27.0 years (range, 12-63 years), 47.5% were female (403/849), and 47.2% were classified as playing competitive or professional sports versus recreational sport (337/714). After adjustment for age and activity level, TFI was associated with presence of medial meniscal tear (odds ratio [OR] of fourth-quartile vs first-quartile patients, 3.86; 95% CI, 2.38-6.24; P < .001), medial meniscal tear requiring greater than two-thirds meniscectomy (OR, 5.64; 95% CI, 2.99-10.67; P < .001), medial femoral condyle chondral damage (OR, 3.42; 95% CI, 1.96-5.95; P < .001), and medial tibiofemoral radiographic osteoarthritic features (OR, 22.03; 95% CI, 5.17-93.86; P < .001). TFI was not associated with adverse outcomes in the lateral tibiofemoral or patellofemoral compartments. CONCLUSION: Increases in TFI are associated with medial meniscal tears, including irreparable medial meniscal tears, medial femoral condyle chondral damage, and early medial tibiofemoral compartment degenerative changes at time of ACLR. These findings highlight the importance of establishing a timely diagnosis and implementing an appropriate treatment plan for patients with ACL injuries. This approach may prevent further instability episodes that place patients at risk of sustaining additional intra-articular injuries in the affected knee. Further research is required to understand the implications of TFI and to determine whether decreasing the TFI alters the natural history after an ACL injury.

Recurrent Instability Episodes and Meniscal or Cartilage Damage After Anterior Cruciate Ligament Injury: A Systematic Review.

BACKGROUND: Delayed anterior cruciate ligament (ACL) reconstruction may be associated with increased risk of subsequent knee joint damage and osteoarthritis (OA). The relationship between recurrent instability episodes and meniscal or cartilage damage after first-time ACL injury is unknown. PURPOSE: To assess the association between recurrent knee instability episodes and prevalence of meniscal lesions, cartilage damage, and OA after first-time ACL injury. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: Six electronic databases were systematically searched using keywords and Medical Subject Heading terms. Studies selected were of English language, included original data, had a prospective design, and provided an outcome of recurrent instability and meniscal lesions, cartilage damage, or OA after first-time ACL injury. Adjusted odds ratios (ORs) were extracted or unadjusted ORs (95% CI) were calculated. PRISMA guidelines were followed, and 2 independent raters assessed study quality using Downs and Black criteria. RESULTS: Of 905 potentially relevant studies, 7 were included. Sample sizes ranged from 43 to 541, and Downs and Black scores ranged from 2 to 12. Clinical and methodological heterogeneity precluded meta-analysis. Six studies reported a positive association between recurrent instability episodes and medial meniscal damage (OR range, 3.46 [95% CI, 1.24-9.99] to 11.56 [1.37-521.06]). The association between instability episodes and lateral meniscal or cartilage damage was inconsistent. No studies examined the association between instability episodes and OA. CONCLUSION: This systematic review provides preliminary evidence that recurrent instability episodes after first-time ACL injury may be associated with increased odds of medial meniscal damage. This highlights the importance of early diagnosis, education, and treatment for individuals with ACL injury, all of which must include a specific focus on the prevention and management of instability episodes. High-quality, prospective cohort studies are needed that assess the effects of diagnostic and treatment delay, recurrent instability episodes on secondary meniscal and cartilage damage, and OA after an initial ACL injury.

Functional Outcomes and Health-Related Quality of Life After Surgical Repair of Full-Thickness Rotator Cuff Tears Using a Mini-Open Technique: A Concise 10-Year Follow-up of a Previous Report.

BACKGROUND: Although good short-term and midterm outcomes are reported for mini-open rotator cuff repair, few prospective studies have investigated long-term results. HYPOTHESIS: Function and health-related quality of life (HRQL) outcomes would be maintained 10 years after mini-open rotator cuff repair. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Patients with a confirmed full-thickness rotator cuff tear who underwent mini-open repair between April 1997 and July 2000 were evaluated preoperatively as well as 1 year and 10 years postoperatively for (1) pain, function, and HRQL using the American Shoulder and Elbow Surgeons (ASES) score and Western Ontario Rotator Cuff Index (WORC) score; (2) active shoulder range of motion (ROM) using goniometry; and (3) satisfaction by an independent evaluator. Changes in function, HRQL, and ROM over time were analyzed using repeated-measures analysis of variance. RESULTS: A total of 84 patients were enrolled, of which 61 (73%) were men; the mean (±SD) age was 53.0 ± 9.9 years. At 10 years, 4 (5%) patients were deceased, and 4 (5%) had symptomatic retears. Fifty-nine (74%) patients were evaluated, composed of 43 (73%) men; 26 (44%) were younger than 60 years. Function and HRQL significantly improved over the course of follow-up (P < .001), primarily within the first postoperative year. At 10 years, the mean ASES score was 90.4 ± 19.4, similar to the 1-year score of 91.1 ± 12.0 (P = .83). The mean WORC score at 10 years was 88.7 ± 17.8, with no change from the 1-year score of 88.4 ± 13.6 (P = .93). This relationship did not change after adjusting for age and tear size. Shoulder ROM was also maintained over 10 years. Flexion ROM improved in the first postoperative year, and this improvement was sustained at 10 years after surgery (P ≥ .30). External rotation ROM was slower to improve postoperatively, and significant improvements were seen between 1 and 10 years (P < .01). Fifty-three patients (90%) were satisfied or very satisfied with their results. Tear size, workers' compensation board claimant status, sex, and smoking status did not influence HRQL or shoulder ROM (P > .06). CONCLUSION: Postoperative improvements in function and HRQL after mini-open rotator cuff repair were retained at 10 years.

The use of early immobilization in the management of acute soft-tissue injuries of the knee: results of a survey of emergency physicians, sports medicine physicians and orthopedic surgeons.

BACKGROUND: Evidence-based guidelines on the use of immobilization in the management of common acute soft-tissue knee injuries do not exist. Our objective was to explore the practice patterns of emergency physicians (EPs), sports medicine physicians (SMPs) and orthopedic surgeons (OS) regarding the use of early immobilization in the management of these injuries. METHODS: We developed a web-based survey and sent it to all EPs, SMPs and OS in a Canadian urban centre. The survey was designed to assess the likelihood of prescribing immobilization and to evaluate factors associated with physicians from these 3 disciplines making this decision. RESULTS: The overall response rate was 44 of 112 (39%): 17 of 58 (29%) EPs, 7 of 15 (47%) SMPs and 20 of 39 (51%) OS. In cases of suspected meniscus injuries, 9 (50%) EPs indicated they would prescribe immobilization, whereas no SMPs and 1 (5%) OS would immobilize (p = 0.002). For suspected anterior cruciate ligament injuries, 13 (77%) EPs, 2 (29%) SMPs and 5 (25%) OS said they would immobilize (p = 0.005). For lateral collateral ligament injuries, 9 (53%) EPs, no SMPs and 6 (32%) OS would immobilize (p = 0.04). All respondents would prescribe immobilization for a grossly unstable knee. CONCLUSION: We found that EPs were are more likely to prescribe immobilization for certain acute soft-tissue knee injuries than SMPs and OS. The development of an evidenced- based guideline for the use of knee immobilization after acute soft-tissue injury may reduce practice variability.

CONTEXTE: Il n'existe pas de lignes directrices factuelles sur le recours à l'immobilisation pour la prise en charge des traumatismes aigus communs qui affectent les tissus mous du genou. Notre objectif était d'explorer les habitudes de pratique des urgentologues, des médecins du sport et des chirurgiens orthopédistes quant au recours à l'immobilisation pour la prise en charge initiale de ces blessures. MÉTHODES: Nous avons conçu un sondage Web et l'avons fait parvenir à tous les urgentologues, médecins du sport et chirurgiens orthopédistes d'un centre urbain canadien. Le sondage visait à évaluer la probabilité que l'immobilisation soit prescrite et à dégager les facteurs associés à ce type de décision chez les praticiens de ces 3 disciplines. RÉSULTATS: Le taux de réponse global a été de 44 sur 112 (39 %) : 17 urgentologues sur 58 (29 %), 7 médecins du sport sur 15 (47 %) et 20 chirurgiens orthopédistes sur 39 (51 %). Dans les cas où l'on soupçonnait une blessure du ménisque, 9 urgentologues (50 %) ont indiqué qu'ils prescriraient l'immobilisation, contre aucun médecin du sport et 1 (5 %) chirurgien orthopédiste (p = 0,002). Dans les cas où l'on soupçonnait une blessure du ligament croisé antérieur, 13 urgentologues (77 %), 2 médecins du sport (29 %) et 5 chirurgiens orthopédistes (25 %) ont affirmé qu'ils immobiliseraient (p = 0,005). Dans les cas de blessure au ligament collatéral latéral, 9 urgentologues (53 %), aucun médecin du sport et 6 chirurgiens orthopédistes (32 %) immobiliseraient (p = 0,04). Tous les répondants ont dit prescrire l'immobilisation pour un genou manifestement instable. CONCLUSION: Nous avons constaté que les urgentologues étaient plus susceptibles de prescrire l'immobilisation pour certains traumatismes aigus affectant les tissus mous du genou comparativement aux médecins du sport et aux chirurgiens orthopédistes. La formulation de lignes directrices factuelles sur le recours à l'immobilisation du genou après un traumatisme aigu des tissus mous pourrait réduire la variabilité des pratiques.

Surgeons' perception of fluoroscopic radiation hazards to vision.

Exposure to ionizing radiation, such as that used in fluoroscopy, can lead to cataracts. This is relevant in orthopedic surgery as fluoroscopic procedures are commonly performed. In this study, we determined perceived level of: (1) personal risk, (2) awareness of risk for cataract formation due to ionizing radiation exposure, (3) awareness of occupational dose limits for ophthalmologic radiation exposure, (4) current radioprotective practices amongst orthopedic surgeons. Canadian Orthopaedic Association members were asked to participate and 264 responses (23%) were received. Many respondents believed that they were at least at moderate risk for cataract formation due to occupational radiation exposure (n = 107; 41%). Fifty-nine respondents (22%) indicated that they lacked sufficient knowledge to estimate risk and almost half (n = 120; 45%) reported having minimal awareness that ionizing radiation may contribute to cataractogenesis; almost 75% (n = 197) reported having minimal awareness that dose limits exist. The association between perceived risk and awareness was significant (P<.001). There is an information deficit among orthopedic surgeons regarding awareness of either the potential cataractogenesis risk due to radiation exposure or the dose limits.

The effect of rhythmic auditory stimulation (RAS) on physical therapy outcomes for patients in gait training following stroke: a feasibility study.

Adults aged 55 to 80 years participated voluntarily in a wait-list control study during in-patient physical therapy following first stroke. All participants (N = 15) received conventional physical therapy gait training throughout 30 treatment sessions. Rhythmic auditory stimulation (RAS)-enhanced gait training was nested within conventional treatments in three conditions: (1) RAS throughout 30 treatments (N = 5); (2) RAS in the last 20 treatments (N = 5); and (3) RAS in the last 10 treatments (N = 5). Cadence and balance outcome measurements were taken at baseline, and following 10, 20, and 30 treatment sessions. Improvements across time were statistically significant in all conditions for one-limb stance, cadence, velocity, stride length, and posture head tilt with no statistically significant improvements for the Timed Up and Go Test and the Functional Reach Test. Statistically significant gains were made in the one-limb stance and cadence with earlier implementations of RAS. Results of the study demonstrate the feasibility of RAS to enhance gait training that warrants further investigation of the protocol to demonstrate the effects of RAS in stroke rehabilitation.

Antegrade tibial tunnel technique for posterior cruciate ligament reconstruction.

Posterior cruciate ligament (PCL) reconstruction remains a difficult procedure even in experienced hands because there is a lack of consensus regarding the most reliable and least technically challenging technique. The commonly used retrograde anteromedial tibial tunnel leads to excessive angulation at the posterior tibia and risks catastrophic neurovascular complications. We present a technique of drilling the transtibial PCL tunnel in an antegrade fashion through a posteromedial portal. This technique offers the advantage of an anterolateral route to reduce graft angulation, as well as drilling away from the important posterior neurovascular structures.

Neurosensory effects of chronic exposure to arsenic via drinking water in Inner Mongolia: II. Vibrotactile and visual function.

This study was designed to assess the effects of exposure to arsenic in drinking water on visual and vibrotactile function in residents of the Bamen region of Inner Mongolia, China. Arsenic was measured by hydride generation atomic fluorescence. 321 participants were divided into three exposure groups- low (non-detectable-20), medium (100-300) and high (400-700 microg/l) arsenic in drinking water (AsW). Three visual tests were administered: acuity, contrast sensitivity and color discrimination (Lanthony's Desaturated 15 Hue Test). Vibration thresholds were measured with a vibrothesiometer. Vibration thresholds were significantly elevated in the high exposure group compared to other groups. Further analysis using a spline regression model suggested that the threshold for vibratory effects is between 150-170 microg/l AsW. These findings provide the first evidence that chronic exposure to arsenic in drinking water impairs vibrotactile thresholds. The results also indicate that arsenic affects neurological function well below the 1000 microg/I concentration reported by NRC (1999). No evidence of arsenic-related effects on visual function was found.

Neurosensory effects of chronic exposure to arsenic via drinking water in Inner Mongolia: I. Signs, symptoms and pinprick testing.

This study was designed to assess the effects of exposure to arsenic in drinking water on neurosensory function. A questionnaire including neurological signs and symptoms and a brief neurological exam consisting of pinprick testing of the arms and legs and knee-jerk test were administered to 321 residents of the Bamen region of Inner Mongolia, China. Arsenic in water was measured by hydride generation atomic fluorescence. Participants were divided into three exposure groups--low (non-detectible-20), medium (100-300) and high (400-700 microg/I) arsenic. Significant group differences were observed in pinprick scores for all four limbs. Results indicate that arsenic alters pinprick (pain) thresholds at well-water concentrations as low as 400 microg/l, well below the 1000 microg/l threshold for neurological effect specified by NRC (1999). Regression models suggest that a 50% increase in pinprick score is associated with a 71-159 ppb increase in arsenic concentration.

The relationship between blood lead levels and neurobehavioral test performance in NHANES III and related occupational studies.

OBJECTIVES: The goals of this study were two-fold: (1) to assess the relationship between blood lead levels and neurobehavioral test performance in a nationally sample of adults from the third National Health and Nutrition Evaluation Survey and (2) to analyze the results from previously published studies of occupational lead exposure that used the same neurobehavioral tests as those included in the survey. METHODS: Regression models were used to test and estimate the relationships between measurements of blood lead and performance on a simple reaction time, a symbol-digit substitution, and a serial digit learning test in adults aged 20-59 years who participated the survey. Mixed models were used to analyze the data from the occupational studies. RESULTS: The blood lead levels of those participating in the survey ranged from 0.7 to 41.8 microg/dl. The estimated geometric mean was 2.51 microg/dl, and the estimated arithmetic mean was 3.30 microg/dl. In the survey, no statistically significant relationships were found between blood lead concentration and performance on the three neurobehavioral tests when adjusted for covariates. In the occupational studies, the groups exposed to lead consistently performed worse than control groups on the simple reaction time and digit-symbol substitution tests. CONCLUSIONS: The results from the survey and the occupational studies do not provide evidence for impairment of neurobehavioral test performance at levels below 25 microg/dl, the concentration that the Centers for Disease Control and Prevention define as elevated in adults. The average blood lead level of the exposed groups in the occupational studies was 41.07 microg/dl, less than 50 microg/dl, the minimum concentration that the Occupational Safety and Health Administration requires for medical removal from the workplace. Given the evidence of impaired neurobehavioral performance in these groups, the 50 microg/dl limit should be reevaluated.

Functional outcome and health-related quality of life after surgical repair of full-thickness rotator cuff tear using a mini-open technique.

BACKGROUND: Rotator cuff tear, a common shoulder injury, can lead to shoulder pain and functional loss. HYPOTHESIS: Surgical repair of full-thickness rotator cuff tears using the mini-open surgical technique will improve shoulder function and health-related quality of life. STUDY DESIGN: Cohort study. Level of evidence, 2. METHODS: Patients with a full-thickness rotator cuff tear who underwent a mini-open repair were evaluated for (1) active shoulder range of motion preoperatively, and 6 months and 12 months postoperatively and (2) health-related quality of life preoperatively, 6 months postoperatively, and annually up to 5 years postoperatively. Satisfaction with the repair and return to work status were ascertained 1 year postoperatively. A subgroup analysis of tear size and patient age was also undertaken. RESULTS: Of the subjects, 61 (73%) were men, and the average age was 53.2 ( +/- 9.9) years. According to repeated-measures analysis of variance, shoulder range of motion (flexion and external rotation) improved significantly from before surgery to 1 year after surgery (P <.001). The mean American Shoulder and Elbow Surgeons scores improved from 53.3 ( +/- 20.6) preoperatively to 90.6 ( +/- 11.7) 1 year postoperatively (P <.001). The mean Western Ontario Rotator Cuff scores also improved from 43.2 ( +/- 20.2) preoperatively to 87.2 ( +/- 14.3) 1 year postoperatively (P <.001). No differences were seen in either the American Shoulder and Elbow Surgeons scores or Western Ontario Rotator Cuff scores between the 1-year examination and the last follow-up assessment undertaken at a median of 5 years postoperatively (P >.05). Ninety-six percent of patients were satisfied or very satisfied with the results of their repair; 78% of patients who were working before surgery returned to work without modification by 1 year postoperatively. For the most part, patient age and size of tear did not influence postoperative range of motion or health-related quality of life. CONCLUSION: Mini-open rotator cuff repair led to improved shoulder function and health-related quality of life up to 5 years postoperatively.

The anatomic characteristics of the tibial insertion of the posterior cruciate ligament.

PURPOSE: The purpose of the study was to better define the tibial insertion of the posterior cruciate ligament (PCL) and to identify landmarks that could be used to aid in placement of independent tibial tunnels for a 2-bundle PCL reconstruction. TYPE OF STUDY: Descriptive anatomic study. METHODS: Ten knees from 8 cadavers were dissected and the PCL was identified. The ligament was peeled away from its insertion and the sides of the insertion site were measured and recorded. The 4 corners of the insertion site were identified and marked. Observations were made of the morphology of the insertion site and the presence of any reproducible anatomic landmarks. A note was made of landmarks that could be easily identified on all of the specimens by direct vision and by palpation with a probe. RESULTS: The ligament consisted of 2 regions, 1 anterolateral, and 1 posteromedial, with a gradual change in the laxity of the ligament as the knee was passed through flexion and extension. The insertion site was situated in a depression between the plateaus of the tibia and extended below the articular surface. The average length +/- standard deviation of the 4 sides was 128 +/- 21.2 mm (medial side), 107 +/- 26.5 mm (superior side), 160 +/- 30.0 mm (lateral side), and 169 +/- 34.5 mm (inferior side). The shape and sides of the insertion site were visually similar among the 10 specimens. The superolateral and superomedial corners were both represented by depressions and a reproducible ridge represented the inferior border. These structures could be visualized as well as palpated on all specimens. CONCLUSIONS: Based on the findings of this study, we describe the anatomic characteristics of the tibial footprint of the PCL. Anatomic reference points that represent the corners of the tibial insertion of the PCL were identified by direct vision or palpation consistently on all specimens included in the study. These reference points could potentially aid in the placement of an anterolateral and posteromedial tibial tunnel for a 2 tibial tunnel PCL reconstruction. CLINICAL RELEVANCE: Reproducible anatomic reference points exist at the tibial insertion of the PCL that can be identified by direct vision and palpation. These reference points may potentially aid in the placement of separate tibial tunnels for a 2-bundle PCL reconstruction.

Investigation of a hybrid method of soft tissue graft fixation for anterior cruciate ligament reconstruction.

To increase knee stability following anterior cruciate ligament (ACL) reconstruction, development of increasingly stronger and stiffer fixation is required. This study assessed the initial pullout force, stiffness of fixation, and failure modes for a novel hybrid fixation method combining periosteal and direct fixation using porcine femoral bone. A soft tissue graft was secured by combining both an interference screw and an EndoButton (Smith and Nephew Endoscopy, Andover, MA). The results were compared with the traditional direct fixation method using a titanium interference screw. Twenty porcine hindlimbs were divided into two groups. Specimens were loaded in line with the bone tunnel on a materials testing machine. Maximum pullout force of the hybrid fixation (588+/-37 N) was significantly greater than with an interference screw alone (516+/-37 N). The stiffness of the hybrid fixation (52.1+/-12.8 N/mm) was similar to that of screw fixation (56.5+/-10.2 N/mm). Graft pullout was predominant for screw fixation, whereas a combination of graft pullout and graft failure was seen for hybrid fixation. These results indicate that initial pullout force of soft tissue grafts can be increased by using the suggested novel hybrid fixation method.

Development and initial validation of a risk score for predicting in-hospital and 1-year mortality in patients with hip fractures.

UNLABELLED: Our objectives were to better define the rates and determinants of in-hospital and 1-year mortality after hip fracture. We studied a population-based cohort of 3981 hip fracture patients. Using multivariable regression methods, we identified risk factors for mortality (older age, male sex, long-term care residence, 10 prefracture co-morbidities) and calculated a hip fracture-specific score that could accurately predict or risk-adjust in-hospital and 1-year mortality. Our methods, after further validation, may be useful for comparing outcomes across hospitals or regions. INTRODUCTION: Hip fractures in the elderly are common and associated with significant mortality and variations in outcome. The rates and determinants of mortality after hip fracture are not well defined. Our objectives were (1) to define the rate of in-hospital and 1-year mortality in hip fracture patients, (2) to describe co-morbidities at the time of fracture, and (3) to develop and validate a multivariable risk-adjustment model for mortality. MATERIALS AND METHODS: We studied a population-based cohort of 3981 hip fracture patients > or =60 years of age admitted to hospitals in a large Canadian health region from 1994 to 2000. We collected sociodemographic and prefracture co-morbidity data. Main outcomes were in-hospital and 1-year mortality. We used multivariable regression methods to first derive a risk-adjustment model for mortality in 2187 patients treated at one hospital and then validated it in 1794 patients treated at another hospital. These models were used to calculate a score that could predict or risk-adjust in-hospital and 1-year mortality after hip fracture. RESULTS AND CONCLUSIONS: The median age of the cohort was 82 years, 71% were female, and 26% had more than four prefracture co-morbidities. In-hospital mortality was 6.3%; 10.2% for men and 4.7% for women (adjusted odds ratio, 1.8; 95% CI, 1.3-2.4). Mortality at 1 year was 30.8%; 37.5% for men and 28.2% for women (adjusted p < 0.001). Older age, male sex, long-term care residence, and 10 different co-morbidities were independently associated with mortality. Risk-adjustment models based on these variables had excellent accuracy for predicting mortality in-hospital (c-statistic = 0.82) and at 1 year (c-statistic = 0.74). We conclude that 1 in 15 elderly patients with hip fracture will die during hospitalization, and almost one-third of those who survive to discharge will die within the year. The determinants of mortality were primarily older age, male sex, and prefracture co-morbidities. Our hip fracture-specific risk-adjustment tool is pragmatic and reliable, and after further validation, may be useful for comparing outcomes across different hospitals or regions.

A three-dimensional finite element stress analysis for tunnel placement and buttons in anterior cruciate ligament reconstructions.

This communication reports the results of a three-dimensional finite element (FE) model of stresses in a surgically altered femur and tibia. The model incorporated a novel approach in implementing orthotropic and inhomogeneous bone properties and non-uniform distributed loading. Cortical, cancellous, and subchondral bone of the femur and the tibia were modeled. Mechanical properties for the cortical and cancellous bone were mapped from published data characterizing the anisotropy and inhomogeneity of the bone properties. Mesh adequacy was determined using stress convergence and strain energy error convergence. Qualitatively, the results of the study compare well with experimental principal compressive strains from the literature. With respect to tunnel placement in anterior cruciate ligament reconstruction, the model predicted stress-shielding at the postero-lateral region of the tunnel wall, and increased stress at the postero-medial region of the tunnel wall. The stresses in the cancellous bone beneath the tunnel were, in general, lower than those above the tunnel. Prolonged stress shielding leads to bone resorption of the posterior tunnel wall leading to tunnel enlargement, and possible compromise of the ACL reconstruction. The stresses on the femoral cortex produced from a button-type fixation were noticeable for low levels of loading; the stress levels were very similar in models incorporating bone properties of patients aged 45 and 65. Repeated compression of the femoral cortex at these stress levels may cause microdamage to the cortex eventually resulting in fatigue failure.